History of Medicine

Sweating Sickness: England’s Forgotten Plague

dancedeath.jpg

We discuss the sweating sickness (and review wine) in the second episode of the Quacks Who Quaff podcast.

The history of medicine is littered with diseases which impacted on the course of humanity. The Black Death. Smallpox. Influenza. HIV/AIDS. Each one has left its own mark on our collective consciousness. And yet there is an often-overlooked addition to this list: sweating sickness. This disease tore its way through Tudor England, killing within hours, before disappearing as quickly and mysteriously as it arrived. In its wake it left its mark, a nation changed. The identity of this disease remains a matter for conjecture to this day. This is the story of England’s forgotten plague.

Background to an outbreak

It’s summer 1485. An epic contest for the throne of England is reaching its bloody climax. In a few weeks on August 22nd at the Battle of Bosworth Henry Tudor will wrest the crown from King Richard III and conclude the Wars of the Roses. Away from the fighting people start dying. As contemporary physicians described:

“A newe Kynde of sickness came through the whole region, which was so sore, so peynfull, and sharp, that the lyke was never harde of to any mannes rememberance before that tyme. “

These words take on added impact when you remember the writer would have experienced patients with bubonic plague. What was this disease “the like was never heard of”? Sudor Anglicus, later known as the English sweating sickness, struck quickly. The French physician Thomas le Forestier described victims feeling apprehensive and generally unwell before violent sweating, shaking and headaches began. Up to half of patients died, usually within 24 hours. Those who lived longer than this tended to survive. However, survival did not seem to offer immunity and patients could be struck multiple times. 15,000 died in London alone. We don’t have an exact figure for its mortality but it is commonly estimated at 30-50%.

Outbreaks continued beyond 1485 and the reign of Henry VII and into that of his grandson Edward VI in five further epidemics; 1508, 1517, 1528, and 1551, each time in summer/autumn. The disease remained limited to England apart from 1528/29 when it also spread to mainland Europe.

John Keys

The principle chronicler of the sweat was the English doctor John Keys (often Latinised to John Caius/Johannes Caius) in his 1552 work ‘A Boke or Counseill Against the Disease Commonly Called the Sweate, or Sweatyng Sicknesse.’ This is how know so much about how the disease presented and progressed.

Key’s noted that the patients most at risk of the disease were:

“either men of wealth, ease or welfare, or of the poorer sort, such as were idle persons, good ale drinkers and tavern haunters.”

Both Cardinal Wolsely and Anne Boleyn contracted the disease but survived. Wolsely survived two attacks. Anne’s brother-in-law William Carey wasn’t so lucky and died of the sweat. The disease’s predilection for the young and wealthy led to it being dubbed the ‘Stop Gallant’ by the poorer classes.

Key’s was the physician to Edward VI, Mary I and Elizabeth I. As he was born in 1510 his work on the first epidemics of sweating sickness was based on prior reports of the illness; it could therefore be said he had performed a kind of literature review. Unlike le Forestier his lack of first hand experience and the fact he focused mostly on noble deaths has led to criticism. However, Keys was clear that the sweat was different to plague and other conditions. This goes with le Forestier and other physicians at the time.

The impact of the sweat permeated Tudor culture. Even in 1604 William Shakespeare was concerned enough about sweating sickness to write in his play ‘Measure by Measure’:

“Thus, what with the war, what with the sweat, what with the gallows, and what with poverty…”

How the sweat changed history

Henry Tudor was an ambitious man with a fairly loose claim to the throne of England: his mother, Lady Margaret Beaufort, was a great-granddaughter of John of Gaunt, Duke of Lancaster, fourth son of Edward III, and his third wife Katherine Swynford. Katherine was Gaunt’s mistress for 25 years before they married and had 4 children already before she gave birth to John Beaufort, Henry’s great-grandfather. If this sounds complicated it is. Henry was not a strong claimant and his chances had been further weakened by an Act of Parliament in 1407 by Henry IV, John of Gaunt’s first son, which recognised his half-siblings but ruled them and their descendants ineligible for the throne.

Henry Tudor’s ancestry from http://www.livimichael.co.uk/succession-the-players

Henry needed alliances if he was going to get anywhere. He attempted to take the crown in 1483 but the campaign was a disaster. He was running out of time and needed to kill Richard III in battle if he was going to be king. He accepted the help of King Charles VIII of France who provided Henry with 2000 mercenaries from France, Germany and Switzerland. This force crossed the English Channel on 7th August 1485. In was in this army that the sweat first appeared. There is debate about whether this was before or after the Battle of Bosworth but Lord Stanley, a key ally of Richard III and a contributor of 30% of the king’s army, used fear of sweating sickness as a reason to not join the royal forces in battle. It’s therefore possible that sweating sickness was seen before Bosworth and helped shape the course of English history.

Arthur Tudor (1486-1502)

Sweating sickness may have had a further impact on the Tudors and their role in our history. Henry VII’s first son, Arthur the Prince of Wales died in 1502 aged 15. Sweating sickness has been suggested as the cause of his sudden death. His death saw Henry VII’s second son, also called Henry, become first in line to the throne which he took in 1509 as King Henry VIII.

What was the sweat?

Unlike other plagues the identity of sweating sickness remains a mystery to this day. The periodicity of the epidemics suggests an environmental or meteorological trigger and possibly an insect or rodent vector.

A similar disease struck Northern France in 1718 in an outbreak known as ‘the Picardy sweat’. 196 local epidemics followed until the disease disappeared in 1861 with its identity also a mystery. Interestingly, the region of France where the Picardy sweat arose is near where Henry Tudor’s group of French, German and Swiss solders amassed prior to the Battle of Bosworth.

Several diseases have been proposed as the true identity of the sweat. Typhus (not as virulent), influenza and ergotism (don’t match the recorded symptoms) have been suggested and dropped. In 1997 it was suggested that a hantavirus could have been responsible. Hantaviruses are spread by inhalation of rodent droppings and cause similar symptoms to sweating sickness before killing with bleeding and complications to the heart and lungs. Although rare they have been identified in wild rodents in Britain. If we remember how the sweat seemed to strike following summer when rodent numbers would be at their highest and add in the poor sanitation of Tudor times then hantavirus is a strong candidate.

We’ll likely never know the true identity of sweating sickness unless it re-emerges. If that’s the case based on the terror it inspired to Tudor England we should be glad to keep it a mystery.

Thanks for reading.

- Jamie

,

The Most Famous Case Report Ever

,

Case reports are nothing new. We’ve all told colleagues about interesting cases we’ve seen. I’ve presented a couple at RCEM. They tend to focus on the weird and wonderful, cases with surprising twists and turns but with actual limited learning. That’s why case reports are at the bottom of the table when it comes to levels of evidence. However, one in particular could be said to have marked a turning point in modern medical practice.

The Morbidity and Mortality Weekly Report (MMWR) has been published weekly by the Centre for Disease Control and Prevention (CDC) since 1950. Each week they release public health information, possible exposures, outbreaks and other health risks for health workers to be aware of. One case report in particular stands out out of all of their back catalogue. It was written by various doctors from the University of California, Los Angeles and Cedars-Mt Sinai Hospital, Los Angeles. It was published on June 5th 1981:

The MMWR June 5th 1981

Reported by MS Gottlieb, MD, HM Schanker, MD, PT Fan, MD, A Saxon, MD, JD Weisman, DO, Div of Clinical Immunology-Allergy, Dept of Medicine, UCLA School of Medicine; I Pozalski, MD, Cedars-Mt. Sinai Hospital, Los Angeles; Field Services Div, Epidemiology Program Office, CDC.

Pneumocystis Pneumonia (PCP) is a rare form of pneumonia caused by the yeast like fungus Pneumocystis jiroveci. The fungus can live in the lungs of healthy people without causing any problems so to see it in 5 otherwise healthy young (the oldest was 36) people was odd.

Less than a month later the MMWR published further cases of PCP as well as Kaposi sarcoma in 26 previously well homosexual men in Los Angeles and New York since 1978. Kaposi sarcoma is very rare form of cancer previously seen usually in older men of Jewish/Mediterranean descent. Again it was virtually unheard of it in young men. It was suspected that something was affecting their immune systems preventing them from fighting off infections and malignancy.

At the time there were many theories as to what was causing the immune systems of patients to shut down. It was felt that it was linked to the ‘gay lifestyle’ in some way leading to the stigmatising description in the media of GRID (Gay-related immunodeficiency) first used in 1982. By 1983 the disease was linked also to injecting drug users, haemophiliacs who’d received blood products and Haitians. This led to another stigmatising phrase ‘the 4H club’ (Homosexuals, Heroin addicts, Haemophiliacs and Haitians).

In 1982 however, the CDC had actually given it a proper name: ‘Acquired Immune Deficiency Syndome’ or ‘AIDS’.

The fact it was being transmitted to blood product recipients suggested the cause had to be viral as only a virus could pass the filtration process. In 1983 two rival teams, one American and one French, both announced they had found the virus causing AIDS with ongoing debate as to who got there first. Each team gave it a different name. In 1985 a third one was chosen: ‘Human Immunodeficiency Virus’ or ‘HIV’. By that time the virus had spread not just in America but in Canada, South America, Australia, China, the Middle East and Europe. Since 1981 worldwide more than 70 million people have been infected with the HIV virus and about 35 million people have died of AIDS. 

The MMWR of 5th June 1981 is now recognised both as the beginning of the HIV/AIDS pandemic and as the first publication of HIV/AIDS. Although only a case report it shows the value of these publications at the front line. Only by recording and publishing the ‘weird and wonderful’ can we start to share practice, appreciate patterns and spot emergent diseases.

Thanks for reading

- Jamie

shutterstock_748216612.jpg

Mass Hysteria & Moral Panic: The Dancing Plagues and #Momo

dance_at_molenbeek.jpg

“The only thing we have to fear is fear itself” - President Franklin Roosevelt

Human beings are social animals with conventions and norms. Yet sometimes we act in ways that defy logic or reason. Very often the inspiration for this is fear. In this week’s blog I’ve looked at the ‘Dancing Plagues’ of the Middle Ages and the ‘Momo Challenge’ of last month and how they illustrate the power of fear over people. In a previous blog I wrote about the importance of being accurate with psychiatric diagnosis and so I’m also going to use them as examples of the difference between mass hysteria and moral panic.

In 1374 in Aachen along the River Rhine in what is now Germany locals suddenly started dancing. They didn’t stop. They couldn’t stop. Justus Hecker, an 18th century physician researched the phenomenon and described it as:

“They formed circles hand in hand, and appearing to have lost all control over their senses, continued dancing, regardless of the bystanders, for hours together, in wild delirium, until at length they fell to the ground in a state of exhaustion. They then complained of extreme oppression, and groaned as if in the agonies of death, until they were swathed in cloths bound tightly round their waists, upon which they again recovered, and remained free from complaint until the next attack.”

The dancing spread to Liege, Utrecht, Tongres and other towns in the Netherlands and Belgium, up and down the Rhine river. It was known as St. John’s Dance or St. Vitus’ Dance as these saints were blamed for causing the ‘disease’.

In July 1518, this time in Strasbourg, a woman known as Frau Troffea started dancing and carried on for 4 to 6 days. By the end of the week 34 people had joined her and at the end of month 400 people were dancing. It didn’t stop. It seemed contagious. Local authorities initially thought that the people just needed to get the dancing out of their systems and so organised musicians to encourage dancing. It didn’t work. Dozens collapsed and died out of exhaustion.

The ‘Dancing Plagues’ continued to occur randomly throughout medieval Europe. It’s still a mystery why so many people acted in such a bizarre way. Possession was blamed but exorcisms had no effect. Doctors at the time wondered if the stars or even spider bites were to blame. Various different theories have since been put forward such as encephalitis which can cause delirium and hallucinations or poisoning of grain by the ergot fungus. None completely explain all the symptoms. There may have been an element of religious demonstration but that doesn’t explain how the dancing seemed contagious.

It may be that ‘Dancing Mania’ was due to mass hysteria.

Mass hysteria is a "conversion disorder," in which a person has physiological symptoms affecting the nervous system in the absence of a physical cause of illness, and which may appear in reaction to psychological distress.

It has been suggested that mass hysteria has 5 principles:

  1. "it is an outbreak of abnormal illness behavior that cannot be explained by physical disease"

  2. "it affects people who would not normally behave in this fashion"

  3. "it excludes symptoms deliberately provoked in groups gathered for that purpose," such as when someone intentionally gathers a group of people and convinces them that they are collectively experiencing a psychological or physiological symptom

  4. "it excludes collective manifestations used to obtain a state of satisfaction unavailable singly, such as fads, crazes, and riots"

  5. "the link between the [individuals experiencing collective obsessional behavior] must not be coincidental," meaning, for instance, that they are all part of the same close-knit community

In 1374 Europe was still recovering from the Black Death of 1347-1351. The people of Strasbourg in 1518 had suffered a famine. At a time where disease and famine were the preserve of God’s wrath perhaps the stress of potential apocalypse manifested itself in a a plague of dancing.

If you think that mass hysteria is confined to the dark pre-Renaissance ages you’d be very wrong. In 1999 26 school children in Belgium fell ill after drinking cans of Coca Cola. After this was reported in the news more students in other schools also fell ill. Coca Cola withdrew nearly 30 million cans from the market as about 100 people eventually complained of feeling unwell after drinking their product. Except when they were examined nothing organically wrong could be found and the students had drunk cans from different factories.

Professor Simon Wessely, the former president of the Royal College of Psychiatrists, has written a lot about mass hysteria and is clear: mass hysteria does not make a person insane. The patient thinks they are unwell and communicate that illness. This brings us to moral panic and #Momo.

maxresdefault.jpg

If you’ve been anywhere near social media the past month chances are you heard about Momo or ‘The Momo Challenge’. These were posts, shared widely, warning about a character called Momo who has started appearing in online videos aimed at children threatening them and encouraging them to perform acts of violence against themselves and others. It led to widespread discussion and warnings from authorities:

Except it wasn’t real. There is no evidence of Momo or any character infiltrating videos of Pepper Pig and inspiring children to hurt themselves. This obsession over an imaginary character was been traced to a solitary post in America warning about Momo. Over the following month there was an exponential growth of interest into this imaginary threat. Charities warned that the fear mongering would actually do more harm than good.

Guardian graphic. Source: Google trends. Numbers represent search interest

Guardian graphic. Source: Google trends. Numbers represent search interest

Professor Wessely defines moral panic as the “phenomenon of masses of people becoming distressed about a perceived — usually unreal or exaggerated — threat portrayed in catastrophising terms by the media“. Like mass hysteria there’s a threat. Unlike mass hysteria people don’t believe themselves to be unwell. The sociologist Stanley Cohen described four stages of moral panic in response to a perceived threat:

  1. The threat is then depicted in a simple and recognizable symbol/form by the media

  2. The portrayal of this symbol rouses public concern

  3. There is a response from authorities and policy makers

  4. The moral panic over the issue results in social changes within the community

Look at these four steps and then the graph above. #Momo illustrates moral panic perfectly. It also brilliantly illustrates how misinformation and as a result panic can be spread by social media. Moral panic is the result of fears the ‘threat’ poses to our way of life. It is therefore a powerful tool by the far right. Watch how Donald Trump and his supporters spread inaccurate information about illegal immigrants to push their border wall agenda.

The world is a scary place and as a species we instinctively fear the unknown especially when our way of life or our lives themselves are believed to be at risk. The panic at Oxford Street, London last December where gun shots were reported is believed to be due to a ‘perfect storm’ of fear over terrorism and violence. People panicked when a fight broke out. Next thing hundreds of shoppers were running and their imagination took over. What’s worse is when that fear is used to ostracise whole groups of people. The Witch Trials of Salem, on which both mass hysteria and moral panic have been blamed, is a classic example of this. For all the drama caused what the #Momo phenomenon also shows is a potential solution to fear: knowledge and a measured response.

Thanks for reading

- Jamie

Flogging, Bellows, Barrels, Smoke Up the Bum and Abraham Lincoln - Early CPR

Last week saw the start of induction of our new third year students starting the clinical phase of their time at university. I was on CPR duty for much of it. CPR as we know it was developed in 1960. For the centuries before that there were many different techniques attempted to revive a patient without a pulse. It’s fair to say these were, ahem, interesting.

Flogging

In the early Middle Ages a patient would be flogged or flagellated sometimes with nettles to try and revive them. It was presumed that the shock would awake the patient rather than any consideration of their circulation.

Bellows

In an early example of artificial ventilation bellows began to be used in the 1500s to blow air down the patient’s throat and into their lungs. However, simple air manoeuvres were not used. Bellows were popular for about 300 years until in 1829, the French physician Leroy d’Etiolles demonstrated through his work on barotrauma that over distension of the lungs could kill an animal so they went out of fashion.

Fumigation

Fast forward to the 1700s and fumigation comes into use. The physician would light a pipe of tobacco and use the above contraption to literally blow tobacco smoke up the patient’s rectum. It was believed that the smoke’s effects would revive the patient through the irritant effects of the tobacco smoke.

Barrel Method

Resuscitation would then go back the lungs and a technique to force air in and out of the chest. This led to the barrel method where the barrel was used to force inspiration and expiration. You can kind of see what they were trying to do here with a mechanical intervention.

Russian Snow Method

Meanwhile in Russia in the early 19th century the snow method came into fashion. The idea being to slow the metabolism of the patient and hope that circulation would return at a later date.

The Assassination of Abraham Lincoln

Whilst at Ford’s Theatre on 14th April 1865 US President Abraham Lincoln was shot by John Wilkes Booth in the back of the head. Charles Leal, a young military surgeon, and another doctor Charles Sabin Taft attempted to revive Lincoln with a three stage approach:

Method “A” “... As the President made no move to revive then, I thought of another way of death, apnea, and I assumed my preferred position for him with artificial respiration to revive …” “… I knelt on the floor on the President, with one knee on each side of the pelvis and in front of him. I leaned forward, opened my mouth and inserted two fingers of his right hand as far as possible .. . and then I opened the larynx and I did a free passage for air to enter the lungs … “

Method “B”: “… I put an assistant in each of his arms to manipulate in order to expand the chest and then slowly pushed his arms down the side of the body as I pressed the diaphragm above: These methods caused the vacuum and air is forced out of their lungs … “

Method “C”: “… Also with the thumb and fingers of my right hand pressure intermittent sliding pressure below the ribs stimulated the apex of the heart …”

Lincoln did become more responsive but it was clear his wounds were fatal and he died the next day. The three stages above are almost recognisable to the ‘ABC’ method we’re taught today. The doctors took steps to protect Lincoln’s airway, there was some consideration to force ventilation and an attempt at pressing the heart. It’s still not CPR as we would know it.

It took the US Military adopting mouth-to-mouth resuscitation and CPR as well as public campaigns helped by the arrival of Resusci Anne (more on her here) for CPR to become a key part of both medicine and health education.

It’s very easy to laugh at these previous techniques and sometimes hard to see the logic behind them. However, we don’t know which staples of Medicine we use today will be deemed irrelevant or even wrong. For example, we no longer perform gastric lavage and even collar and blocks are being debated as sometimes doing more than good. Maybe in the future medics will view us as incredulously as we do at someone blowing tobacco smoke up the rectum of a moribund patient. Maybe.

Thanks for reading.

- Jamie

Smallpox: the Giants' Shoulders Edward Jenner Stood on to Overcome 'The Speckled Monster'

Convergent evolution is a key principle in Biology. Basically, it means that nature will find the same ‘solutions’ for organisms filling similar environmental niches. So in different species with no close relation but who encounter similar environments (say sharks and dolphins) you’ll see similar features (both have fins). The same is true in the history of science. Very few discoveries are actually made in solitude; more often there were several people working on the same problem but often only one gets the fame. For Charles Darwin see Alfred Russel Wallace. For Sir Isaac Newton see Robert Hooke.

We discuss the unsung heroes in the fight against smallpox and variolation (and review wine) in the third episode of the Quacks Who Quaff podcast.

When it comes to vaccination and the conquest of smallpox, one of the most deadly diseases to ever afflict mankind, one name always comes to mind: Edward Jenner. We all know the story: an English country doctor in the 18th century observed how milkmaids who contracted cowpox from their cattle were immune to the far more serious smallpox. On 14th May 1796 he deliberately infected the eight-year-old boy James Phipps with cowpox. The boy develops a mild fever. Later Jenner exposes Phipps to pus from a smallpox blister. The boy is unaffected by smallpox. A legend is born. Vaccination becomes the mainstay of the fight against smallpox. In the 20th century a worldwide campaign results in smallpox being the first disease to be eradicated.

Of course, as we all know, things are rarely this straightforward and there are many less famous individuals who all contributed to the successful fight against smallpox.

Dr Jenner performing his first vaccination on James Phipps, a boy of age 8. May 14th, 1796. Painting by Ernest Board (early 20th century).

Smallpox, the ‘speckled monster’, has a mortality rate of 30% and is caused by a highly contagious airborne virus. It long affected mankind; smallpox scars have been seen in Egyptian mummiesfrom the 3rd Century BCE. Occurring in outbreaks it is estimated to have killed up to 500 million peoplein the 20th century alone. Throughout history it was no respecter of status or geography, killing monarchs and playing a role in the downfall of indigenous peoples around the world. Superstition followed smallpox with the disease even being worshipped as a god around the world.

Doctors in the West had no answer to it. But in other parts of the world solutions were found. With colonisation and exploration the West started to hear about them. More than seventy years before Jenner’s work two people on either side of the Atlantic were inspired by custom from Africa and Asia. 

Left: Shitala, the North Indian goddess of pustules and sores

Right: Sopona, the god of smallpox in the Yoruba region of Nigeria

Lady Mary Wortley Montagu


In 1721 in London Lady Mary Wortley Montagu the wife of the Ambassador to Turkey who had lost her brother to smallpox having survived the disease herself is keen to protect her daughter. Whilst in Turkey she learned of the local practice of ‘variolation’ or inoculation against smallpox. Pus from the pustules of patients with mild smallpox is collected and scratched into the skin of an uninfected person. This was a version of a process dating back to circa 1000 AD in China where pustule material was blown up the nose of a patient. Mary was impressed and her son was inoculated in Turkey in 1715. 

Six years later in London her daughter was similarly inoculated in the presence of doctors of the royal court, the first such procedure in Britain. She campaigns for the practice to be spread.

Cotton Mather

Also in 1721, an outbreak of smallpox is ravaging Boston, Massachusetts. An influential minister Cotton Mather is told by one of his African slaves, Onesimus, about a procedure similar to inoculation. According to Onesimus as a younger man a cut was made into his skin and smallpox pustules were rubbed into the wound. He told Mather that this had made him immune to smallpox. Mather hears of the same practice in China and Turkey and is intrigued. He finds a doctor, Zabdiel Boylston, and the two start performing the first inoculations in America.

Lady Wortley Montagu and Cotton Mather never met, they lived on opposite sides of the Atlantic and yet learnt of the same practice. Convergent medical advances in practice.

Inoculation is not without risk however and Prince Octavius, son of King George III dies in 1783 following inoculation. People inoculated with smallpox are also potentially contagious. An alternative is sought.

In 1768 an English physician John Fewster identified that cowpox offered immunity against smallpox and begins offering the practice of immunisation. In 1774 Benjamin Festy, a dairy farmer in Yetminster, Dorset, also aware of the immunity offered by cowpox,, has his wife and children infected with the disease. He tests the procedure by then exposing his son to smallpox. His son is fine. The process is called vaccination after the Latin word for cow. However, neither men publish their work. In France in 1780 politician Jacques Antoine Rabaut-Pommier opens a hospital and offers vaccination against smallpox. It is said that he told an English doctor called Dr Pugh about the practice. The English physician promised to tell his friend, also a doctor, about vaccination. His friend’s name? Edward Jenner.

It is Jenner who publishes his work and pushes for vaccination as a preventative measure against smallpox. It is his vaccine which is used as the UK Parliament through a succession of Acts starting in 1840 makes variolation illegal and provides free vaccination against smallpox. In a precursor of the ignorance of the ‘anti-vaxxer’ movement there is some public hysteria but vaccination proves safe and effective (as it still is).

Cartoon by British satirist James Gillray from 1802 showing vaccination hysteria

Arguably, without Jenner’s work such an effective campaign would have been held back. As the American financier Bernard Baruch put it, “Millions saw the apple fall, but Newton was the one who asked why.” However, Newton himself felt that “if I have seen further it is because I have stood on the shoulders of giants.” History in the West has a habit of focusing on rich white men at the exclusion of others, especially women and slaves. Any appreciation of Jenner’s work must also include those giants whose shoulders he stood by acknowledging the contribution of people like Lady Wortley Montagu and Onesimus and of Fewster and Festy - the Wallaces to his Darwin.

Thanks for reading

- Jamie

How 'The Unknown Woman of the Seine' became 'Resusci Anne'

20141210_105259.jpg

She’s been called “the most kissed face in the world.” I think it’s fair to say that most of us will encounter Resusci Anne/Resus Anne/Rescue Anne/CPR Anne at some point of our lives. The mannequin itself dates from the 1960s when it was first produced by Laerdal Medical. However, as often with medical history, the story of Anne goes back further than that.

Paris in the 1880s showing the beginnings of the Eiffel Tower

Paris in the 1880s showing the beginnings of the Eiffel Tower

It’s Paris in the late 1880s; a busy, bustling city where, much like London, there was what we would now consider a morbid curiosity with death and it was not uncommon for people to vanish. The body of a young woman, presumed to be no more than 16 years old, is pulled out of the River Seine. As is customary her body is displayed in the mortuary window on a marble slab (a popular attraction at the time) in the hope a family will come forward. They don’t.

Her body shows no sign of disease or trauma. Suicide is suspected. But something else intrigues the pathologist. Her face upon which is a calm, knowing half smile quite unlike anything you’d expect from a person drowning. The pathologist was so taken by her he ordered a plaster cast to be made of her face.

189624-131-BAF1184D.jpg

Copies of the plaster cast became widespread as both a decoration and artistic inspiration. Parallels were drawn with Ophelia, the character in William Shakespeare’s ‘Hamlet’ who drowns after falling out of a willow tree. The French philosopher Albert Camus compared her enigmatic smile to the Mona Lisa.

In Richard Le Gallienne’s 1899 novella, ‘The Worshipper of the Image’, the protagonist Antony falls in love with the death mask. The Russian born poet Vladimir Nabokov wrote a whole 1934 poem titled “L’Inconnue de la Seine” in which he imagined her final days:

Urging on this life’s denouement,
loving nothing upon this earth,
I keep staring at the white mask
of your lifeless face.

In 1926 the death mask was included in a catalogue of death masks and was titled, ‘L'Inconnue de la Seine’ (The Unknown Woman of the Seine) and her legend was complete.

Fast forward to 1955 and the Norwegian toy manufacturer Asmund Laerdal saves his son Tore from near drowning in a river. Shortly after he is approached to design a mannequin to help teach cardio-pulmonary resuscitation. He decides that a female mannequin would be less scary for students and wants her to have as natural a face as possible.   Remembering a plaster cast of L’Inconnue he decides to replicate her face. L’Inconnue is reborn as ‘Resusci Anne’. The rest is history.

As Laerdal themselves put it: "Like Leonardo da Vinci's Mona Lisa, and John Everett Millais' Ophelia, the girl from the Seine represents an ideal of beauty and innocence." An anonymous victim of drowning now responsible for teaching cardio-pulmonary resuscitation around the world having briefly been the focus of gothic romantic obsession. It’s unlikely she could ever have imagined this legacy in her short life.

Thanks for reading

- Jamie

The Story behind Gray's Anatomy (the real one)

Choosing the Twitter name @mcdreeamie might have been mostly because I work at NUH DREEAM but I’d be lying if I didn’t know about the TV show ‘Grey’s Anatomy’ and watched the odd episode. However, this blog is about the real Gray’s Anatomy, the book. So please only read on if you’re interested in the book and not Meredith or Derek.

I was bought a copy of Gray’s Anatomy as a present from my uncle once my place in medical school was guaranteed and it has made a eye-catching addition to my book shelf ever since. For this blog I thought I’d look a bit into Gray and how the book came about.

Henry Gray

Henry Gray was born in 1827 in Belgravia, London. That’s pretty much all we know about his early life until he started at St. George’s University, also in London, in 1842. He’s thought to have lied about his age in order to enrol.

Back then in order to be a medical student one would also have to a practising member of the Church of England and show proof. To become a staff surgeon at St. George's Hospital, Gray would first have to pass the Apothecaries exam, then an exam to obtain membership in the Royal College of Surgeons, and later a difficult exam to become a Fellow of the Royal College.  He was described as good looking and a bit dandyish and hard working. He was interested in anatomy and dissection from the very beginning.

Gray benefited, along with his peers, from a recent change in the law: The Anatomy Act of 1832. This gave freer licence to medical students and teachers to practice human dissection. Whereas before restrictions had led to a dark business in grave robbing and corpse selling now everyone wanting to practice dissection had to be registered with the Home Secretary. London, the rest of England and Wales, Scotland and Ireland each had an inspector of anatomy who would keep a list of all bodies being dissected and report to the Home Secretary. Bodies could be dissected or claimed from prisons or workhouses if no one next of kin came for them. This meant Gray would have been able to practice anatomy in the open and within the law.

When he was 21 he won prizes in surgery. He became a member of the Pathological Society of London and a member of the Royal College of Surgeons. In 1852 , still in his twenties, he was made a governor of the hospital.

Self portrait of Henry Vandyke Carter

By 1853 he had met Henry Vandyke Carter, a medical student with a talent for drawing. Gray entered and won the Astley Cooper Prize (100 pounds - about £13000 now) for his work “The structure and use of the human spleen.” His 350 page book contained over 50 illustrations by Carter although no credit was given and payment was incomplete.

In 1855 Gray approached the shy Carter again this time regarding the possibility of a textbook for medical students. Carter was more careful this time and only began work when promised £10 (£1000 now) a month for 15 months to produce drawings. To put that into perspective I’ve found one freelance book illustrator online who changes £320 a day! By summer 1858 the first copies were ready for printing for the students arriving later that year.

Gray's markings on the first edition's title page, downplaying Carter's contributions and his titles

Called Anatomy: Descriptive and Surgical Gray sought to boost his name whilst diminishing that of Carter and his contribution. Carter, presumably very fed up of Gray by this point, went to India to practice and never received a penny of royalties.

Early reviews were a bit mixed. The British Medical Journal called it “far superior to all other treatise on anatomy, … a book which must take its place as THE manual of Anatomy Descriptive and Surgical.” The Medical Times and Gazette, however, found it “ not wanted…low and unscientific in tone…compiled, for the most part, in a manner inconsistent with the professions of honesty which we find in the preface… . A more unphilosophical amalgam of anatomic details and crude surgery we never met with.”

The second edition was released in 1861. That same year Gray’s nephew Charles became ill with smallpox. Gray treated Charles back to health. However, despite having received an early form of smallpox vaccination, Gray himself contracted the disease. He developed confluent smallpox, a more serious form where the lesions meet to form one whole sheet. On 13th June 1861, when he was due to be interviewed for a new post at St. George’s, he died aged just 34. As a smallpox patient all of his possessions, including his writings, were burnt. Carter stayed in India for 30 years before returning to England in 1888. He died of tuberculosis in 1897.

Gray’s Anatomy has never been out of print. In 2004 a Student edition was also released. Gray’s is published through Elsevier with online materials as well.

Henry Gray was clearly a precocious talent, albeit one with a thirst for fame. St. George’s continue to honour one of their most renowned alumni with their anatomy society. Whilst there have been rumblings of plagiarism he has clearly achieved the recognition he craved uniting nearly two centuries of students and practitioners who have used Gray’s.

Thanks for reading

- Jamie

The Wound Man: From Textbook to Emblem and Hollywood

Wound-man,_16th_Century_Wellcome_L0010200.jpg

If you think you’re having a bad day just remember The Wound Man. Stabbed, bludgeoned and shot yet still standing tall it’s safe to say that his image has been on a journey over more than half a millennium to becoming truly iconic. This journey has taken him from the pages of a medieval textbook to Hollywood via James Bond and the Royal College of Emergency Medicine.

Gunpowder made its way to Europe during the 14th century, probably along the Silk Road trade route with Asia. This meant that as well as the traditional war wounds from blades and arrows doctors were also seeing the effects of cannon and shrapnel. Doctors needed some form of reference to help with the myriad new forms of trauma they might encounter.

084_0.jpg

Along came Johannes de Ketham/von Kirchheim, a German physician living and working in 15th century Italy. In 1491 he published Fasciculus Medicinae (the little bundle of Medicine) in Venice; basically the Oxford Handbook of Medicine of its time complying medical knowledge as it was. Written in Latin, the original edition consisted of six illustrations with accompanying text. The world’s first ‘Wound Man’ was one of these illustrations. The illustrations and sections were as follows (diagrams are from the 1495 edition):

Urine and blood letting

  • Urine section: the ‘little bundle’ starts immediately with a section on how a physician could use the colour and smell of a patient’s urine to diagnose their condition

  • Bloodletting/phlebotomy section: a full male figure showing arteries and veins and where the patient could be bled

  • Zodiac figure’: another full male figure annotated with when blood can be taken from certain areas of the body depending on the time of year

‘Zodiac Man’

Obstetrics and Gynaecology

  • Gynaecology and obstetrics: including a pregnant anatomical female figure, and texts related to sexuality, generation, and disorders particular to women

  • ‘Wound Man’: this section illustrated various specific injuries and how to treat them

The original ‘Wound Man’

‘Disease Man’

  • ‘Disease Man’: labelled with various diseases and illnesses

The Fasciculus Medicinae was published again in 1495, 1500, 1509, 1513 and 1522 by which time its information was outdated and it was replaced as a prominent textbook. However, the concept of the ‘Wound Man’ continued with new injuries matching the advancements of military technology.

Possibly the most famous example of a ‘Wound Man’ was included in Feldbuch der Wundarznei (Fieldbook of Surgery), written by the Austrian field surgeon Hans von Gersdorff in 1531.

‘Wound Men’ continued to be used in textbooks until the 17th century, their forms changing with the artistic fashions of the day.

‘Wound Man’ from Feldbuch der Wundarznei (Fieldbook of Surgery), written by Hans von Gersdorff in 1531

The iconography of the ‘Wound Man’ led to its inclusion in the official blazon for the Royal College of Emergency Medicine, adopted on January 24, 1997. Used on the dexter side, it was chosen to show the injured patient in contrast to the healthy man on the sinister side. He represents how emergency medics are trained to treat patients with all kinds of injuries and injury mechanisms as well as the sheer variety seen in trauma patients.

400px-Royal_College_of_Emergency_Medicine.jpg

‘Wound Men’ have been potent icons in fiction as well. ‘The Wound Man’ was a potential title for Ian Fleming’s James Bond novel ‘Dr No’, published in 1958, rejected partly because of the possibility people would mispronounce it as ‘wound up’ rather than a wounded man. In the 1981 novel Red Dragon by Thomas Harris the serial killer Hannibal Lector murders a patient and displays them with multiple injuries similar to a ‘Wound Man’ illustration in one of his books. This was also included in NBC’s television series Hannibal.

460051_600.jpg

It’s safe to say that Medicine is full of symbols. ‘Wound Men’ are one of the most enduring as symbols of education, traumatic injury and an example of Medicine’s roots over the centuries.

Thanks for reading

- Jamie

How Saline Earned its Salt

shutterstock_146678423.jpg

The other day in Resus as I was putting up a bag of fluids for a patient I wondered how long it was we’d been using what seems an incredibly simple but important intervention for our patients. “Putting up a bag of fluids” is a core part of the resuscitation of an unwell patient to the extent it just rolls off the tongue.

Turns out the history of IV saline goes back to Victorian Britain and the cholera pandemics. The Industrial Revolution brought unprecedented numbers of people to the cities, especially London where the population trebled between 1815 and 1860. In many places sewage disposal was not much changed from Tudor days and so struggled to cope. By and large the response was simply to tip the waste into cesspits or into the nearest river hence ‘The Great Stink’ of 1858 which brought the city of London and even Parliament to a standstill.

These conditions were perfect for cholera, a disease brought to Britain from the Indian subcontinent in 1832. A secretory diarrhoea spread via the faeco-oral route it ‘enjoyed’ 5 pandemics between 1817 and 1896. Cholera presents with ‘rice water’ diarrhoea (up to a litre an hour) with a mortality rate up to 70% in untreated patients largely due to extreme dehydration.

Cholera challenged medics at the time and inspired some great work such as that of John Snow on Broad Street in 1854 who rejected the miasmic theory of spread and instead proposed there was a causative agent and that contaminated water was the source. In the same year the causative agent was identified by Filippo Pacini in Italy and was first grown in culture in 1884 by Robert Koch working in Egypt and India. Fluid replacement with intravenous fluid was another such innovation.

By 1832 the work of Dr W B O’Shaughnessy had concluded that the blood of cholera patients had lost most of its water as well as its saline contents and the Lancet recommended “the injection into the veins of tepid water, holding a solution of the normal salts of the blood.” That same year Thomas Latta, a physician working in Leith, Scotland attempted to treat a patient with cholera doing just this.

He first tried treating patients with fluids inserted rectally but found that not only did it not work it actually seemed to make their vomiting and diarrhoea worse. So then he tried intravenous injection. He wrote describing how over half an hour he injected 6 pints (3.4 litres) of fluid in the basilic vein of an elderly lady with cholera: “soon the sharpened features, and sunken eye, and fallen jaw, pale and cold, bearing the manifest imprint of death’s signet, began to glow with returning animation; the pulse returned to the wrist…” Sadly he left the patient in the hands of the house surgeon who did not repeat the treatment as the patient deteriorated again and so she died 5 hours later.

That same year Dr Robert Christison wrote to the Dutch government advising them on this new treatment. He described 37 cases treated with intravenous fluids of whom 12 survived. He mentioned certain risks including air embolus, phlebitis and the potential risks of introducing so much fluid to a patient but generally recommended the treatment. Looking back there were probably other risks too such as secondary infections from unsterile injections they wouldn’t have been aware of.

In these early days there was no standardisation of what the fluid should contain with some physicians using egg whites with their fluid and some adding albumin. It wasn’t until Dr Sydney Ringer’s work in the 1880s that an optimum physiological solution was found. The dangers of potential fluid overload were identified quite early on as well with S.K. Mujumbar of Port Blair, India writing in 1916 of the need to identify cholera patients who actually need fluids so as not to cause “an extra amount of work on the already weakened and embarrassed heart”.

0.9% Saline has since become a staple of modern medicine and is included on the World Health Organisation’s list of essential medicines last published in 2017.

Further pandemics of cholera occurred in 1899-1923 and 1961-1975 by which time advances in public health medicine meant Western Europe was unaffected. The last outbreak in the USA took place in 1910-1911. Cholera remains endemic in many countries in Africa and has continued to re-surface whenever sanitation is affected such as in Haiti following Hurricane Matthew. Diarrhoeal disease is the second highest cause of mortality and leading cause of malnutrition in the under-fives worldwide. The WHO describes diarrhoea as “preventable and treatable”. Re-hydration whether orally or intravenously remains the mainstay of treatment.

So whenever we are putting up a bag of fluid for a patient we are continuing a tradition first started by Thomas Latta injecting 6 pints of fluid into the basilic vein of his patient in Leith.

Thanks for reading

- Jamie