Carousing will catch up with you

The Huns were a nomadic people who are though to have originated in Central Asia.  By 370 AD they had migrated into Europe.  They formed a unified empire for the first time under the rule of a single King in 447.  That King's name is still synonomous with brutality today - Attila the Hun.

Attila ruled from 433 until his death in 453.  Orginally his brother Bleda ruled half the tribe and Atilla the other, until Bleda's death in 447 when Atilla became the sole King.

 

(Public domain image sourced from Wikipedia)

Attila was known as Flagellum Dei by the Romans (Scourge of God).  He spent much of his reign waging war across Europe, burning and pillaging in his wake.  His actions are partially behind the fall of the Roman Empire.  At its height Attila's empire stretched from the Ural river to the Rhine.

However it's Attila's death which is of interest today.

A bridge too far

Your correspondent recently went on a journey to the land of the long white cloud.  During that sojourn she observed the following historic bridge and heard a story about a nurse named Edith Cavell.

What does a nurse have to do with a bridge? Read on..

Staying Abreast

This year marks the fiftieth anniversary of the world's first silicon breast augmentation.

For almost a hundred years doctors, and patients, had been experimenting with various ways to change the size and shape of breasts.  The first recorded case of a breast implant in the literature was undertaken by a German surgeon named Vincenz Czerny, who transplanted a benign fat tumour (known as a lipoma) to reduce asymmetry after removing a tumour from a woman's breast.  Since that time various methods of using the patient's own tissue have been tried, mainly at the time of surgery to effect a reconstruction. 

Jay's Jutting Jaw

Jay Leno’s distinctively large chin has been something of a trademark for the comedian. The title of his 1996 autobiography is ‘Leading with my Chin’.   However you may be surprised to learn that the Tonight show host’s distinctively large mandible is most likely the result of an inherited genetic condition.

Obstetrics and WWI

As we come to the end of Remembrance Day for another year, I found myself reflecting on a medical history story that directly relates to the onset of WWI.  

The brachial plexus is a group of nerves which supplies the arm and hand.  They run from the spinal cord and through the neck into the arm.  As a result they are unfortunately susceptible to trauma during the birth process.  Particularly this can occur during an obstetric emergency where a baby's head becomes trapped during birth, either from the shoulders being wedged under the mother's pubic bone or an obstructed breech (feet first) birth. The subsequent mechanical manipulation required to free the baby is the usual cause. However when certain death is the alternative - sometimes a brachial plexus palsy is the lesser of two traumas.

Unfortunately, Kaiser Wilhelm did not see it this way.

Get your Goat

This history of medicine would be quite drab without the enormous rollcall of quacks and charlatans.  Sometimes the stories are so bizarre it's hard to believe they are true.  Today's self styled "doctor" is no exception.

Dr. John Romulus Brinkley (later to become John Richard Brinkley) lived from 1885-1942.  The son of a man who practiced as a medic in North Carolina during the Civil war, his father was married four times legally and had one other marriage that was anulled because John Brinkley Snr was underaged at the time.  John Jnr himself was born out of wedlock, to the niece of his father's current wife.

Alice Bunker Stockham and Tokology

One of the nurses at work, knowing my love for all things medical and historical decided to loan me a book.

Tokology: A book for every woman was authored by Alice Bunker Stockham  (1833-1912)  in 1886 (although I believe this copy is almost certainly a later edition.  It is essentially a guide for the layman about pregnancy and women's health.  Stockham is an utterly intriguing character.  An obstetrician and gynaecologist from Chicago, she was only the fifth woman to be made a doctor in the United States.

Study

I must apologise for her long sabbatical.  I have been off studying for, sitting and ultimately passing my examinations. (I then had a very long rest!).

To celebrate my return to the realm of blogging I bring you the following image:

 

(The above image was sourced from the national library of medicine.  It was taken by WHO photographer D. Henrioud).

The above image is undated but believed to be several centuries old and found on the wall of a museum in Shanghai.  It depicts students in the field of acupuncture being trained on a model.  Correct insertion of the needle would find the student hitting wax.  Incorrect and a stream of water would be emitted. 

I am not a student of acupuncture but I appreciate the stress of a clinical examination, no matter the century!

Before the Birth of One of Her Children

I recently found a link to a poem written by the first poet and first female writer to be printed in the British North American Colonies.  Anne Bradstreet was born in England in 1612.  She immigrated to America in 1630 with her husband Simon as part of a fleet of Puritan immigrants.

Bradstreet suffered from smallpox as a child, an illness that went on to cause her paralysis in later life.  She was also stricken with tuberculosis in later life.  Despite this she gave birth to eight children and lived to the age of sixty.

Bradstreet's works reflected on the hardships of her life in the Colonies, and were about her husband and her children.  They give insight into the Puritan faith, in particular its strict moral code.

One of the most interesting of her poems is entitled, ' Before the Birth of One of her Children'.

The simple verse betrays not only Bradstreet's deep love for her children, but also the inherent fear and respect with which she held childbirth.  It gives great insight into the mental prepartion mothers of her time underwent before giving birth. 

George V: Mercy or Convenience?

George V grandfather of the current British monarch, Elizabeth II was born in 1865 and died on the 20th January 1936.  He reigned from the 6th May 1910 until his death.  He is notable for being the reigning monarch during the first world war. 

(George V)

Mrs. Papanicolaou

Most women in the developed world will be familiar with the concept of a pap smear.  A pap smear involves an examination every few years of a women's cervix where cells are wiped and smeared onto a slide.  These are then examined for early signs of cancer.  Developed in 1923 it is the most successful screening test for cancer in history, dropping death rates by 80% in those countries with population wide screening programs.

The test was invented by a Greek physiologist named Georgios Papanicolaou. He was born on the island of Evia on the 13th May 1883.  He attended the University of Munich and achieved his PhD in zoology in 1910.   He then eloped with the woman he would spend the next 47 years of his life with, Andromache Mavroyeni, who went by Mary.  The two returned to Greece in 1912, where Georgios served in the Balkan Wars.  Following this, he and Mary immigrated to New York City in 1912.

Although initially playing violin in restaurants to pay the bills, Georgios quickly found work at Cornell Medical College slowly rising up the ranks.  It was here that he made the observation that eventually led to the pap smear.

Test Tube Baby

In three days time the world's very first baby conceived via IVF turns 34.

Born on the 25th July 1978, Louise Joy Brown was born at the Oldham General Hospital in the United Kingdom.  Her parents, Lesley and John Brown had been unsuccessfully trying to conceive for nine years, prevented due to the fact that Lesley had blocked fallopian tubes.

Louise Brown, moments after birth. 

As early as the 1930s the possibility had been raised by researchers that fertilisation of embryos could occur outside the human body (in vitro).  In the late 1940s experiments were being conducted in the US in women where eggs were collected and exposed to sperm.  In 1959 the first mammalian in vitro pregnancys were achieved using rabbits.

However, demand for assisted pregnancy did not really take off until the 1960s.  Falling adoption rates occurred due to better social support for single mothers and safer and wider access to abortion services.  In 1961 ovum were first collected using laproscopic methods.  In 1973 the first pregnancy in occurred, facilitated by the team of Carl Wood and John Leeton in Melbourne Australia.  Unfortunately, this resulted in a miscarriage.  Then in 1976, a team of researchers headed by Patrick Steptoe and Robert Edwards reported on an embryo transfer which resulted in ectopic pregnancy. 

In 1977 Steptoe and Edwards performed another embryo transfer, this time on Lesley Brown.  Unlike previously, they transferred the embryo after two and a half days.  This time the pregnancy took.  Lesley Brown was monitored very closely throughout, with regular ultrasounds and amniocentesis.  About a week prior to her due date, Mrs. Brown developed preeclampsia and the decison was made to deliver her baby early.  Louise Joy was born on the 25th July 1978 at 1147pm weighing 2.3 kilograms via emergency caeserean section.  Although referred to by the UK media as a "test tube baby" she was actually conceived in a petri dish.

Her sister, Natalie, was born four years later and became the world's fortieth IVF baby.

Since then the technology of IVF has improved in leaps and bounds.  The discovery of how to control cycles and stimulate ovulation allowed IVF to become widely useful in a clinical setting.  Other techniques such as intra-cytoplasic sperm injection (ICSI) means that IVF is now applicable to male infertility as well. For their work, Prof Edwards won the Nobel Prize in biology in 2010.  (Dr. Steptoe passed away in 1988 and would have shared the award, unfortunately the Nobel is not awarded post humously). 

There are now well over five million children world wide that owe their existence to IVF and related technologies.  All due to the bravery of Lesley and John Brown.

Louise Brown, delightfully, is now the mother of a son, Cameron, conceived naturally and born in 2006.  Her father John passed away in 2006.  Lesley Brown, unfortunately, passed away just a month ago from complications of a gallbladder infection.

Speaking on behalf of Prof Edwards a spokesperson said it best:


"Lesley was a devoted mum and grandmother and through her bravery and determination many millions of women have been given the chance to become mothers.  She was a lovely, gentle lady and we will all remember her with deep affection."

Prof Edwards, Lesley Brown, Louise Brown and her son Cameron. 

Wascally Wabbits

In September 1726 a young woman named Mary Toft, about 25 at the time, went into labour with her third child.  The pregnancy had been complicated.  Forced to undertake heavy work in the fields throughout she stated that she had suffered a great deal of pain and a month prior had passed several pieces of flesh and clots.

On the night Mary laboured in September her neigbour watched incredulously as Mary produced several pieces of animal flesh.  The neighbour showed these to Mary's mother in law, a midwife, who contacted John Howard a local surgeon and "man-midwife".

Sceptical, Howard attended Mary the following day.  Initially he found nothing. However Mary once again went into labour a few days later.  Howard returned and subsequently delivered three legs of a tabby cat, a rabbit leg and the intestines of a cat. 

The D-Downfall of Anne Boelyn

Anne Boelyn.

Love her or hate her, it's hard to decide.

Henry the Eighth couldn't really figure it out either.

Anne Boelyn was born somewhere between 1501 and 1507 at Hever Castle in Kent.  She was sent to France to wait apon Queen Claude of France and complete her studies, returning to England when she was about twenty.  This education in France proved pivotal and may have shaped some of Anne's more reformative beliefs in her later life.

Anne's family, and in particular her Uncle, Thomas Howard, the Duke of Norfolk, were ambitious for position at court.  They must have been delighted when Anne quickly caught the eye of King Henry VIII in 1526 and that within a year he had proposed marriaged to her.

The slight problem being, of course, that he was already married to Catherine of Aragon.

Catherine of Aragon, Henry's first wife, had birthed six children.  A stillborn son, a stillborn daughter, two sons who lived less than a month, both named Henry, Duke of Cornwell, an unnamed daughter who lived less than a week, and Mary, who would go on to become Queen of England.

She had not borne a living son, and Henry was determined to set her aside. 

Observations in Midwifery

A truly unique tome is currently up for auction in the United Kingdom. 

Observations in Midwifery, by Percival Willughby is a record of 150 case histories attended by Willughby over his years of practice.  Written in about 1670 it was not published until many years after his death in 1863.  Only 100 copies were produced, 17 sold, and only 2 remain in existance today.

The Clap

Gonorrhoea and syphilis.  Two microscopic organisms that over the years have removed more men from the battlefield of various conflicts than fists, bayonets, bullets, sabres, mustard gas, grenades, mortars, tanks or any creative combination thereof, combined.  

An address by Surgeon General Gorgas before the General Sessions of the American Public Health Association in August 1917 expresses the wish that if he were provided a magic wand and were given the choice to eradicate wounds or venereal disease, he would choose venereal disease.  "A man with a flesh wound through the thigh is back in the trenches within ten days or two weeks, frequently in less time. If he contracts a venereal disease, his average disability is very much longer. In other words, to the commanding general, the loss is greater for a man who contracts gonorrhea than for a man who is shot through the thigh, and if the commanding general could lay aside all question of morality,he would probably choose the eradication of venereal disease rather than the prevention of wounds."

Caesar

Your intrepid reporter is currently at an intensive pre-examination revision course, learning all about saving the lives of mother's and babies.  Which is by way of an excuse as to why there will be no detailed post this month.

Instead from the collection of the US National Library of Medicine we have the following image.  A woodcut entitled La commare o riccoglitrice dell'eccmo. sr. Scipion Mercurii, and dating back to 1601 it depicts a woman being restrained by two other man as another surgically extracts a foetus from her abdomen.

One of the earliest known images of caeserean section.

Caeserean section as we know it today was not how the procedure was performed prior to mid this century. Generally it was only performed post-mortem, as in after the mother was already dead, which meant the success rate of also delivering a live baby was quite slim.

Thankfully on my revision course I am learning that we have come a long way....
 
Contrary to popular belief, by the way, it seems likely that Julius Caesar was not born this way, as his mother survived his birth - but we'll save his story for another day.   

Hitler and His Habit

The history of humans and drug use is a fascinating one.  Human beings have been using mood-altering substances since the dawn of time.  Traces of alcohol have been found in pots excavated from ancient dig sites in Greece and Rome.  For centuries the biggest trade commodities world wide have been alcohol, nicotine, coffee and opiates, mood altering substances all.  

It seems that something about being human makes us want to alter our state of mind and the Fuhrer was not immune.  

Amphetamine was synthesised for the first time in 1887 by a chemist working at the University of Berlin named Lazăr Edeleanu (given the subject of this story, it is perhaps relevant that he was a Romanian Jew).  Methamphetamine, a related compound, came along in 1893 thanks to a Japanese chemist named Nagai Nagayoshi.  It was first marketed in 1900 under the trade name Benzdrine as a bronchodilator and an appetite suppressant.  Most people are more aware of amphetamine today by its street names such as ice, speed and ecstasy.  They are also probably much more aware of its other properties.  Amphetamine, and its related compounds are very, very good stimulants. 

Unfortunately they also have a number of deleterious side effects.   These include paranoia, agitation, hallucinations, florid psychosis and rapid increasing dependence. 

Over the years several nations have experiemented with amphetamines to help their soldiers stay awake.  Perhaps the most notorious culprit in this department was the German army.  During World War II thousands of German soldiers became addicted to methamphetamine, marketed as Pervitin. 

There’s no concrete evidence that Hitler was also using Pervitin.  However the hearsay is fairly compelling.  Given the widespread use of the drug by the German army, it is certain that its properties were very well known to him.  

What is known is that every morning from 1941 Theodor Morell, Hitler’s personal physician, attended him and gave him an intravenous injection.  Throughout 1943 these injections began to be administered at several times throughout the day.  Reportedly these injections contained 'vitamins', however following their administration Hitler was said to become very active, alert, happy, talkative and able to stay awake for great periods of time.  

 

(Dr. Theodor Morell)

Hitler is widely described as having been insane especially as his behaviour and military judgement became increasingly erratic.  A lack of judgement led to the complete disaster of the Battle of Stalingrad in 1943 and from there the tide of war turned significantly against the Nazis. 

He became increasingly paranoid and aggressive.  He developed a shake in his left hand, attributed by some to Parkinson’s, but also possibly a side effect of the drugs.  Previously very clear on the importance of personal responsibility, Hitler began to blame his subordinates, often violently, for lapses in judgement that were clearly his fault.  

While these symptoms can also be due to schizophrenia, Hitler was 53 in 1942, which is unusually old for a psychotic mental disorder to make its first appearance.  

No, it seems likely that Hitler was a speed addict.  

Methamphetamine is a dangerous drug of addiction which is causing us enormous problems in many societies.  Nonetheless, perhaps we owe a debt of gratitude to Lazăr Edeleanu.  After all, the effects of methamphetamine probably helped the Allies win the war. 

       

Ship of Fools

One hundred years ago today at two twenty am in the freezing waters of the North Atlantic Ocean the RMS Titanic sank.  In one of the greatest peacetime maritime disasters in history 1,514 people lost their lives.

For the duration of the short voyage the passengers and crew of the Titanic were served by a small medical staff made up of two surgeons, two nurses and a hospital steward.  

I'm reaching and I know it...

In 1981 a syndrome was first described that baffled doctors and quickly killed its victims.  That syndrome came to be known as AIDS.  

Today AIDS or more correctly the precursor virus HIV, is more of a chronic illness in the western world.  We have good treatment and most sufferers can expect to live well into old age. 

However in the mid eighties and early nineties, this was not the case.  

Dr. Turkey is old enough to remember the large public health campaign that occurred in Australia in the late 1980s, which is the origin of today's picture interlude. 

 

(Copyright the QAHC)   (This is the Royal Easter Show Edition?  See, there is a link!)

Condoman was created in 1988 by a group of indigenous health workers in Queensland who felt that the Grim Reaper ads being run for the general population were culturally inappropriate.  The 'Don't be shame be game' slogan for condom use was incredibly successful amongst Aboriginal and Torres Strait Islanders and the program eventually spread out to the Pacific Islands. (The general population from memory also responded well).

Australia's overall response to the HIV/AIDS epidemic was one of the best in the world, resulting in a halt and reversal of infection rates.  It set the standard for how to respond to the threat of a blood borne/sexually transmitted virus.  Australian public health workers are particularly proud of this and the fact that they also managed to do it in a culturally appropriate way. 

Unfortunately perhaps due to the fact that things are better these days for sufferers infection rates are once again on the rise, particularly amongst our indigenous populations.  Condoman had to make a return in 2009.  

Hopefully we won't require the Grim Reaper. 

Three Hundred Per Cent

As a doctor currently training in the fabulous speciality of obstetrics, (with a background in the even more fabulous specialty of General Practice) your correspondent stands on the hallowed ground halfway between medicine and surgery.

In that while she performs a great deal of surgery in her day to day life, she still has the ability to mock surgeons (gently of course, as they are her rather friendly and useful colleagues).

Thus how the following adventurous tale of Dr. Robert Liston first came to her ears.

Dr. Liston was a Scotsman, born in 1794 and from his description sounds like quite a character.  In a pre-anaesthetic era speed of surgery was a patient's only hope to avoid pain and infection.  Liston was famous for removing a 20 kilogram scrotal tumour in 4 minutes.

Rather than try to describe the man myself, I will let his contempory, Dr. Richard Gordon, do so for me:

"He was six foot two, and operated in a bottle-green coat with wellington boots. He sprung across the blood-stained boards upon his swooning, sweating, strapped-down patient like a duelist, calling, 'Time me gentlemen, time me!' to students craning with pocket watches from the iron-railinged galleries. Everyone swore that the first flash of his knife was followed so swiftly by the rasp of saw on bone that sight and sound seemed simultaneous. To free both hands, he would clasp the bloody knife between his teeth."

Liston was an imposing and acerbic fellow.  He left Edinburgh, where he had trained and practiced throughout his early career, in 1834 principally because he was so unpopular in the medical community there.  Not least of that was due to knocking down the infamous anatomist Dr. Knox in front of his students.  He assumed that some of the students had slept with the young woman being dissected while she was alive and that their behaviour was voyeuristic.  (As it turned out there was even worse foul play at foot!)

However, his somewhat abrasive personality was not always in the best interest of patients.  In one of the most famous cases associated with his name, Dr Liston was involved in an argument with a junior doctor about whether a mass on a boy's neck was a carotid artery aneurysm (a large swelling of a blood vessel) or an abscess (an infection).  Dr. Liston proceeded to settle the argument by removing his scalpel and lancing the mass there and then. The young boy bled to death in a matter of minutes. 

The remainder of Liston's career was spent in London, where he pioneered some amazing accomplishments, including the first British operation under anaesthesia in 1846.  A leg amputation, performed in 28 seconds, which of course makes one wonder if anaesthesia was required at all.

(in this photo Joseph Lister is actually the gentleman on the top left - I may be geeking out slightly.)

He also invented the Bulldog artery forceps.  I used a variation of them the other day. 

But this is, of course, not why I am telling this story.  

Legend has it that one day Dr. Liston was performing an amputation.  He proceeded to do so in his usual 2 and a half minutes but in his enthusiasm also amputated the fingers of his young surgical assistant, and cut through the coattails of a distinguished spectator who had leaned in too close.  

The spectator perished from fright instantly, the patient a few days later from overwhelming infection, and the assistant a few days after that, also from infection.

It remains the only operation in history with a three hundred percent mortality rate.  

As I tell my surgical colleagues - they've got a lot to live up to ;). 

Louis' Penis Problem

Poor old Louis the 16th. Reportedly a shy, overweight and somewhat uncouth teenager, his father’s mistress referred to him as a “fat, ill-bred boy.” An Austrian courtier in fact stated, “nature seems to have refused everything to the dauphin.” (1)

They weren’t wrong. The poor boy’s life ended on the executioners block at the age of thirty-eight.


Louis XVI

However, he was the heir to the throne of France, so fat or not, the short life he did live was carried out in the lap of luxury. At the age of 14 he was married to the young Marie Antoinette, Archduchess of Austria, aged 13 at the time. She was a young, poised girl, who grew into a woman of fair beauty.


Marie Antoinette

At 13 and 14, one might have expected that it would have taken a while for the marriage to be consummated.

I’m fairly certain that nobody expected it to take seven years.

The Queen of Austria had a strong sense of duty, one which she had vigorously instilled in her children. The young dauphine knew that her position in the French court and the stability of the alliance between France and Austria depended on her producing an heir. The Queen wrote often to her daughter and urged her time and time again to ‘inspire passion’ in her new husband(2). However, despite due diligence in this regard, night after night Marie Antoinette lay down next to her husband and... nothing happened.

Eventually the royal doctors were consulted. They made conciliatory noises and suggested that the Prince was not yet mature. They advised time and patience.

Obviously they failed to actually lay hands on the royal personage. Had they examined the young Prince, they would almost certainly have discovered his phimosis.

Phimosis is a condition in which the foreskin of the penis is adherent. It tends to cause pain during intercourse, as the foreskin can only partially retract and constricts the glans.

Management involves either circumcision, or a small incision in the skin of the foreskin, and blunt dissection. These are both fairly simple operations, however it is generally true that most men become squeamish with just the concept of knife near a penis. Imagine this in the pre-anaesthetic era, and perhaps you understand some of Louis’s problem.

Louis outright refused surgery initially. However, he and Marie Antoinette apparently discussed the problem and he eventually agreed that he would undergo the procedure by his sixteenth birthday (after much persuasion I would imagine!).

However Louis’s sixteenth birthday came and went without surgery.

In 1774, another attempt was made. The surgeon got as far as exposing the site of surgery and spreading out his instruments, before the patient fainted clean away. It seems that this would have been the perfect opportunity, but obviously the surgeon was to timid to incur the Dauphin’s displeasure, and the royal jewels remained untouched.

Eventually in 1775, Louis the 15th passed away, and his son became king. However, his marital woes with Marie Antoinette continued. The situation became even more precarious when two months after the coronation Louis’s sister-in-law, Marie Therese, gave birth to a son (quite originally named Louis Antoine). This child would be the heir to the French throne for a further seven years.

The situation left the couple exposed to a great deal of ridicule by the French public. The rumours of infidelity that dogged Marie Antoinette for the rest of her life have their origins in this time.

Finally in 1777, Emperor Joseph, Holy Roman Emperor and Marie Antoinette’s older brother, arrived for a six week visit designed in part to sort the couple out. He spoke to both his sister and brother in law.

We know of the advice he gave a couple from a letter that Joseph wrote to his own younger brother. Louis it seemed, was able 'to have strong, well conditioned erections',(3), however was unable to carry out the sexual act. Joseph stated that ‘this is incomprehensible, because with all that, he sometimes has nightly emissions, but says plainly that what he does, he does from a sense of duty but never from pleasure.' The Emperor stated quite frankly that if he had a chance to solve the problem sooner Louis, “would have been whipped so that he ejaculated out of sheer rage like a donkey”.(2).



Emperor Joseph

I’m not sure if any donkey’s or whips were involved in the final solution, but whatever Joseph said to Louis, it worked. Louis finally submitted to surgery, and on April 30 1777, the marriage was finally consummated.

The couple went on to have four children together. However, two died in infancy, one died in prison after the revolution, and only one daughter survived to adulthood and exile.

Louis and Marie Antoinette on the other hand, barely had a chance to enjoy their adulthood. Nonetheless, we can say with certainty that despite their early problems, neither of them died a virgin.


Louis faces his executioners

(1) (1) http://www.readinggroupgold.com/product/product.aspx?isbn=0312361505&show=more

(2) (2) http://en.wikipedia.org/wiki/User:Papirini/Marie_Antoinette

(3)(3) http://www.abc.net.au/rn/science/ockham/stories/s13875.htm