How World War 1 changed global attitudes to war and infectious diseases.

World War 1 was a key transition point towards scientific medicine. Medical officers incorporated Louis Pasteur's discoveries into their understanding of microorganisms as the cause of infectious diseases, which were therefore susceptible to rational control and treatment measures even in the pre-antibiotic era. Typhoid vaccination led to the successful evasion of the disastrous epidemics of previous wars. The incidence of tetanus was probably decreased by giving millions of doses of horse antitoxin to wounded soldiers. Quinine treated but could not control malaria; its use required mass compulsion. Tuberculosis was not a great military problem during World War 1, although mortality in civilian populations increased substantially. Treatment of sexually transmitted infections remained a matter of aversive conditioning, with invasive antiseptics used in the absence of antibiotics. Pandemic influenza in 1918-19 killed more people than died during the entire war, showing how much remained beyond the capability of the scientists and doctors who fought infectious diseases during World War 1.

Types and Treatments of Surgical Diseases in Ancient China Found in Bamboo and Silk Texts: Focusing on External Injuries, Burns and Scalds, Intestines, Anus Diseases.

This article aims to analyze the types of surgical diseases and treatments in ancient China as documented in bamboo and silk texts, with a particular focus on (external) injury, tetanus, burns, rectal and anal diseases, and inguinal hernias. For this analysis, I gathered 85 instances of disease and treatments recorded in these texts. The 85 cases were further categorized into 13 (external) injuries, 13 metal wounds, 6 tetanus, 22 burns, 16 rectal and anal diseases, and 15 inguinal hernias. The analysis revealed that the treatment of (external) injury and burns focused primarily on the wound site, while the treatment of metal wounds and tetanus centered on addressing the internal body. Internal treatments were mainly prescribed through the use of medicine and food. Surgical intervention was recommended primarily for diseases of the rectum and anus, with medications applied to the woundspost-surgery. For inguinal hernias, a high-protein diet was typically prescribed. As we've seen, in ancient China, surgical diseases were mainly treated with medication, surgery, and dietary prescriptions. And among these prescriptions, drug prescriptions were utilized not only by medical doctors but also by witch-doctors treating diseases in civilian society and soldiers stationed at frontline military posts. In the absence of medical doctors in both civilian society and frontline units, witch-doctors and frontline units purchased or stockpiled prescription drugs and used them to treat patients according to prescription.

Prevention of tetanus during the First World War.

The emergence of tetanus in wounded soldiers during the first months of the First World War (WWI) resulted from combat on richly manured fields in Belgium and Northern France, the use of modern explosives that produced deep tissue wounds and the intimate contact between the soldier and the soil upon which he fought. In response, routine prophylactic injections with anti-tetanus serum were given to wounded soldiers removed from the firing line. Subsequently, a steep fall in the incidence of tetanus was observed on both sides of the conflict. Because of fatal serum anaphylaxis associated with administration of serum at a time when purification methods still needed to be improved, it must be presumed that tens to hundreds of men might have died as a result of the routine administration of anti-tetanus serum during WWI. Yet anti-tetanus serum undoubtedly prevented life threatening tetanus among several hundred thousands of wounded men, making it one of the most successful preventive interventions in wartime medicine. After the abrupt fall in tetanus incidence in 1914 due to introduction of anti-tetanus serum, the incidence of the disease tended to become even lower as the war went on. This was probably due to earlier and more thorough surgical treatment, consisting of opening, cleaning, excision and drainage of wounds as early as possible. In this overview, recent battlefield findings from the Meuse-Argonne offensive in 1918 are used to illustrate common practices employed in the prevention of tetanus during WWI.

[The medical literature of the Egyptian campaign]. / La littérature médicale de la campagne d'Egypte.

Bonaparte's Egyptian Campaign (1798 - 1801), like all other episodes from the Napoleonic era, gave rise to an extensive literature on the subject, but most of all a significant medical literature. This fact is due to many reasons:--an important health service for this expeditionary corps of more than 36.000 men, with two main figures at its hea, Desgenettes and Larrey--but also with valuable subordinates like Assalini, Savaresi, Balme, Pugnet or Barbès.--A Commission for Science and Art, of which a few doctors and surgeons were members, but most of all pharmacists like Boudet or Rouyer--The presence in the field of Ludwig Frank, the nephew of the famous Johann Peter Frank.--The creation in Cairo of an Egyptian Institute and the publication of the masterly Description of Egypt and the establishment of printing houses.--The emergence of the myth of the Orient and its mysteries.--An extensive array of indigenous pathologies, which is characteristic of those countries. For instance: plague, dysentery, yellow fever, Egyptian ophthalmia, as well as more common diseases like tetanus, scurvy or venereal diseases. The main medical works that cover this period and its pathologies are skimmed.

"No doubt this childhood disease on Vestmannö can be prevented"--neonatal tetanus on the Westman Islands.

At the beginning of the 1800 s neonatal tetanus was a major health hazard on the Westman Islands, an archipelago immediately south of Iceland. Up to 60­70% of newborn babies died in the course of the first two weeks of life, and Danish health authorities were almost helpless in the face of this mysterious disease. In 1847 the young Danish doctor Peter Anton Schleisner (1818-1900) was sent to the islands to investigate the conditions there. He established a maternity hospital, gave advice on hygiene and encouraged breast-feeding and a number of changes in diet. Since there was no known treatment, Schleisner's only option was to resort to preventive measures. He dressed the umbilical stump with balsamum copaivae and tried well-established methods such as opium tincture with saffron and mercurial ointment if there was any sign of infection. By the time he returned to Denmark after nine months, mortality had been halved. Neonatal mortality on the Westman Islands remained at the same low level throughout the rest of the 19th century. According to popular belief this was due to the naflaolian (navel oil) which Schleisner introduced. Nevertheless, it can be partly attributed to generally improved living standards, a relatively higher number of mothers in better social circumstances, a greater urban influence, changed lifestyle and hygienic measures. Schleisner's efforts are considered to have had major significance when conditions are compared with those on the Scottish island of St Kilda where the situation was the same and improved only just before the turn of the century.

[Alferecía and the first cases of tetanus neonaturum described in Chile in 1894]. / La alferecía y los primeros casos de tétanos neonatal descritos en Chile en 1894.

Federico Puga Borne presented the first two cases of known Chilean tetanus neonatorum in 1891. These cases had a fatal course, were poorly described and had no necropsy. The presentation was done in a regular session of the Sociéte Scientifique du Chili, founded in 1891 by a French citizen settled in the country, and published in the Actes de la Sociéte Scientifique du Chili. At this time, tetanus had never been seen in a newborn in Chile, while it was very common in other South American countries; its popular name was alferecía, but this term covered many other neurological disorders.

St Kilda, the neonatal tetanus tragedy of the nineteenth century and some twenty-first century answers.

Neonatal tetanus was the cause of death of two thirds of newborn babies on the archipelago of St Kilda in the Outer Hebrides for at least 150 years. This was a major factor in the community becoming non-viable. While the cause of the tetanus infections has never been clearly established, modern bacteriological evidence suggests an alternative source of infection to the previously established theory.

The eponymous Dr James Marion Sims MD, LLD (1813-1883).

Dr James Marion Sims was born in 1813 in Lancaster County, South Carolina. It was while pioneering numerous surgical procedures in Alabama that in 1849 he achieved the outstanding landmark in medical history of successfully, and consistently, repairing vesicovaginal fistulae. Sims soon developed a reputation as a fine surgeon, with new operations and techniques, using novel surgical instruments and his innovative approaches frequently published. Moving to New York City in 1853, he further established hospitals devoted entirely to women's health. Sims was controversial, with flamboyant descriptions of self-confident success, yet they were tempered with sober reflection of failure and loss. Today we remain with the Sims speculum and Sims position, eponymous tributes to his accomplishments as the 'Father of Gynaecology'.

P.A. Schleisner: a pioneer in epidemiology.

In 1847 Schleisner (b. 1818) was sent from Copenhagen to the Vestmanna Islands in Iceland to study the epidemic of tetanus neonatorum. The neonatal mortality in those islands at that time was 600-740 per 1000 children. He built a small hospital and introduced treatment with Peru balsam of the umbilicus. Schleisner probably assumed that the infection was caused by airborne infection, contact infection or poor hygiene. The neonatal mortality fell to about 50 per 1000. Schleisner published his results in 1849. Semmelweiss published his observations in 1850 and Snow successfully fought the cholera epidemic in London in 1854. Schleisner deserves recognition as a pioneer in the field of epidemiology.

Tetanus: pathophysiology, management, and prophylaxis.

As tetanus has become a rare disease in the developed world, physicians have become less comfortable with its diagnosis and management. The extent of adequate antitetanus immunity in the adult population, especially the elderly, is waning, in great measure because primary care physicians have not made prophylaxis a priority in their routine encounters with patients. Furthermore, as the population of immunocompromised hosts grows, an increasing percentage of our patients may not respond to standard active immunization routines. Unless these trends are reversed, we face a substantial increase in the incidence of this dread disorder. Tetanus is also of interest as a relatively simple model of disordered motor control that can instruct us in the management of the many more common causes of neurogenic muscular rigidity. The toxin produced by Clostridium tetani finds increasing use in laboratories investigating brain function as well. Clinical tetanus is divided into four symptomatic types: generalized tetanus, local tetanus, cephalic tetanus, and neonatal tetanus. This monograph discusses the diagnostic aspects of each type of tetanus, its pathophysiology, diagnosis, differential diagnosis, and treatment. Preventing tetanus should be a high priority for all primary care physicians. Active immunization with tetanus toxoid is remarkably effective and safe. Passive immunization with human tetanus immune globulin is indicated in certain circumstances, which are discussed below.

Neonatal tetanus in St Kilda.

Neonatal tetanus was prevalent in the Scottish Islands in the 18th and 19th centuries. In the island of St Kilda, neonatal mortality reached 690 per 1,000 live births, and was passively accepted by the community. Many speculative ideas concerning its aetiology were propounded until unsanitary conditions were counteracted by simple measures of hygiene in caring for the newborn babies.

Analysis of the reported symptoms that preceded the death of King Rajasinghe of Sithawake (1592 AD).

A copy of an ola leaf manuscript, the original of which was written around the late 1590s, was published recently. It describes the sequence of events leading to the death of the warrior King Rajasinghe of the Sithawake Kingdom (1521-1593). A study of the contents of this letter is presented. The dressing applied to a wound on the foot of the King is described in that letter. It is likely that this dressing would have been an ideal medium to produce the highly potent tetanus exotoxin. The toxin would have diffused into the open wound and produced the sequence of symptoms and signs mentioned in the letter. An analysis of the symptoms and signs noted during the King's last illness as described in the letter is presented. Laryngospasm, and tonic and clonic spasms are easily identified. In addition, a group of symptoms attributed in the 1960s to sympathetic over-activity in tetanus are also recognisable. The conclusion is drawn that the King died of tetanus. The intriguing possibility of the wilful use of a lethal dressing on an open wound as a biological contact poison is left open for discussion.

Neurosurgical treatment for tetanus.

Soon after the discovery of the tetanus antitoxin, animal experiments led to the conclusion that intracerebral injection of the antitoxin would be useful in the treatment of tetanus. The French surgeon Quenu carried out the first injection and gave a description of the neurosurgical technique required. The method was applied in other European countries until it was declared to be less efficient than simple subcutaneous or intravenous injections. Outside Europe, intracerebral injections of tetanus antitoxin were reported and photographed in Montevideo, Uruguay, in 1901.

Extracts from John Hennen's Principles of Military Surgery.

Born in Castlebar, County Mayo, Ireland, John Hennen graduated in Edinburgh and had a career as an army surgeon, serving through the Peninsular War. His Principles of Military Surgery reached a third edition (posthumously) in 1829; his views on nerve-injuries, tetanus, head-injuries and syphilis are considered below.

Tetanus and the evolution of intensive care in Australia.

A review of two series of patients with tetanus from the Royal Adelaide Hospital provides a historical perspective on the evolution of intensive care in Australia. Nine consecutive severe cases presenting in 1957 constituted one of the first series published. Four patients died. The second series of 38 severe cases, among a total of 56 cases presenting between 1967 and 1985, included two deaths, comparing favourably with survival in other contemporary series. The specialty of intensive care evolved considerably during this time. Neuromuscular blockade introduced in the first series produced radical changes in management. Supportive measures that were not then widely practised, involving intermittent positive pressure ventilation, were used in the second series for up to 46 days and evolved into standard ICU practice. The option of using a tank respirator was rejected. Older patients were susceptible to complications commonly related to respiratory, cardiovascular and diabetic comorbidities, but most returned to their previous lifestyle. Severe tetanus often resulted from mild injuries in patients who were incompletely immunised. Four patients developed tetanus following surgical procedures. The use of nitrous oxide in the first series was abandoned owing to adverse effects on bone marrow function. Complications reported in early literature, such as fractures and myositis ossificans, presumably related to unrelieved spasm, are no longer seen. Clinicians are now likely to see the condition only if working with counter-disaster teams overseas.

[Neonatal tetanus--an explanation why the slaves in the Danish West Indian Islands not were self-sustaining]. / Neonatal tetanus--en forklaring på slavernes manglende reproduktionsevne i Dansk Vestindien.

The sugar plantation complex in West India was based on forced labour, mostly slaves from Africa. The problem was that this population had to be sustained by a constant stream of new slaves just to maintain their numbers. This demographic imbalance has during generations puzzled scholars and doctors. Modern research, however, shows that the fertility rates were normal. The problem was the infant mortality. The slaves' cultural tradition concerning childbirth had fatal consequences by being transferred to West India, where many newborn slave children died of neonatal tetanus.