More 1918 influenza research leads to pneumonia

Actually, this isn't much of a surprise - the Army's WW1 medical history that we've scanned and uploaded said as much in the 1920s. Here's the NIH press release with Jeff Taubenberger who used to work at AFIP on this subject. The samples of influenza tissues referred to were collected by the Army Medical Museum and are in the AFIP's repository now. (And thanks to Jeff Reznick for passing this one along).

Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic
Implications for Future Pandemic Planning

The majority of deaths during the influenza pandemic of 1918-1919 were not caused by the influenza virus acting alone, report researchers from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. Instead, most victims succumbed to bacterial pneumonia following influenza virus infection. The pneumonia was caused when bacteria that normally inhabit the nose and throat invaded the lungs along a pathway created when the virus destroyed the cells that line the bronchial tubes and lungs.

A future influenza pandemic may unfold in a similar manner, say the NIAID authors, whose paper in the Oct. 1 issue of The Journal of Infectious Diseases is now available online. Therefore, the authors conclude, comprehensive pandemic preparations should include not only efforts to produce new or improved influenza vaccines and antiviral drugs but also provisions to stockpile antibiotics and bacterial vaccines as well.

The work presents complementary lines of evidence from the fields of pathology and history of medicine to support this conclusion. "The weight of evidence we examined from both historical and modern analyses of the 1918 influenza pandemic favors a scenario in which viral damage followed by bacterial pneumonia led to the vast majority of deaths," says co-author NIAID Director Anthony S. Fauci, M.D. "In essence, the virus landed the first blow while bacteria delivered the knockout punch."

NIAID co-author and pathologist Jeffery Taubenberger, M.D., Ph.D., examined lung tissue samples from 58 soldiers who died of influenza at various U. S. military bases in 1918 and 1919. The samples, preserved in paraffin blocks, were re-cut and stained to allow microscopic evaluation. Examination revealed a spectrum of tissue damage "ranging from changes characteristic of the primary viral pneumonia and evidence of tissue repair to evidence of severe, acute, secondary bacterial pneumonia," says Dr. Taubenberger. In most cases, he adds, the predominant disease at the time of death appeared to have been bacterial pneumonia. There also was evidence that the virus destroyed the cells lining the bronchial tubes, including cells with protective hair-like projections, or cilia. This loss made other kinds of cells throughout the entire respiratory tract — including cells deep in the lungs — vulnerable to attack by bacteria that migrated down the newly created pathway from the nose and throat.

In a quest to obtain all scientific publications reporting on the pathology and bacteriology of the 1918-1919 influenza pandemic, Dr. Taubenberger and NIAID co-author David Morens, M.D., searched bibliography sources for papers in any language. They also reviewed scientific and medical journals published in English, French and German, and located all papers reporting on autopsies conducted on influenza victims. From a pool of more than 2,000 publications that appeared between 1919 and 1929, the researchers identified 118 key autopsy series reports. In total, the autopsy series they reviewed represented 8,398 individual autopsies conducted in 15 countries.

The published reports "clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory flora in most influenza fatalities," says Dr. Morens. Pathologists of the time, he adds, were nearly unanimous in the conviction that deaths were not caused directly by the then-unidentified influenza virus, but rather resulted from severe secondary pneumonia caused by various bacteria. Absent the secondary bacterial infections, many patients might have survived, experts at the time believed. Indeed, the availability of antibiotics during the other influenza pandemics of the 20th century, specifically those of 1957 and 1968, was probably a key factor in the lower number of worldwide deaths during those outbreaks, notes Dr. Morens.

The cause and timing of the next influenza pandemic cannot be predicted with certainty, the authors acknowledge, nor can the virulence of the pandemic influenza virus strain. However, it is possible that — as in 1918 — a similar pattern of viral damage followed by bacterial invasion could unfold, say the authors. Preparations for diagnosing, treating and preventing bacterial pneumonia should be among highest priorities in influenza pandemic planning, they write. "We are encouraged by the fact that pandemic planners are already considering and implementing some of these actions," says Dr. Fauci.

Visit http://www.PandemicFlu.gov for one-stop access to U.S. Government information on avian and pandemic flu.
NIAID conducts and supports research — at NIH, throughout the United States, and worldwide — to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.Reference: DM Morens et al. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: Implications for pandemic influenza preparedness. The Journal of Infectious Diseases DOI: 10.1086/591708 (2008).

Save the Date: Stigma of Leprosy Discussion, Wed., 8/27, 2pm in the Museum

Save the Date: Stigma of Leprosy Discussion, Wed., 8/27, 2pm in the Museum

Afternoon Coffee Talk at the National Museum of Health and Medicine

"Carville: The Landscape of Stigma" with guest speaker Elizabeth Schexnyder, Curator, The National Hansen's Disease Museum.

Join a discussion on how the fear of leprosy led to displays of stigma associated with the disease. Learn how "othering" human beings diagnosed with leprosy shaped the unique social and physical landscape of the National Leprosarium at Carville, Louisiana. After the talk, visit the temporary exhibition 'Triumph at Carville: A Tale of Leprosy in America.'

When: Wednesday, August 27, 2:00-3:00 p.m.

Where: Russell Auditorium (in the Museum, Bldg. 54)

Cost: FREE!! Coffee!!

A day in the life...

Today began with nothing much on the calendar, but Bruce from the Department of Veterinary Pathology (VetPath) stopped by to say that Dr. John King was arriving with his donation of 35mm slides for the museum. Dr. King and Cornell University had been digitizing the collection as Dr. John M. King's Necropsy Show & Tell and posting them online. They got about 1/2 done, but Dr. King donated all the slides to us and we're going to finish the scanning job.

Dr. King was in his early 80s, and lively and full of interesting stories about veterinary pathology and how there are some controversies in the field like the bursting aortas of racehorses (which I'd never heard of - the competing theories are high blood pressure v. King's compressing the chest when collapsing or mating). He's also a collector of veterinary instruments and brought down some for us.

When I mentioned this collection coming in, I didn't tell you readers that it's 48,000 35mm slides in 108 notebooks, arranged by animal and pathology (ie herpes, heart disease, liver failure). Cool, huh?

Midday was a tour for Lauren the intern's mom. It's always fun to take people that are interested on a tour. Lauren's done a great job for us this summer, working most recently on updating the Vorwald Collection finding aid and adding more material into the trade literature collection (ie advertising), General Medical Products Information Collection.

Later on in the day, we got a call from people doing renovations in the area the AFIP director works in and so we removed paintings of the former directors for safe storage while the work goes on.

Trigeminal neuralgia

Tomorrow's Washington Post magazine, which gets delivered to my house on Saturday, runs an article about a man with trigeminal neuralgia, "an affliction so intolerable it's known as the 'suicide disease,'" because the pain is said to be the worst a person can experience. It's a sudden, electrical pain that can be triggered by as little as water from the shower cascading over the face, by shaving, by applying makeup. This sounded so familiar because my dad had this kind of pain and I heard it described in exactly the same way. It took me a while to remember what he called it, and a quick Google search told me that his tic douloureux and trigeminal neuralgia were the same thing. Today there are a few treatment options but he had to live with it for many years. I don't know how he did it.

AFIP medical examiners mentioned in Post and Times

Human remains from a long lost plane crash have been found and identified by the Armed Forces Institute of Pathology's medical examiners. The story is "9 Years Later, a Fatal Mystery Solved; Experts Trace Body Part From 1948 Plane Crash to Roanoke Seaman," By Michael E. Ruane, Washington Post Staff Writer, Saturday, August 16, 2008. A similar case is reported on in "Missing pilot to be brought home; Recovered remains to receive Arlington burial," by Jennifer Harper, Washington Times Thursday, August 14, 2008.

The AFIP isn't mentioned by name in either article which is typical. The Armed Forces DNA Identification Laboratory (AFDIL) is, but they are a component of the Office of the Armed Forces Medical Examiner, which in turn falls under the AFIP. And the medical examiners would have done the fingerprint work mentioned in the Post article, not the DNA technicians.



Remember, the museum has on display Resolved, an exhibit on forensic identification of military dead that's just opened.

Ford's Theatre renovation and reopening

A museum in Ford's Theatre is mentioned in passing in this article "The History Will Linger At Remade Ford's Theatre," By Michael E. Ruane, Washington Post Staff Writer, Friday, August 15, 2008; Page A01.

Ruane wrote, "The government bought the theater from Ford and used it over the years as a museum and as an office and storage building."

Well, that was the Army Medical Museum which was there for almost two decades, before it moved to a new bulding on the Mall (which was knocked down in 1968 for the Hirschorn). I wrote about the Museum there in Washington History (available from the Washington Historical Society) last year. Here's some relevant paragraphs edited down somewhat:

After President Lincoln's assassination in 1865, the federal government purchased and renovated the notorious Ford's Theatre to house the museum, the Surgeon General's Library, and the more than 16,000 bound volumes of the Records and Pension Division of the Surgeon General's Office. The move to Ford's Theatre in December 1866 permitted the museum to expand its collecting to include Native American weapons and “specimens of comparative anatomy.” Now the museum, with its larger exhibit space and broader scope, would become a well-known Washington-area landmark.

The museum had no difficulty attracting the public. Medical specimens, including many anomalies and curiosities, fascinated both lay and professional visitors alike. No doubt part of the fascination lay in the innate morbid curiosity of seeing human remains usually available in circus side-shows, but the Civil War had just ended, and the displays of specimens from maimed soldiers of both sides led visitors to see the museum as an unintentional national memorial. The glass cases of specimens were flanked by flags and standards of ambulances corps as well as Union and Confederate swords and sabers. While the displays were systematic, rather than artistic, they were nonetheless alluring, especially for thrill-seekers. A reporter for the popular Appleton’s Journal captured the atmosphere:

It is, indeed, not such a collection as the timid would care to visit at midnight, and alone. Fancy the pale moonlight lighting up with a bluish tinge, the blanched skeletons and grinning skulls — the same moon that saw, in many a case, the death-blow given, or the bullet pierce. The thought is not a comforting one, and those fancies would not be calculated, at such a time, to inspire courage. But in broad daylight, with the sun shining outside, and brightening up, with its tinge of life and activity, the tessellated floor, with the noise and traffic of the street outside, and the hum and murmur of numerous clerks and attendants inside, even those of timid proclivities do not then hesitate to inspect closely and with curiosity the objects which, twelve hours later, when the building is dark and deserted, they would scarce care to approach.

Opened to the public on April 16, 1867, the museum drew around 6,000 visitors by the end of the year. “It cannot fail to be one of the most absorbing spots on earth to the student of surgery or medicine,” opined guidebook author Mary Clemmer Ames in 1874, “but to the unscientific mind, especially to one still aching with the memories of war, it must remain a museum of horrors. . . . No! the Museum is a very interesting, but can never be a popular place to visit." In spite, or because, of Ames's concerns, by 1874, the number of visitors sometimes reached more than 2,600 per month, even the museum was only open from 10 am to 3 pm on weekdays, and on Saturday from 10 am to 2 pm. As early as 1866, the museum was well-known enough to be mentioned in Atlantic Monthly. In Dr. S. Weir Mitchell's fictional story, "The Case of George Dedlow," the hero, who lost both legs due to the war, was contacted by spirits during a séance. The spirits proved to be his amputated limbs, preserved in the Medical Museum: "A strange sense of wonder filled [Dedlow], and, to the amazement of every one, I arose, and, staggering a little, walked across the room on limbs invisible to them or me. It was no wonder I staggered, for, as I briefly reflected, my legs had been nine months in the strongest alcohol." Undoubtedly, readers of the story would have wished to visit the museum to look for the imaginary Dedlow's limbs.


As early as 1880, the Ford's Theatre building was proving inadequate for the expanding museum and library. In fact one exterior wall as falling away, and eventually the interior floors collapsed after the museum had moved out. In 1881 the museum attracted 40,000 visitors, while in 1888, the library had 5,000 readers. In his annual message to Congress, President Rutherford Hayes asked for an appropriation to replace the building. “The collection of books, specimens, and records constituting the Army Medical Museum and Library are of national importance. . . ,” Hayes wrote. “Their destruction would be an irreparable loss not only to the United States but to the world.”

Some congressmen opposed the idea of a new building, suggesting instead that the Army's medical records merge with the Pension Bureau's in their new building (now the National Building Museum), or amalgam the library with the Library of Congress and the museum with the Smithsonian Institution. Representative Clarkson Potter of New York objected on emotional grounds and opposed funding the museum and “preserving the relics and bones or wounds caused by the war at any place in our capital,” wishing instead that "they were all buried and covered all over with green grass and hidden from sight forever." On the other side, the more forward-thinking Representative Theodore Lyman of Massachusetts envisioned an institution something like today’s National Institutes of Health and "discern[ed] a hope that , , , germs may be used for inoculation and may protect us from . . . diseases, just as vaccination protects against smallpox.” Lyman deemed the museum’s studies “essential to the welfare of our people,” and the library “now the first in the world, and whose not less admirable collection of military pathology, are placed at the disposal of all investigators.”

The full article, "The Rise and Fall of the Army Medical Museum," has much more information in it of course.

To show that nothing really changes, we're currently scheduled to move off of Walter Reed Army Medical Center's DC campus due to the BRAC closure of the base, but no new home has been designated for us.

Ruane also wrote, "On the morning of June 9, 1893, the building was packed with 500 government clerks, occupying several floors of jury-rigged office space, when the interior collapsed, according to a Washington Post account the next day. Scores were killed and injured, and the theater's already altered interior was destroyed."

The space wasn't jury-rigged - actually it was built of cast iron, fireproof construction, but the space wasn't strong enough for all the tons of pension records that were being stored there.

Unknown

I was at Arlington National Cemetery Sunday morning when it opened so I could photograph the grave markers of the parents of a friend of mine from San Diego. She was able to come back for her dad's funeral in March but can't swing another trip to visit their grave. While I was there I wandered around and found the memorial that marks the graves of sailors and Marines who went down on the United States Battleship Maine in Havana Harbor in 1898.
The ship exploded and all hands, 229 of them, were lost. Seventeen years later their bodies were repatriated and buried in section 24 of Arlington, near the mast of the Maine. Their names are engraved on the foundation of the memorial.

A sad story in and of itself, but the most poignant part is when you walk among the tombstones and see this. Our Resolved exhibit shows how far we've come and made this kind of memorial obsolete.

Another view of our Resolved exhibit

I think this is my favorite view of the exhibit. That's a transfer case draped with a flag and a backdrop from the Joint POW/MIA Accounting Command Forensic Anthropology Lab at Hickam AFB in Hawaii, showing the process of reconstructing human skeletons with the aim of identification. I always assumed it was a casket that brought our soldiers home, but it's not. The same grim purpose, a more utilitarian box.

Military medicine training article

Speaking of moulages and training, here's an article that talks about their current use. "Trial by (Simulated) Fire: Military Doctors Learn to Practice Wartime Medicine on Mock Battlefield," By Philip Rucker, Washington Post Staff Writer, Friday, August 8, 2008; B01. I met the doctor who's quoted at the end, Capt. Trueman Sharp, last year when the museum got a collection of Vietnam-era medical data from his department for scanning - the Wound Data Munitions Effectiveness Team (WDMET) records include wounding information, x-rays, 35mm slides and sometimes fragments. We've got the material being scanned now, but it's going to take a while to finish.

1918 flu comic for downloading

In my private life, I dabble in comic art history. Dave Lasky's done a comic book "No Ordinary Flu" about the 1918 influenza epidemic for King County in Washington State. You can download it as a pdf in multiple languages. Their website reads:

To promote pandemic flu preparedness, Public Health - Seattle & King County has developed a 12-page comic book on pandemic flu. Targeting readers of all ages, this story tells the tale of a family’s experience of the 1918 influenza pandemic. It also explains the threat of pandemic flu today, illustrates what to expect during a pandemic (such as school closures), and offers tips to help households prepare.

You can also hear Lasky on KUOW's Sound Focus for August 6th - "No Ordinary Flu and Recipes for Peaches." Here's a direct link.

Thanks to cartoonists Scott Gilbert and Scott Faulkner for the tips!

Is there any place for human remains in a museum (these days)?

Mike's post yesterday about a conference at which the title of this post will be discussed leads me to show you these pictures. They're all from our Resolved exhibit on identifying human remains. I'll show more pictures of the exhibit in future posts, but try to imagine the gaps if these body parts, out of squeamishness or political correctness, were no longer in our collection. Imagine our anatomical collections manager trying to explain, in words alone, how a female and male pelvis are different. Or what the mandible of a child of a particular age looks like (remember, no objects for illustration). Or the differences among the skulls of Europeans, Asians, and Africans. I'm still kind of new to the museum game as an employee, but as a long-time museum-goer, I think there's not a lot of place for this kind of question from museum professionals.

Human remains symposium in Paris text online

My colleagues at Biomedicine on Display caught this - International Symposium "FROM ANATOMIC COLLECTIONS TO OBJECTS OF WORSHIP". It dealt with human remains in museums, and the issues of repatriating them. The panels were as follows:

first round-table : repatriating human remains: why, for whom, under which conditions?
second round-table : Is there any place today for human remains inside museums?
third round table : the status of human remains from a legal, ethical and philosophical point of view
fourth round table : How to reach a mutual understanding? Institutional mediations and negotiations

Obviously the phrasing of the 2nd round-table just bugs me right away. Why shouldn't there be a place for human remains in a museum? I don't particularly care if mine end up there, and former museum pathologist Daniel Lamb insisted on it.

The whole text of the symposium is downloadable and I'm looking forward to reading it.

War Surgery in Afghanistan and Iraq featured by New York Times

This book, War Surgery in Afghanistan and Iraq, is by a friend of mine who's been working on it for several years. The book is in the grand tradition of the Medical and Surgical History of the War of the Rebellion which was also compiled to address problems of injuries during a war. It's published by the Borden Institute at Walter Reed where a lot of my friends and colleagues work as well - we're currently working on a photographic history of Walter Reed medical center for the 100th anniversary, right before they shut it down.

The article about the atlas of injuries is "To Heal the Wounded," By DONALD G. McNEIL Jr., New York Times August 5, 2008

There's also audio files linked to on the main page, as well as photographs.

Limb lab continuation - that Civil War amputee

In a paper for Invisible Culture 5 - "Shooting Soldiers: Civil War Medical Images, Memory, and Identity in America," by J.T.H. Connor and Michael G. Rhode, we used Stratton's image. We noted, "After the war, disabled veterans used their photographs to support themselves in a variety of ways. Private Alfred Stratton took the most direct route. During the war, he endured a double amputation of both arms in 1864 and, as a result, received a pension of twenty-five dollars a month. In 1869, he visited the Museum and had his photograph taken. In later years, he sold carte-de-visites of himself in a uniform as a disabled soldier."

Here's the medical museum's photograph of Stratton:



And the cartes-de-visite Stratton sold to support himself:


This paper has pretty much everything I know about the Museum's Civil War photography and is one of my favorites of articles I've written.

Complicated grief

The Washington Post ran an article today about a condition called complicated grief. We have all had loss in our lives that we have grieved over but as deep as the grief is when fresh, over time it lessens. People who suffer from complicated grief don’t experience that lessening. A discovery that a part of the brain called the nucleus accumbens is activated by thoughts and memories of what was lost helps to explain this phenomenon. This part of the brain is associated with cravings and addiction, and in anticipating a reward. The theory is that those people who can't adjust to their loss are experiencing something pleasurable in their memories and "are addicted to the happy memories."

This discovery also explains why these people don't respond to traditional remedies for depression, which act on a different brain system involving serotonin. Scientists thing that a drug that acts on dopamine, which is involved with the nucleus accumbens, might be more effective.

Limb Lab presentation report at blog

Dr. Val Jones reported on Linker and Reznick's presentations a couple of weeks ago on her blog Revolution Health. I'll see if I can put up a picture of the Civil War amputee that sold the pictures of himself - his name was Alfred Stratton, I think.

Appalling practice by US hospitals reported by Times

This extensive investigative report must be read to be believed: "GETTING TOUGH: Immigrants Deported, by U.S. Hospitals," By DEBORAH SONTAG, New York Times August 3 2008.

Many hospitals are taking it upon themselves to repatriate seriously injured or ill immigrants because nursing homes won't accept them without insurance.

Surgeon General's Lecture Series at 1100 on 8 August 2008 in Memorial Auditorium, NNMC, Bethesda, MD

My buddy Andre sent this announcement about a lecture. I imagine you cant contact him if you need any additional information:

This is just a reminder that the Surgeon General's Speaker Series is set to continue on 8 August 2008 at 11:00 AM in Memorial Auditorium at the National Naval Medical Center, in Bethesda, MD. The lecture, "Jonathan Messersmith Foltz: Colorful Naval Surgeon and Friend and Foe of President James Buchanan," will be delivered by Ludwig Deppisch, MD, author of the recently acclaimed book, The White House Physician: A History from Washington to George W. Bush. This lecture will be open to all who wish to attend. As a note, this talk will hold special appeal to anyone interested in mid-nineteenth century American political and naval history. The subject of the lecture is a notable Victorian-era Navy surgeon who was linked to many famous literary, political, and scientific figures of his day including President James Buchanan, Admiral David Farragut, Samuel Morse, Edgar Allan Poe, and Queen Victoria. Dr. Foltz served as the first military White House physician, a Fleet Surgeon with Admiral David Farragut at the Battle of Mobile Bay, and in 1871 he was appointed as the Surgeon General of the Navy (becoming only the second person to hold that post).

André B. Sobocinski
Deputy Historian/ Publications Manager
Office of the Historian
Bureau of Medicine and Surgery (BUMED)
Tel: (202) 762-3244
Fax: (202) 762-3380
E-Mail: Andre.Sobocinski@med.navy.mil
http://navyhistory.med.navy.mil/

Moulage instruction booklet

As mentioned a couple of days ago, here's an instruction book for moulages meant to simulate mass casualties - Instructor's Guide for Casualty Simulation Kit Device 11E10

Mid-Atlantic history of medicine seminar

Since I'm on vacation, I can actually post to the blog during the day. Here's an announcement that Andrea wanted up:

Announcing the 6th Annual Joint Atlantic Seminar for the History of
Medicine, to be held the weekend of September 26-27, 2008, and hosted
by the Section of the History of Medicine and the Program in the
History of Science and Medicine at Yale University in New Haven, CT.
The seminar is organized and coordinated by graduate students across
North America working in fields related to the history of medicine.
Our mission is to foster a sense of community and provide a forum for
sharing and critiquing graduate research by peers from a variety of
institutions and backgrounds.

There is no fee for the Seminar, but registration is required.
The deadline for registration is September 10, 2008.

Please email Julia Irwin at JASMed2008@gmail.com to register.
For further information, see our website at www.jointatlantic.org