BEATING COVID-19

COVID-19  is raging worse than ever! As of today, December 1, 2020, the global deaths are 1,474,643.  We in the USA have surpassed a quarter of a million people dying from COVID-19, and the worst is yet to come over a long terrible winter.  Studying the Johns Hopkins statistics does not show that any country has the answer to the pandemic,. Although Europe is coming down off their peak, presumably due to strictly enforced public health measures. The vaccine of three companies is just around the corner, with the first batch of 6.4 million doses to be delivered as our Christmas present from Pfizer. The vaccine is our only hope, as we can’t seem to follow the public health measures that the science says will at least curb the virus’s ability to spread.  Despite all the warnings, this Thanksgiving saw more travel and large group gatherings that served to spread the virus, and cause the spike in the case numbers which we are witnessing.

We have politicized the virus. It has become a sign of freedom and resistance to tyranny that wants to take away our God-given rights not to wear masks, and to ignore public health advice to avoid crowds.  The Supreme Court has struck down regulations to prevent gatherings for religious purposes.  Although I must admit, it seems rather arbitrary to allow strip joints to stay open and close churches. It has also not been helpful to have our leaders violate their own edicts, such as going to hairdressers when those establishments were supposed to be closed, or attend large group dinners at swank gourmet restaurants when only outdoor dining was allowed, or fail to wear masks when present in large gatherings. It makes you think they don’t really believe it either.

The initial response in March was full of mixed messages – wear a mask, don’t wear a mask, stay 3 feet apart or is it 6 feet or 15 feet? We have learned a lot, but not everything, in the last ten months, and now the message is much clearer, backed by good science that has shown wearing masks does a good job of keeping the virus from spreading from an infected person. However, masks do not seem to be as effective in keeping the virus from spreading to a non-infected person.  The most recent study was the Danish study of 6000 subjects, which showed a 20% decrease in infection risk in mask users.  The masks, however, do keep an infected person from spreading the virus.  Additionally, several anecdotal events have shown that to be so. Two hairstylists who both had COVID-19 did not transmit their virus to a single person of their 139 clients that patronized their business.  Both had dutifully worn masks during their encounters with customers.  Although no double-blinded controlled studies have been done, it seems fairly certain that masks are protective in keeping the virus confined to the infected person, but protects the non-infected person to a lesser extent but still not insignificant. No one knows if they are free  of the virus or asymptomatic carriers, even if they have a negative PCR the day before. To assume that you are not dangerous to others is not only impolite and selfish, but potentially threatening to others just like carrying a loaded gun and pointing it at passer-bys.

We owe the face mask to a French surgeon, Paul Berger, who in 1899 decided not wearing a mask during the conduct of an operation exposed the wound to the potential of contamination from the mouths and noses of the people that were conducting the operation by just breathing. He concluded that it was not good to spray saliva into open wounds. That is essentially what happens when the surgeons do not wear face coverings. And it is what we do by just breathing.  Loud speaking, coughing, sneezing and singing increases the droplets we expel.  The surgical community did not accept his idea, and laughed at him.  Later, one of the smartest and most famous surgeons of the time, Jan Mikulicz, came to his defense with a publication that changed the minds of the surgical world.  From then on, all surgeons all over the world wear masks during the conduct of any operation. No matter what you think of masks, would you be put off by the surgeon who refuses to wear a mask for your operation? Besides, the downside of mask use is non-existent except for convenience.

It does not appear that we have the ability or mindset to successfully combat the virus with public health measures alone, regardless of whether we have a national plan or not. We will have to rely on the vaccine.

It was Edward Jenner in 1768 that gave us the idea of vaccination.  It was he that named it that, vaccine, (from “vacca” the Latin for cow) after he used pus scraped from the hands of a milkmaid which she had contracted by milking infected cows that gave milkmaids a mild disease called Cowpox.  But once they had it, they were immune to one of the most vicious virus killers of all times, Smallpox.  Smallpox has killed more people than all the epidemics and all the wars combined, starting around the time we started to change from hunter-gatherer societies into closer-knit agriculture-based settlements 12,000 years ago.  The first historically recorded epidemic was the Antonine Plague at the height of the Roman Empire that killed at least 5,000,000—for which most scholars credit Smallpox. Jenner likely has saved more lives than any other human being in history.

But it is still many months before enough people are vaccinated that we will finally attain “herd immunity.”

There will be people who are afraid to get vaccinated, such as the anti-vaxxers. Also, others for political implications, do not want to take the “Trump vaccine.”  That in addition to the huge volume of vaccine that will be necessary for millions of people to get two doses three weeks apart. This will slow down the battle against containing the virus.  Until then, we need to do all we can to keep the virus from killing more people, and I am afraid that includes masks and social distancing regardless of constitutional issues. How to convince the majority of this is the trick.  Trump should bite the bullet and wear a mask. After all, 73 million people voted for him, and he still commands a large following. He needs to set an example. There are others who could be recruited to set the standard.  These would be the leaders of our society, such as movie stars George Clooney and Angelina Jolie, for example, and including respected media icons, such as Sean Hannity and Anderson Cooper with politicians both on the right and the left including AOC, Nancy Pelosi, Ted Cruz, Mitch McConnell, business leaders such as Elon Musk, Warren Buffett, and many more who could change people’s minds, and do what all surgeons have been doing for 120 years with no visible ill effects.  A media campaign with prominent people of various persuasions, politics, and backgrounds would help to de-politicize mask-wearing and do wonders, even save a few lives!

The Renaissance

Historians have often disagreed as to what brought about the dark ages in the first place and then the “re-birth” of the arts, science, medicine, and the intense thirst for knowledge. A variety of factors played a role, the influence of the Byzantine Empire through the Crusades, the brushes with the Islamic culture over the Pyrenees in the Iberian Peninsula with trade, war, and study of Medieval scholars in the higher learning centers of Al- Andalus, and the revitalization of art, especially south of the Alps in Florence, Italy. Gradually the knowledge of the past percolated back into Central Europe.

Leonardo da Vinci is perhaps the one single person who most embodies the Renaissance. He was a painter, a sculptor, a prolific inventor, a geographer, and an engineer, but what interested him most was the anatomy of the human body. He did very meticulous dissections, with detailed drawings, and knew anatomy better than most physicians of his day. His detailed drawings and writings which influenced the next generation, such as Ambroise Paré, and Andreas Vesalius. One of the meticulous observations seen above has the most accurate depictions of the upper extremity ever rendered.

But it was not until the 16th Century that the darkness truly started to lift in medicine and surgery.

Ambroise Paré, a French barber surgeon, learned that ligating vessels was better than pouring boiling oil into wounds to stop the bleeding. Ambroise devised rapid techniques amputating a limb that was injured on the battlefield. He also learned that injuries treated with a bandage soaked in turpentine was enormously superior to cauterization. He also devised prosthetic limbs, provided you survived the amputation.

Ambroise Paré also dabbled in obstetrics and came up with some maneuvers to make difficult deliveries survivable. He invented the internal podalic version, and manual extraction of the fetus when in a breech position. His collected works and experiences, Les Oeuvres, were published in 1585 and raised the status of the barber- surgeons throughout Europe. He utilized the anatomic discoveries of Andreas Vesalius, which challenged Galen’s drawings of monkey anatomy that had been the standard for over 1000 years.

Vesalius was the game changer with his book, De Humani Corporis Fabrica. This book was illustrated by a student of the famed painter, Titian, who often used allegorical poses of the dissected corpses to symbolize some moral or spiritual meaning. Vesalius was a firm believer that to understand the anatomy, the student had to do the dissection personally.

The old method of having servants do the dissection, and observing what was done, was inferior to doing the dissection by yourself. Vesalius encouraged his students to get their hands dirty. Vesalius experienced some unpleasant brushes with the Inquisition, as some of his discoveries conflicted with scripture, such as the fact that women had the same number of ribs as men.

It remains a mystery why with all the smart people going back to the ancient Greeks like Aristotle with his astute observations of nature, Aristarchus who deduced that the earth revolved around the sun, and Posidonius who calculated earth’s circumference to an accuracy within a few hundred miles. Archemedes even created an analog computer, the Antikithera mechanism. Then, Da Vinci came up with so many brilliant conclusions on subjects that ranged from human anatomy to why ancient extinct skeletal remains are found on mountain peaks. Why has science made so little progress? The dark ages still had a stranglehold with influence for quite some time after they officially ended. Perhaps that is why we advanced so haltingly in the healing arts and all of science.

Vesalius gave lectures at the University of Bologna and University Padua, where one of his eminent contemporaries, Fallopius, was the first to describe the structures that still bear his name, the Fallopian tubes that conduct the egg from the ovaries to the uterus. Fallopius also offered a few helpful suggestions, and even some corrections to Fabrica, which Vesalius graciously accepted and incorporated.

Vesalius was punished for his advanced thinking and discoveries and was strongly encouraged to make a penance trip to the Holy Land. He shipwrecked on one of the many Greek islands where he died, a loss that set back the newfound anatomic knowledge.

The English doctor, William Harvey, also trekked to Italy and entered the University of Padua in 1599. In England, it was still not acceptable to dissect human corpses. In 1628 he published his most well-known work, which explained how the human heart works, De Motu Cordis, and corrected the mistakes of Galen which had stood unchallenged for millennia.

Through a simple experiment, he showed that venous blood flows to the heart, while arterial blood is always pumped away from the heart, as is evident when an artery is transected.

Revolutions and Enlightenment

The American Revolution, the French Revolution, the Industrial Revolution, and so many more followed the “Rebirth.” And with it came the progress of new knowledge. Louis the XIV, the Sun King, led a life at the height of opulence and glory. He lived in luxury at Versailles, surrounded by art, beauty, culture, and wealth.  Were it not for a pain in his buttocks, things would have been perfect. He had a “fistula in ano,” an abnormal connection from the inside of the rectum to the skin outside. It frequently got infected causing swelling, pain, and pus to discharge. He consulted his physician and surgeon, Charles-François Felix. Unfortunately, his learned adviser didn’t have the slightest idea what to do for this humbling and agonizing problem. So, he did what doctors often do, stall. He told Louis that he must do sitz baths for a year before he could treat him. In the meantime, he went to the Bastille, the central prison in Paris, and found 72 prisoners who had the same condition. For the next year, he experimented with different treatment options to see what worked best. Felix found that unroofing the fistula, just slicing it open worked well. Finally, the year was up, and it was time to treat the King. The King reluctantly agreed to have the surgery Felix advised, as he saw no improvement, and had no other choice. No anesthesia was available. The King assumed the undignified position for the surgeon to approach the fistula, and Felix went to work. The records at Versailles indicate that the operation was a three-hour ordeal, but the King did not scream once. He did say, “Oh, Mon Dieu” twice, roughly translated as OMG. Felix crafted a knife that had a leading blunt probe that was inserted through the fistula track, and had a sharp portion that was then used to transect the fistula, and overlying anal sphincter. It is on display at Versailles in a glass case and named the “bistouri royal.”

Louis XIV with his Queen and Confessor giving him solace just before the operation

The operation was a success, and the surgeon was well rewarded. He received 15,000 Louis d’ Or approximately $5,000,000 in today’s currency. Additionally, there was a chateau in the south of France, and the title of Baron, that came with the fee. Compare that to today’s Medicare reimbursement for a fistulotomy, the kingly sum of $436.87!

Although not in historic proper timeline order, it seems appropriate to mention David Henry Goodsall at this point. He does not come on the scene until 1900 when he was able to correctly describe the path of an anal fistula, a frequent question on surgery in-training exams.

Goodsall’s rule states that if a line is drawn through the middle of the anal ring parallel to the floor, the internal opening of the fistula will be in direct opposition to the external opening on the skin. If the external opening is posterior to that line, the internal opening will follow a curving path to the dorsal midline. The exception to the rule is, if the external opening is more than 3.75 cm from the anal verge, the path may curve to the posterior midline regardless of where it is.

Appendicitis was almost always a fatal condition, as that, too, had no known treatment, and the surgeon did not have the luxury of trying out different procedures for a year.

The very first successful removal of the appendix was done at St. George’s Hospital in London, in 1735, by a French surgeon, Claudius Amyand, on an 11-year-old boy. He described the operation, which he presented to the Royal Society.

 

 

St. George’s Hospital< Hyde Park Corner

 

Amyand had to wait for the proper credit, as many were accorded that honor erroneously, not knowing he preceded them by 150 years. Charles McBurney wrote about “the McBurney” incision in 1894, actually 1st described by another surgeon, Louis L. MacArthur.

Although the pathophysiology was not well understood at that time, it was a Harvard pathologist, Reginald Herbert Fitz, who described it accurately in 1886, 150 years later. He wrote a paper entitled: “Perforating Inflammation of the Vermiform Appendix; With Special Reference to Its Early Diagnosis and Treatment,” as the little worm-like projection from the cecum, that was the cause, and not what was thought to be a process that involved the entire cecum, called typhlitis or peri-typhlitis.

John Hunter is considered to be one of the early “Fathers of Modern Surgery.” He was a man who would not accept any idea that he himself had not thoroughly vetted. He was a scientist that depended on direct observation, trial and error, and experimentation to prove a  theory.   He

 

was considered to be a surgeon, and he felt himself a surgeon, although he saw the shortcomings of the craft of surgery. He tacitly acknowledged that surgery had its flaws, “It is like an armed savage who attempts to get that by force which a civilized man would get by stratagem,” he said. Surgery was a treatment option when other, less invasive measures failed. He was known to collect everything that moved,    and even plants, a total of 14,000 exhibits at the end of his life. One of his prize specimens was the skeleton of a giant man (7’7”), who specifically left a will which refused any part of him to be used in one of Hunter’s exhibits, but Hunter bribed one of the morticians. The skeleton is now on display at the Hunterian Museum in London. What would the legal and ethical implications of that be in our time? Hunter came by his “trade,” not through any academic route, he was an assistant to his brother who taught an anatomy course for eleven years, then assisted a surgeon for one year. Subsequently, he was an army surgeon for three years. He was appointed to be the Surgeon to King George III, (yes, that George, against whom we fought the Revolutionary War).

 

He published several scholarly books on venereal diseases, the development of human teeth, inflammation, blood, and gun-shot wounds. He was an ardent supporter of learning by doing; surgery was not something that could be taught only by reading. He died at the age of 65, on October 16, 1793, immediately after a fierce argument with his hospital’s Board of Directors, who did not want him to bring medical students to observe operations (a discussion we still have today).

 

His death mask, to the right, shows a man with determination and wisdom. He was described by one of his assistants, “as a man, warm but impatient, readily provoked, and when irritated, not easily soothed,” a character trait common to many surgeons. His house in London had two entrances, one for the family, and one on a different level, the entrance for his macabre laboratory, where he prepared many of his exhibits for display. The house became immortalized, and Hunter, himself, was thought to be the most likely inspiration for Robert Louis Stevenson’s novel, The Strange Case of Dr. Jekyll and Mr. Hyde.

Sir Astley Cooper

Operating on the crowned heads of the European Empires was quite rewarding. Sir Astley Cooper, a student of John Hunter, was Surgeon to George IV. His aristocratic title was bestowed on him by George IV for removing a huge mass on the King’s head.

 

Cooper has several anatomic structures named after him; the most remembered today are two ligaments: the suspensory ligaments of the breast are Cooper’s ligaments, as is the thickened periosteum, just above the superior pubic ramus, the ligament of Cooper. It is Cooper’s ligaments in the breast that cause the skin to give the “peau de orange” appearance with underlying cancer, plugging the lymphatics causing swelling of the skin, but Cooper’s ligaments tug on and create the fine dimpling of the skin that gives it that orange peel appearance. The other Cooper’s ligament provides the strong anchoring structure in the pelvis for the Mc Vay hernia repair. His contributions to surgery were diversified, from ligating the aorta for aneurysms, the study of the cerebral circulation, anatomy of the inner ear, and more practical applications, such as hernia repair, and treating breast diseases. Cooper’s published works include anatomy of hernias, breast, and thymus, as well as lectures on surgery, and treatment of fractures.

 

Sir Astley Cooper has a special place in the education of women surgeons. The fact is that women were not accepted into medical schools in that era, much less becoming surgeons. The strange story of James Barry changed that. James was actually a female who very much wanted to be a surgeon.

 

 

She dressed as a boy, and entered the medical school in Edinburgh, Scotland where she came under the influence of Sir Astley Cooper, and eventually became a very talented, capable, and accomplished surgeon. Her real name was Miranda Steuart. She continued to dress and appear as a man; she also joined the British Army and fought in the Crimean War. By that time, she had attained the rank of General, because she was an outstanding surgeon.

 

She gets the credit for performing the first successful Cesarian section, where both mother and child survived! Being from Edinburgh, which had a  reputation for hygiene concerns,  she was very meticulous about sanitation during the execution of surgery, long before Lister came up with his carbolic acid spray. She got into a knock-down-drag-out fight with a fellow army surgeon who was less interested in cleanliness. Miranda was court-martialed for behavior “unbecoming an officer and a gentleman.” But she prevailed both in the fight, and the court-martial. When she died, it was discovered at her post-mortem exam that she was, in fact, a female. Also elucidated was that she had had a child, which she obviously hid from society.

 

Florence Nightingale worked with Dr. Barry in that war, but the two did not get along. There were nurse-surgeon hierarchical issues, something that remains a point of contention at times, even today.

 

Wars have always advanced the surgical sciences, because with war comes trauma, which usually requires intervention to stop the bleeding, cut off the mangled extremity which would only get infected, and eventually kill its owner, extract the bullets, dress the burns, etc. Dominique Jean Larrey was Napoleon’s surgeon, and whatever battle, whatever country Napoleon went to, Larrey was sure to follow.

 

He made the astute observation that the sooner the surgeon gets to the injured soldier, the better the outcome. With that as his leading theme, and observing how quickly the French “flying artillery” crisscrossed the battlefield, he adapted it, and “Voilá,” came up with the “flying ambulance.” It may have been a bit overstated, as it was just a horse-drawn cart, but it served its purpose, getting the fallen soldier off the battlefield, and into the surgeon’s tent. He created the rule for triage we still use today, treating the wounded according to the seriousness, and urgency, without regard for rank, or nationality, of the injured.

 

The concept of early intervention would be copied, and improved by another icon of surgery, Michael DeBakey, in the 1950s, during the Korean Conflict, where the Mobile Army Surgical Hospital (MASH) was set up right in the conflict zone. Only this time the horse and buggy “Flying ambulance” was replaced by a real flying machine, a helicopter, dubbed the “Angel of Mercy” by the soldiers on the battlefront.

 

 

 

Edward Jenner studied anatomy and surgery with John Hunter at St. George’s Hospital in London.     Jenner took Hunter’s advice, a well-known philosophy among the intelligentsia of the Age of Enlightenment, “ Don’t think, try!” In  1796 he noted that milkmaids that contracted “Cowpox” did not get Smallpox, a disease that wiped out one in five inhabitants in the villages in Briton.  He experimented by inoculating his gardener’s son and even his own son with pus he had collected from the pustules of infected cow’s udders.  Although the children had a mild febrile illness with skin lesions, they were immune to the lethal form of the disease.  He coined the word vaccine from the fact that it came from vaca, the Latin for cow.  Jenner has saved more lives than any individual in human history including today. It was in 1970 that the World Health  Organization declared  Smallpox eradicated, in no small part due to vaccination.

 

 

In 1822 Alexis St. Martin was shot, by accident, in the left lower chest. A Surgeon, doctor William Beaumont, was called to attend to him. Beaumont did not think that St. Martin would survive, but he did. Beaumont took the opportunity to study him, becoming the father of gastric physiology. He put bits of meat on a string, and placed it through the skin opening into the stomach, but retrieved it periodically, to see what the stomach acid did to it. Alexis attempted to escape from Beaumont, but was caught, and returned to him for further study.

 

 

 

 

Louis Pasteur was a brilliant chemist, who came up with the germ theory of diseases, that ended the popular idea of so-called spontaneous generation as a reality. Pasteur discovered the etiology of TB, rabies, as well as cholera, smallpox, anthrax, and made vaccines to block rabies, smallpox, and Anthrax. He ascertained that most bacteria were killed by the heat generated with the process of Pasteurization, a life-saving discovery that saved, perhaps millions, through the ages, and still does.

He contributed to a variety of industries, among them the fermentation of grape juice, and silk manufacturing. He recognized that virulence is variable. Less virulence allowed vaccination, while more virulence led to epidemics.

He is also responsible for giving us the understanding that many chemicals have a mirror image form, each with different characteristics. Although he was not a physician, without him, we would all be ignorant of microbiology, the cause of all bacterial and viral diseases.

The implementation of Pasteur’s discoveries, however, took a while to permeate all of the medical community. The Viennese obstetrician and surgeon, Ignaz Semmelweis, wrote a paper explaining the cause and prevention of the dreaded Puerperal Sepsis (Kindbettfiebers). He noticed that in his hospital, the Allgemeines Krankenhaus, in the city of Vienna, the service of the professors had a much higher maternal mortality than the women who were delivered by midwives. The professors would do the autopsies on the women who died, and then proceed into the delivery room, often not washing their hands, or changing clothes. Semmelweis believed in Pasteur’s work of tiny plants that cause disease, but the professors in Vienna didn’t. They laughed at Ignaz. “Tiny plants growing on your hands … Ridiculous!”

 

All he wanted was for us to wash our hands between patients! He lost his job, but continued railing against his colleagues in the newspapers, claiming that they were killing women… which indeed they were. To stop him, they had him committed to an insane asylum, where he died, a broken, discredited man, with the knowledge that he was right.

 

ROBERT KOCH 1843-1910

Robert Koch was a Surgeon during the Franco-Prussian War, and later led the battle against ignorance of the denial of microbes. Koch’s postulates helped in convincing the world of the truth of Pasteur’s theories:

  1. The bacteria must be present in every case of the disease.
  2. The bacteria must be isolated from the host with the disease, and grown in pure culture.
  3. The specific disease must be reproduced when a pure culture of the bacteria is inoculated into a healthy susceptible host.
  4. The bacteria must be recoverable from the experimentally infected host.

The above are the four famous Koch’s Postulates that prove the etiology of a disease.

 

He identified the bacteria that caused anthrax, cholera, and tuberculosis. He also developed the PPD (Purified Protein Derivative), the still-used test to determine if the tubercle bacillus has infected an individual.

 He did not patent it, as he wanted it available to all for study, and disease prevention, thus giving up all royalties that could have made him a rich man. He discovered Agar, (a product of red algae), still used today to grow bacteria. He garnered the Nobel Prize in 1905 for his achievements.

 

Joseph Lister listened to Pasteur. He believed that the little plants do cause infectious diseases. Pasteur advised the railroad builders that if the railroad crosstie timbers were soaked in creosote, they would not rot nearly as quickly as when untreated. Lister used the phenol extracted from creosote and devised an atomizer that sprayed the phenol (carbolic acid) into the air. He used it to spray into operating rooms, and soaked his hands in carbolic acid before surgical procedures, and also dressed wounds in bandages soaked in it. Lo and behold the infections all but disappeared! That too took a while to sink in, with no help from literature. The Lancet, which was and remains a respected journal, warned the profession against these “progressive ideas”! Something they failed to do when they promoted hydroxychloroquine for Covid.

 

The above is Lister’s invention that made a vapor of the phenol that was sprayed around the operating theater.

 

 

 

 

 

I visited Lord Lister’s home on June 7, 2005, to pay my respects, about135 years after he lived in Edinburgh, Scotland, with his wife Agnes, daughter of James Syme, the innovator of the Syme amputation (cutting half the foot across the metatarsals). Lister eventually replaced Syme as Chair of Surgery.

 

 

 

Lord Lister (center with his hands clasped) surrounded by all his residents at the Old Royal Infirmary of Edinburgh 1855.

 

 

 

 

 

In eighteen-forty-six, William Morton, a dentist, gave a public demonstration on the effects of Ether at the Massachusetts General Hospital. The operation was to be the removal of a neck tumor. He used a device that contained a sponge soaked with Ether. He had learned about Ether when he was a medical student at Harvard, from his chemistry professor. Much of the rest of his life was spent in trying to profit from this drug and trying to claim credit for its discovery.

 

Morton’s tombstone reads, “Science has control over pain.” Shortly after Morton’s public display, a Scottish obstetrician, James Y. Simpson, introduced Chloroform in 1847, which had a much quicker onset but was more of an explosive risk than Ether. Queen Victoria made Chloroform popular when she used it for the delivery of Prince Leopold.

 

 

Wilhelm Conrad Röntgen was a German physicist who was experimenting with cathode tubes, and noted that a strange and eerie glow was coming from them in the dark. He surmised that they emitted some kind of energy, that he named the X-ray. He exposed his wife’s (cleverly not his) hand to it, placed a photographic plate underneath it, and there were her bones and wedding band, the first X-ray. X-rays revolutionized diagnosis, and consequently, treatment. Without X-ray, we would literally be in the dark!

 

 

 

BERNHARD RUDOLF KONRAD von LANGENBECK 1810-1887

 

Langenbeck was a German surgeon who gained much of his surgical training courtesy of numerous wars against Denmark, Austria, Prussia, and France. After the various wars, his hospital was Charité in Berlin where he became acquainted with Rudolf Virchow, “the Father of Modern Pathology,” (whose name is memorialized in the Virchow’s Triad and also Virchow’s node). They are both honored by a building dedicated to educational purposes and a meeting place for physicians – the Langenbeck -Virchow- House in Berlin. Langenbeck invented a variety of instruments, especially retractors that still grace surgical trays in every operating room. He is perhaps best known for creating the method of training surgical residents, and is considered the “Father of the Surgical Residency.” The term “resident” derives from the fact that Langenbeck insisted that the surgeon in training would reside at the hospital 24/7. Hence he or she is a “resident.” The famous surgeons that were part of his house staff read like a Who’s Who in surgery: Billroth, Kocher, Bassini, Esmarch, Trendelenburg, and even Halsted spent a short time with him.

 

 

 

Mary Edwards Walker 1832-1919

The only woman ever to receive the Congressional Medal of Honor was for her services above and beyond the call of duty during the US Civil War. She was the first woman surgeon in the Union Army, and was captured by the Confederates, and treated as a spy. She was raised on the family farm in New York state. From that time on, she wore men’s clothing, as it did not restrict her ability to work alongside her brothers in the heavy labor farm work required. Her medical education was at Syracuse Medical College. She was an active surgeon during the war and participated in numerous battles including Manassas, Fredericksburg, Chattanooga, and Chickamauga.

Even when captured, she helped Confederate doctors perform amputations. During her imprisonment, she suffered neurologic damage, for which she received a military pension after the war. She lectured and was active in women’s rights movements that made her popular among feminists and female physicians. She died in 1919, one year before the 19th Amendment to the Constitution passed, which guaranteed women the right to vote.

 

Theodor Billroth 1829-1894

Langenbeck’s illustrious protégé, went on to found his own school of surgery, the Vienna School, that in-turn produced more famous surgical icons, with many firsts: Wölfler- gastroenterostomy, Czerny- vaginal hysterectomy, Mikulicz- the pyloroplasty, Eiselsberg- the founder of neurosurgery and creator of the ER, and William Halsted- the radical mastectomy.

 

 

 Billroth was an amateur musician and had mastered the violin and the piano. He had also bought the former home of Ludwig van Beethoven, and often Billroth would host musical evenings with Johannes Brahms, the composer considered by many to be Beethoven’s successor. Billroth often invited his resident, Jan Mikulicz, an accomplished pianist, to play quartets, and the like, in Beethoven’s former residence. Jan became one of the great surgeons in his own right. 

 

 

Billroth was the creator of many firsts in surgery: the 1st gastrectomy, the 1st esophagectomy, and the 1stlaryngectomy. He was an early adopter of the white coat and asepsis. His methods of reconstructions of the stomach, post resection, bear his name, the Billroth I, and the Billroth II, which confuses every beginning surgery intern. One intern  even  asked  me  whether it was Dr. Billroth I, or Dr. Billroth II, that was the more famous one.

Robert Virchow 1821-1002

Virchow, although not a surgeon, was crucial for surgeons to do their work. He was the “Father of Pathology.” He produced volumes of scientific articles in excess of 2000, introduced the microscope for use in pathology, and developed many principles of the medical sciences. Omnis cellula e cellula– all cells (come) from cells. He coined words and christened multiple diseases, such as spina bifida, amyloid degeneration, leukemia, chordoma, embolism, thrombosis, parenchyma, osteoid, and many more. He is the sole inventor of the modern autopsy, a systematic investigation into a deceased individual’s journey from birth to death. His work at Charité in Berlin influenced many surgeons, including Kocher, Langenbeck, and Bergman. He ventured into a diverse variety of fields in addition to medicine: anthropology, forensic criminology, and politics among others, vehemently disputing that Aryans can be identified as a single race, much less be superior to other races. “Medicine is a social science, and politics is nothing else but medicine on a large scale,” he remarked. Virchow’s strong opinions inevitably led to a confrontation with the most powerful politician of the time, Otto von Bismarck, Chancellor of the German Empire. Robert got under Bismarck’s skin to such an extent that Bismarck challenged him to a duel. By the rules, the challenged chooses the weapons. Virchow brilliantly chose Kielbasa, Polish sausages, filled with Trichinella Spiralis, the cause of Trichinosis (also his discovery). Bismarck turned him down as the duel was undignified and furthermore Bismarck thought it too risky.

 

The Romans and the Dark Ages

Galen, surgeon to the Gladiators

Much of what the Greeks knew, the Romans adopted. But they added their own knowledge through Celsus and Galen. Celsus was an encyclopedist, and likely not a practicing physician. He compiled the known Materia Medica, as well as the surgical knowledge of that era in one compilation, De Medicina, where he describes the techniques of fixing an umbilical hernia, draining an abscess, and removing foreign bodies. Celsus also recommended putting honey in the abscess cavity. He admonished surgeons to cut away the dead skin to allow adequate drainage to continue. Galen was a practicing surgeon who started his career in the gladiatorial colosseum of Pergamum. As in the Greek era, the dissection of humans was still not allowed. He learned from dissecting monkeys that he regarded as very similar to human anatomy. Also, when he treated injured gladiators, he gleaned  the essence of human anatomy. He had very advanced instruments, and used them to great advantage  in his job  as a  surgeon  to  the  gladiators. The mortality of gladiators dramatically decreased after he started caring for them.

Roman surgical instruments used in the Second Century A.D. found in Bingen, Germany

Because he had imperfect knowledge, based on animal anatomy, he got some things wrong. He never understood the function of the heart and thought it was like a tidal wave organ that created a “to and fro” motion of blood, just like waves.

Galen thought that the left and right side of the heart was connected by openings in the heart’s septa, an idea that was eventually refuted, and disproved by Andreas Vesalius some 1500 years later.

The second Dark Ages, from the 5th to the 15th century AD, were indeed dark for surgery. Disease was again thought to be God’s punishment for man’s wickedness, reversing the teachings of Hippocrates. Treating illness, therefore, was thwarting God’s will, and thwarting God’s will is not the right thing to do. Little progress was made in the middle ages. Bloodletting was the standard treatment for whatever ailed you, from headache, sore throat, and just as a prophylactic measure to “keep you healthy.” During the plague epidemics, doctors refused to visit patients for fear of becoming infected themselves. Nevertheless, healthy nutrition was advised to have a higher resistance to disease, and compulsory baths, at least four times a year, were mandated, whether you needed it or not. Bladder stones were crushed with curved forceps inserted transurethrally, or by manual methods, transrectally. The barber-surgeon needed to be ready to leave town quickly, if his ministrations went awry.

Although darkness descended on all of the former Roman Empire, the Middle East enjoyed the unfolding of the Golden Era of Islam from 700 AD to 1400 AD. Science, culture, art, and medicine flourished, as the descendants of Mohammad did not discard the wisdom of the Greeks. Socrates, Aristotle, and Plato were preserved. The Islamic culture maintained the knowledge that had been so ardently developed by Aristarchus, Archimedes, Pythagoras, and Hero, as well as the Hippocratic philosophy in dealing with the sick.

Islam was much more open to accepting other cultures than it is now. As Islam spread through northern Africa into the Iberian Peninsula, great centers of learning sprang up in Cordova, Segovia, Toledo, and Barcelona, in what the Muslims called Al-Andalus. The intellectuals of the Court of Charlemagne stole over the Pyrenees into Al-Andalus to study at the madrassas (schools) to learn algebra, trigonometry, and medicine. The great Arab physicians were Avicenna (Ibn Sina) and Abulcasis (Al- Zahwarwi). We owe the use of ligature with catgut and the control of bleeding to those doctors of medicine and surgery. Abulcasis was the first to do a tracheostomy, and he invented some 200 surgical instruments, including obstetric forceps. He introduced temporal artery ligation for the treatment of migraine headaches, brought back the Hippocratic method of reducing the dislocated shoulder (euphemistically called the dirty sock method because the doctor put his heel into the armpit of the patient, grabbed his hand, and pulled). Abulcasis even realized that teeth needed to be cleaned to keep them from getting caries. Lipstick and perfume were also among his ideas. In The Canon of Medicine,  Avicenna outlined his tenants of caring for the sick, and recognized that we must wash our hands between patients a millennium before Ignaz Semmelweis reintroduced that concept, an idea that was not accepted by Ignaz’s contemporaries, and eventually drove him to an insane asylum where he died.

Abulcasis had a variety of instruments which he invented for his use.

VETERAN’S DAY

In remembrance of Veteran’s Day.

Major Iwasiuk was stationed in the Azores, Portugal from 1970 to 1972, during the Vietnam War. He proudly served his country in the United States Air Force Medical Corps. He bravely defended the Azores and not one Vietcong made landfall during his tour of duty.

The Early Years

PROLOG: I do like to write.  I have written eight books and numerous essays including peer-reviewed scientific articles.  I think my reasons to write are similar to any artistic endeavor, to get recognition, to impart knowledge, scholarship, gentility, enlightenment, and civility, among the many motivations.  But when my writings call forth hate, disrespect, lack of intellect, or are targeted for censorship, and my name is listed for future punishment by the evolving “thought police,” my reasons are not fulfilled and, in fact, become perverted into something I reject and is not why I like to write.  I am delighted to have people comment on my writings with support or intellectually stated opposition.  I like a good discussion. That makes it worthwhile.  When the opposition is hateful, threatening, or nonsensical, it is a turnoff. Yet I still want to write! For the time being, I am going to turn it back to writings that tell a tale or aim to educate.  I have been a professor in my past life, so I believe I can deliver on that.  One of my last books was on the history of surgery; We Stand On the Shoulders of Giants, whose target audience were surgeons in training, and which has had a modicum of commercial success. As my first effort, I am going to serialize that book and put out one chapter a week.  It is not full of “doctor talk” and tells the very human story of how we learned to use the knife on our fellow humans to cure, to help, and to ease suffering.  It is readable for general audiences, and I hope you find that interesting. If you want it all at once, you can buy it through Amazon.com. Once in a while, if some really juicy political point comes around, I may not be able to resist commenting again and just expect and learn to tolerate the hateful comments and assure a place on AOC’s Enemies of the People list following in my parent’s footsteps.

AND NOW: THE EARLY YEARS

When did humans decide to start whittling on other humans, not as a means to harm, but as a means to cure? We don’t really know when surgery made its debut, but we do have evidence that some 8,500 years ago Homo Sapiens decided to open other Homo Sapiens’ skull bones, for reasons that are shrouded in the fog of history. It could have been earlier, as there is no trace left from flesh that long ago, but there are trephination holes in the calvarium of skulls that were found in northern France from 6500 BCE. These were very precise, perfectly round, and not only done intentionally, but with great care. These also show evidence of healing, as the holes they made started to have remodeled bone at the edges, proving these people survived their “operation,” at least for enough time for the bone to
reshape itself, which would suggest several years. We have known that Neanderthals used stone tools to kill, and butcher their fellow species, by finding knife marks, as well as teeth marks on bones, and opening marrow cavities to extract it, as long ago as 100,000 years, but that was not for benevolent purposes, and these beings did not survive those assaults. The
trephination holes, however, were clearly meant to alleviate some real or imagined maladies, perhaps releasing blood clots, or evil spirits, that created mental aberration in their “patients.”

In ancient Peru, similar skulls were unearthed, and not only were holes made, but means of closing the openings were created with, at first, the bone that had been excised, but later with very precisely made gold plates that fit perfectly into the defect, without falling into the brain. I have seen them in the Gold Museum in Lima, but they were from later times, perhaps 500 years, or thereabout. They were more successful than similar efforts, just a couple of hundred years ago, during our Civil War, when almost no one survived that kind of insult, because of wound infections and sepsis. The Incas used very sharp obsidian glass knives (Tumi knives), sharper than modern scalpels, and likely had the use of topical anesthesia provided by the indigenous coca leaves, to keep their patients from having pain. How they prevented infection remains a mystery.

To the left is a pendant I purchased for my wife, of an Incan ceremonial Tumi knife, at that museum in Lima, Peru. It was also used to open the chest, to harvest hearts for their human sacrifices.

The Code of Hammurabi, inscribed in a large rock with cuneiform writing, is of the Babylonian era in 1754 BCE. It outlined all manner of laws, that included a code of conduct, from a means of establishing a fair price to pay an ox-cart driver to transport an amphora of wine or oil, to what a surgeon could charge to set a bone or open an abscess. Even back then, there was a price to pay. If the surgeon caused a patient to lose an eye, the surgeon had both his hands cut-off in retribution. Now the law just takes the surgeon’s bank accounts to settle the claim and leaves his hands so he can continue to pay off his debts.


Egypt was the next world power, exerting its influence from Africa to the far reaches of Asia, with its culture, goods, and gods. Writing was already well established, and a document that was 4.48 meters in length, was bought by Edwin Smith, who was a dealer of antiquities. He acquired this scroll in 1862 in Luxor, Egypt. Hieroglyphics had just been decoded, thanks to one of Napoleon’s officers, who found the Rosetta Stone on one of the Egyptian campaigns. It was a decree of Ptolemy V, written in three languages: Ancient Egyptian in Hieroglyphic Script, Demotic Script, a more modern Egyptian language dating to the 5th Century AD, and Greek. The Rosetta Stone allowed hieroglyphics to be deciphered. The Edwin Smith Papyrus dates to the 16th – 17th Dynasties of the Second Intermediate Period of ancient Egypt, ca 1600 BCE. Where previous writings were based in magic, this one was rational and scientific, with just a few magic spells that could be used as a last resort. It was likely a manual of military surgery, dealing with war injuries, wounds, tumors, and dislocations. The Edwin Smith Papyrus had treatment options for lacerations with wound suture closure, bandages, splints, and controlling bleeding using raw meat which would have factors that promoted blood clotting. Honey was found to prevent infection and is still used today for that purpose. The word “brain” was first used in this document before it was in any other language. It surpassed the medical knowledge described by Hippocrates, who lived a thousand years later.

Egyptian surgical tools were quite sophisticated (see left). The Egyptians were also very knowledgeable in anatomy, as they had that experience from dealing with the dead, by separating the organs for burial into Coptic jars, from the rest of the body.
Later the 1st Dark Age descended on all of that. The Late Bronze Age Collapse, the half-century from 1200 BC to 1150 BC, set back humanity for nine hundred years. The cause is unknown, but likely was climate change related to Vulcanic activity. If you have ever been to the island of Santorini in Greece, you will appreciate that a whole island went up in smoke, and left just a narrow crescent of land for human habitation. Culture, knowledge, medicine, and economies just melted away for centuries.
India, far away from the volcanic mayhem, was not affected by the Bronze Age Collapse. The culture was on par with Egypt. They had medical treatment with herbs, medications, and surgery in 1500 BCE that rivaled anything in Egypt.

Maharishi Sushruta describes drilling decayed teeth and using plants, probably marijuana, for easing pain during procedures. India had the strange custom of punishing people by amputating their noses. Without a nose, individuals are quite disfigured and have a severe shame stigma. Sushruta devised a very sophisticated reconstruction of the nose, from the forehead with a rotation flap.

After a long sleep, Europe woke up. Greeks revived culture, art, science, math, philosophy, and medicine. Hippocrates lived from 460 to 350 BCE (90 years). He denied the theory that disease was because of the god’s punishment of man. He espoused the belief that man’s maladies were the result of diet, living habits, and environmental factors. We owe Hippocrates for the ethical and moral foundations of the medical profession. Although the Hippocratic oath is often modified, and is not in its original form, most doctors have taken a version of the Hippocratic Oath which contains some or all of these principles:

• Avoid causing harm
• Respect your teachers
• Share your knowledge
• Leave the knife to those that are expert craftsmen therein
• Empathize with the sick
• If you don’t know, say so
• Respect privacy (the first version of HIPPA)
• An ounce of prevention is worth a pound of cure
• Treat the person, not the disease
• Do not give poison to the patients, even if they ask
The exact phrase, “Primum non nocere” – “First do no harm,” does not actually appear in the original oath. It is attributed to Thomas Sydenham, the English Hippocrates, and Father of English medicine, who introduced us to opioids, and cinchona bark (quinine) for treating malaria. The emblem of the doctor is the single staff with one serpent coiled around it. That is the staff of Aesculapius. The two snakes coiled around a staff that has wings is the sign for Mercury, the messenger god, the god of business, and thieves.
The staff of Mercury was mistakenly designated as the medical emblem when the US Army was designing uniforms, and a typical government
“Olympian God Dummkopf” picked the wrong emblem.

COMMUNISM /DEMOCRATIC SOCIALISM

This is my last political commentary for awhile.  The election has given me a headache and writer’s block. I am sorry not to see Trump win because I thought he had a clearer vision for our country with no Socialism, less intrusive bureaucracy, a more logical immigration policy, a realistic energy policy, a robust foreign policy, and spectacular economic success twice. Although his tweets were often disturbing, 70 million Americans voted for Trump, but 75 million voted for Biden. Too many male and female snowflakes could not accept a strong personality, a New Yorker who did not mince his words. He meant what he said and said what he meant. You know what he stood for, unlike a lot of politicians.  

I accept the majority decision to elect Joe Biden if after all the legal challenges it truly turns out to be a majority.  Unlike some of my friends, I will not wear any “NOT MY PRESIDENT” T-shirts, as I believe that once the people have spoken, we should be loyal to our country and our democracy.    I wish him well and hope that he will be able to remain President for all four years and have no physical or other issues to hamper his ability to perform his duties as President.  Joe is not a Socialist, and I don’t wish for him or our country’s path to be dragged to the dark side of Socialism, which is likely if Kamala takes over for him.

I must say that Kamala was a calculated choice for VP… with very little experience, even counting a brief three-year stint in the Senate, to be second in line for the most important job in the world is more than bothersome. There were more qualified women that he could have chosen. There were many racially diverse people that were more suited for the job. It was a sharp left turn that he thought would attract that side of his party. That really didn’t work all that well for him. The Democratic seats in the House were trimmed, and the Senate likely will remain in Republican control. Likewise, the majority of state governments remain in Republican control which will make an impact on the upcoming redistricting. Instead of the predicted blue wave, it was more like muddy water.  Biden will have a difficult job negotiating his boat through the hazards of trying to continue the growth of the economy, while at the same time battling the virus that has so far defeated all countries in the world (despite the fact that Trump will be gone) and with or without science or social distancing. It will be up to the vaccine (if it works) to defeat it). Politically he has the radical left-wing that will not let him negotiate with the moderate Republicans without giving him considerable pushback, insisting instead on their agenda of abolishing fossil fuels and switching to renewable energy sources. Gridlock will face him not only in his own party but the whole mix of House, Senate, and Supreme Court mediations. Socially he is caught between defunding the police and controlling the racially charged mobs.  This is in the face of more black people, especially men who voted for Trump than in any other election. In the words of Willie Brown in his freelance column in the San Francisco Chronicle, November 7, 2020, Willie’s World, “It’s not a pretty picture.”

Many of you will not be familiar with Kamala’s ascent to power.  Willie Brown was the powerful Speaker of the California Assembly.  He was a skillful black politician, who ran the California State Assembly for 15 years, and I must admit one of the best orators I have ever heard. When I was a representative of the California Medical Association, he addressed our Medical assembly.  I briefly met him at one of the CMA annual meetings when I was President of our County Medical Society.  He kept us (600 doctors) waiting for two hours (and we all waited) when he appeared roaring up in his red Porsche, with a Highway Patrol escort, sirens and all. He gave a great speech, just what doctors wanted to hear, giving him a standing ovation. Willie was a real politician.  The reason I mention him is that he was the person that launched  Kamala into politics when she was 29 years old and he was 60 years old.  Because of him, she became the Attorney General of California (California’s “top cop”).  A recent article mentioned her liaison with Willie after he separated from his wife. I am sure that because of a typo in the article, she was mentioned as a “mattress” for Willie Brown (instead of the intended word “mistress”).  But in retrospect, it was perhaps not that far off target for a typo!  I wish her well despite my little story, that I intend to be funny, not malicious,  and that is not why I would not like to see her ascend to the Presidency.  She is the most left-leaning of the left-wing, based on her voting record in the Senate, even more left than Bernie Sanders.

Before I (temporarily) hang up politics, I would like to leave you with one more thought. Kamala and the Squad, along with Bolshevic Bernie, would turn this country into a Democratic Socialist country given the chance.  How do I know?  AOC has already given me all the evidence.  Her latest Tweet was the clincher, a plan to create a list for what she called all the “Trump sycophants” that wrote on social media, like me!  The PARTY needs to know whom to punish for thought crimes. Undoubtedly the “Thought Police” will create the list. Lenin and Stalin, Marxist Socialists and Hitler, the National Socialist, were all fond of making lists.  This governmental surveillance is the classic giveaway described by George Orwell in his novel “1984”. My parents were on the list created by Stalin’s Thought Police that marked them for extermination.  Ironically, I likely will make AOC’s list. Hopefully, with 70 million people in the mix, it will take a while to get to me.

My writings will return to my favorite topics of history and science.  I hope you will continue to read my literary offerings! 

WHERE DO WE STAND NOW?

Modified from Phil Hands

We still don’t know and likely will not for at least a week until all the votes are counted, the mail-in votes, and the military votes that are still to be received, provided they can sort out the issues in Wisconsin, Michigan, Nevada, and Arizona.  As Major Daily of Chicago, my old home town, was fond of saying, “Vote early and vote often.”

There are some conclusions we can reach, even without knowing who our President will be. The Senate likely will remain in Republican control, and the House surprisingly has gained a few more Republican seats as it stands now (199D 188R) but not controlling power.  A divided Legislative and Executive Branch makes for a stalemate government with few changes in our future and is actually preferred by Wall Street because no major legislation will go through.

Biden/Harris, without the Senate, do not have the power to institute the most radical changes, the Green New Deal, changes in taxation, changes in the Constitution, namely the 1st and 2nd Amendment, or Medicare for All. The Senate also controls the funnel of new Supreme Court appointments. The “hypocritical” replacement of RBG turns out to be the potential savior of the Supreme Court. No “court-packing” is possible now, nor is the statehood for Washington D.C. or Puerto Rico. The Constitution is silent about immigration, but historically the Legislative Branch has most of the control of who comes into the country and who can become a citizen.  Nevertheless, the Executive Branch obviously can enact regulations through executive orders, such as building (or tearing down) the wall that impacts immigration.  Biden and Harris are for open borders with no restrictions on immigration.  We may see changes there if Biden eventually gets to 270 electoral votes.  Biden has committed to reuniting the “caged children” with their parents. Most of the parents have been located but have refused to take their children back (a human tragedy), and as we know, possession is 9/10th of the law.  It will be interesting to see how Biden can force the parents to repatriate their offspring.  Speaking of offspring, with a Biden victory, Hunter will get back to the undertaking of making his bank accounts grow. All of China’s activities are likely to go back to business as usual. With Biden/ Harris, we are not assured strict enforcement of law and order, so there may be continued unrest in the large cities with uncontrolled riots, looting, and arson. We may need those 2nd Amendment rights, after all. Biden has promised to rejoin the Paris Climate Agreement. However, none of the member countries have so far lived up to their promises to cut carbon emissions, except for Gambia, and likely will not.

The Green New Deal will have to wait at least to the next mid-term election on November 8, 2022, if they can flip the Senate. Hopefully, more real “climate science” will be elucidated in the next two years before we embark on radical changes in our energy policy.  If there is a change in attitude toward nuclear energy, it may make the debate on fossil fuels immaterial. Building nuclear power plants will nevertheless take time.

Until our election is resolved, keep biting your nails!

CAN YOU BE BOUGHT?

What are we going to get with Biden?  Medicare for all, free education from Kindergarten through college, a guaranteed job with all the amenities – vacation, pension, medical care, etc., universal child care, a guaranteed income for every citizen, reparations for those whose ancestors were slaves or native Americans, affordable housing, and more.

Bernie Sanders figured this all out from behind his desk in Washington, D.C.  He most likely will be Biden’s Secretary of State, with Elizabeth Warren taking the Secretary of the Treasury, and Alexandra Ocasio Cortez chairing the committee on Climate Policy if Biden wins.

A think tank at George Mason University in Virginia, has estimated that the Sanders give away plan would cost close to $3.26 Trillion a year.  The annual revenue of the federal government is $3.86 trillion, and we still have a deficit of nearly a trillion a year except for 2020, which will be 3 trillion because of who else is responsible for everything? – Trump, of course!  The tax revenue would have to almost triple to accomplish this.  When you write your check to the IRS next year just triple the amount.  That should do it! Besides, Elizabeth Warren, being Secretary of the Treasury, can just print more if we run out of money.

Sweden tried something similar in the 1970s.  Their country nearly bankrupted because the high earners were taxed at a 90% level and the average person at 70%.  The high earners moved out of the country, and the ordinary people who could not leave worked less to reduce their income.  Corporations moved out as well.  Sweden had to rescind their stiff taxes and lower the cost of the free giveaway programs.  They are still very generous but have lowered their expectations and taxes.  There could be a restructuring of taxation so that the money will come from people that have nest eggs squirreled away.  These people cannot leave the country as their assets, are in the U.S., either tied up in property, or if they are in retirement accounts those assets can just be frozen. 

Elizabeth Warren calls this the “Wealth Tax.” Of course, the government can do this only once, since when they confiscate the wealth, there will be none left for the next year. How much money do you really need to live anyway?  Besides, we eat way too much meat, and that just produces methane to add to our already massive amounts of Green House Gases, and half the population is obese! Travel will also be markedly reduced because of energy rationing. So we really won’t need very much money! Potatoes are cheap, and you will not be flying anywhere.

This will be the biggest change to our government and way of life.  To accomplish this Democrats will need both the House and the Senate, in addition to the White House and a majority in the Supreme Court. Additionally, fossil fuels will be markedly diminished by 2035 and completely eliminated by 2050.  I hope you like small cars, all-electric of course. SUVs are so over the top anyway! All structures will need either rebuilding or a retrofit to accommodate the new energy restrictions, smaller double glass pained windows, and self-closing doors that do not let heat escape, with better insulation and solar panels on every roof.  All walls will need super insulation, and heat or cooling depending on the season, will need to be rationed. In fact, all energy will need some sort of “fair” distribution so that everyone will be affected equally. Rolling blackouts, schedules of when you can or cannot use electricity, and the cost of energy will have to go up.  As is often the case, some people will be more equal than others. Government buildings will have priority because they must be made comfortable so that the Bureaucrats can work on our welfare, which requires a lot more energy than any activity that we the peones require.

With the takedown of the wall, there will be an increase of migration into this country from our southern border. This will finally make our country consistent with the Statue of Libery that welcomes all to our shores. But there will be some negative results that we must tolerate as a gesture of brotherhood and friendship. There will be additional stress to our safety net for immigrants that need medical care, housing, and food.  With the restructuring of the police, more social services and welfare funds will require emergency funding for the influx of the undocumented workers which, by the way, will increase the unemployment numbers. Since ICE may be defunded as well, large cities will tempoarely (or permanently) need to house the influx of people.  San Francisco style sanctuary measures will become more common in other large cities. It may be wise for anyone who needs to travel to large cities to get an extra pair of rubber golashes to protect against stepping in human waste in the streets. Now wearing masks will have another  purpose, that of mitigating against maloderous smells. That is one way to persuade the population to put on their masks when out in public.

Most of Trump’s reduction of bureaucratic rules will be reinstated, making conduct of business in industry, agriculture, and energy more complex and expensive. This will also impact employment adversely, but it will increase the employment opportunities for the new arrivals as they undoubtedly will work for less.

When you vote on November 3rd, rest assured, Joe Biden will take care of you! He promised!

FOLLOWING THE SCIENCE

Two issues in this election deal with science: the pandemic and global warming.  The candidates have very divergent views on these chapters of science.

What is science?  It is seen as the holy grail of knowledge.  You must follow the science. The Scientific Method, peer review, consensus of 99% of the scientists, the science is settled, the proof is incontrovertible; these are the buzz words when one hears non-scientists talking of science. Real scientists are rarely that certain. Science is supposed to be the opposite of guesswork. But that is precisely what science is –guesswork.  Someone considered a scientist makes a guess, then makes some observations or an experiment or two, and if those bear out his original guess, he/she publishes it in a “peer-reviewed” journal.  Peers are respected people who, if they agree with the scientist, often his buddies, publish his findings. This then joins the body of knowledge that we call “science.” There are, however, flaws in the method.  Sometimes peer review is based on insider trading. I’ll help you if you help me. And payoffs and bribery are not unheard of either. It is sometimes based on jealousy that suppresses a new idea that later turns out to be true.

Galileo Galilei was such a scientist.  He came upon an older idea of a Polish astronomer, Copernicus, who guessed that our planet revolves around the sun (Heliocentrism). Galileo did some experiments using the telescope that a Dutch lens maker had originally invented and proved that we indeed travel around the sun and not the other way around.  He published his findings and presented them to his friend Pope Urban VIII.  That was heresy, and Galileo had to stand trial for his life.  He had to renounce his discovery and was allowed to live in house arrest for the duration of his life.  The truth does get suppressed more than we think, although burning at the stake has become outmoded thankfully.

Many times the scientist gets fooled, or gets lured by flattery, money, or confirmation bias (accepting only results or observation that support your theory and rejecting those that do not) into accepting a false premise that sneaks into the hallowed body of science. Science is still the best we have, but it is not infallible. My point is that nothing is unchallengeable. Nothing is settled. I have been a scientist for most of my life.  Almost nothing I learned in school is useful anymore.   It is full of outdated, often mistaken ideas that, if applied, would kill people. You have to follow the correct science. If that science is new and in evolution, it is almost never settled by any means. The study of a new virus (the novel Corona virus) is “new science.”

We all harbor bacteria (the microbiome) within us, somewhere between two to six pounds. It makes essential chemicals without which we would die. But there are microorganisms that kill us.  Millions of humans have succumbed to them with numerous plagues.  The first historically recorded one was the Antonine Plague during the reign of Marcus Aurelius Antonius in Rome, and was likely smallpox. It took 60 to 70 million lives, including Emperor Marcus Aurelius. 

Infection is facilitated by how virulent the organism is, how many organisms are transmitted, the site and method of entry, and host resistance.  How many organisms are transmitted is a function of how many are broadcast, how many reach the host, which is related to how long the exposure is.  The issue of masks has anecdotal evidence for efficacy, but the gold standard double-blind controlled study that science touts as the only way to be sure has not been done on masks and likely will never get done.  The risks of wearing a mask are nil except for the inconvenience.  Perhaps we don’t need to be absolutely certain; good enough is good enough if it might help.  The social distancing of 6 feet is also an arbitrary number, which likely is not enough.  The science is still incomplete.  Shutting down is probably the most contentious and also has the least science.  The U.S. followed our CDC and Dr. Anthony Fauci’s theory, with its consequence of unemployment numbers approaching the Great Depression and GDP loss of nearly 33%.  Sweden did not lockdown but did voluntary mask-wearing and social distancing. Restaurants, beauty salons, fitness centers, etc. stayed open.  They had an 8.6%  loss of GDP and only minor changes in unemployment. Sweden has 5,933 deaths to date. Their case fatality is 5% compared to ours of 3%.  What is missing in our percentage is all the people with strokes and heart attacks that did not go to the hospital because they were afraid, and all the victims of alcohol, domestic abuse, and suicide because of no job and no income. Anthony Fauci and Anders Tegnell, Sweden’s epidemiologist, had the same data and the same science, yet they came out with opposite conclusions. In retrospect, considering everything, the guess of Tegnell won out with practically the same mortality but not tanking the economy. Following science may or may not be the right thing to do depending on which scientist you believe and what your goals are. It points out you should be skeptical about everything.

The second science topic in this election is global warming.  Al Gore tells us the science is settled. Scientists that don’t follow those precepts are called “deniers,” just like those that deny the Holocaust. It is meant to ridicule!  Climate science is very complex, and the consequences of believing or not believing in what causes climate change are enormous, economically and lifestyle-wise. The earth’s temperature will likely continue to rise, and in 12 years, the devastation will be irreversible, so they say. The global ice caps will melt, and the oceans will rise, flooding the coastal cities and many of the islands around the world.  It is all based on the rising levels of CO2, which supposedly is the main cause of global warming.

Henry Ford revolutionized the world with the Model T. The first one rolled off the production line on October 1, 1908. With that, COstarted to rise. It had been 280 ppm but rose to 300 ppm by 1950 and was up to 415 ppm in September 2020. CO2 is a so-called greenhouse gas that prevents the loss of heat from the earth and is said to cause the average global temperature to rise.  The average temperature has gone up at a rate of 0.18˚C a decade. At this point, it is 1˚C higher than its average. 1.5˚C rise is said to be the point of no return. This is all blamed on  CO2 levels.  Yet CO2 has been below 200 ppm in the past, and the polar ice caps were non-existent, with polar bears running through the lush green forest above the Arctic Circle, and CO2 has also been 4000 ppm, ten times higher than now, with the earth frozen from pole to pole like a snowball.  I do question that  COis the only important factor controlling global warming.  There are so many other factors that could contribute.  Would it not be an irony if we all traded our SUVs for Nissan electric cars, and the temperature kept on rising? Climate has always changed, and that is the only thing that is certain is it will continue to change! Just because a rise in CO2 is seen related to a rise in global temperature is no assurance that lowering CO2 will lower temperature. Just because B follows A  does not mean that B was caused by A, and if A decreases, it will reciprocally lower B.   Something Aristotle call the Post Hoc Fallacy, a classic error in logic. No one has done the experiment of lowering CO2 and seeing a corresponding drop in global temperature.

Text Box: From Ian Plimer's book Heaven and Earth, Global Warming the Missing Science

If anything, good indirect science questions the CO2 greenhouse theory. (see the graph left of global temperature plotted against CO2 and sunspot cycle length. Sunspot cycle length matches global temperature much better than CO2 levels). An interesting aside is that in the year 1812, there were no sunspots.  It was one of the colder years of the century.  It was the year Napoleon invaded Russia. The majority of his army froze to death, and Tchaikovsky had the opportunity to write his 1812 Overture to celebrate Russia’s victory over Napoleon. There are now many scientists that believe we have a lot more time to worry about it.  And we need a lot more basic research before we commit to the Green New Deal, a drastic change that will affect our daily lives.

I am not opposed to decreasing our use of fossil fuels regardless of what it does to global temperature.  Without oil and coal burning, the air would be cleaner, and both these fossil products could be used in a much wiser manner than just burning them.  It is, after all, a non-renewable commodity.  But to do this all within 14-30 years will be devastating to our economy, especially the developing countries.  Taking away oil will be harmful to our economy, but it will be lethal to the developing countries.  The more “progressive” of our politicians are hell-bent on making us fossil fuel-free by 2035, but they have nothing to replace it with except renewable energy, like solar and wind.  These sources provide us with less than 10% of our energy needs.  As I have emphasized in several of my other writings on this topic, Germany has tried to convert to renewable for 12 years now at tremendous expense ( 1.2 trillion € for conversion and 32 billion € a year maintenance) and have only been able to reach 54% of their energy requirements with renewables).  This leaves Germany with electric costs to their population three times greater than ours.

Nuclear sources work very well in France. They provide 75% of its energy.  They have had 12 minor accidents in that industry with no deaths and no long term shutdowns over the 58 years they have been in business. Worldwide, there have been the well-known accidents of Chernobyl and Fukushima, with only 29 deaths the entire time peaceful nuclear has been used. The cancer threat has been manageable around Chernobyl, 0.7% mostly in the cleanup crew who had the highest exposure, and surprisingly primarily thyroid cancer, which has very low mortality.  The most damaging blow to the use of nuclear energy was the 1979 movie, The China Syndrome, with Jane Fonda, Michael Douglas, and Jack Lemmon. A fictional scenario where a nuclear plant accident melts through the earth all the way to China. Twelve days after it premiered, as if planned as a movie promotion, Three Mile Island in Pennsylvania had a meltdown.  There were no deaths from the Three Mile Island incidence, and the nuclear plant only got 15 millimeters closer to China.  The movie, however, grossed $52 million and created more panic about nuclear energy than ever. Compare that to the death toll from coal and oil at 300,000 a year! But the radical environmentalists refuse to consider nuclear and have convinced the population to reject it also. Political corruption had and continues to influence the closure of nuclear powerplants. Powerful politicians that held public office mandated the scrapping of nuclear powerplants and pushed renewables while having major ownership of fossil fuels.  Why would they do that? They knew renewable could not make up the difference, and they just happened to have lots of oil for sale. 

Following the wrong science through thoughtless application, inadequate investigation, corruption, and scientific errors has caused some spectacular disasters. The release of methyl isocyanate into the atmosphere in Bhopal, India, killed 8000 people. Inadequately tested Thalidamide caused 10,000 births of deformed children. A tuberculosis vaccine that mistakenly had live tubercle bacillus gave active TB to hundreds of people. I live in Santa Paula, California. On March 13, 1928, one of the biggest structural disasters in history happened here because a geologist mistakenly built a dam in a cañon with unsuitable geology to support it, and it collapsed, a scientific geological mistake. Six hundred people were swept out to sea. Still, now an occasional body is found. One thousand two hundred houses disappeared, untold animals drowned, 24,000 acres of farmland were destroyed, not a sterling moment for the science of geology!

Perhaps progressives are too far ahead of themselves. Following the science is a good thing if it is the right science.  Following the wrong science is devastating! Shutting down the country again would be the wrong choice. Eliminating fossil fuel without an equivalent replacement would be wrong as well. We need to resist voting in the people who are willing to accept untested science, and science still in evolution, to make life-altering decisions for us. When you endorse people that have a marginal grasp of the science, what can we say about your intellect? It is better not to be so open-minded that your brain falls out! It is always a good policy not to be the first or last to adopt new ideas.