By Richard P. Holm, MD

A.P. Kalem said, “War is never a lasting solution for any problem.” However, is that statement completely true? War, through the ages, has brought great advances and solutions in medicine.

Perhaps the first innovation in medicine that evolved during warring times came with drilling holes through the boney skulls of warriors whose heads were smashed in by clubs. Once a hole was made, one could insert a finger and pull out the caved-in skull bone with the added benefit of providing an escape hole for bleeding, releasing pressure off the brain. There are museums that have 7,000-year-old skulls with healed over burr holes, and this treatment called trephination, is still done today.

During the 1700 and 1800s, the world-wide imperialism of the British came from their conquering navy. This was partially because the Brits knew lime and lemon juice with vitamin C prevented scurvy which is a life-threatening progressive condition of profound weakness, gum disease, skin ulcers and bleeding. Opposing navies riddled with scurvy had no chance against the Brits.

During the Crimean War of the 1850s, Florence Nightingale and her team of newly trained nurses showed how nursing made a difference. They cleaned up injured soldiers, provided a warm dry bed, gave healing nutrition and, in general, cared for the soldier, which remarkably reduced the death rate by two-thirds. Nursing grew from that beginning.

The Civil War brought the advancement of anesthesia with easily used ether and the education of myriads of surgeons who spread their surgical skills throughout the country after the war. Also, the Civil War generated the development of the ambulance wagon, an effective method of transferring the injured from the battlefield to a place for treatment and comfort. For example, in the battle of Antietam, every wounded-living Union soldier was off the battlefield by the end of the day.

During the Boer War and World War I, X-Ray machines became available at portable hospitals, facilitating the repair of boney injuries. The field of orthopedics evolved as surgeons had growing trauma experience along with the aid of anesthesia and antisepsis. Also, blood transfusions and intravenous fluids came to be used during WWI and brought into reality how very sick people no longer had to die from dehydration.

Civil War General William T. Sherman said, “War is cruelty . . . and at best barbarism. Its glory is all moonshine . . . war is hell.” That said, in response to the terrible injuries and illnesses of war, we have learned and improved medicine in ways to relieve suffering and enhance healing during times of both war and peace.

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By Richard P. Holm, MD
 
Ms. A. was in the bagel shop line and told the server she was allergic to peanuts. The server reassured her there were no peanuts in the bagel but was unaware some peanut butter was left on the knife from an earlier sandwich. After a few bites of the bagel, Ms. A.’s face and lips started swelling, she itched all over, slipped off her chair, vomited and fell flat losing consciousness. When the ambulance arrived the emergency team kept her flat, gave an intramuscular injection into her thigh muscle of epinephrine (also known as adrenalin), then took her off to the hospital.  

Anaphylaxis is a severe allergic reaction that can follow exposure to an allergic trigger and will happen in the lifetime of one or two out of every one hundred people. Symptoms are secondary to the release of histamine and other mediators causing a severe drop in circulating blood pressure. Triggers can be from food such as peanuts, wheat, nuts, shellfish or milk, an insect bite or sting, or a medication like penicillin. The full list is long. 
Aside from avoiding the trigger in the first place, the single most important treatment for anaphylaxis is epinephrine which is a hormone released from our adrenal glands. There are few reasons not to give an injection of epinephrine if there is a chance that anaphylaxis is happening. Our bodies make natural epinephrine when we are faced with fight or flight situations. Antihistamines like Benadryl®, Claritin® and others have no role in the prevention or treatment of anaphylaxis as they only help the itch. The single treatment for anaphylaxis is epinephrine, period. Have injectable epinephrine available and near persons at risk and use it if worried. 

To obtain a self-injector of epinephrine, you need a prescription. There are now five types available and they all work well. Ask your pharmacist to get you the least expensive one and be sure you know how to use it.  
The price for a kit with two autoinjectors runs from $375 to $600. The cost to the pharmaceutical company to purchase one autoinjector from the manufacturer was reported as approximately $30 by NBC News in 2016 after a U.S. House Committee looked at the price of autoinjectors. I believe excessive markup of the prices of medicine by drug manufacturers or pharmaceutical companies is unethical and we need to pressure our national legislators to do something about it. 
Patients with anaphylactic allergies must know what to avoid, have epinephrine available, use it when necessary, and after any reaction see their provider. 
​
Ms. A recovered fine and never went without her epinephrine rescue injector again. 
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By Richard P. Holm, MD
 
Starting sometime in the middle ages, throughout many lands, there were “bonesetters” who knew about splinting, how to treat broken bones with splints made from sticks, leather and clay. They even had a guild, a medieval union of sorts, a cohesive group of workers organized to ensure quality, consistency and education. Medical schools for physicians existed at that time, but neither bonesetters nor surgeons attended those schools.
 
In the 1700s, Nicholas Andre’, a researcher and professor of medicine at the University of Paris, formally described splinting, a technique used by bonesetters, as a method to treat boney deformities, such as clubbed feet in newborn children. He likened it to the straightening of young tree saplings. Andre’ wrote a textbook on the subject entitled L’Orthopedie. The ancient Greek word orthos means free from deformity, to straighten; and the ancient Greek word paideia refers to the art of raising a child. Together they provide for the name of a present-day surgical specialty. Literally, orthopedics means to straighten the bent bones of children.
 
Surgical methods in the 1700s and 1800s were very immature. Anesthesia was first developed during the early 1800s and ether was widely used during the Civil War. After the war, surgeons brought their surgical experience home to small towns throughout the U.S. It wasn’t until after the war that we learned of bacteria and discovered we could avoid infection following surgery. In addition, X-rays were discovered by Wilhelm Roentgen in 1895, which allowed for the marvelous and revealing image of our internal boney structure.
 
These advancements helped set the stage for expanding the focus of orthopedics from casting and making-straight the boney deformities of children. In the 1890s, Evan Thomas, a well-known bonesetter from Liverpool, England, encouraged his son Hugh to go to medical school. While learning medicine, Hugh learned from his father bone setting and casting methods, which at the time were not being taught in schools. The younger Thomas was influential in bringing this curriculum to medical schools. He later set up practice with his nephew Robert Jones, and the two worked to develop orthopedic surgical methods in treating bone injuries in construction workers, and then war injuries in military men during World War I.
 
Thus, we trace the evolution from bonesetters, and straightening the bones of children; to anesthetized yet unsterile amputations during the Civil War; to bone setting taught in medical school; to surgical repair of boney injuries in World War I; to the marvelous ever-developing field of orthopedic surgery today.
 
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By Richard P. Holm, MD
 
When in life does one come to confront the tough truth that each of us will eventually die? In my years as an internist caring for young and old alike, some people understand this early, and some people never get it. In denying death, we intensify our fear of it. Usually, however, it is sometime during their 50s that people first look into the eyes of death. Put it off as we may, the hard certainty is that we are all aging and one day an end will come. Shakespeare described advanced age in his play As You Like It, Act II, Scene VII (All the world’s a stage):
“. . . Last scene of all, That ends this strange eventful history, Is second childishness and mere oblivion, Sans (without) teeth, sans eyes, sans taste, sans everything.”
 
Shakespeare’s description of advanced age during the 1600s is rather bleak and scary. I think, with modern medicine and the support of a loving family, we could do better. I clearly believe that advanced age and facing our own death should not fill us with dread. The following is a more hopeful version to end Shakespeare’s excerpt:
“. . . He did not have to end his life alone; If over time he’d shared his caring, raised 
the worth of others, fed the love he’d sown. His death would find him kindly prized and praised, While kin sang festive songs of joy, amazed.”
 
Fear comes from the oldest reptilian part of our brain. Fear helps us run from attackers but can also make us run from making important choices about our health. Fear can even bring us to push forward with treatment that may cause significant suffering, even when we are very old and even when treatment is futile and it’s time to quit.
 
Fear of dying can prevent us from making plans about end-of-life care and, most importantly, prevent us from talking to our families about those wishes. How do we want to be cared for if we should lose mental capacity from a stroke or dementia? Do we wish to have a feeding tube, resuscitation, antibiotics when there is no quality of life left, when one doesn’t recognize family and when the only option will be residing in a bed somewhere “sans everything.”
 
I would rather die and be:
“. . . kindly prized and praised, While kin sing festive songs of joy, amazed.”
 
For free and easy access to the entire Prairie Doc® library, visit www.prairiedoc.org and follow The Prairie Doc® on Facebook, featuring On Call with the Prairie Doc® a medical Q&A show streaming live and broadcast on SDPTV most Thursdays at 7 p.m. central.