Mobile laboratories, champagne and silver nitrate

I’ve been trying to get my head around what the actual day-to-day nursing of a dysentery patient would have looked like – and the relationship between the nurses at the Casualty Clearing Stations with the bacteriologists. What the nurses understood of the bacteriology, their relationship to the process of diagnosis etc etc. 

I’ve been reading an article by a guy called Robert Atenstaedt about the development of bacteriology (full citation below). He talks about the British going into the Crimean War with such a tiny, unprepared medical team (old soldiers who couldn't carry themselves let alone patients). It was the first war after Telegraph was invented, and the immediacy of the news about soldiers suffering (from dysentery amongst other things) generated outrage at home. That outrage drove the creation of the medical corps. It makes me think of learning about Vietnam, the televised war. It also puts Florence Nightingale in context.

He goes on to say that, despite new knowledge, bacteriologists in WW1 were considered low status - it was routine water testing. Anyone with medical training was wanted for what was felt to be more important work. So it makes sense that Sister Williams was able to carve a niche for herself as a bacteriologist. 

 And now it comes to the link between the bacteriologists and the nurses.

Briony, seeking the Wellcome Library online catalogue has found the Mobile Laboratory. We were scanning through a whole screen of thumbnails and suddenly it was there. This image, I nearly squealed.

Atenstaedt describes the first one, quoting :

a motor vehicle was fitted out with all the pathology paraphernalia of the day including microscopes, centrifuges, autoclaves and incubators: 'The inside of this multum-in-parvo thing on wheels was equipped with everything that the heart of a bacteriologist would require’

(if you’re wondering what multum-in-parvo means, it’s ‘much in little” - ie. the old school way of saying ‘tardis’).

He says there were 15 mobile laboratories built, and each had a two-seater cycle car for collecting specimens. I love the two-seater cycle car. It’s our physical link between the nurses and the laboratory. It's the pathway the samples take. 

A woman called Rachel at the British Royal College of Nursing helped me out, showing my how to search their archive. British Journal of Nursing has some fabulous articles about the treatment of dysentery. Some highlights: 

A SEVERE CASE OF DYSENTERY (Dec 1915)

The feeding of the patient from October 22nd to 26th consisted of small quantities of albumin water, egg-flip, jelly, brandy, and champagne, given every two hours

and

WHAT ARE THE CAUSES OF DYSENTERY, AND HOW IS IT TREATED? (a prize winning paper by Miss Bessie Grey Johnson 1917)

The patient should be kept warm in bed, and should use the bedpan for all evacuations... If there is not too much tenesmus, rectal injections of either of the following solutions, as prescribed, warmed to 100' F., should be allowed to run slowly into the bowel from a funnel through a long soft tube :- Boric acid, I drachm to I pint. Nitrate of silver, 5 or 10grains to I pint. Quinine, 10grains to I pint.

I read these aloud to Gregory and Briony who gasp and giggle and at one point Gregory muttered, “Pure witchcraft”.

Another prize winning article is all my heart desires: WHAT PRECAUTIONS WOULD YOU TAKE IN SAVING FOR MICROSCOPIC EXAMINATION, A SPECIMEN OF URINE, A SPECIMEN OF SPUTUM, A SPECIMEN OF FAECES? 

I still have a lot of questions. I want to know who drove the cycle car? Who ordered the specimens? Where did the nurses store them? How far did the mobile laboratories travel? And who emptied the bedpans...

Atenstaedt article details:

"The Development of Bacteriology, Sanitation Science and Allied Research in the British Army 1850-1918: Equipping the RAMC for War by RL Atenstaedt (JR Army Med Corps 156 (3): 154-158) 

And the Logie goes to...

On our journey up to QLD, Scale Free Network(ers) Briony Barr and Gregory Crocetti encountered a chap named Clinton, who lived in a beautiful rainforest home in a hidden little valley of Mullumbimby. Without having even mentioned that we were working on The Invisible War - Clinton told us he was the keeper of a Logie - awarded to his dearly departed friend Megan Williams. 

Before we knew it, the Logie award was in front of us, showing that Megan Williams won 'Most Popular Actress in a single drama/mini-series' for her work in ANZACs.

Megan is also remembered for her role as Alice Watkin Sullivan in the famous Australian tv series 'The Sullivans'. And with a little digging, we discovered that Megan had played the role of Sister Kate Baker in the 1985 TV mini-series ANZACs, which was a hit for Channel 9. 

ANZACs was the first dramatic role for Paul (hoges) Hogan of Australian Tax evasion and Crocodile Dundee fame, but Megan Williams was the real star of the series, winning the only individual Logie.

It's so great to see the role of an ANZAC nurse given Australia's premier TV award so many years ago!

As a rather amazing coincidence, the lovely lady at Auspcious Arts - who manages our project funding from the Department of Veterans Affairs - is also named Megan Williams.

Meet the Scientists: Dr François-Xavier Weill

François-Xavier Weill is one of those rare truly interdisciplinary researchers: one part Microbiologist, one part Historian and one part Epidemiologist.

His work mainly focuses on the evolution, emergence and detection of new strains of enteric pathogens (which basically includes the nastier versions of Salmonella, Shigella, Vibrio and E. coli) around the different human populations on Earth…so that we can better understand how, when and why enteric diseases spread.

Of particular interest to our research, was François-Xavier’s focus for several years on the epidemiological mapping of large numbers of different Shigella species around the globe over the 100-odd years. This (currently) unpublished research specifically shows which Shigella species were prevalent during WWI and suggests how they might have moved around the globe during the war. We’ll link to the article highlighting this amazing body of work when it appears in late 2015!

Briony, Ailsa and I travelled out to Cambridge (UK) to meet with François-Xavier in his home...stopping to admire the punts along the river Cam.

In our highly caffeinated meeting, our discussions included:

• the role of nutrition in affecting the acidity of the stomach – lowering the defenses of soldiers and nurses to dysentery;
• the high similarity between E. coli and Shigella (something Kat Holt had also mentioned) – Shigella is essentially a weaponised E. coli, adapted to infect and rapidly multiply in humans;
• the change from Shigella dysenteriae to Shigella flexneri with improved hygiene, corresponding with the modern understanding of how S. dysenteriae wreaked havoc in the god-awful conditions in Gallipoli to the lesser incidence of S. flexneri in the much improved (and less tropical) trenches on the Western Front;
• how the identity of the dysentery-causing agents were strongly contested in the early 20th century – with many scientists insisting that amoebic dysentery (caused by the amoeba Entamoeba histolytica) was the only significant disease;
• how the high morbidity of bacillary dysentery (that is, dysentery caused by the Shigella bacillus) created such a high burden to the resourcing of the war, considering the need for intensive nursing of each infected soldier over a period of several days to weeks;
• the difficulty in studying dysentery, given that there are no animal models – that is, disease-causing Shigella only infect humans – and it’s never easy to experiment on humans…
• and finally what sensitive creatures Shigella really are, especially outside of their niche in the large intestine!

François-Xavier also made the interesting suggestion that we consider using Shigella dysenteriae type 1 as the anti-hero in our story, due to its ability to make the deadly Shiga toxin…although this presents other new difficulties to our current storyline!

Chasing Sister Williams

Since I found the reference to Sister F E Williams in the Official History of the Australian Medical Services, I’ve been looking for traces of her, wondering if she could be the hero of the story, if she can have ever met D’Herelle, how a woman came to be a bacteriologist at that time anyway.

The folks at the State Library of Victoria sent me this article by Dr Kirsty Harris, University of Melbourne.

It turns out Fannie Eleanor Williams was a noted bacteriologist who specialised in dysentery – starting as a technician working under a bacteriologist in Gallipoli, moving on to Cairo and then the Western Front. Here she is, in the laboratory on Lemos(Australian War Memorial Collection item ID H13944)

After the war Fannie Williams was one of the first three staff members of the Walter and Eliza Hall Institute, Australia’s oldest research institute - the first female scientist employed there. She worked there until she retired, and ran her own lab. They have their own little bio for her - where I found this picture. 

 http://www.wehi.edu.au/about-history/notable-scientists/miss-fannie-williams

Her early published articles were co-authored with Charles Martin, from Army hospitals during the war. I looked them up in the British Journal of Medicine and they look a bit like this:

She says great things like:

Attempts to isolate dysentery bacilli from 217 cases in which the stools contained muco-pus with or without blood were made. In many cases the amount of mucus in the stool was very small…The method employed was to wash the mucus, break it up in sterile broth and plate out some drops on the surface of a MaConkey plate.

Her dates don’t line up for Pozieres, and I think we want our main character to actually suffer dysentery, So it looks like she can’t be the hero of our story. But I’m enjoying seeking the aesthetic of the laboratory between the science-paper lines. I’m wondering what her relationship would have been like with the normal nursing staff, how she obtained her samples (!) (me - not getting over the whole thing about poo samples). There's something about having the specificity of what scientists knew about dysentery at the very moment our story is set. And there's something important for me about connecting this understanding to an Australian woman. Someone who lived in the same city as me. 

Meet the Scientists: Prof. Philippe Sansonetti

Pasteur-ising

How could a trip to Paris be complete without paying homage to Louis Pasteur?

First up, Briony and I visited the Museé Pasteur – a museum dedicated to the legacy of the man who discovered the role of microbes in fermentation, created vaccines for rabies and anthrax and much, much more.

Since the time of Aristotle, it was thought that many life forms spontaneously emerged from water, dust, rotting flesh or the aether. But Pasteur championed the idea of biogenesis (Omne vivum ex vivo "all life from life"), famously demonstrating that sterilised meat will not rot without exposure to microbes from the surrounding air (luckily, he didn’t try that experiment with a McDonalds burger).

Pasteur also famously showed that microbes were responsible for spoiling beverages such as milk, beer and wine – and invented the process of pasteurisation – where the heating of these liquids killed most bacteria and moulds, preventing the potential growth of spoiling or disease-causing microbes.

The creation of the anthrax and rabies vaccines brought great wealth to Pasteur, and led to the creation of the Institut Pasteur  - dedicated to the study of microbes. Still to this day, the Pasteur Institute is a world leader in the research of microbes, particularly their role in disease. And it was here at the Institut Pasteur, that we were to encounter Professor Philippe Sansonetti.

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Sansonetti vs Shigella

The anti-hero in our upcoming book The Invisible War is Shigella flexneri, the bacterium responsible for most of the dysentery (severe diarrhoea) in the trenches during WWI.

While S. flexneri still causes millions of cases of dysentery in the poorest societies on Earth each year, we now understand a lot more about how it causes dysentery – in no small part due to Professor Sansonetti.

The thing that makes all Shigella bacteria so pathogenic (that is, able to cause disease) in humans, is the ability for a very small number of Shigella cells to invade our intestinal epithelium (the wall of our gut). And once inside, these Shigella can take over our epithelial cells – stealing our energy and assimilating our building blocks to make billions more…causing continuous eruptions from our gut wall to invade new regions of our intestine. This process releases lots of blood, which mixes with the eruptions of our intestinal mucus (trying to flush them away), to create bloody, mucous stools – characteristic of dysentery!

Working on Shigella for over 30 years, Prof. Sansonetti has provided the most complete and unified view of any bacterial-controlled disease process. Perhaps not surprisingly, these discoveries are now being employed to develop a vaccine against different types of Shigella still causing illnesses and deaths around the world every day.

We sat down with Philippe to learn more about his discoveries into how Shigella cells invade the human gut epithelium and how they take over once inside – so that we were best able to describe this process in our story. Probably the most interesting thing we learned about was how Shigella bacteria can trigger the ruffling of an adjacent intestinal cell (see above image), a process of engulfing which essentially ‘tricks’ our intestine into swallowing and internalising the Shigella…after which, all hell breaks loose!

Meet the Scientists: Dr. Kathryn Holt

We began our research into the dysentery-causing bacteria Shigella with local expert Kat Holt.

The Holt group at the University of Melbourne are the next generation of microbiologists – a laboratory full of computer nerds, who sequence whole genomes of different disease-causing bacteria. But unlike traditional genome-sequencing approaches, their approach is to sequence and compare whole populations of clinical isolates from different locations, focusing on differences in the genetic differences in their transmission, antibiotic resistance, detection and more.

In our meeting, Kat told us about how so few Shigella can cause an infection and the important role of nutrition in preventing Shigella from infecting and causing dysentery. She also described the Shigella invasion plasmid (a plasmid is a mobile set of genes in circular form, separate from the genome), and the role this massive set of genes play in gaining entry through our defenses and into our intestinal epithelium (the cells lining our gut), and how they take advantage of our immune system to spread throughout our large intestine in a dysentery infection.

Kat also told us about her amazing work in discovering the changing infections of different Shigella species (such as Shigella sonnei) around Earth over the last century and implications this has for the millions of people still infected by Shigella each year and the role that clean water supplies can have in preventing dysentery.

Kat also rightly emphasised that the endogenous (native) human intestinal biota (particularly our resident bacteria) would play a large role in trying to fight off any Shigella bacteria in our gut…something we will surely work into our story!

Researching "The Invisible War": State Library and the nurses

Sitting in the La Trobe Reading Room with its great arched ceiling and old timber chairs. My book requests arrive from the stacks and are announced by text message, lighting up my silent phone. Nurses’ writing. Olive Haynes, Elsie Tranter, R. A. Kirkcaldie, a collection of letters, a contemporaneous diary, an after-the-fact memoir respectively. I read them quickly in the echoing afternoon, skimming for the trenches, for the women’s workload, for their political opinions.

Olive Haynes, from the website of The State Library of South Australia, item B68419

Of course the letters are censored. The memoir is rosy and nostalgic. The journal is full of descriptions of new landscapes, of days off, and the songs the soldiers sang. What did their working days look like? What exactly did they do? What did the wards smell like? Which muscles ached at the end of the day? I want to see the grit of their daily lives. I want to see their horror and despair (did they feel those things? I can’t find it. They are so unerringly brave and hopeful in their own texts). I love Olive best, possibly because of Anzac Girls, finding the letter which must have inspired the Turkish delight scene, or the one from the night of the storm on Lemnos, And of course when she contracts dysentery. She’s so stoic though, and gives very little information, just rails against being kept in bed. I’m going to have to find a first hand account from a person who suffered dysentery elsewhere. I’m only part way into Elsie’s diaries – she’s still so full of hope, of love for the soldiers, of wonder at the places she’s visiting. I wonder how things will change for her and if it will reflect in her diaries? 

Meet the Scientists: Dr. Jeremy Barr

The main stimulus for The Invisible War came from an article by Jeremy Barr “Bacteriophage adhering to mucus provide a non–host-derived immunity”, published in the prestigious US journal PNAS in June 2013.

Here, Jeremy, along with group leader Forest Rohwer, writer Merry Youle and other co-authors described a mutual symbiosis between mucus-producing (animal) “host” with their phage partners – where the virus partner limits mucosal bacteria, while the animal host presents new bacterial hosts in the mucus for the phage to reproduce.

The enemy of my enemy is a phage

Widely hailed as the discovery of a new immune system, we knew we had to speak to Jeremy Barr about the potential to describe this newly symbiotic relationship as a story in our series. We were overwhelmed by Jeremy’s enthusiasm about collaborating to communicate this discovery as widely as possible.

Jeremy also had an implicit understanding about the power of using narrative to engage people in a topic, something at the heart of our mission. One of our extra incentives for creating this particular story was the challenge of writing a story with a virus as a hero…something we hadn’t anticipated at the start of our process of creating Small Friends stories!

Researching "The Invisible War": Coburg RSL

Coburg RSL. Where the Boer War, the World Wars and Vietnam are jumbled together in two glass cabinets of memorabilia. The bar’s furniture is in upheaval, the walls smell of fresh paint and while we sit, turning over artifacts, two men mount a new flatscreen to the wall and then cheer as channel nine lights up the room.

We open medical kits rolled in neat little boxes, that could have been made by Brunswick hipsters selling moustache wax. But they weren’t. They were made last century, to be taken to war.

Gregory strikes gold. “The War Pictorial” a monthly magazine, contemporary to the war, full of photographs. We pour over them, showing each other the images, horses chest deep in mud, hospital tents tidy and shiny, hospital tents bombed and lying in piles of wreckage, women in munitions factories, women with shovels over their shoulders, women welding, women spinning wool to make bandages. I’m compelled by the pictures of these women.