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Hello, I'm Brandon Hewlett. I am an epidemiologist specializing in infectious diseases, and this is the Filth in America podcast, where we're going to explore all things public health. This is episode one, and and the podcast itself came from a course I did, also called Filth in America, at Vanderbilt University, where I was telling a lot of the stories of public health. Where did some of these things that we take for granted or don't even think about today? Where did sanitation come from? How do we know to do this? Where did antisepsis come from, as we'll talk about today? Where did some of these other basic things that we all take for granted come from? And what are the lessons that we can learn from these stories in our modern world? I think this is a real dynamic time in public health when a lot of things that we used to do and take for granted are being called into question. So it's important to think about where these things come from, and that's the goal of this particular podcast. And I hope you'll join us for a variety of episodes. So today we'll dive right into antisepsis and story of Middleton Goldsmith. Today we're going to be talking about the birth of modern antisepsis in the hospital. You know, I think that most of us, when we go into the hospital for a surgical procedure, either planned or unplanned because of a trauma or whatever, we assume that there's going to be a lot of people doing a lot of things to keep us safe while we are there, to help prevent surgical site infections, as we call them. And among these are things like washing hands, cleanliness, a lot of succine shots of an operating room where you see they go through really, really incredible measures to try to keep the operating theater itself clean, to wash hands, put on gloves, sterile gowns, sterile fields. But it's important to note that that wasn't always the case, especially in an era before we have the germ theory of disease. So while physicians, if we go back 160, 170 years, knew about these post-operative complications, things like pus and things like we would call infection coming out of a wound after some sort of surgery were not unknown to people at that time. At the dawn of the Civil War, folks did not really have an understanding as to why this happened and where these things come from. The germ theory of disease isn't really widely known. Louis Pasteur does some experiments in the 1870s and ultimately proposed what we now call the germ theory of disease in 1878, right? Our Civil War is 1860 to 1865 or 1866, depending on how you look at it. So this is long before that understanding. There were some kind of cutting-edge scientists. Um guy by the name of Ignaz Similwise, who was in Europe, theorized that there was something called cadaverous particles that would come from examining cadavers, dead people, for teaching purposes and then going immediately to take care of women who were giving birth or had immediately given birth. Those women oftentimes became sick when that practice was followed, and he very much believed it was something called cadaverous particles, not really germs, but cadaverous particles that were somehow coming with the physicians from the cadaver lab to the living patients, and instituted a hand hygiene regimen using chlorinated Lyme solution, which one can only imagine what that does to their hands, but it does help. He doesn't publish this until 1861, and even then it's not widely accepted. And in fact, uh Dr. Simmelwise dies in an insane asylum in Vienna. So I think it's fair to say it wasn't widely accepted and wasn't widely known in the United States. Oliver Wendell Holmes, Sr., who was a noted physician at the time, he advocated for washing hands, um, certainly as early as the 1840s, but that too was not widely accepted. Um there were many folks that said, well, you know, that just slows down the time in the case, and we don't really need to be wasting time doing these kinds of things. Um there's so many other things that we can be doing that might matter. And the prevailing theories of disease at that time don't have anything that would lead one to believe that dirty hands are the cause of disease. There was two common theories of disease. The older one was kind of the heroic theory of disease that's based on hero in ancient Greece. And this is a concept of the alignment of the four humors and the stars. And a lot of diseases are caused by an imbalance of these humors. So the physician's role was to try to externally rebalance the humors, right? So they might bleed you if the disease was thought to be caused by too much sanguine, which they did for a lot of fevers. Um, generally not a good idea, generally not the thing to do, but that's the way they approached it. The other, and I think more commonly accepted theory of that air, particularly in the United States, was the miasmatic theory. And the thinking there was that there were gases or bad air, uh, miasma literally means bad air, that would come off of things like deteriorating or rotting, trash, flesh, swamps, things like this. And that bad air would waft through and then could cause infection and other diseases. The treatment a lot of times would be to try to do things to eliminate the miasma. So typically you might locate things away from areas that smelled bad, uh. from a butchering operation, certainly swamps you want to be away from. Early on in the history of America, there's a lot of emphasis placed on getting garbage and trash and other decomposing things away from people out of the town. Um, and a lot of uh American public health has its origins in trying to do those kinds of things, uh. And as well as ventilation, right? Ventilation in hospitals, ventilation in ha homes and other places. And in fact, by the time of the Civil War, the lessons of the Crimean War, which is the British War, uh, were widely known, and they recommended a pretty robust spacing of patients. And this was really reinforced by people like Clara Barton, to some degree Florence Nightingale, and other people that were the kind of forerunners of modern nursing, and looking at the cleanliness of hospitals and the diet of people recovering from injury, things that we would take for granted today, those were known. But as the reality of the Civil War uh starts to take shape in this country, we have the problem that no one in the Army, to include the physicians, had ever done anything on this scale, right? This was massive compared to what previous wars, and we have huge numbers of casualties. Early in the war here in Tennessee, there was the Battle of Shiloh, which you can go visit the site. There are more casualties in basically a day and a half of the Battle of Shiloh than were in all previous American wars combined. So the scale of doing these things and the way they have to think about it in an era when there's not ambulances yet, hospitals are just basically tents, they weren't anything special, and that has to change, and there's lots and lots of crowding. In fact, before some of the reforms that happened during the Civil War, at the outside of the Civil War, patients may have only had about 175 square feet per patient in a hospital, which is about a tenth of what the recommendations following the advent of the Crimean War were, so they were crowded in. Interestingly, this miasmetic theory, which we said, you know, is pretty common at the time, led to some things which didn't necessarily have good outcomes for patients. Well, I think decluttering, decrowding patients, keeping things clean, and having appropriate ventilation is generally a good thing. Because of the layout of hospitals and what they don't know, right, they typically have to remove waste, either through bedpans or dumped into some rudimentary sewer that would run by. And of course, it would typically run from the interior of the hospital to the outside of the hospital. And of course, the walls where the windows would be in a fixed facility or the edge of the tent would be also at the edge. So oftentimes the sewage would run that way. So they might move patients towards the edge of the facility where the sewage is running right by them, and they noticed that they got a lot of infections, particularly something called hospital gangrene. So this effort to improve conditions oftentimes didn't result in improvement in outcomes for the patients. There are certainly other times when the way they tried to get ventilation, including cutting holes and ceilings and creating more airflow would actually draw air from kind of dirty areas where the bedpants might be collected or where these sewers were, which are oftentimes open sewers, right across the patient, out the window, and then out of the building. As you might imagine, this is not conducive to healing from a surgical wound. So there's a lot of things that they're trying to figure out in terms of improving the outcomes of these patients. Now, early in the war, right, surgical techniques were known. We were actually fairly good surgeons. The Europeans were typically thought of as the best in the world, but American surgeons weren't too far behind in terms of technique. They knew how to do many of the procedures. And while there are refinements during the Civil War, a lot of the basic techniques were already established, and many of the surgeons would know, not all, but many would know uh appropriate ways to do the surgeries that were required to deal with this large number of trauma patients. However, they didn't always do those kinds of things. Uh the weapons of the Civil War, uh certainly at the outset, were very modern by standards. There was the Mana-ball, a 57 or 566 caliber soft-lead conical bullet that would come out, it was effective maybe as far as 800 yards. But by today's standard, this bullet was moving very, very slowly, uh, about a third of the speed of modern bullets. So while it could go very far, and of course a bullet of that size is going to put a lot of force when it hits somebody, uh, it typically just didn't go through very, very quickly like you would think of a projectile going faster. Uh so it would slam in and typically just tear through the flesh and shatter bone. Oftentimes uh it would take in bits of cloth from a soldier's uniform or whatever else uh he was wearing into the wound. Those uniforms, of course, were fairly dirty. So conditions would be ripe for infection. However, it didn't often just wholesale take off a limb if you were, say, shot in the arm or shot in the leg, right? You'd have a hole uh in a wound and it would bring this stuff in, and when it hit the bone, the bone would shatter into all these little pieces. And you really can't clean all that out. Very, very difficult. So then as now, one of the standard things that would be done would be amputation. I mean, even if you had some of these same types of wounds today, you may well uh have uh amputations because you can't clean all this out. At first, many American surgeons were hesitant to do this, because this is going to result in somebody not having an arm and not having a leg, and there's a lot of societal pressure around that kind of disfigurement at the time. Other times, other wounds, say you're shot in the face or something, you may not be able to amputate. In fact, American surgeons were oftentimes criticized by their European counterparts for not amputating early on. And part of the reason this criticism happened was early amputation definitely resulted in better overall outcomes for the patient. Because by amputating these torn-up limbs, you would decrease the risk of infection. You might imagine you had a wound with all these little bone fragments in there that you can't get out and pieces of uniform and it's dirty and all of this, they get infected very, very quickly. And now today we would understand that's because of the dirtiness and germs getting in there and all of this, but they don't understand the germ part at that time. In fact, some folks thought that the development of pus was an essential part of healing, that this miasma may be coming out. So they didn't amputate as early, early in the war as they should have. Later, by the end of the war, they were amputating very, very early on. And from a technique standpoint, American surgeons were oftentimes thought of as some of the best in the world by the end of the American Civil War. So once they get this part down, and amputation really becomes one of the primary modes of treating, particularly extremity wounds done by these kinds of weapons, there is another problem that really affects soldiers of the Civil War that are going into these hospitals, and that is infection of the surgical site. Now, as we said, that surgical technique was pretty good. Uh one of the big myths is that Civil War era surgeons were just kind of uninformed butchers arbitrarily lopping things off without anesthetic. None of that's true. They were doing the best they can uh with the techniques and the knowledge of the time. Uh you've also got to remember the volume. I mean, there may have been one surgeon uh for every 1,000 or 1,500 uh men, if that. Um when you've got 22,000 men or 28,000 or so uh that you'll see in these medicines all wounded in the space of a few hours, it's really, really, really difficult to take care of all these things. The surgeons really would just go for hours and hours and hours, but they needed to increase the speed, and they did. Uh, and the amputations are also much faster than trying to debrite and clean out a lot of these other wounds. So they were very effective. You could treat more soldiers in the time that you had before they bled out or other things happened, exposure or whatever, and they would die. So they really started doing these things. One of the other myths that I mentioned is that Civil War surgeries were done without anesthesia. That is absolutely not the case. Uh the vast majority, at least 97 percent, probably more, of the surgeries done during the American Civil War, certainly in Army hospitals, were done with anesthesia, uh. There were some innovations in the way the anesthesia was applied. Um and anesthesia really had been the standard for a lot of surgical care since the 1840s. So most of the physicians would have had uh significant experience with it and used it. And even when supplies uh on the southern side began to get harder and harder, they would use whatever they had. If they had chloroform, they would use it, if they had ether, they would use it. Um, and they were experienced in using both. So they were doing these right things, but infections really were the killer. A lot of times if a soldier survived the initial wound, um, which if you're shot in the arm, you probably did, shot in the hand. Uh obviously, if uh you know you take a cannonball to the chest, you probably didn't survive very long to get to surgery. But uh those kinds of wounds were survivable. They would get to a hospital, they would fairly rapidly uh be seen by a surgeon. Um more often than not, the surgeons would consult with each other prior to performing any sort of amputation because you know you can't go back once you cut things off and everyone would agree. And so they they followed pretty good procedures. Um when you amputate the wound appropriately, and again, it really matters where the wound is uh on how successful the amputation. If you think of a leg, uh, you know, if you're shot in the lower leg or shot in the knee, I could cut off part of your leg. I got a little extra leg to work with. If I'm shot in the hip, why you know there's not a whole lot to work with. So the success rate from, say, a lower part of the lower extremity amputation, which is much greater than, say, be shot in the hip, because you've got more room to work with and you can do appropriate amputations, um, and they would leave a flap, close these wounds up, and the patients oftentimes survived this, especially if they got there in time. And as the war goes on and you see the implementation of the levels of care concept that was developed by Dr. Jonathan Letterman, which we'll talk about in another episode of this podcast, um, the speed at which soldiers were cleared from the battlefield really, really goes up. And after these unbelievably bloody days, the bloodest day in American history, Antietam, you know, all of the soldiers that are wounded are cleared from the battlefield in less than 24 hours. So they've got a pretty good shot at making it to the hospital alive and receiving this definitive care, which they did. But then they would tend to get infections, say, two or three days after the procedure. And as we said, this is not completely understood. A lot of folks look at it in terms of a miasma, this bad air contaminating wounds. But physicians did very much try to deal with this because it was a significant factor in determining overall outcomes. Um, by the middle of the Civil War, some 45 to 50 percent in some cases of soldiers that developed these infections died. That's a lot of soldiers coming in that survive the battle-field injury, survive being transported to the hospital, survive multiple surgeries, and then die of infections. And they did try to do lots of different things that were mostly ineffective at managing or treating these infections. Again, with the miasmatic theory, there's thinking about bad air. So many, many hospitals experimented with burning things or putting things in the air that seemed to be pungent or noxious chemicals to destroy the miasma. They would they would do bromine in the air, sulfur compounds, a lot of things that are very pungent, and that kind of makes sense, right? I mean, it seems like, well, gee, this is doing something. When I smell it, it's potent. So, yeah, it could probably kill whatever this miasma. Now, of course, as we know today, that wasn't really the problem. But that's the way they're thinking. Um, they also had topical treatments. At this particular time, they really worry about three types of diseases, one called erisipolis, which today we know is largely caused by. By Group A Streptococcus. It is so named because of a bright red rash that you see on the skin. It is a skin infection that can progress. You see it commonly on the hands and face. It can technically occur anywhere, but certainly on the extremities. At that time, they call that Aerosipolis. The next one was what they called a piema. Today we would call that septicemia. This is where bacteria that have caused an infection or an abscess somewhere in the body, possibly one of these Aerosipolis type things that has become abscessed, progress to where the bacteria now are entering the bloodstream and continuing to multiply and do their things. So you'll get an infection of the blood. You used to hear it colloquially referred to as blood poisoning, but it's really septicemia when somebody can go to shock, septic shock, and they become very complicated patients, and the outcomes for those patients are very, very poor once you get to that point. And then finally the dreaded hospital gangrene. Now, it's important to know the hospital gangrene, the disease that they called hospital gangrene was a hospital-acquired situation where you had dying tissue, and typically there was a characteristic smell associated with the dying tissue. In that particular case, they would try to treat it. Some physicians thought that all three of these diseases were the same thing. Today, what we call gangrene is not the same. Hospital gangrene was really for all these wound infections that would result in kind of dead tissue or some sort of smell. Today we think of gangrene as a disease caused specifically in most cases by clostridium perfingans. It does have that characteristic smell. It does have that tissue death, but we also have different kinds of gangrene. There's wet gangrene and dry gangrene and gas gangrene and different things that we will manage differently depending on what's going on. In those cases, you know, it is again generally this clostridium that's causing it, uh. for dry gangrene, but they're separate uh diseases. Oftentimes, additional surgeries to clean out the dying flesh are necessary. Uh at this time during the Civil War, of course, it's all lumped together. We don't know in most cases that there are germs in there. They just look at it clinically. Well, there's dying tissue, this is a problem. What do we do about it? And so they had a lot of poultices and other topical treatments that they would try. There was a lot of description of charcoal poultices, charcoal thought to maybe pull pus out or pull whatever contaminating miasma out. Um there were other things which I think we would find pretty horrible today. Uh turpentine was commonly used on wounds. One can imagine what that had to feel like. Um they would use certain preparations of hydrochloric, so think bleach, think hydrochloric and other chlorine compounds, which again had to hurt and uh were very, very damaging to the tissue. One of the most common, uh commonly experimented with uh topicals was nitric acid. Again, you can imagine, but nitric acid on an already infected surgical wound. That sounds unpleasant. Um it had very, very, very limited positive effect. And while the nitric acid probably would kill the bacteria, even though they don't know that that's what's happening, it has the tiny little side effect of destroying all the tissue uh that's there. So you're not really uh getting anything positive, right? You're just destroying more tissue. So it didn't work. Other preparations of whiskey were oftentimes used. Coffee was given as a stimulant to soldiers to see if that could get them to perk up, um, and that was found to really be generally ineffective. All right, so on that backdrop, enter Middleton Goldsmith. He was a surgeon in the Federal Army in the American Civil War. He primarily worked in Louisville and Nashville. Um he was born in Port Tobacco, Maryland in 1818. He himself was the surgeon, uh the son of a surgeon by the name of Alvin Goldsmith. Um his father moves to Kentucky and becomes professor of surgery at the Kentucky School of Medicine in Louisville somewhere in the mid-1830s. Um Middleton, his son, served as his anatomy and surgical assistant. Now, at that time, typically the surgeon themselves might have an assistant that would help them with the nuts and bolts of whatever procedure they were doing, uh, wouldn't necessarily lead the procedure. Remember, this is a time before we have all the operating room assistants and all of these things that we have today, and nursing is not as broad a profession at that time as it is today. Middleton ultimately uh enrolls in the New York College of Physicians and Surgeons in 1837, graduating in 1840. He was a very popular guy. Um, he was multi-talented. Of course, he comes to medical school with quite a lot of anatomical knowledge, having assisted his father for so many years. Uh, but he also was uh a guitar player and a banjo player. He knew Greek and Latin, uh, and he had a reputation of being an excellent storyteller. Uh he had actually co-founded the New York Pathologic Society, and by 1844, he became chair of surgery at Castleton Medical College in Vermont. Uh, twelve years later or so, he follows his father and becomes chair of surgery at the Kentucky School of Medicine, and not long after that becomes the Dean of faculty. So when the American Civil War happens, he joins the Federal Army, the U.S. Army, really at the beginning as a brigade surgeon and was quickly promoted up and was promoted to surgeon-in-chief of all military hospitals in Kentucky and later the Army of the Ohio. So he supervises the daily operations of multiple hospitals. And as the war progresses, these multiple hospitals are not only in the state of Kentucky, but also all the way down here to Nashville, where we had quite a lot of hospitals. Certainly by the end of the war, and really 1864, we have a tremendous number of general hospitals in the Nashville area. Now, by the end of the Civil War, hospitals were really three different types. You kind of had an aid station. Today we might think of it as a first aid location, where a person who was wounded would immediately be brought. These were located relatively close to whatever action was going on so that they could get that first aid, and decisions could be made as to who would live and who would go back to a hospital. The next level of care would be a field hospital. Now, these would typically be set up in a structure, but were not thought to be permanent. So they would oftentimes be done in barns, maybe tents. This would oftentimes be the place where patients first got surgical care later in the war, certainly by 1864. There are ambulances that would bring them from the field to dressing station or that aid station back to the field hospital. But there was never any thought that a patient would stay at those field hospitals. They would typically get the rapid surgery that they needed to keep them from bleeding to death. This might include amputations, it might include other things. And then from a field hospital, they would typically be brought back to a general hospital. Now, general hospitals were fixed facilities oftentimes, so they might often be in buildings. Some of them were in tents, but these were not tinted structures that were designed to be moved with any speed. They were really going to be permanent and not really moved. They were typically, particularly with the Federal Army, in cities, and Nashville and Louisville have quite a few of these, so patients are brought back not only in ambulances, but also on the railroad. In fact, the ambulance train was invented in this period to bring patients back to Nashville. So when they had these post-operative complications, it would typically be in a general hospital. And as we said, about 45 to 50 percent of patients, particularly early on in the war, who got hospital gangrene and some of these other infections died. There was very little that can be done. And Middleton Goldsmith is really, really concerned about this problem. And while in his hospitals, many of the recommendations from Clara Barton and the experience of the Crimean War that we talked about had been implemented, this particular problem continued to occur, and he really didn't think that most of the tissue-dissolving treatments like nitric acid and these other things seemed to help. He did notice that in some of his hospital wards, where they used bromine as an aerosolized deodorant and method to get rid of the miasmas, patients seem to recover more. These hospital gangrene patients seem to have better outcomes than other wards. So he starts looking at bromine specifically. And from that, he develops a method of applying bromine deep into the layers of the muscle, down into the muscular layers after surgery, after wounds had been surgically debrided. He had a method of injecting bromine subcutaneously to the surfaces of wounds, and indeed also applying it topically to the exposed surfaces. He really would do all these treatments early on in the surgical care for patients. Generally, he did not continually apply this, so there weren't really needs for a second application unless he noted that the gangrene odor occurred. And he started seeing really, really, really positive outcomes. Patients that ordinarily would be considered expectant at the time, the word for dying, didn't seem to. Oftentimes they recovered. And those that recovered oftentimes recovered far more quickly. Even when a patient can be saved with additional surgical procedures, it might be weeks before they recover. In some of Goldsmith's patients with this bromine treatment, the injected treatment, they might recover from the infection and get back on the road to overall recovery in as little as two days. So he decides to do a more formal inquiry into this particular phenomenon. And he takes a couple of hundred patients as it happens and treats them with this preparation of bromine, and he compares it with not only other concentrations of bromine, but with other treatments. So he has several different groups, patients treated with bromine in any way, patients treated with what they call pure bromine, a little higher concentration of this bromine solution, other ones that were treated with bromine after other treatments failed, those that were treated with nitric acid, some of these poultices, and so on. And amazingly, out of his first 159 or so patients, the vast majority recovered from hospital gangrene. In fact, only four of the patients treated with bromine died. Now think about that in the context of best case scenario before this was 45% of these patients dying. He definitely found that the patients treated with the pure, the higher concentration of bromine did better. 27 of those were initially treated with the higher concentration, and 25 of those patients survived, which is unheard of at the time. Patients that had other treatments that failed, there weren't that many of them, but in his initial trial, there were eight, and all eight of those that had failed another treatment when subsequently retreated with bromine survived, while the other treatments, those that were treated with nitric acid exclusively, typically did not do as well. They had death rates in that 45 to 50 percent ray, and those that had no treatment or only surgical treatment also died at that rate. So it was pretty clear and convincing that something is going on with this bromine. And he gets really excited about this, as you might imagine. And hey, there's a way that we can stop about half the patients from dying. I mean, it gets down from 45 to 4 percent. That's amazing. And it's really less than that by the time you kind of perfects it, it's really 2 percent. Um that is in line with roughly what we might think of today, right? We we don't really expect most patients to die from an infection following surgery, although it does occasionally still happen. Um, it's very uncommon. The majority of surgeries go pretty well from an infection standpoint. We do all these different things to prevent that. So he looks at it and starts implementing protocols at the hospitals that he supervises using this technique. And again, these are larger hospitals in Louisville and later Nashville, uh, a variety of different wound types, but he understands that there's gonna be some skepticism. Remember, we said there were people that had other theories of how to prevent these infections, the hand hygiene and other, and they were not well received. So he knows in order to get this to become standard of practice, he's gonna have to do a study and he's gonna have to write it out. Remember, he is an academic physician prior to the American Civil War. So what he does is he uh writes up a protocol for use in hospitals in Nashville and uh to some degree Louisville. There were more by this time in Nashville, and he keeps doing this same procedure over and over again on more and more and more patients. And he also invites surgeons from other areas to come in and review his data. And some of these surgeons are initially fairly skeptical. Everyone that he invites are fairly senior surgeons that would know uh what the likely outcomes of the various patient types and had taken care of many of these patients over the course of the war in. And uh one was named Dr. Weeks and some others, and they were shocked. They were absolutely shocked at how well this treatment seemed to work, and they also were shocked at how rapidly it seemed to work. Even patients that were retreated with bromine after failing got better faster than patients that were not treated with bromine. In fact, when you had a hospital gangrene patient, they might have no sign of infection within five days. Oftentimes, even by the next day, the signs of the infection were going away. Um they really, really couldn't believe this seemed almost miraculous, too good to be true. But the surgeons that he brings in to look at these patients and review these cases, both documentary descriptions of the cases and the patients themselves, were just shocked and write their own letters. And these begin to be shared throughout the Army, but also into journals that were published around one in particular, the American Medical Times, which is kind of part medical newspaper, part academic journal, and shared with civilian physicians who also read this and are initially somewhat skeptical, I think, in some cases, but start seeing patients that have recovered following this treatment once those patients have come back from the Army and are back wherever they're from, New York or Minnesota or wherever, and they themselves start writing additional articles imploring other physicians to start using the technique of Middleton Goldsmith, this bromine treatment for wounds. So it starts getting fairly wide notice fairly quickly. And so a larger study is done across the area that uh Goldsmith is in charge of and involving multiple surgeons following this treatment. He publishes the recipe for the bromine preparation that he uses so others can try it and experiment with it. And nearly universally, people find that the bromine treatment is effective. There are some surgeons who kind of cling to using nitric acid and to say that works pretty well, but they they kind of concede that while, yeah, the nitric acid works well, bromine seems to do the same thing without damaging tissue. Now, if you look at the data that was initially published, the nitric acid patients, again, don't do nearly as well when uh there's a really detailed and thorough examination of them. But different surgeons have different opinions and they definitely look at it differently. Um this continues to go on. It gets used in more and more different uh types of settings, different kinds of hospitals, uh, different types of patients, and it seems to be successful almost everywhere it's used. The death rates plummet. And in fact, by the end of the Civil War, overall the soldiers who made it to the hospital, depending on which hospital it was, and whether it's a federal hospital or confederate hospital, um becomes about six to eight percent of all the cases amid the hospital actually survived. So you think of all the things that could kill you in a hospital, including your wound, um the uh incidence of death in the hospital really, really, really goes down. Uh, and this is really important. So it does get accepted, and there's all these letters written. So finally, Goldsmith decides to do a formal treatise of some sort about this and go into great detail on how he came up with it, the types of preparations, the types of wounds in patients, uh, list out all his data, what we would call a clinical trial data today. This was a very open process, uh. And he writes all this up into a booklet for the Surgeon General of the Army. Now, um at that time, um, the Surgeon General of the Army is the highest medical officer in the United States Army. Umficer's rank, hence the name of Surgeon General. This person has a lot of policy decisions. Uh it had changed throughout the war. By the end of the war, the surgeon generals that were brought into that position were generally younger and generally more educated in modern techniques, so they were a little more open, I think, to things that Goldsmith was proposing. But also they've got this huge problem on their hands. And I think sometimes the necessity of dealing with these huge problems makes one open to more and more things. So the Surgeon General receives this well done study, comments on it. And by the end of the war, this is standard practice in most hospitals. So you think, well, okay, this is where it comes from. Why it wasn't bromine used everywhere else after that? I've never heard this story before. Well, things tend to change. One of the first things that comes up, the Army, once this booklet is written for the Surgeon General, it's considered an Army document. So they keep it, and while they might share it with other Army physicians after the war, the Army shrinks. By 1867, that's back down to 17,000. I mean, there's just very few people that stay in the Army. The Army is gutted. Of course, after the Civil War, there is no Confederate Army, so there's no surgeons who had hospital experience that are in the Confederate Army. There is some discussion about this procedure. But so that all goes away. And this pamphlet, while published under Army auspices, the Army doesn't continue to publish it publicly. They say, well, it's done, and it goes on. And Middleton Goldsmith goes back to Louisville and resumes his post as a surgeon with that medical school. After the war, many of the surgeons who operated in this area, both Confederate and Federal, go back, many more Confederate surgeons, of course, they can't go back to where they were practicing before the war. I mean, that area might have been destroyed, their house might be destroyed. Certainly there's fewer people. So there are Confederate surgeons that come back into academia that were not there before. Some of the medical schools in the South do not reopen, particularly some here in Nashville, for example, don't, or get absorbed into new educational institutions that are founded later. So there's a big shift, medical education shifts, who's doing it, where they're doing it. So really, as you saw with society around the Civil War, everything shifts. And Louisville becomes a much more Confederate-leaning city. There's a lot of ex-Confederates in the medical community in Louisville. And of course, they don't like the fact that Middleton Goldsmith was this very successful federal surgeon. So he's kind of forced out of his practice in Kentucky, and he goes back to Vermont, where he lives the rest of his life. And he doesn't really practice like he did before the war. He doesn't really work in an academic. He's kind of semi-retired, although he consults, people write him all the time about things. He publishes articles, and he's reading and writing up until he dies. But the primary treatise, remember, this is owned by the Army and it doesn't get the attention. In 1867, Joseph Lister publishes his work showing a connection between cleanliness and surgical infections. And of course, not very long after that, in the overall scheme of things, Pasteur, as we said, starts doing his experiments, and the germ theory of disease comes out, and those two developments go. So those are the two individuals that we think of in the modern era as having credit for all these things that we do to prevent surgical site infections, the cleanliness, the cleaning of instruments, the cleaning of hands, the keeping fields clean, and topical antiseptics. Now, important, these are not antibiotics, these are not pills that you would swallow. These are topicals that were put on a wound and or injected deep into the wound. Other chemicals were used later on that were a little easier to handle, were a little less noxious than bromine is. Today, bromine is not used very widely in hospitals at all. It is easier and cheaper to use a lot of chlorine-based disinfectants on surfaces, and we have other things that we do to prevent wound, including the use of antibiotics, which are standard now, prophylactic antibiotics, anytime you have surgery, whether it's a traumatic surgery or just a routine surgery. But Lister kept publishing and, of course, gets involved with a variety of the medical clinics and Lister's techniques and the chemicals that Lister advocate using get to be the standard going forward. So Goldsmith and his pioneering work in antisepsis really kind of get lost to history until fairly recently. Now, if you search Middleton Goldsmith, you will see some records of him. There's a wonderful article that was published in 2011 in the Journal of Surgery that you can see that details really the heroic efforts that this guy does when he has nothing to go on. And I think so much of public health initially is that way, right? There's a defined problem, and people wanting to solve that particular problem, given the information that they know today. And it's not always perfect, but they make a very good effort, and like Goldsmith, oftentimes are able to have a very positive impact even when they don't completely understand what's going on to the degree that those that follow them do. Certainly, you know, if you if we had the knowledge of germs and these things getting into wounds and causing infections and so on that we do today, Goldsmith can say, well, let's just look for things that kill these germs and see which one of those work without killing the patient, which is kind of what we do with antibiotics today. But he doesn't have benefit of that. He can just see what he sees in front of him. He's only got access to the types of chemicals that were readily available to him. He doesn't have a lot of the modern chemical factories and so on to make things for him. There isn't really this concept of a large-scale clinical trial, even though he kind of pioneers doing that. So he does, like a lot of public health, does the best that he can with what he'd got and uh ultimately has a fairly good rate of success. Um and it's all it's ultimately all other social events that prevent this from coming out, not other medical things, other political activities going on in the United States at the time. Um, and it's so here we are 160 years later, and just now rediscovering the wonderful story of Middleton Goldsmith and the birth of antisepsis in the Civil War. So if you like these stories and other ones like that about where these things come from, we'd love for you to tune in to future episodes of the Filth in America podcast. I'm your host, Brandon Hewlett, and we'll see you again soon.