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The Liverpool cholera epidemic of 1832 and anatomical dissection--medical mistrust and civil unrest.

Asiatic cholera reached Britain for the first time in late 1831, with the main epidemic occurring during 1832. The disease caused profuse diarrhea, severe dehydration, collapse, and often death. There was widespread public fear, and the political and medical response to this new disease was variable and inadequate. In the summer of 1832, a series of "cholera riots" occurred in various towns and cities throughout Britain, frequently directed against the authorities, doctors, or both. The city of Liverpool, in the northwest of England, experienced more riots than elsewhere. Between 29 May and 10 June 1832, eight major street riots occurred, with several other minor disturbances. The object of the crowd's anger was the local medical fraternity. The public perception was that cholera victims were being removed to the hospital to be killed by doctors in order to use them for anatomical dissection. "Bring out the Burkers" was one cry of the Liverpool mobs, referring to the Burke and Hare scandal four years earlier, when two men had murdered people in Edinburgh in order to sell their bodies for dissection to the local anatomy school. This issue was of special concern to the Liverpool citizenry because in 1826, thirty-three bodies had been discovered on the Liverpool docks, about to be shipped to Scotland for dissection. Two years later a local surgeon, William Gill, was tried and found guilty of running an extensive local grave-robbing system to supply corpses for his dissection rooms. The widespread cholera rioting in Liverpool was thus as much related to local anatomical issues as it was to the national epidemic. The riots ended relatively abruptly, largely in response to an appeal by the Roman Catholic clergy read from church pulpits, and also published in the local press. In addition, a respected local doctor, James Collins, published a passionate appeal for calm. The Liverpool Cholera Riots of 1832 demonstrate the complex social responses to epidemic disease, as well as the fragile interface between the public and the medical profession.

Anatomy↗

Ambient temperature and the occurrence of collective violence: a new analysis.

Prevalent folklore suggests that riots tend to occur during periods of very hot weather. Baron and Ransberger examined 102 major riots in the United States between 1967 and 1971 and concluded that the frequency of collective violence and ambient temperature are curvilinearly related. The present article points out that the Baron and Ransberger analysis did not take account of the different number of days in different temperature ranges. The artifact is eliminated, and the probability of a riot, conditional upon temperature, is estimated. When this is done, the evidence strongly suggests that the conditional probability of a riot increases monotonically with temperature. Some general implications of such data analyses are discussed.

Humans↗

Epidemics of violence.

The concept of behavioral contagion implies that certain behaviors may spread through populations in a way analogous to the spread of microbial diseases. If so, mathematical models that are helpful in understanding the spread of infectious diseases may also help to understand the spread of certain behaviors. The objective of this paper was to explore the possibility that the Kermack-McKendrick model of epidemic spread may help to explain the outbreak of riots in crowds. Predictions made by the mathematical model were compared to descriptions of crowd behavior and of police methods for preventing and controlling the outbreak of riots. Many of the predictions made by the model are consistent with published observations about circumstances where riots may occur, and methods useful for controlling them.

Epidemiologic Methods↗

Acute mass burns caused by o-chlorobenzylidene malononitrile (CS) tear gas.

The use of tear gas in controlling riots has been an accepted practice in many countries for the past four decades. In a recent event, a large quantity of tear-gas canisters were used during a situation of unrest in a Hong Kong Refugees' Detention Centre. We report 96 cases of acute burn injury as an unpredicted side effect of o-chlorobenzylidene malononitrile (CS) tear gas. There were 47 females and 49 males with an age ranging between < 1 to 51 years. These burns were categorized as minor burns, with the total body surface area (TBSA) ranging from 1 to 8 per cent with mean percentage of 3. Most of the patients sustained superficial or partial-skin thickness injuries. Only two patients were admitted to the Prince of Wales Hospital Burns Centre because of deeper burns; debridement and skin grafting was required in one of them. The mechanism of burn injury was due to the flame generated from the grenade explosion, direct contact between the hot canister and the victim's skin, and the effect of the chemical powder inside the canisters when it splashed onto the victim's body. We suggest that the noxious transient effects of tear gas are underestimated, furthermore varying cutaneous effects and deep burns may result from its uncontrolled use during riots. There is a continuing need to reassess the potential toxic effects of CS tear gas as a riot control agent and to debate whether its future use can be condoned under any circumstances.

Acute Disease↗

Terrorism in Indonesia.

Indonesia has had its share of natural and manmade disasters. From 1997 to 2002, Indonesia has experienced 90 incidents of terrorist bomb attacks. In 13 (14.4%) of the terrorist attacks, the bombs did not explode. A total of 224 persons have been killed, and 340 persons have been injured. Most of those killed or injured were the result of the bombings in Jakarta and Bali. Besides bombings, there have been riots, especially in Jakarta. The Indonesian Surgeons Association established the 1-1-8 Emergency Ambulance Service Foundation to develop the Prehospital Emergency Medical Services in Indonesia. Despite difficulties, this service has been implemented in 18 cities. The occurrence of disasters, riots, ethnic conflicts, terrorist attacks, and the introduction of the Advanced Trauma Life Support (ATLS) course in 1995, have helped to convince the people and the government that it was important to develop this 1-1-8 Emergency Ambulance Services system, and agreed to accept a Safe Community Program. With the Safe Community Program, Jakarta with its Integrated 1-1-8 Emergency Ambulance Service managed to provide proper emergency medical care to the casualties caused by terrorist bombings, riots, and in the three weeks of floods during which 75% of Jakarta was submerged.

Civil Defense↗

Traditional sampling with laboratory analysis and solid phase microextraction sampling with field gas chromatography/mass spectrometry by military industrial hygienists.

The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the United States Department of Defense or the Uniformed Services University of the Health Sciences. Rapid on-site detection and identification of environmental contaminants to which personnel may be exposed is often needed during military deployment situations. The availability of military industrial hygienists with capabilities for "complete" on-site exposure assessment of chemical species should allow detection and identification of a number of important stressors almost immediately following sample collection. Portable gas chromatography/mass spectrometry (GC/MS) provides a rapid and efficient separation of volatile and semivolatile organic analytes, accompanied by sensitive electron impact ionization-mass spectrometry (EI-MS) detection. The use of GC/MS in the field is limited, however, by equipment cost, complexity of the equipment, and the analytical process. Additionally, a skilled operator is needed to obtain useful separations and to interpret mass spectral data. To demonstrate benefits and limitations of "complete" exposure assessment capabilities, a previously unidentified complex mixture, produced by thermal dispersion of riot control agents, was examined. Established active sampling methods were used with laboratory analyses. Solid phase microextraction, a passive sampling method that simplifies preparation for GC/MS analysis, also was used with a field-portable GC/MS system. Both sampling/analysis methods were used to detect CS riot control agent-derived air contaminants dispersed from riot control type canisters through oxidizer-supported combustion of a chemical fuel.

Chemistry Techniques, Analytical↗

The comparison of two agar media for germ tube and chlamydospore production by Candida albicans.

A simple (2% oxgall) agar medium is described for the production of both germ tubes and chlamydospores by over 500 clinical isolates of Candida albicans. In comparison studies between the 2% oxgall agar and the more complex "cream of rice" infusion-oxgall-Tween 80 agar (RIOT), germ tubes were formed by 478 isolates in both media, by 9 isolates in only the oxgall medium and by 11 isolates in only the RIOT medium. Chlamydospores were formed by 481 isolates in both media, by 2 isolates in only the oxgall medium and by 9 isolates in only the RIOT medium. The data also show that both the germ tubes and chlamydospores were needed for the presumptive clinical identification of C. albicans.

Agar↗

Ocular injuries caused by plastic bullet shotguns in Switzerland.

Five patients with blunt ocular trauma due to hard plastic shotguns used by police forces during riots presented to the Ophthalmology Department of University Hospital in Zurich, Switzerland, between December 2000 and May 2001. All five eyes suffered ocular concussion. Three of five eyes presented with severe damage to the anterior segment of the eye, two of these eyes showed combined involvement of the anterior and posterior segments. Two patients completely recovered their visual acuity in the injured eye, two reached a final visual acuity of 6/12 and in one case the injured eye was legally blinded. Three of the patients claimed to have been uninvolved bystanders at the riots. The theoretical probability of hitting the head/neck area or one of the two eyes for each shot fired at a person from different operational distances is calculated and ophthalmological and technical aspects of this special type of plastic bullet shotgun used in Switzerland are discussed.

Adult↗

Plastic bullet injuries in Northern Ireland: experiences during a week of civil disturbance.

BACKGROUND: Plastic bullets were introduced to Northern Ireland for riot-control purposes in 1973. Their use has been controversial, with a number of fatalities. In the week beginning July 7, 1996, some 8,000 plastic bullets were fired during widespread rioting. METHODS: Details of injuries attributed to plastic bullets were obtained retrospectively from patient notes for the period July 8 to 14, 1996, in six hospitals. A total of 172 injuries in 155 patients were recorded. RESULTS: Nineteen percent of injuries were to the face/head/neck, 20% were to the chest or abdomen, and 61% were to the limbs. Abbreviated Injury Scale scores ranged from I to 3. Forty-two patients were admitted for hospitalization, three to intensive care units. No fatalities occurred. CONCLUSION: Plastic bullet impact to the abdomen or above may cause life-threatening injuries. Below this site, major trauma is unlikely.

Abbreviated Injury Scale↗

Depressive illness and aggression in Belfast.

An inverse relation has been suggested between the incidence of depressive illness and the opportunity to externalize aggressive behaviour. The riot situation in Belfast in 1969-70 provided an opportunity to study this hypothesis. The incidences of depressive illness in the city and a neighbouring peaceful rural county were compared over a number of years. Data regarding age, sex, area of the city, and type of depression were obtained. The city was divided into areas and four of these were studied in detail. Similar data were obtained for persons showing aggressive behaviour.There was a significant decrease in depressive illness in Belfast in both sexes and all age groups. This was more pronounced in males but the decrease was confined to those in social groups IV and V. The decrease was more significant in riot areas. The suicide rate fell by almost 50% and there was a noticeable increase in the rates of homicide and crimes of violence. In contrast the rural county showed a sharp increase in male depressives.

Adolescent↗

New Jersey Medical School's unique relationship to its community.

The Newark, New Jersey, riot of 1967, sparked in part by tensions created by the conflicting emphasis of President Lyndon Johnson's Model Cities Program, community action programs, and the New Jersey state medical school's move to Newark's Central Ward, has profoundly affected the medical school and its delivery of medical care in Newark. This paper delineates how these Johnson-era programs contributed to the riot and details the continuing legacy of these events on the medical school and the delivery of health care in Newark. The paper concludes that New Jersey Medical School is expected by its community to have a higher standard of local involvement than comparable institutions. Furthermore, it suggests that New Jersey Medical School's relationship and commitment to its community serve as a model for community interactions for medical schools throughout the United States.

Cities↗

Plastic bullet injuries of the face and jaws.

The plastic bullet or plastic baton round was introduced as an anti-riot weapon in 1976. It has evolved from the rubber bullet and wooden baton round. During the recent unrest in South Africa the plastic bullet was used in riot control. Five cases of facial injury are reported. One involved the middle third of the face and 4 the lower third. In all cases skin lacerations compounded facial fractures. Mandibular fractures ranged from a single displaced body fracture to severe comminuted fractures. The middle-third injury was sufficiently severe to result in blindness of one eye.

Adult↗

[Prehospital medical care organization during the 2003 G8 summit: a new concept of Mobile Medical Squadrons (MMS)].

OBJECTIVE: The occurrence of the 2003 G8 summit in Evian and the threat of major civil riots or even terrorist attacks in the Swiss neighbourhood forced us to imagine a new system of rescue and medical care in case of numerous victims. Previous occurrences of the G8 in Europe or America have demonstrated the need of flexible and mobile structures, able to respond quickly to crowd movements, unlike the usual static structure of rescue systems designed for major accidents. METHODS: We developed a new concept of Mobile Medical Squadrons (MMS) consisting of several vehicles and medical care and rescue human resources. In our concept, each MMS consisted of 3 emergency doctors, 5 paramedics and 9 first-aid workers. They were designed to handle 15 patients, with a large autonomy in terms of rescue, medical care, evacuation and medical authority. The equipment included medical, resuscitation, simple decontamination, evacuation and communication materials. RESULTS: The MMS were dispatched four times during the G8 summit following civil riots. They took care of 12 injured patients. CONCLUSION: The concept of MMS as a reinforcement of the existing rescue and health care resources appears as a new flexible, a modular and useful concept for the medical management of collective prehospital emergency situations. Its use is suggested instead of the traditional static concept of rescue systems designed for major accidents.

Allied Health Personnel↗

Acute effects of the potent lacrimator o-chlorobenzylidene malononitrile (CS) tear gas.

1. The use of tear gas to control civil unrest is accepted practice by government authorities worldwide. It is rarely used in Hong Kong but during a recent riot at a Vietnamese detention centre large quantities were used and this was cause for some concern. 2. All patients presenting to the British Red Cross Clinic after the incident were seen by one of the authors. To establish if exposure to tear gas had serious effects on the health of the detainees, the case records of the 184 patients with symptoms consistent with CS exposure were reviewed 2 months later. 3. The most common complaints were burns (52%), cough (38%), headache (29%), shortness of breath (21%), chest pain (19%), sore throat (15%) and fever (13%). However, the only common findings on examination by a physician were burns (52%) and an inflamed throat (27%). All burns could be categorised as "minor' according to the American Burns Association classification and all were consistent with CS gas exposure. 4. Some patients complained of other symptoms that had not been previously reported in the literature, such as haemoptysis (8%) and haematemesis (4%), but these were only confirmed in one patient. 5. The majority of patients had recovered within 2 weeks of exposure although one asthmatic patient complained of shortness of breath lasting for 33 days and a sore throat lasting for 38 days after the incident. She had abnormally low peak expiratory flow readings, but had a clinical history of asthma. 6. No serious sequelae were encountered, but the incidence of burns in these patients was higher than would be expected from a review of the literature. However, very little data on the effects of tear gas in a riot situation has been published. There have been reports of high concentrations of CS gas causing reactive airways dysfunction but this was not seen in our group of patients.

Adolescent↗

[Violence in the university environment: the case of the National University of Colombia].

OBJECTIVE: To estimate the prevalence of beliefs, attitudes, perceptions and practices in the roles of witness and possible actor in riots, among the student community of the National University of Colombia in Bogotá. METHODS: A survey was applied to 500 undergraduate students in places within the university campus (cafeterias, study rooms, meeting places libraries). The survey comprised 18 variables which were grouped according to type and degree of violence. The information obtained was included in an access 200 database and analyzed with the SPSS 8.0 software for Windows. RESULTS: From 496 useful surveys, 271 students (54.5%) were identified as non-aggressors, 163 (32.8) as type 1 aggressor and 63 (12.7%) as type 2 aggressors. Significant relationships were found between the types of violence and the male sex, marital status, academic average, number of intimate couples but not with age nor with studying a given career. CONCLUSIONS: Violent means of expression had little or no acceptance at all by the majority of students surveyed, who prefer their opinions to be expressed through the student representatives or in working groups. However, persons participating in riots state that the available means or alternatives of expression are not enough, justifying their violent acts in certain situations. The aggressors tend to be males and believe that violent actions are more acceptable.

Adolescent↗

[Four cholera epidemics in nineteenth-century London].

Asiatic cholera originated in India and spread to Europe in the early years of the nineteenth-century. In Britain the first cases were diagnosed late in 1831. The epidemic, reached London in February 1832. The authorities were poorly prepared for the invasion of a new epidemic and the doctors disagreed bitterly on the measures to be taken. There was little co-operation between the authorities, and the fact that the urban poor mistrusted the medical profession did not improve the situation. All this resulted in several cholera riots. These riots were not, however, as violent as those in several other cities in Europe. The 1832-33 cholera epidemic claimed 4,000 to 7,000 victims in London. It seems probable that several isolated cases of cholera occurred in London in 1852. It was not, however, until September 1853 that it was officially announced by the British authorities that a cholera epidemic was claiming victims not only in London but also in other parts of the country. During this epidemic numerous Londoners lodged complaints against nuisances in the metropolis. Yet, in most cases, the fines imposed on offenders were rather slight, since the authorities were extremely reluctant to interfere with anyone's trade or business. It was during this epidemic that John Snow, a London doctor, succeeded in tracing the epidemic to a single water pump on Broad Street in the Golden Square area. Snow did not, however, succeed in convincing the majority of his colleagues regarding the erroneous nature of the miasma theory during the epidemic of 1853/54, which cost the lives of some 12,000 people in the city area....

Cholera↗

Report of accidental CS ingestion among seven patients in central Israel and review of the current literature.

A report of seven people who accidentally drank a juice contaminated with CS (o-chlorobenzylidene malononitrile) is given. Due to its mucosal irritating properties, CS (also known as "tear gas") is commonly used by policemen and soldiers in riot control. However, only a few reports of its ingestion by humans exist. Ingestion of CS may cause immediate irritation of the oral mucosa and gastrointestinal symptoms later on. Damage of internal organs, which has been shown in animals but only rarely in humans, is probably related to the dose ingested. The extensive use of CS gas merits recognition of the signs and symptoms of its exposure in order to reduce anxiety in both patients and medical staff and to facilitate fast and efficient management.

Adult↗

The effects of external ocular irritation on intraocular pressure.

Riot control agents (tear gases) cause intense eye irritation and reflex squeezing of the eyes. The intraocular pressure under these circumstances is unknown but animal and human studies of ocular irritation and forces acting upon the eye indicate a transient increase in intraocular pressure which is not necessarily detrimental to vision.

Animals↗