Thalidomide has been described as the biggest man made medical disaster of all time. This first part covers what thalidomide is, the animal testing that lead its manufacturer to market it as safe, and its release into the market.
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Welcome to Stuff You Missed in History Class, a production of I Heart Radios How Stuff Works. Hello, and welcome to the podcast. I'm Tracy V. Wilson and I'm Holly Fry. We have gotten a lot of requests over the years to talk about the drug the litamide, including from Ginger Cheyenne, Emily, Brittany, Randy, Rebecca, Hannah, Tricia, Jackie and Terrell. And we've had some spikes in those requestsed a couple of different points, including when this was a plot line on the TV show called The Midwife. We got some rite in a row over the last couple of weeks. Uh. This has been described as the biggest man made medical disaster of all time. From ninety seven to nineteen sixty two, the litamide was marketed as being completely safe and it was used as a treatment for morning sickness, but it was not safe. At least ten thousand people who were exposed to the litamide in the womb were born with a ring as of disabilities and medical conditions, and about forty percent of them didn't survive infancy, and the drug also caused a really unknown number of miscarriages and still births, possibly tens of thousands more. A lot of the people who've asked us about this episode have framed it in the context of babies, but there are thousands of adults living today who were harmed by this drug many parts of the world. They refer to themselves as the Litta miters. As of when we're recording this in twenty nineteen, most of these folks are in their late fifties and early sixties, although as we will discuss, there are also people who are a lot younger than that. So people who weren't personally affected by this might imagine this story as something that sort of is confined back in the past, but it's really a story that's ongoing until today, and it's also a long enough story that we're covering it in two parts. So today we're going to talk about what the litamide is, the animal testing that let its manufacturer to market it as safe and it's released onto the market. Next time we will be talking more about its aftermath and how it affected everything from drug regulations to abortion law. Um there is some disability rights stuff along the way that it's pretty appalling in terms of how people were treated, and that's going to apply really to both episodes. Yeah, obviously not a lighthearted rump today. Just heads up, as if you had not gleaned to that already from Tracy's introme. So, the letta mine is a taradogen, which means it's something that disrupts development, and taradogens can affect any stage of development, but the term is frequently used to describe things that negatively affect the development of an embryo or fetus, including causing miscarriage. And lots of things can act as taradogens, including hyperthermia, infectious disease, environmental pollutants, and alcohol. Pharmaceuticals can also have the potential to act as taradogens. Many countries have some kind of a system now for categorizing the level of risk and whether the dry is recommended for use during pregnancy. So in the US, for example, these categories range from A, in which the risk to a fetus seems to be remote to category X, in which the drugs risks during a pregnancy outweigh any possible benefits. Today, drugs that fall into category X or otherwise have serious teratgenic effects are typically only used with a range of safety precautions in place. Patients who could become pregnant may need to have a negative pregnancy test before they start treatment, and they may also be required to use multiple forms of birth control and be tested for pregnancy while they're being treated. Since f d A, drug labeling rules in the United States have required a section called quote Females and Males of Reproductive Potential and that details these recommendations along with whether the drug has been shown to cause infertility. Yeah, the exact rules and laws obviously vary all over the world, but even with these types of precautions, it's still possible for a drug that's known to have these kinds of effects to harm a developing fetus. A doctor might not communicate the risks clearly enough for a patient might not fully understand them, or contraceptives could fail for a variety of reasons. Especially in places that don't have a robust medical system, patients might share their medications with each other without fully understanding the risks involved, and especially because these same places don't often have the resources to really follow up and monitor patients, it's possible that babies may be born with disabilities or health effects that aren't ever reported or connected back to the drug. Even in places that do have really robust medical systems. The level of monitoring and compliance involved with this can really be a lot. Sometimes it is just not sustainable in real world conditions. But none of these steps were in place when the lita mine was developed, and no one knew about its teratogenic effects when it was first put on the market. So we're going to get into why that was in a moment, but first we're going to have an overview of the conditions and disabilities that the litamide causes in a developing fetus. So the condition that's most associated with the litamide is folk amelia, and that's when the bones and a person's limbs are shortened or missing. This usually affects the long bones and the arms and the legs, so sometimes it results in the hands or the feet being connected to the trunk of the body without a limb in between. Most of the time these effects are symmetrical, with both legs or both arms or all four limbs affected, and the arms are affected the most often with the litamide. The litamide can also cause a similar condition called amelia, or the total absence of the limb. The litamide can also affect a person's digits, including having extra or missing fingers or toes. Sometimes the size and shape of the bones can also cause the hands or feet to have a different size or shape than a typical hand or foot. The eyes and the ears can be affected as well. They might be missing completely or missing parts of their structures, and that can cause problems with a vision or hearing, as well as blindness and deafness. These are the most outwardly visible effects of the litamide exposure in utero, but the drug can also cause internal organ damage, including heart, kidney, nervous system, and g I problems, as well as damage to the reproductive organs, and sometimes this is not immediately apparent at birth, even after a medical examination, so these conditions are then discovered later in life. People who are exposed to the litamide before birth also have higher rates of cognitive disabilities and epilepsy. Altogether, these and other effects of the litamite exposure in the womb are known as the litamide embryopathy or fetal the litamide syndrome. Most of the research into the litamides effects was conducted on infants in the nineteen sixties, and there hasn't been nearly as much follow up from the medical community as people have grown own and aged, so it's really possible that there are other delayed effects that haven't been widely studied or traced back to the litamide. One exception is whether the litamides effects can be passed down to a person's children, and the litamized effects don't appear to be inheritable. These are a lot of different effects for one drug to cause, and many people have several of them, and that's largely tied to exactly when during the pregnancy that the litamite exposure happened and what was developing within the embryo or fetus at that time. The litamides effects tend to be the most severe between twenty and thirty six days after conception. At this point in pregnancy, things are moving very quickly, with lots of growing and development happening in multiple body systems all at once. Just one dose of the lidamide can disrupt all of this, causing multiple negative health effects or disabilities in at least fifty of pregnancies, and some studies suggest at that rate is actually even higher than that, and this is why the litamite it's use as a morning sickness treatment affected so many people. So dramatically. Morning sickness occurs in about sevent pregnancies, and it can happen at any time of the day and at any point during the pregnancy, but it's really the most common in the first trimester. It's usually the worst from four to seven weeks after conception, and that largely overlaps with the window when the lidamides effects are also the most severe and affect the most parts of the body. So we're going to talk about how Solida Mine made it to market without anyone discovering any of this after we first pause for a sponsor break. Internationally, the pharmaceutical industry really expanded dramatically after the end of World War two. People needed treatments for illnesses and injuries that had resulted from the war. Multiple countries had started establishing national health care systems in the decades that we're leading up to the war and then afterward, and that led to more demand for medicines overall. There were also breakthroughs and various types of medicines, including antibiotics and anti anxiety medications, and those had also led pharmaceutical companies to develop new drugs very aggressively to try to compete sedatives in particular, became incredibly popular as a newly developed class of drugs. The sedative known as Milltown was launched in nineteen fifty five, and it quickly became the best selling drug in the United States. Drug manufacturers around the world we're trying to break into this fast growing segment of the drug market, hoping for a similar success of their own. West German pharmaceutical company Shami grunenthalogy mbH was founded in nineteen forty six and was one of the companies trying to rapidly develop new drugs and bring them to market. In nineteen fifty four, they synthesized the drug that would come to be known as the litamided for the first time and they applied for a patent. A paper describing the drugs pharmacological effects, including its sedative effects, was published in nineteen fifty six, and that paper, it was referred to as K seventeen, was also when Grunenthal conducted some safety tests on this new drug, and one of the tests that was conducted is called the median lethal dose or LD fifty test, and this test is conducted on lab animals and it's used to determine how much of a substance it takes for it to become deadly. The l D fifty is the amount of the substance that it takes to kill fifty of the test subjects. The LD fifty tests for the litamide were conducted on mice and they suggested that there was no dose, no matter how high, that would be lethal and fifty percent of the subjects. Everyone thought this was amazing in terms of the folks developing it. It's set the litamide apart from other sedatives and sleep aids, which could be lethal at high doses, like an overdose could cause someone to die. Based on these results, Grudenthal started marketing this drug as safe and non toxic. In November of eighteen fifty six, Grunenthal began marketing a flu remedy called grip X, which combines solidamined with other substances like quinine and vitamin C. In ninety seven, it launched several versions of a drug called coundragone, which was solidimized for use as a daytime sedative or a nintime sleep aid. Grip X and coundragone were available without a prescription. The idea that you could just go to a pharmacy in nineteen fifty seven and get a sedative over the counter marketed as a sedative blows my mind just a little bit. Yeah, same, I don't I don't know what to add to there. There are plenty of drugs that have sleepiness or drowsiness as a side effect, but like, if that's in the US at least, you can't just walk up to a counter and say I would like a sedative please and get one. In many parts of the world, in the nineteen fifties, it was common for doctors to prescribe or recommend a variety of medicines of pregnant patients for the sake of their physical comfort and mental health, and this included sedatives and stimulants and other medications. The prevailing attitudes about both prescription and over the counter medicines during pregnancy was pretty cavalier compared to how it is today, and soon after Contragone hit the market, patients and doctors started reporting that it wasn't just providing RESTful sleep or a calmer mood during pregnancy, it was also treating mourning sickness. Soon doctors were recommending contragone for the off label use of mourning sickness treatment and prevention. Patients who had taken it were also recommending it to their pregnant friends and family members. I mean, people who took this drug described as being miraculous in terms of the difference that it made in the morning sickness level. But none of the tests that had been performed on solidamide before it was released were conducted on pregnant animals, and even if they had been, it turns out that mice and rats aren't susceptible to solidamide in the same way that humans and many other mammals are. Although there had been and some clinical trials, no one in them had been pregnant. Also, the clinical trials themselves were very small and not very thorough. Testing on some other sedatives at this time had involved things like examining the urine to analyze how the drug had been broken down inside the body and how much of the drug was being excreted without being broken down at all. Nothing like this was performed for the litamide. It also doesn't appear that these clinical trials were double blind or involved any kind of comparison between the drug anniple cebo. On top of that, the papers that were published to support the litamide safety and efficacy read more like doctors testimonials than research that was actually backed up by data. Vitikin Lens, who was one of the doctors who made the connection between the litamide and its teratogenic effects, later said quote the papers published in nineteen fifty six by Kun's at All on animal experiments and by Young on clinical experiences with the linamide have so little scientific value that, in my opinion, they should not have been accepted for print. In other words, all this testing was not very thorough or rigorous or well documented. Just one example of how it all fell short is that it later turned out that the reason that they could not find a lethal dose of the litamide and mice wasn't because the drug was inherently safe. It was because the mice weren't actually absorbing most of it. Different preparations of the drug that were tested later on and were more easily absorbed turned out to be highly toxic. Based on the litamide success in West Germany, Grunenthal began working on distributing it to other parts of the world. It was ultimately marketed and distributed through various other pharmaceutical companies in forty six different countries under a range of brand names, including dist of All in the UK and Australia and soften On in parts of Europe. As all of that was happening, doctors in places where the litamide was being used to treat morning sickness, we're starting to encounter babies who had a collection of health problems and disabilities that they'd never really seen before. In nineteen fifty nine, a gynecologist in Munich reported a baby born with folk amelia. There wasn't a clear connection at that time, but later on the doctor learned that the baby's mother had taken gripp X while pregnant. This wasn't actually the earliest documented case of solidamide having a teratogenic effect, That had happened back in December of nineteen fifty six, before the drug was even on the market. This case was a baby born to a Grunenthal employee and his wife, and he had been given free samples at work and their child was born without ears. That connection was not uncovered until much later. So at first doctors were reporting what they described as this strange epidemic of folk amelia, but they weren't really sure what was causing it, as that was happening, though, doctors were noticing a different pattern and adults who were taking the lidamide. As ly as April of nineteen fifty nine, pharmacists were reporting that patients were experiencing things like tingling hands and feet, or cold hands and feet, or a sense of giddiness after taking the litamide. In October of nineteen fifty nine, a doctor named Ralph Voss reported neuritis or nerve inflammation and people who had taken contragne for a year. Voss contacted Grunenthal, who told him quote, no such side effects have come to our notice. Another doctor named Horse Frankel was also working with patients that were experiencing nearitis after taking the litamine. He wrote a paper detailing twenty cases, but for unclear reasons, it wasn't printed until nineteen sixty one. Meanwhile, Voss delivered a presentation on the naritis issue on April nineteen sixty In December of that year, a letter titled is the litamide to blame was printed in the British Medical Journal. It was written by A Leslie Florence of Aberdeenshire, and it described four cases of tingling, cold extremities, leg cramps, and other side effects, and adult patients taking the lidamide, these improved, but they didn't really go away when the patients stopped taking the drug. The letter included the line quote it would appear that these symptoms could possibly be a toxic effect of the lidamide. By May of nineteen sixty one, Grudenthal had received reports of more than one thousand cases of neuritis that were connected to thelidamide. The company was forced to make the drug available only by prescription. Before that point, it had been responsible for more than half of the company's gross revenues, and it was West Germany's most popular over the counter sedative, with more than twenty million tablets sold each month. Even after these reports of neurological side effects and after it became available only by prescription, Grunenthal continued to market solidamide as completely safe, even during pregnancy. So we should note that even today, it is very common for a drug's side effects, including some very serious side effects, to be discovered after the drug is approved and out on the market, even when they're meticulously controlled and carefully planned out. Clinical trials are very small compared to the general population, and the real world has a lot of factors that might not be present in the context of a controlled study. But it's clear that Grunenthal's original testing on the litamide was not very thorough, and the company does not appear to have looked into whether all these reports of near rytis pointed to a greater problem with the drug. And in nineteen sixty one doctors started making connections between the litamide as used for morning sickness and the drugs teratogenic effects. One was the German doctor vitikin Lens who we mentioned earlier, and he had noticed the unusual increase in phok melia and other conditions that we now know as part of fetal the litamide syndrome. He went back through medical records and he found that this pattern had started very suddenly. He didn't initially know what the exact cause was, but he was confident that there was one, and that it might be some kind of chemical exposure, like an undisclosed chemical spill, or perhaps a new household product. Thousands of miles away. Dr William McBride was working at a hospital in Australia and on May fourth, nineteen sixty one, a baby was born there with both folk Amelia and bowel atresia, which is a condition in which part of the bowel is blocked are absent. Thousands of babies were born every year at the hospital, but this was the first time in its history that a baby had been born with that combination of conditions. Two more babies with folk amelia and bowel atricia were born between May fourth and June eight. McBride realized all three had been exposed to the lidamide, which had been on the market in Australia since June of nineteen sixty. On June he convinced the hospital to withdraw the litamide from use and informed the drug company Distillers, which was distributing the litamide in Australia. This was the first published letter specif typically linking the litamide to its teratogenic effects. McBride later told The New York Times that he also wrote to the company headquarters in London, but quote the reply from the medical director of the London office implied that I was utterly wrong. His high handed letter implying that I was just a colonial annoyed me. I was determined to prove I was right. The following month, Dr Hans Vicker documented twenty babies with folk amelia, five of which were known to have been exposed to the lidamide in the womb. But Viker had been told in error that the litamide was being used very widely in the US, but that the US was not experiencing the folk amelia epidemic that other countries were. He learned from Dr Lens that this was not true, and when he went back through his records specifically looking for the litamide, he confirmed its use in even more cases. After his communication with Viker, Lens called Grunenthal and was told to expect a visit from somebody in a few days. He told them that the needed attention immediately, that in a few days hundreds more people could be taking this drug for the first time. Lens also sent a registered letter to the company on November sixteenth, nineteen sixty one, detailing his concerns. Meanwhile, in Australia, drug company distillers removed the litamide from the market on November twenty one. It was only after all this that Grudenthal finally took action, pulling the litamide off the German market on November nineteen sixty one. As words spread, it was taken off the market in the UK on December two. On December sixteenth, Solidamide and Congenital Abnormalities was published in The Lancet. The lidamide was taken off the market in more countries in the weeks that followed. It was banned worldwide in nineteen sixty two, although in some places it was not formally made illegal until much later. It was only after all of this that there was any kind of formal study of the litamide and pregnant animals. Dr McBride had actually tried to do this in Australia, but he didn't really have any experience in how to perform this kind of trial or access to the lab animals that he would need to do it. The results of this study were published in a letter to The Lancet on April nineteen sixty two, showing that the litamide had similar to ratogenic effects and rabbits as it was now clear to be having in humans. We're going to talk about the aftermath of all of this, and about why the US isn't one of the countries that we have talked about so far. After we first paused for another sponsor break between nineteen fifty seven and nineteen sixty two, The litamide was sold in forty six different countries around the world, but it was never officially introduced in the United States. Richardson Meryl, the drug company, had planned to distribute the litamide in the US under the trade named Kevi Don Meryl submitted an application to the Food and Drug Administration. At that time, the US did have some laws that we're governing the drug approval process. That application was given to Dr Francis Oldham Kelsey to review. Kelsey was born on Vancouver Island in British Columbia, Canada, and she had first started studying unsafe pharmaceuticals while she was a graduate student at the University of Chicago, and there she earned both her PhD and her medical degree. At the university, Dr Eugene Galing was trying to figure out what had caused the deaths of more than one d people who had taken a drug called Elixir of Sulfonilla mine, and Kelsey was one of the graduate students who helped pinpoint the cause as a solvent that had been used to add a raspberry flavor to make the drug less bitter. Kelsey was really new to the job as a drug application reviewer at the f d A. The kevin On application was only the second one that she had been given, and in her account, it was given to her because she was new and it was supposed to be an easy one. The littamide was already being used in countries all over the world. It was regarded as completely safe, so really this process seemed like a formality. But when Kelsey started reviewing the application, sheep had some concerns about the litamne safety testing, a lot of those same problems that we talked about before, and after some back and forth with Meryl, she rejected the application on November tenth, nineteen sixty. Meryl reapplied in December. Kelsey read the letter in the British Medical Journal about neuropathy and people that had taken the lidomide, which he talked about before the break. She pushed back on Meryl, noting that a simple sleep age shouldn't be causing neuropathy and that a drug that was causing neuropathy could not be as safe and non toxic as the company was claiming. This went back and forth for weeks. At one point Kelsey met with executives from the company and, in her words, quote, I had the feeling throughout the day that they were at no time being wholly frank with me. As Kelsey continued to refuse to approve the kevidan application, more and more information was coming out about the effects that the litamide was having on the nervous systems of adults and on prenatal development. Merrill finally withdrew its application in April of nineteen sixty two, as countries were banning the litamide. President John F. Kennedy later awarded Dr Kelsey the President's Award for Distinguished Federal Civilian Service, and she was awarded numerous other honors for her work in drug safety. During her lifetime. She died, and I think so that was pretty recently. For her part, Kelsey insisted that this was a team effort and that her colleagues and supervisors should also get the credit. Even though thelidamide did not receive FDA approval for distribution in the US, the US did have cases of fetal palidamide syndrome. Richardson. Merrill had distributed more than two million doses of the drug two doctors as samples, and those have been given to patients either as sedatives or to treat mourning sickness. At least seventeen people in the United States were born with fetal palidamide syndrome. Richardson Merrill was also the company that marketed the lidamite in Canada, where it stayed down the market until March second, nineteen sixty two. It's possible that there were a lot more than seventeen people, because only about half of those folks parents had gotten the litamite in the US. The rest of them had gotten it while traveling, So it's totally possible that there are a lot more people that just aren't recorded in that that official list. Babies continued to be born with feetle with the litamite syndrome after the drug was banned around the world, including babies that were conceived after the bands. People who had bought or been given the medicine before it was pulled from the shelves still had it in their medicine cabinets. People who had not heard about the drug's effects continued to take it or to share it with other people. Some people had also just been given a sample of a few pills in an envelope that was maybe labeled with dosage instructions, but not with the name of the drugs, so they might not have even known that it was the litamide that they were taking. In some countries, governments and medical associations tried to warn the public lick about the dangers of the litamide and urged them to go through their medicine cabinets to make sure they did not have the litamide or any unlabeled pills. One person who was a big part of this outreach was Dr Helen Brook Tausig, along with surgical technician Vivian Thomas and surgeon Alfred Blaylock. Tausig was one of the people who developed a surgical treatment for the tetrology of fellow, which caused what was then known as blue Baby syndrome. That is on the list for another episode, especially Dr Tausig and Vivian Thomas um in particular. In January of nineteen sixty two, Tausig learned about what was happening in Europe, and she flew overseas to examine babies who had been harmed by the litamide. When she got back to the US, she undertook an extensive campaign to try to raise awareness about the drug's effects, including speaking before the American College of physicians and writing numerous articles meant for a general audience to try to warn people about the drug, but this didn't happen everywhere. In austra Alia, for example, distillers pulled the drug off the market in nineteen sixty one and warned the Australian government of the drugs teratogenic effects, but there was not a wide scale effort to notify pharmacies, hospitals, doctors offices, or the public about what was happening. As many as a quarter of the thelidamide survivors born in Australia were conceived after December nineteen sixty one. In Spain, it took years for the government to formally outlost solidamide or to remove it from the official Register of Drugs, and sometimes warnings used the term the liidamide while the drug was being sold under other brand names. There were seven different brands of the litamide sold in Japan alone. Even in places with more coordinated efforts to warn people about the dangers of the drug, the first generation of the litamide survivors included people born as late as nineteen sixty four and possibly even later. Because all of this traced back to a drug that they had believed was safe. This whole crisis led to just an incredible and crushing sense of shame, grief, depression, and anger for everyone involved, whether they had prescribed the drug or taken it or given it to a friend or family member. Many babies born with solidamide embryopathy died in their first year of life. Those who survived usually had multiple disabilities that have seriously affected the rest of their lives, which means that this whole crisis was exacerbated by attitudes about disability and the state of disability rights. The various countries where solidamide was sold all had their own nuances, but in general, disability was more heavily stigmatized than it is now, and doctors approached the subject very differently than they do today. So if you read articles written about this crisis as it was unfolding, a lot of them don't even sound like they're describing human beings worthy of life. The default response, even among medical professionals, was often to see these newborns as a hopeless and even monstrous track agedy, rather than as a person who could live and thrive with the right care and accessibility. There were even cases and suspected cases of infanticide. In one documented example, a Belgian woman named Suzanne Vanderputt admitted to killing her daughter with barbiturous dissolved in milk. She was acquitted in nineteen sixty two, and many countries, doctors recommended that babies with folk amelia or other disabilities be placed in institutions rather than being sent home with their families, regardless of the level of care that the baby actually needed. My mom worked in long term care for kids with multiple disabilities for years and years, and she definitely worked with kids who needed some kind of twenty four hour medical assistance. This was not the case with a lot of children who were born after being exposed to the linamide. Sometimes medical staff took newborns away from the delivery room before their parents had held them or even seen them, and a lot of places, parents who took their baby home did so against medical advice and after being strongly discouraged from doing so by their doctors. And whether a child was growing up in an institution or at home, most communities were far less accessible than they are today, and today there is still a long way to go. In most of the world, schools and other public buildings were not accessible for wheelchairs. Parents, teachers, and administrators had little to no education or experience in how to make a home or a school accessible to children with these types of disabilities. Prosthetics and adaptive devices had not really been developed for children. So, in other words, there were barriers everywhere, physical barriers to being able to access facilities, and societal barriers due to prevailing attitudes about disability. US includes the litamied survivors who have described being bullied and harassed by peers and by adults because of their disabilities. The ones who grew up in care have often described feeling like strangers every time they visited their family, least once they got older. But really this is us as full of information and heartbreaking as this is simply the beginning of the story. The Solido mine crisis led to totally revised drug standards around the world, a criminal investigation, and decades of lawsuits and ongoing efforts to get access to necessary support and services. And we're going to talk about all of that next time. I also have a little bit of listener mail to close us out, all right, This is from Rachel. Rachel says, Hello, ladies, I listened to your episode on the women of the Civil War and loved it, especially learning about Elizabeth Thorne. So fantastic, but it made me think about how other women have played a part in military service. I've listened to your episodes on the Night Witches and the six Triple eight, Central Postal Directory Battalion and others, but I really wanted to look into more Canadian history, seeing as that's where I am from, and I stumbled across the Nursing Sisters. The Nursing Sisters started out as volunteers during the South African War, but eventually gained a relative rank as lieutenants and then officers. By World War One, they were nicknamed the Bluebirds because of their blue dresses and white veils, which I just love, and by the end of World War Two they had been renamed as the Royal Canadian Army Medical Corps. Another interesting fact, two of the Nursing Sisters, Meta Hodge and Eleanor Thompson, in World War One, became the first women to be awarded a wartime Medal of Valor in Canada. There's a great heritage minute on this story which I'll link below, and then moving on to a more personal note. Also, I'm not sure if you remember Momo the historian hound, but that's my dog, and I wanted to thank you again for getting us through so many awful bats. I don't know if I could do it without you, guys, so I've added pictures of her into Thanks again, and have a great day, ladies. I was from Rachel. Thank you so much. Rachel. Of course we even remember Momo this story and hound Mo Mo such a good dog. Thank you so much for this um this email and for sharing this information about the nursing sisters. I don't know if they will make it into a full episode at some point, but in case they do not, there's a little tidbit about it about them for our listeners. If you would like to write to us about this or any other podcast, where at History podcast at how stuff Works dot com. And then we're all over social media at miss in History, and that's where you'll find our Facebook, Twitter, Pinterest, and Instagram. You can come to our website, which is missed in History dot com, and you'll find show notes for all the episodes Holly and I have never done together in a searchable archive of every episode ever. And you can subscribe to the show on Apple podcast. I heart Radio app, and wherever else to get your podcasts. Stuff you Missed in History Class is a production of I heart Radio's How Stuff Works. For more podcasts for my heart Radio, visit the iHeart radio app, Apple Podcasts, or wherever you listen to your favorite shows.