Tetanus

impossible to track. By the time this comes out, those numbers would be woefully out. Sabe. Yeah, two more weeks are going to pass before this is out, so those numbers would be wrong anyway by then. Also, just a lot of upsetting and alarming developments happening in the US Department of Health and Human Services and the National Institute

of Health. We have already done an episode on measles that came out on February twenty eighth of twenty twenty four, and that's a little bit more recent than we would typically rerun as a Saturday Classic. So I decided to take a look at another disease that's preventable today. Thanks to vaccines which do not cause autism. Not any vaccine, not for any disease. None of them cause autism. The disease, though,

is tetanus. Since this is an episode about a medical development, of course there will be some medical experiment stuff in the episode, including some experiments involving animals. I really don't think any of that is particularly graphic, but just in case, Uh yeah, I can handle it based on my read through, which is a pretty low bar of getting upsetness. So I think we're safe. But if not, I'm sorry. Tetanus has probably been around for most of human history, possibly

even longer. It's caused by the bacteria Clostridium tetani, which is present in the environment in a lot of the world. It's described with words like ubiquitous. In the words of John Sundwall in a lecture given under the auspices of the Kansas Academy of Science in nineteen seventeen, quote, this germ has a wide distribution, and its spores are found wherever there is dirt. Barnyards are veritable repositories for them.

Rusty nails appear to be rendezvous. Even the dirt that besmears the healthy living child may contain millions of these spores of Tetanus basillai. The spores can only grow when they gain deep entrance into the body and are shut off from oxygen. One of the oldest known medical texts in the world is the Edwin Smith Surgical Papyrus, named for Edwin Smith, who bought it in eighteen sixty two.

This Egyptian medical text dates back to about fifteen hundred BCE, and it includes a description of somebody with a head injury that penetrated all the way through the futures of the skull. Afterward, according to one translation, quote, the cord of his mandible is contracted. He discharges blood from both his nostrils and from both his ears, while he suffers with stiffness in his neck. As this patient's condition progresses quote, his mouth is bound, both his eyebrows are drawn, while

his face is as if he wept. This earliest description is usually translated and interpreted as describing a case of tetanus, but it doesn't entirely convey what tetanus is like as an illness. Tetanus doesn't cause bleeding from the ears or nose. That was probably a product of the patient's head trauma,

not the tetanus that followed it. Beyond that, without getting into a lengthy backgrounder on neurotransmitters, Claustritium tetani produces two toxins, and one of them, called tetanospasmen, interferes with neurotransmitter that control motor neuron activity. The nerves start firing uncontrollably, which causes intense muscle spasms. These can be excruciating and powerful enough to cause compression fractures or other breaks in a

person's bones. Tetanus can also lead to suffocation and heart failure. Even with medical treatment, tetanus is fatal between ten and twenty percent of the time, and without treatment the fatality rate goes up to eighty five percent or even more. It sounds awful, yes it does. The muscles in the face and the jaw are often affected in tetanus, and that can cause a person to look like they are grinning.

The spasms also cause tristmas, also known as lockjaw, and that can make it difficult or impossible for the persons who open their mouth. The Edwin Smith Papyrus offers a way to try to deal with this lock jaw that's by placing a wooden brace padded with linen in the patient's mouth to try to keep it open enough that they can be fed a liquid diet while being kept upright. Tetanus also appears in the Sashruda Samhita, which dates back to about the sixth century BCE and is one of

the foundational texts of iervedic medicine. We did an episode on Sashruda in January of twenty nineteen. In a chapter on diseases of the nervous system, the Sashruda Samhita describes one caused by enraged or agitated value that's the air element in iervedic medicine. This disease quote rarely yields to medicine and is cured in rare instances only with the greatest difficulty. Its characteristic symptom being a paralysis of the jawbone,

which makes deglutition extremely difficult. This disease in the text is described as bending the body like a bow and in its extreme form, fixing the eyes in their sockets, paralyzing the jaw and breaking the sides. The Chinese medical text known as the Yellow Emperor's Classic of Internal medicine is attributed to a semi mythical figure who's described as living around twenty six hundred BCE, but it was probably

written more than two thousand years later than that. Traditional Chinese medicine incorporates the idea of energy channels or meridians in the body. The translation of the Yellow Emperor's Classic that I had access to for research didn't use the word tetanus anywhere, but it describes the collapse of the chi in the bladder and small intestine meridian as causing opisthoughtanus, stiffness in the back, convulsive spasms, paleness, and spontaneous sweating.

Once that sweating stops, the patient dies. Apisthoughtanus is the extreme, very arching spasms that are associated with tetanus. The first thing we'd think of as a really clear clinical description of tetanus from a more Western medical perspective is from Greek physician Hippocrates, written around the fifth century BCE. In

a treatise on Internal afflictions, Hippocrates describes three types of tetanus. First, when it follows a wound, Hippocrates says, the patient's quote jaws are fixed and he is unable to open his mouth, his eyes shed tears and look awry. His back becomes rigid. He cannot bend his legs, nor his arms and spine. Hippocrates describes this disease as severe and requiring a media

attention and in many cases fatal. For treatment, Hippocrates advises anointing the patient with warm oil infused with wormwood, bay leaves, or hen made seed with frankincense soaked in white wine. According to Hippocrates, the second type of tetanus is similar, but it starts with angina also pronounced angina that's chest pain, or with a saff infection or separation of the tonsils, and occasionally it can also start with a wound. Quote this patient is drawn backwards and cries aloud from the

pain in his back and chest. He is drawn so forcefully that the attendants can hardly prevent him from falling out of bed. Then the third form is less lethal, arising from some of the same possible causes or from

having fallen backward. Another work by Hippocrates called on Epidemics, also includes several examples of tennis cases, One developed after a surgery, another after a javelin wound after a person's finger was crushed by an anchor after an ankle injury whose treatment involved irritating the wound, after being injured by a piece of wood from a missile thrown by a catapult.

In the words of Roman author Alice Cornelius Celsus in the first century CE, quote, there is no disease more distressing and more acute than that which, by a sort of rigor of the sinews, now draws down the head to the shoulder blades, now the chin to the chest, now stretches out the next straight and immobile. The Greeks call the first aposthotanus, the next amprosthotanus, and the last tetanus,

although some with less exactitude use these terms indiscriminately. For centuries after this, European medical writing on tetanus tended to be really similar. Many physicians base their work on Hippocrates. Even if Hippocrates wasn't cited, they still usually described tetanus

as following a wound. Most commented on how often the condition was fatal, and many of the recommended treatments related to things that one might hope would relieve the spasms, like being rubbed with oils or wines or liniments or wrapped in warm dressings or given warm baths. In the sixteenth century, past podcast subject Amboise Parre developed an instrument to open a tetanus patient's mouth so that they could

be fed. Overall, the focus was on trying to get the muscles to relax and supporting the patient with the hope that they would recover, but often a certainty that they would not. Knowledge of the cause of tetanus and how to treat and prevent it didn't really start to advance until the nineteenth century, which we will get to

after a sponsor break. As we said, before the break, people figured out that tetanus was connected to wounds thousands of years ago, but it wasn't until the nineteenth century that we started to get a sense of exactly what was happening inside those wounds and elsewhere in the body. In eighteen thirty eight, Luigi Carlo Ferini gave an address before the Medical Turgical Society of Bologna in which he described the use of electricity in the treatment of tetanus.

He had based this on the work of Carlo Mettiucci, who was experimenting with electricity and frogs. Farini found that the application of direct current to the body of a patient who had developed tetanus after a gunshot wound seemed to interrupt the spasms. Unfortunately, this effect was temporary. It lasted only about thirty minutes. This didn't really provide a breakthrough in the understanding of tetanus, but it was connected to the electrical activity of the neurons that is part

of the disease. Several discoveries were made. In eighteen eighty four, Italian scientists Antonio Carle and Giorgio Rotone had both studied medicine in Turin. They exposed a rat but to fluid from a sore from someone who had died of tetanus, and that rabbit also developed tetanus. This showed some kind of contagion was causing the disease. But to be clear, tetanus is not transmitted from person to person. You would

have to really do something on purpose like this. Also in eighteen eighty four, Arthur Nicolier, who was a twenty two year old medical student in Germany, identified a bacillus in the soil. If you look at this basillis under a microscope, it looks kind of like a tiny straight pin. There's this rod like basillis with a knob on the end.

That knob is the spore. Today, we know that these spores are incredibly hearty, they are resistant to most disinfectants, and they can survive freezing and being autoclaved at a temperature of one hundred and twenty one degrees celsius or two forty nine point eight fahrenheit for ten or fifteen minutes. Nicolier induce tetanus in mice by injecting them with soil

that was contaminated with this spore forming basillis. He concluded that the basillis produced a poison that acted similarly to strychnine. Within a few years, multiple researchers all concluded that this basillis could produce a toxin. While Nicolier was able to find the tetanus basillis in the soil, he was not able to isolate it in a lab. Credit for that goes to Japanese physician and bacteriologist Kitasato Shiva Siburo in

eighteen eighty nine. Kitasato was born in Japan and had earned his medical degree from the University of Tokyo Medical School in eighteen eighty three. Two years later, the Japanese government had sent him to the Institute of Hygiene in Berlin to study bacteriology and infectious diseases with groundbreaking microbiologist

Robert Koch. It was while in Berlin that Quitasato isolated the tetanus bacillis Clestridium tetanani is an anaerobic microorganism, so doing this required Kitasato to develop new methods for growing bacteria while also keeping them isolated from the air. Kitasato started working with physiologist Emil von Behring, who is from West Prussia in what's now Germany. While Kitasato was studying tetanus,

von Behring was studying diphtheria. We have talked about diphtheria in our episode on the Nome Serum run that ran as a Saturday Classic on January twenty second, twenty twenty two. These diseases have some similarities. They're both caused by bacteria producing toxins rather than by those bacteria reproducing and proliferating within the body. This is one reason why still today

there's no definitive lab test for tetanus. Once a person has developed symptoms, tetanus bacteria are found in their wound only about thirty percent of the time time, and the bacteria can also be present in the wounds of people who have no symptoms and never develop the disease. In eighteen ninety, Kitasato and von Behring published a paper titled the Mechanism of Immunity and Animals to Diphtheria and Tetanus. This paper described a method they had found to prevent

tetanus and healthy animals. From an English translation of the paper, they summed it up in a sentence quote, the immunity of rabbits and mice which have been immunized against tetanus depends on the ability of the cell free blood fluid to render harmless the toxic substance which the Tetanus bacillis produces. In their experiments, these two men exposed animals to a weakened version of the toxin, gradually building up their immunity.

Then they did a series of experiments to show that the blood serum of these animals could neutralize the toxins in other aias animals. In other words, the serum contained antitoxins, also called antibodies. Kittasato and von Bearing injected rabbits with serum that contained these antibodies, and then they exposed the rabbits to an amount of tetanus bacteria that had previously

been proven to be fatal. Every rabbit remained healthy. And then the same was true if the treated rabbits were injected with tetanus toxin instead of with the bacteria that produce it. These rabbits could withstand a dose of toxin that was twenty times higher than what it would take to kill an untreated rabbit. Kittasato and von Bearing also said that the serum from these immune animals could be used as a therapeutic treatment on animals that had already

developed tetanus. A week after this paper was published, Von Bearing published another paper on his own, which was focused only on diphtheria, and the work he started eventually led to a reliable treatment for that disease. He was awarded the Nobel Prize in Physiology or Medicine for this work in nineteen oh one, the first time that prize was ever awarded. Since the Nobel Prize committee was focused on diphtheria and not tetanus, Kitasato was not included in the

award or mentioned in the speech. Side note. Kitasato left Germany in eighteen ninety one, returning to Japan and establishing his own laboratory that was later subsidized by the Japanese government. Then, in eighteen ninety four, he was sent to Hong Kong during an epidemic of bubonic plague. There he isolated and identified the Bacillis that was causing that disease, a couple of days before Swiss researcher Alexandra Yersen made the same discovery.

Although Kitasato published his work on this first, Yarson's was seen as more conclusively linking the disease to the basillis, and that bacillus today is known as Rcinia pestis after him. Quitasato and von Bhring had made definitive connections between tetanus bacteria, the toxin it produced, and the protective value of blood serum from animals that had developed an immunity to that toxin, but their work was just small animals like rabbits, guinea pigs,

and mice. It didn't immediately lead to workable treatments for humans or for other large animals. That started to change in eighteen ninety five, when Edmund Nocard reported success with horses tetanus bacteria really thrive in horse manures, so tetanus could be a serious problem for cavalry units, farmers, basically anywhere that there were lots of horses. No Card was a veterinarian, a veterinary professor, and a biologist who had

worked with Louis Pasteur. After his initial success, no Card produced about seven thousand files of anti tetanus serum and he distributed it among his veterinary colleagues. The first anti tetanus serums used in humans followed not long afterward. Throughout history, one of the groups most at risk for tetanus infection has been newborn babies, but among medical researchers in the late nineteenth century, tetanus was more often thought of as

a hazard on the battlefield. There had been five hundred five reported cases during the US Civil War with a mortality rate of eighty nine percent, and three hundred and fifty reported cases during the Franco Prussian War with a mortality rate of ninety percent. Tetanus became a bigger threat during World War One, which started about twenty years after not cards discoveries, and we'll get into that after a sponsor break earlier In the episode, we read from a

lecture given by John Sundwall in nineteen seventeen. Here is something else that lecture had to say about tetanus quote. It is known as the fourth of July bacillis. It was once a customed to exhibit our copious and excessive

patriotism with every form of pyrotechnic art. Frequently premature explosions of the firecrackers, et cetera drove the accumulated dirt on the hand with its numerous spores, deep into the skin, and as a rule, the obituary column of the local press within a few days would announce the subsequent fate of many of our little patriots. This basic idea also

applied to the battlefield during World War One. Advances in munitions and explosive meant that more soldiers were being struck with shrapnel and debris that could drive tetanusors deep into their bodies a lot more often. The proliferation of trench warfare also meant that more soldiers were developing conditions like trench foot and frostbite, both of which could lead to breaks in the skin that could provide an entry point

for tetanus bacteria. Over the course of the war, doctors also concluded that infections with aerobic bacteria could facilitate tetanus infections by consuming the oxygen in a wound, leaving an environment that was hospitable to the anaerobic Tetanus bacillis. In the years before the war, researchers had started producing tetanus antitoxin for use in humans by building up the immunity

of horses and then harvesting their serum. By the time the war started, the Institute Pasteur was preparing about eighty thousand vials of tetanus anti toxin for humans using about three hundred horses. By nineteen the institute had nearly fifteen hundred horses, producing more than six hundred thousand vials of anti toxin per month. The Institute Pastor was not the only place that was doing this. That's just what I

had the numbers for. Over the course of the war, essentially, through trial and error, civilian and military doctors and surgeons worked out treatment and prevention protocols for tetanus in injured soldiers, and that was through use of these serums. Ultimately, the treatment started with treating the wound itself, excizing all wounds and removing all the damage tissue, ideally within twelve hours

of the injury. This is because doctors found a clear connection between the presence of tetanus bacteria and the wounds of soldiers whose injuries were surgically treated and those who weren't. Like we said earlier, it's often not possible to find bacteria in the wounds of people who developed tetanus, but

there was still a clear correlation there. Tetanus rates were lower in soldiers whose wounds had been exized, even if that first excision didn't lead to satisfactory wound healing and it had to be redone and then after their wounds were excised, the soldiers were treated with tetanus antibody serum, both as a prophylactic measure if there was enough available, and as a treatment if they started developing signs of tetanus.

One bulletin from the UK War Office Committee for the Study of Tetanus advised nurses to be alert for symptoms quote. All nursing sisters engaged in dressing wounds should be warned to give the alarm if the muscles round the wound are found to be harder or more rigid than the muscles of the uninjured limb or side. Over the course of the war, doctors also developed standard doses of tetanus antitoxin.

By nineteen nineteen, the prophylactic dose was five hundred units contained in three cubic centimeters or less of horse serum. A unit was quote ten times the least quantity of anti technic serum necessary to save the life of a three hundred and fifty gram guinea pig for ninety six hours, against the official test dose of a standard toxin furnished by the Hygienic Laboratory of the Public Health and Marine

Hospital Service, a super easy unit of measures. I'm assuming that the Germans had a different standard, probably at this point, maybe not. Under ideal circumstances, an injured soldier was given the first prophylactic dose by injection as soon as he

had been removed from the line of fire. Subsequent injections were shown to significantly reduce the risk of developing tetanus, but whether soldiers actually got those additional doses just really depended on whether there was enough serum available and whether the medical staff had the capacity to do it. If they were just really overwhelmed. It might not happen even when soldiers only got one injection, though they tended to have milder or more localized cases of tetanus if they

still developed it. Doses of anti toxin for treatment rather than prophylaxis, could be much higher, ranging from fifty thousand to one hundred thousand units in the early days of treatment, depending on whether the patient's body seemed to be responding to it. One of the reasons for working out the lowest effective dose of antitoxin was, of course, to conserve a limited supply, but another was the risk of severe allergic reactions to the horse serum, which was known as

serum sickness. This risk seemed to be higher at higher doses. For example, a nineteen nineteen report by the UK War Office Committee for the Study of Tetanus reported that two million prophylactic doses of anti tetanic serum had been administered to soldiers being treated in England, and there had been

eleven cases of shock related to the serum. All of those patients did recover, but in the fourteen hundred cases of tetanus they were treated with therapeutic doses in England, there were forty nine cases of shock, or three point five percent of the patients. Among those patients, twelve died or zero point eight percent of those fourteen hundred cases, but some of those deaths likely were not related to the anti toxins, so this was rare, but it could happen.

The development of tetanus anti taxin almost completely eliminated tetanus among injured soldiers by the end of the war. For example, in France, at the start of the war, about one and a quarter percent of the soldiers who were admitted to the hospital developed tetanus, and all of those patients died. After the tetanus anti toxin serum was introduced to that number of tetans cases dropped to zero. Results were pretty similar across other armies involved on both sides of the war.

While tetanus anti toxin could be administered to soldiers prophylactically after they were injured, it wasn't a vaccine that could offer more long term resistance to the disease. But in nineteen twenty four, another French veterinarian and bacteriologists, Gaston Ramon, developed the first tetanus vaccine. Ramon had previously developed a similar vaccine for diphtheria. This vaccine is known as tetanus toxoid.

Toxoid is a toxin that's been inactivated so that it's no longer dangerous, so the immune system learns to produce antibodies to the toxin before it encounters the real thing. This vaccine can also help prevent tetanus from developing if it's administered to an otherwise unvaccinated person after they have sustained an injury. During World War Two, so tetanus toxoid became a routine vaccine administered to soldiers, and then it became more widely available to the general public after the

war was over. It seems like deaths from tetanus started to drop as soon as the vaccine was put into use, but there isn't consistent data on that. In the US, for example, tetanus did not become a reportable disease until nineteen forty seven, so before that point we don't have an exact number for how many people contracted tetanus. But the largest number of tetanus cases reported in the United States was in nineteen forty eight, and from there the

numbers declined. Deaths from tetanus have decreased by ninety nine percent in the US since nineteen forty seven. The vaccine that was being used when it was first introduced targeted three illnesses tetanus, diphtheria, and protessis, all of which are caused by toxin producing bacteria. Today, in the United States, the two versions of the tetanus vaccine that are most widely used are teet APP, which targets all three of those diseases, and td which targets only tetanus and diphtheria.

Tetanus antitoxin is still also used to treat people who do develop symptoms of tetanus and to prevent it in people who sustain some kind of injury and have not been vaccinated. It's usually called tetanus immune globulin, and it can be made using horse serum or serum from donated human blood, which carries less of a risk of serum sickness.

Because tetanus exists in the soil and forms very hardy spores, it isn't a disease that could be eradicated like smallpox or render pest, at least not with any technology that exists today. We do have episodes about the eradication of both smallpox and render pest for more information on those.

Tetanos spores are basically all around all the time, and recovering from tetanus doesn't make you immune to it later on, so the closest thing to eradication is ensuring broad vaccine coverage so that people who are exposed to tetanus bacteria don't develop the disease. Today, the World Health Organization recommends a six vaccine series that stretches over a person's infancy, childhood, and adolescence. This six shot series is close to one

hundred percent effective. Some countries, including the United States, also recommend a booster every ten years. Tetanus is rare and wealthy parts of the world where there are robust vaccine programs and where the vaccine is also available in places like doctors' offices, urgent care centers, and emergency rooms for people who sustain some kind of injury and need that vaccine, but it is still a major cause of death in

poorer countries than regions where that's not the case. Tetanus cases can also spike after major natural disasters like earthquakes, tsunamis, and hurricanes. Today, the majority of tetanus cases and deaths are in newborns. Babies who are born in surroundings that aren't sanitary, or whose umbilical cords are cut with instruments that are not sterile, or whose umbilical stumps are covered in non sterile dressings. People can also contract tetanus after

giving birth in these kinds of environments. In the nineteen eighties, the World Health Organization and other organizations embarked on the Maternal and Neonatal Tetanus Elimination Initiative. This initiative was then relaunched in nineteen ninety nine, and it involves multiple strategies including improving access to skilled birth attendants who use hygienic practices during delivery and newborn care, and vaccine programs, including

immunizing people during pregnantancy. When somebody is immune to tetanus, that immunity passes to their child and it protects the newborn during their first weeks of life until they can get their own vaccines. Same thing is true for protessis and diphtheria, which are the other two diseases prevented by

the t EDAPP vaccine. This transfer of maternal tetanus antibodies was studied back in the nineteenth century, when German physician Paul Irlick conducted experimentss with mice and goats and their offspring. Between nineteen ninety eight and twenty eighteen, tetanus rates in newborns dropped by about ninety seven percent around the world thanks to these programs, But even with that success, around twenty five thousand newborns still died of neonatal tetanus in

twenty eighteen. Numbers have not changed much since then, in part because of disruptions caused by the COVID nineteen pandemic. In twenty twenty one, which is the most recent year that statistics are EVD available and estimated, twenty four thousand newborns died of tetanus, and as of twenty twenty four, there are ten countries where maternal and neonatal tetanus have

not been eradicated yet. I tried to track down whether the various funding cuts to foreign aid and foreign health programs that's been happening in the US is affecting this particular project, and I do not know the answer. That's what I know about tetanus, though. Do you have some listener mail that may or may not have antibodies in it.

It kind of does have antibodies in it. I instead of reading one email, I just wanted to thank the enormous number of people who sent us emails and Facebook comments and Instagram comments, even a couple of comments on x that used to be Twitter and on Blue Sky, which I don't think we've ever set out loud on the podcast that we're on Blue Sky now now in response to the beginning of our Spring Unearthed episode. I have not responded to any of these email or emails

or comments. I did read all of them. The response was truly, truly overwhelming. I was going to make a list of everybody's names and just say thank you everybody, but even that got overwhelming, and I was also afraid I would miss people. And like we said at the beginning of the episode, a couple of weeks are going to pass between recording this and it coming out, probably get more emails during that time. Basically, we got a lot of really really great email, and so thank you

everyone for that. A lot of people expressed concerns that we were going to get a lot of hate or flack or be hassled in some way. I just wanted to say thank you all very much for your concerns. This was a reasonable concern. I feel we got almost no flak. I was really braced for impact. We only got good impact. We got a giant, ongoing, multiple weeks long impact of hugs basically with minimal badness in all

of that. Hooray, which was great, honestly, because I was afraid that was not going to be what would happen, because like like we said, we don't typically make just explicitly direct political statements on the show, so we've gotten way worse response to way more oblique things that we've said before. Honestly, So again, thank you so much to

all of you. I've read and appreciated all of your stuff. Also, I wanted to say, so many people in your emails said that the beginning of that episode made you feel less alone, So I just wanted to say, hey, you are not alone. We heard that from so many people in the emails. It's clear that a lot of people

are feeling really alone right now. But it's obvious to me from that response that none of us are alone in this moment, even if we might feel alone in some way, like the Big Hands Off March marches across the country and the world. Honestly, on April fifth. I saw some criticisms of those marches for like not having a clear objective set out from the beginning and not

being disruptive. But one of the things I thought was really good about them was showing how there were crowds of hundreds of people even in tiny little towns where people were probably feeling like they were only one or only a handful. So I just wanted to say I absolutely empathize with the feeling of a loneness. Living in

Massachusetts right now, I don't feel very alone. I feel like I'm surrounded by angry people taking action, But having lived previously in North Carolina and Georgia, I didn't always feel that way. So again, you're not alone. And thank you again for all of these lovely, lovely emails and Facebook comments and Instagram comments and all of that that

we have been getting over the last couple of weeks. Now, if you would like to send us some notes about this or any other podcast or a history podcast at iHeartRadio dot com. You can subscribe to our show on the iHeartRadio app and anywhere else that you like to get podcasts stuff you missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.