Russian Surgery in the Crimean War:

NIKOLAy PIROGOV and the first anesthesia

     “Stretcher parties were constantly arriving with casualties, setting them down one beside the other on the floor – which was already so packed that the wretched men were jostling one another and smearing one another with their blood – and then leaving to fetch more… Gloomy-faced surgeons in their rolled up shirtsleeves knelt beside wounded men while an apothecary assistant held up the candle, pushing their fingers into bullet wounds and searching them or turning over severed limbs that still hung by a thread…” . Thus described an eyewitness, Leo Tostoy, the main hospital in his Sebastopol Sketches about the Crimean War. The hospital was

Siege of Sebastopol by Franz Roubaud (from Wikipedia)

 set up in the large “Noble’s Club”, where the billiard room morphed into the operating room and the ballroom into an open ward for the wounded. Moving within this grim scene was an eminent surgeon who greatly advanced the knowledge of battle surgery: Nikolay Pirogov.

     Pirogov was born in 1810, the thirteenth child of a Moscow

Nikolay Pirogov by Ilya Repin (from
Wikipedia)

family whose house perished when Napoleon set fire to the city in 1812. His father died early, but being a quick learner Nikolay raced through school and was admitted to Moscow University at age 14 to study medicine. He found the curriculum inadequate but won a scholarship for further training at Dorpat University (now in Estonia) under a German faculty. There he learned experimental

physiology, did numerous anatomy dissections, and rose to become Professor of Surgery, publishing an atlas of surgical anatomy shortly thereafter (see illustration below). He studied briefly in Paris and Germany. At the age of 30 he won the Chair of Surgery at St. Petersburg’s Medico-Surgical Academy and directorship of the Surgical Department at the Army Hospital. During 14 years there he performed about 12,000 autopsies and, utilizing the cold weather, made frozen sections of the human body at various levels to produce a 5 volume Anatomia Topographica, a highly praised work. “Pirogov’s triangle” (the hypoglossohyoid triangle in the neck) is described there. The young and restless surgeon, as one might expect, battled an entrenched and reactionary medical staff jealous of his growing fame.    

From: Chirurgische Anatomie der
Arterienstämme und Fascien,2nd ed, orig pub'd
1840 (from Internet Archives)

     In 1846 ether was first demonstrated at the Massachusetts General Hospital and only a few months later Pirogov published a manuscript describing his own research on both animals and humans (himself first). He tested ether by inhalation, intravenously, and by enema, realizing its wonderful potential. In the spring of 1847 he was appointed by the Tsar to provide ether anesthesia for the Army fighting in the Caucasus, both to relieve suffering and to boost the morale of men terrified of painful surgery if wounded. Pirogov designed a tight-fitting inhalation mask employing a valve to regulate the ether-air mix, and did not hesitate to perform amputations in the presence of other soldiers, who indeed were relieved to witness the painless surgery. This was the first use of anesthesia in wartime.

     On return Pirogov experimented with chloroform, finding it easier to transport and store, and safe if used properly. The supreme test came in the Crimean War, in which the Russians lost over 250,000 men during the eleven-month siege of Sebastopol alone. Pirogov volunteered his services and with the influence of Grand Duchess Elena Pavlovna was appointed chief surgeon. Pavlovna

Grand Duchess Elena Pavlovna, by
Karl Briullov (from Wikipedia)

was the originator of the Russian nursing service, called the “Holy Cross Community”, whose volunteers worked tirelessly under Pirogov’s direction in the besieged city (Florence Nightingale’s nurses were far away from fighting). At Sebastopol Pirogov instituted a system of triage still used today. He freely gave anesthesia (the British used it sparingly), mainly chloroform, used plaster casts frequently for severe fractures (avoiding amputations), and was a believer in the transmission of sepsis, requiring hand washing by his surgeons and limited wound probing for bullets. He advised prompt treatment in the field whenever possible, an innovation still observed. He also invented an amputation of the foot that saved higher leg amputations. His experience was distilled into the monumental, Principles of War Surgery (available in German), a work studied until WW II.

     (Little known is that 36 American surgeons worked under Pirogov and in the Caucasus during the siege. They were volunteers, though paid, and at their request the American representative in the Tsar’s court, an ex-Governor of Connecticut, arranged the details. About half of them died of typhus or cholera, but lessons learned were later helpful in the American Civil War.)

     After the war, as educational reforms were introduced by Tsar Alexander II, Pirogov resigned from the Medico-Surgical Academy and became an education advisor, working in Odessa, Kiev, and later as advisor to Russians studying in Germany. While in

Memorial statue of Pirogov, Moscow
(from Himetop, creative commons license)

Heidelberg he consulted on a bullet wound in Garibaldi’s ankle. In 1870 he was invited by the Red Cross to inspect the military hospitals in the Franco-Prussian War, and found that most of his recommendations from the Crimean War were being observed. A similar evaluation was performed in 1877 in the Russo-Turkish War, at which he now emphasized even more the importance of antisepsis.

     Between these assignments and in his waning days Pirogov retired to an estate near Vinnytsia (now in Ukraine) where he was a country doctor and farmer. There he composed, but did not finish, his memoirs, a mix of diary, autobiography, and reflective philosophy.

     He died in 1881, and was mourned as a hero throughout Russia. The Society of Russian Physicians, formed in 1884 in Pirogov’s honor, was influential in Russian medicine until abolished in 1918 by personal order of Lenin. The same fate met the Russian Red Cross, a direct descendent of the innovative use of wartime

Entrance to Pirogov Estate and Museum, Vinnystia,
Ukraine (from Wikipedia)

volunteer nurses organized by Grand Duchess Pavlovna. Pirogov’s reputation was revived under the later Soviets.

     Nikolay Pirogov is an underappreciated pioneer in anesthesia and battle surgery, a gifted anatomist and educator, and a humanitarian supporting the highest ideals of his profession. Sadly, few of the works by or about him are available in English.

    

SOURCES:

     Pirogov N: Questions of Life: Diary of an Old Physician. 1991 (orig. in 1885)

     Tolstoy L: Sebastopol Sketches. 1986 (orig 1855-6)

     Raymond E A: “American Doctors in the Crimean War”. 1974. Connecticut Medicine, 38: 373-6.

     Hendriks IF, Bovil JG, Boer F, Houwaart ES, Hogendoom PCW: “Nikolay Ivanovich Pirogov: A Surgeon’s Contribution to Military and Civilian Anaesthesia". 2015. Anaesthesia 70: 219-27.

     Pirogov, N: Recherches Partiques et Physiologiques sur l’Etherisation. 1847

     Sorokina, T: “The Great Russian Surgeon Nikolay Ivanovich Pirogov (1810-1881)”. 2011. Vesalius 17: 10-15.

     Halperin G. “Nikolai Ivanovich Pirogov – Surgeon, Anatomist, Educator”. 1956. Bull Hist Med 30: 347-55.

     Fried BM. “Pirogoff in the Crimean Campaign, 1854-55” 1955. Bull NY Acad Med 31: 519-36.

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ARSENIC POISONING:

 MEDICINE IN THE COURTROOM

     Imagine wanting to eliminate a rival, whether for love or for money. What better way than poison. No violence needed, just cunning. And so it was in early 19^th century Europe, where poisoning, especially with arsenic, was fairly common. Arsenic was everywhere - as rat poison, in dyes for paints, clothing, and wallpaper, and in medications.  Sheep dipping required large amounts and it was even found in flypaper. You could buy it at the local chemist or grocer. “White arsenic” (arsenic trioxide), the common form, was odorless and tasteless, ideal for lacing food or coffee.

     In the courtroom the decision to send an accused to freedom or to the hangman often relied on circumstantial evidence rather than science. In 1815 England was shaken when a 22 year old servant, Elizabeth Fenning, crying to the last that she was innocent, was hanged for poisoning (non-fatally) the family where she worked. Circumstantial evidence alone convinced the jury, in spite of lack of hard evidence of arsenic in those affected. Thousands turned out for her funeral and a public outcry ensued, making it clear that better science, and evidence collection, were needed.

     Two years before, in France, a young physician and chemist, Mateu Orfila, noted that white arsenic powder in coffee or other organic fluids failed to precipitate with standard reagents. He correctly saw the importance of this in criminal cases. Orfila, born on the island of Minorca, had studied medicine in Valencia and

Mateu Orfila (from Wikipedia)

then chemistry in Barcelona and Paris. He was quick, bright, self-confident, and an excellent lecturer, traits that catapulted him rapidly into influential chemistry and medical circles. He was helped by a superb baritone voice (said to be adequate for the Paris Opera) that gained him entry into select Paris salons. He was a constant proponent of the value of chemistry to medicine, a theme resisted by many clinicians at the time. Orfila soon was able to isolate arsenic in organic material and rapidly widened his research. He published the first full book in years on toxicology, Traité des Poisons, in 2 volumes over 1814-5, a popular book translated into several languages. In 1819 he was appointed professor of legal medicine at the Paris Faculty of Medicine, and was consulted frequently in criminal poisoning cases. Later in life he was president of the Royal Academy of Medicine.

     One of Orfila’s students, a Scot named Robert Christison, on returning to Scotland noticed there an absence of knowledge of toxicology and published the first English language text on the

Robert Christison (from Wikipedia)

subject. He too was frequently consulted on court cases and became professor of medical jurisprudence in Edinburgh. 

     Better science soon came. In 1833, John Brodle was accused of poisoning his grandfather by placing arsenic in his coffee. The coffee grounds and stomach contents of the victim were sent off to Michael Faraday for testing, who passed them on to his assistant, James Marsh, whose findings were inconclusive - Brodle went free. Marsh appreciated that the usual precipitation methods could not detect arsenic in tiny amounts. He knew from Carl Wilhelm Scheele, an important Swedish chemist, that the combination of arsenic, zinc, and nitric acid produced a gas, arsine. He devised an apparatus (see insert) featuring a tube with a

stopcock at the top through which the arsine could pass. When the arsine was flamed a precipitate of metallic arsenic formed on a glass plate held over the stopcock. At first tricky to use, with modification it became the standard test for arsenic. Little is known of Marsh’s life except that he was a respected scientist for the military and had invented a vibrating interrupter to turn circuits off and on.

      A few years later, in 1840, in the village of Beyssac, south-central France, a Marie Lafarge was accused of poisoning her husband. Tests for arsenic on his remains were inconclusive, and when repeated were negative. The juge d’instruction ordered the body exhumed, 10 months after burial, for more tests. This time the “Marsh test”, applied to the putrid remains, was negative. But a physician who relied on the clinical picture still doubted the results so the juge ordered a fourth assay, appointing experts, including Mateu Orfila, to do the tests. Orfila’s team found arsenic this time, landing Madame in jail for life. Orfila claimed that the previous team had performed the test improperly. It was the first criminal trial decided by the Marsh test. Madame LaFarge’s case was another that evoked a media blitz which

Madame LaFarge (from Wikipedia)

divided the country “as much as the Dreyfus case”, according to some. LaFarge’s memoirs, written in jail, were a best seller.

      Aware of the sensitivity of the Marsh test, Orfila realized that he could now assay blood and tissue levels for arsenic at levels unheard of before. He was aware of experiments done a few years earlier by Francois Magendie on strychnine, proving that it was absorbed through the venous system and not the lymphatics. Orfila did similar experiments, now measuring levels in blood and tissues, something impossible for Magendie who relied on clinical effects. Testing for organic poisons, such as strychnine and nicotine, soon followed. Forensic science, and experimental pharmacology, were now established.

     “Medical jurisprudence” chairs were established in many of Europe's medical centers in succeeding years. In the U.S., by contrast, the first full time position in “legal medicine” was not until 1937 at Harvard. The physician chosen for the position, Alan Moritz, was first sent to Europe for two years to study at already existing departments. Moritz pushed the AMA to advocate for physician medical examiners. In 1944 only seven states had medical examiners - in others the coroners were laymen. The AMA agreed with Moritz and exerted its influence. Gradually medical examiners replaced lay coroners, and forensic pathology is now a board specialty in the U.S.

      

SOURCES:

           Bertomeu-Sanchez, JR, and Nieto-Galan, A, eds: Chemistry, Medicine, and Crime. 2006.

           Jentzen, JM. Death Investigation in America. 2009

           Stratmann, L. The Secret Poisoner: A Century of Murder. 2016.

           Chaille, SE. 1949.  “Origin and Progress of Medical Jurisprudence, 1776-1876”. J Crim Law and Criminology, 40: 397-444.

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     HOW STANFORD CAME AND WENT 

               FROM SAN FRANCISCO

                             

     On the southeast corner of Pacific Avenue and Divisidero Street in San Francisco stands a large beautifully preserved wooden Victorian mansion, replete with turrets, its own water supply on the top floor, and large windows looking out on perhaps the most expensive real estate in the city. Few who drive by as they cross

Ellinwood House (photograph by author)

Pacific Heights know that it belonged to perhaps the most hated doctor who ever lived in the City. His name was Charles N. Ellinwood (1838-1917). The story is an interesting one.

     Dr. Ellinwood was President of, and Professor of Physiology at the Cooper Medical College and Treasurer of its hospital, located at Clay and Webster Streets at the time of the great San Francisco earthquake in 1906. He was the sole legatee of the past owner of

the school, the successful and wealthy surgeon, Dr. Levi Cooper Lane (1830-1902), who had died some years earlier followed soon

Dr. Levi Cooper Lane (Medical History Center, Stanford,
Creative Commons lic.)

afterward by his wife. They were childless. Ellinwood was left exclusive control of the school’s endowment with the full expectation that he would continue the wise and successful administration that characterized Dr. Lane’s long tenure. Lane himself had re-established the proprietary school begun by his pioneer uncle Dr. Samuel Elias Cooper (1822-1862), and had made it a highly respected and perhaps the most prestigious medical school in the western United States. Lane was highly entrepreneurial and used his wealth to build the Lane Hospital, the most modern hospital of its time and form and endow the famous Lane Medical Library. It was and remains the largest library of its kind in the West. He gathered around him the finest skilled medical faculty in San Francisco to teach and manage the hospital’s wards and clinics. Lane also endowed the famous annual Lane Lectureship, which attracted a series of world-renowned speakers to San Francisco. Lane and his hospital competed successfully with the University of California School of Medicine, then under the direction of Lane’s archrival and one-time AMA President, Dr. Beverly Cole (1829-1901). The Toland Medical College, another proprietary institution, had been given gratuitously to the Regents of the fledgling Berkeley University of California in 1873 by its founder, 49er physician, Dr. Hugh Toland (1806-1880). UC migrated from its Stockton Street origins to Parnassus in 1895 thanks to then San Francisco mayor Adolph Sutro’s beneficence, where it later built its own hospital.

     The Lane Hospital, an imposing brick structure with its large auditorium, remained in use on Sacramento and Webster Streets until 1970 with it’s founder’s heart remaining, at his request, in an urn in a prominent place near the podium.

In April 1906, most of the City was destroyed by fire and earthquake and the Cooper College was severely damaged. The Trustees requested funds from Ellinwood to effect repairs and in a contentious meeting in June 1906, Ellinwood as Board President, whose relations with Dean Dr. Henry Gibbons Jr. (1840-1911) were not the best, simply refused to release any money to the school. Nor would he release money to maintain the important Lane Library and annual Lane Lectures.  As can be imagined, the trustees were frustrated and furious but Ellinwood stood firm insisting that the money left to him in the Lane legacy was a personal gift. He insulted them declaring that the quality of the school did not warrant the expenditure of any funds.  The trustees ultimately fired Ellinwood but were advised, considering the terms of Dr. and Mrs. Lane’s wills, that there was no way to break Ellinwood’s absolute control over the endowment. The faculty - all-volunteer in the days before outside funding - and the Lane Medical School and Hospital which they staffed, were left high and dry. Ellinwood kept the money.

     Gibbons as Dean, in desperation and with the approval of the trustees, approached Stanford University to finalize discussions begun several years earlier to turn over control of the school if the Palo Alto institution would maintain it in the City and keep its clinical faculty. Thus began the Stanford University Medical School in San Francisco.

     Stanford continued its significant presence in San Francisco for over 50 years, training a succession of successful doctors with a prestigious world-class faculty. It utilized the Lane buildings and added to them. It also ran a division of the San Francisco General Hospital with distinction until 1959, when consolidation occurred as construction of the new Stanford Medical School and Hospital was completed on the Palo Alto campus.

     At that point the local Stanford San Francisco Clinical Faculty again was faced with a crisis, as most of them had no intention of leaving their San Francisco practices for the hinterland. They also wanted to maintain connections with the hospital where they admitted their patients. For the next several years the hospital sans medical school continued under various iterations and sponsorships until it was re-built and became what it is today, Pacific Medical Center, a prominent and highly successful San Francisco institution, now part of the Sutter Health System.

     The origins of PMC and its hectic history is largely unknown today. Dr. Ellinwood has also been mercifully forgotten except by his descendants who continued to occupy the mansion he built on Pacific Avenue for many years. The Lane name persists as Lane intended: in the form of the fabulous Lane medical library and the annual Lane lectureship, associated with the world-class medical school on the Stanford campus in Palo Alto some 30 miles away from where the story originated.

Arthur E. Lyons MD

Source:

https://lane.stanford.edu/med-history/wilson/chap01.htm

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DAKIN’S SOLUTION and THE GREAT WAR

     There must be surgeons who still remember Dakin’s Solution, a tried and true antiseptic solution, named after its inventor Henry Dakin. 

     Like many surgical advances this one started in wartime – the First World War.  Soldiers attacked by shells and bullets ever more destructive to human flesh, fighting in fields and trenches in well-manured farmland, suffered gaping wounds prone to anaerobic infections and gas gangrene. Delays transporting the wounded to proper hospitals added to the burden. 

     To combat the problem Alexis Carrel, a French surgeon at the Rockefeller Institute in New York who already had a Nobel Prize 

Alexis Carrel (Wellcome Library)

for pioneering work in vascular surgery, stepped in. He and his wife were vacationing in France when the Great War broke out and being a French citizen was  called up.

     Through an influential American friend he was put in touch with the French War Minister who granted him a hospital for research if he could get his own funds for a laboratory. Carrel reached to the Rockefeller Foundation and received ample funds, and the name of a good chemist – Henry Dakin.

     Henry Dakin was born in London in 1880. As a schoolboy he was apprenticed to a City Analyst and did analyses of water, sewage, etc. He enjoyed chemistry and went on to obtain a degree and work in the field. In 1905 he accepted a job in the private

Henry Dakin (from Wellcome Library)

biochemical laboratory of Dr. Christian Herter in New York (on the top floor of his large house). Herter, a wealthy, respected, physician with ties to the Rockefeller Institute, had given up his practice to found the laboratory, do chemical investigations, and consult. He died in 1910, and Dakin stayed on as director of the lab at Mrs. Herter’s request. Dakin’s main work was in amino acid and lipid metabolism.

      When the war broke out Dakin, a British citizen, was eager to help and responded to the call from Carrel. They collaborated at “Temporary Hospital #21”, set up in the Round Royal Hotel outside Compiège, a village just 14 kilometers from the front. The Round Royal was a huge luxury hotel, once owned by Napoleon III, now housing 50 beds on the main floor and more (for officers) upstairs. The thunder of cannons not far away provided background noise to the constant flow of mangled, infected bodies arriving at the hospital. 

     Life at the Round Royal was hard. There were occasional shellings and bombings of nearby Campiègne itself, but no one deserted. Madame Carrel helped supervise nursing. On site were a radiologist, bacteriologist, pharmacist, biologist, and surgeons. 

     Antibiotics were unknown. Surgeons realized that debridement of damaged tissue was essential to survival but antiseptics for cleaning wounds proved either toxic or poorly effective (due to inactivation by proteins in tissue fluids). Almoth Wright, the British bacteriologist, had introduced concentrated saline as a way to draw out more lymph to clean wounds, but this too was inadequate.

     Dakin set to work. He tested over 200 compounds, finally settling on a dilute solution (0.05%) of sodium hypochlorite 

Carrel-Dakin tubing
(from Treatment of
Infected Wounds)

buffered with boric acid (to reduce tissue irritation). Dakin’s new solution was washed through tubing with holes in the wall that was introduced into deep areas of wounds. At first the fluid was pushed in by syringe but later IV drips were used. Nurses had to frequently adjust IV drips and change dressings and the solution, being unstable, was mixed on site. Using bacteriologic culture counts, wounds were closed when sterile on 2 or 3 cultures. The results were amazing. Suppuration was almost eliminated and healing accelerated, and the method quickly became the preferred one throughout the allied front. Dakin also invented an electrolysis process for making hypochlorite from sea water, allowing a hospital ship an unlimited supply. And he synthesized chloramine-T, a surface disinfectant.     

Method of wound irrigation (from
Treatment of Infected Wounds)

     When the U.S. entered the war Carrel returned to New York to head a school on the grounds of the Rockefeller Institute to train doctors in military medicine, where the Carrel-Dakins method was taught. 

Alexis Carrel teaching at Rockefeller Institute
(from National Library of Medicine)

     Dakin, on his return to the U.S., married Mrs. Herter, who was 16 years his senior, and moved into a large house in Scarborough overlooking the Hudson River. There Dakin built his own laboratory, pursued work on amino and fatty acids and published a Handbook of Chemical Antiseptics. His chemical work was of high caliber and earned him honorary degrees, a fellowship in the Royal Society, several medals, and later a directorship in Merck & Co. He was an editor of the Journal of Biological Chemistry. As a person he was reserved and shy, seldom collaborated, did not take on “post-docs”, did not have a university affiliation, and entertained infrequently. Thus he is less well-known than he might have been. 

     Henry Dakin considered his antiseptic work as less important “chemically” than his other work, but it was clearly important to grateful war surgeons and their patients.

Sources

Edwards, W.S.  Alexis Carrel: Visionary Surgeon. 1974

Malinin, T.I.  Surgery and Life: The Extraordinary Career of Alexis Carrel. 1979

Mottier, G.  L’Ambulance du Docteur Alexis Carrel.  1977.

Dis Colon Rectum 1983; 26: 354-358 (contains Dakin’s original   

          paper).

Hawthorne, R.M.  Henry Drysdale Dakin, Biochemist: The Option of Obscurity.  Persp Biol Med 1983; 26 (4): 553-67.

Carrel, A. and Dehelly, G.  The Treatment of Infected Wounds. 1917 

         (English Translation).

“Dr. H.D. Dakin” (obituary). Nature 1952; 169: 481-2.

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Nathan Smith

Motive Force of Four Medical Schools

Nathan Smith MD
(from "Life and Letters", Internet Archive)

     Perhaps the most important New England physician of the post-Revolution years, Nathan Smith, was born in 1762 in Rhode Island but raised in Chester, Vermont, a frontier town at the time. Nathan’s father died soon after, landing most of the farm chores on him, though somehow he accumulated enough education to later teach school. At age 22 he witnessed a mid-thigh amputation without anesthesia, an experience that, amazingly, galvanized him to study medicine. The surgeon, Dr. Goodhue, accepted him as an apprentice only after further study of basic subjects, and he apprenticed in midwifery as well. Finally he started a practice in Cornish NH, with no medical degree and no license (there was no state licensing board). Feeling inadequately prepared, he went 2 years later to Harvard Medical School (founded in 1783), studying under Dr. John Warren, to secure a Bachelor of Medicine degree (one year course). He was the school’s fifth graduate.

     Back in practice and noting the scanty education of his neighboring practitioners, he approached Dartmouth College in Hanover about opening a local medical school. Wisely the College advised him to first study in Europe, which he did in Edinburgh and London. Interestingly, he was not overly impressed with his professors and their complicated disease nosologies.

     On return he headed for Dartmouth, giving his first medical

Old Medical Building, Dartmouth
(from "Life and Letters", Internet Archive)

lectures in 1797. A few years later he was teaching medicine, surgery, materia medica, jurisprudence, and (for awhile) chemistry – a one-man medical faculty - and was awarded the full MD degree. His ten-week lecture sessions were popular, attracting both students and local practitioners. He was helped by Dr. Lyman Spalding, who covered for him in his practice and briefly taught chemistry. Spalding later founded the U.S. pharmacopeia.

      In medical practice Smith was conservative. He urged

cleanliness,  bled seldom, and was sparing with harsh purgatives, attitudes distinct from those of Benjamin Rush and other advocates of "heroic medicine". Regarding treatment of typhoid he wrote, “… I feel well convinced that all powerful remedies or measures adopted in the early stages of Typhous Fever are liable to do harm”. Though it is not known if he ever studied Morgagni’s work on pathology (that emphasized the local causation of disease), he practiced as if he had. Averse to grand theories he used autopsies to clarify his clinical impressions, an innovative approach at the time and one just emerging in Paris.

      He was perhaps better known for excellence in surgery. He operated reluctantly. Cleanliness helped his results. Most of his work related to trauma – fractures, horse kicks, injuries from axes, etc. “Couching” for cataracts (dislodging the lens from position with a needle through the sclera) was common, as were amputations. Particularly advanced was Smith’s advocacy of removal of bone affected by subacute or chronic osteomyelitis. He used a trepanning saw to remove a round area around the necrosis, which apparently achieved adequate healing. Another Smith, Joseph, underwent the procedure in his left tibia, saving him an amputation. Joseph Smith went on to found the Mormon Church.

     Over time Nathan became tired. Teaching duties, a growing family, and an expanding practice were taxing enough, but decisive were lack of financial support for his school and the stress of obtaining bodies for anatomy instruction. One grave-robbing student had been fined, a riot had occurred over another stolen corpse, and corporal punishment was contemplated by the legislature. Yale

Ticket to Smith's lectures at Yale - students paid the
professors directly.
(from "Life and Letters", Internet Archive)

University fortuitously asked him to join Benjamin Silliman, a chemist, to found a medical school at Yale, an offer he accepted, though he had to convert from Episcopalianism to Congregationalism. Smith was appointed professor of “The Theory and Practice of Physics, Surgery, and Obstetrics”, and was joined by Silliman and 3 other faculty members. He arrived in New Haven in 1813, penniless and having to borrow money.

      Next Bowdoin College in Maine wanted to open a medical school, hoping Smith would head it. He negotiated time away from Yale to give 10-week courses as one of 3 faculty members. But Yale soon pressured him to give up Maine, which he did 4 years later (1825). During his time at Bowdoin he also acted as an advisor in establishing a medical school in Vermont, thus being involved in some way in the founding of 4 medical schools and serving as full professor in three.

     In late 1828, at the age of 66, Nathan Smith suffered the first of a series of strokes, dying the next year. He left behind a wife and ten children. Four of his children were boys and all became

physicians, as did several grandsons. His second son, Nathan Ryno Smith, was a founder of Jefferson Medical College.

      Nathan Smith left a rich legacy. Beloved by both students and patients, he was easily the most prominent physician in all of New England, skilled in both medicine and surgery. He wrote little, but two of his works were influential and ahead of their time: A Practical Essay on Typhous Fever (praised by William Osler 72 years later) and Observations on the Pathology and Treatment of Necrosis (in bone). His influence on medical education is almost unequaled, and his teaching spawned a whole generation of physicians, many of whom became important educators.

    

SOURCES

     Smith, Nathan R, ed. Medical and Surgical Memoirs, by Nathan Smith, 1831. (contains his above-cited works)

     Hayward, O.S. “Nathan Smith (1762-1829), Politician”. NEJM 1960, v263, p.1235

     Hayward, OS. Improve, Perfect, and Perpetuate: Dr. Nathan Smith and Early American Medical Education. 1998.

     Field, WW. The Good Dr. Smith: The Life and Times of Dr. Nathan Smith. 1992.

     Smith, EA. The Life and Letters of Nathan Smith, M.B, M.D. 1914.

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 THE DEATH of PRESIDENT HARDING

     “PRESIDENT RAPIDLY IMPROVING”, ran the headline of the San Francisco Chronicle on August 1, 1923, referring to President Warren Harding, ill and bedded down in the Palace Hotel in San Francisco. 

     But the next day readers were astounded by, “HARDING DEAD. BELOVED PRESIDENT SUCCUMBS SUDDENLY IN EARLY EVENING”. 

     What happened? What was the illness that brought Harding to the Palace Hotel?  And who took care of him?

    

     Warren Harding was elected president in 1920, and was felt by some even then to not look well. He smoked a lot and his blood pressure had been high for some time, usually around 180. In January of 1923 he was laid up with “the flu”, with poorly defined chest complaints, after which he often had to sit up at night to 

Warren Harding (Wikipedia)

breathe comfortably. On the golf course he was panting, unable to finish the course. Close associates feared for his health.

      A trip to Alaska, to settle some political problems but mainly as a rest, should help restore him, and Harding’s doctor, Charles Sawyer, agreed. On the way he felt better but on the return trip, in Vancouver, he weakened, with abdominal pain followed by shortness of breath and intermittent chest pains. Sawyer incriminated recently consumed bad crabmeat. In Seattle Harding almost collapsed during a speech. His staff was alarmed and arranged to bypass an Oregon stop and rush him directly to a suite on the eighth floor in the Palace Hotel in San Francisco (visible at http://thepalacehotel.org ), arriving on July 29.

     The President’s physician, Dr. Sawyer, was a homeopathic physician and a family friend, but with rudimentary training. He had treated Mrs. Harding for a kidney problem and on her

Dr. Charles Sawyer (Wikipedia)

insistence was brought to the White House. (And Harding’s father was a homeopathic physician.) A better-trained naval physician Dr. Joel T. Boone was also hired, mainly to be physician on the presidential yacht. He had graduated from the Hahnemann Medical College, and the U.S. Navy Medical School.

     On the way to San Francisco Dr. Boone examined the President and, realizing that crabmeat was not the problem, alerted Herbert Hoover, Secretary of Commerce and part of the entourage, who in turn spoke to Hubert Work, Secretary of the Interior and a former doctor (trained at the U. of Pennsylvania). Work examined Harding and found his blood pressure low, his heart grossly enlarged, the sounds muffled, and his pulse regular but rapid. Hoover wanted consultation and telegraphed an old friend, Lyman Wilbur, president of Stanford University and formerly dean of the Stanford Medical School. Wilbur, on vacation in the Sierra Mountains,

Dr. Lyman Wilbur (Wikipedia)

rushed down, bringing Charles M. Cooper, a Stanford internist, with him to the Palace Hotel. 

     They agreed with the findings and noted tenderness over the gallbladder. Fever ensued, with pneumonia in the right lung seen on X-ray. Digitalis was administered with some improvement, but on August 2, as his wife was reading to him, she noticed her husband suddenly bathed in  sweat. Moments later he stiffened, then slumped, without breath or pulse. An autopsy was refused. Wilbur and Cooper suspected a stroke as the immediate cause of death. 

     The official statement, authored by all the physicians, was “apoplexy or the rupture of a blood vessel in the axis of the brain near the respiratory center”. Wilbur and Cooper added a further note that he had cardiac enlargement, probably with thickened blood vessels, angina, nocturnal dyspnea, and Cheyne-Stokes respiration. Gall bladder disease was suspected. Sawyer’s misdiagnoses were not mentioned.

     What was known about blood pressure and heart disease at the time, and might other measures have been taken? The auscultatory method of blood pressure measurement was invented by the

Nicolai Korotkoff (Wikipedia)

Russian Nicolai Korotkoff, first reported in1905, a method that was easy, allowed diastolic measurement, and rapidly replaced previous more cumbersome methods. After just a few years it became apparent that high blood pressure predisposed to cardiovascular problems, and by 1911 about two thirds of U.S. life insurance companies had made it part of their physical examination. Alas, there was no treatment until after WWII.

     Anginal pain, which Harding almost certainly had, was known to relate to coronary vessel disease, the case of John Hunter being a prime example. Myocardial infarction had been thought to be rapidly fatal and to have made this diagnosis in Vancouver, or instead of “the flu” in January, would have been unlikely (though occasional reports had described longer survivors). As late as 1919 James Herrick published the first case of myocardial infarction diagnosed by EKG findings, inverted T waves in this case, that were identical to those seen in dogs with ligated coronary arteries. Other features, such as Q waves, were still unrecognized and until then the EKG was used only for rhythm disturbances. No EKG is mentioned in Harding’s case. The only cardiac drug in use was digitalis and the only diuretics available were caffeine and theophylline, not very potent.

     In short, cardiac knowledge, especially of diagnostic tools, was still in its infancy. And aside from digitalis, little of medicinal use was available. Though earlier diagnosis of heart disease would have led to more rest and earlier use of digitalis, the tools for more sophisticated management were not at hand.

Sources

  Ferrell, R H.  The Strange Deaths of President Harding. 1996

  Starling, E W and Sugrue, T.  Starling of the White House, 1946.

  Robinson, E E and Edwards, P C. The Memoirs of Ray Wyman 

         Wilbur. 1960

  Herrick, J. “Thrombosis of the Coronary Arteries. JAMA 1919. 

         72(6): 387-90.

  “President Harding’s Last Illness: official bulletins of attending 

         physicians”. JAMA 1923. 81(7), p603.

  Lewis, WH. The Evolution of Clinical Sphygmomanometry. Bull  

         N Y Acad Med 1941. November, p 971.

THE FIRST VA SCANDAL

     “Hospital delays are killing America’s war veterans.”

     Thus flashed a headline from CNN in November 2013, news that revealed widespread system failure in the Veterans Administration. But this was not the first VA disgrace. A major corruption scandal marred the hospital system at its very inception.

     Following the Civil War Congress established the National Home for Disabled Volunteer Soldiers to care for soldiers with

National Home for Disabled Soldiers, Virginia
(National Library of  Medicine)

war-related disabilities. After World War One Congress agreed that veterans of that war should also receive medical care and appropriated money to the National Home and to the Public Health Service to use their facilities. In 1921 the veterans’ scattered medical care and hospital services were consolidated into one organization, the Veterans Bureau. President Warren Harding appointed Charles Forbes to run the Bureau.

     Forbes was unusual. Educated at Columbia University and MIT, he enlisted in the Army as an engineer, was arrested for desertion but reinstated without trial and remained for 8 years. After discharge he worked as a civilian engineer, dabbled in politics, and ended up in Hawaii involved in construction at the Pearl Harbor Navy Base. When (then) Senator Harding visited Hawaii on

Charles Forbes (Wikipedia)

vacation Forbes hosted him and the two became good friends. Forbes later enlisted in WWI, earning the Croix de Guerre and the Distinguished Service Medal. Soon after the War Harding ran for president and Forbes, now a civilian, helped him gain the Republican nomination.

    

    Harding rewarded Forbes by appointing him to head the newly created Veterans Bureau, in spite of advice by advisers not to. The annual budget was near $500,000,000 – almost a fifth of the national expenditures.

     Once in office Forbes threw out all restraints. He hired large numbers of his friends and “good Republicans”. He took long trips to inspect hospitals and hospital sites with contractor friends, nicknamed “joy rides”. Drinking parties and expensive hotels took more time than inspections. He paid excessive sums for new sites, pocketing the difference, and engaged in various kickback and insider bidding schemes with his construction firm cronies chosen to build new hospitals. He gave the general counsel for the Bureau, Charles Cramer, a generous cut on the profits, ensuring legal cooperation. Hospital conditions for the veterans were often inadequate, and often patients who no longer needed treatment were kept in, depriving others of needed care.  The newly built hospitals were poorly made, one without a kitchen and another without a laundry (the one in Palo Alto).

Veterans Bureau meeting, with Forbes
(Library of Congress)

     A huge government warehouse in Maryland full of medical supplies caught Forbes’ attention. The contents were valued at between 5 and 7 million dollars (between 70 and 98 million today). He sold most of it for about 20% of its value to a Boston firm, Thompson and Kelley, expecting profits on resale. 150 freight cars showed up, into which disappeared sheets, pajamas, bandages, drugs, liquor, and many other supplies. Protests erupted, especially from Hugh Cumming, Surgeon General of the Public Health Service, entitled to 20% of the warehouse contents. It proved to be Forbes’ downfall.

     President Harding had brushed off earlier rumors of Forbes' shenanigans, but now called him in, twice. At the second interview Harding became so enraged that he grabbed him and shook him “as a dog would a rat”, ordering him to resign. Forbes slipped off to Europe and resigned from there, returning later. On March 2, 1923, the Senate announced their intention to investigate.

     Twelve days later Charles Cramer shot himself in the head in a bathroom, leaving on his bureau a poem about death that he had clipped from a newspaper. The Senate hearings brought out the whole story, relying especially on testimony from Elias Mortimer, a contractor included in the scam who had become incensed when Forbes took a trip with his wife. Forbes and John J. Thompson, purchaser of the warehouse contents, were later convicted at trial of defrauding the government and each fined $10,000 and sentenced to two years in prison. Thompson was sick and died before he got to prison and Forbes was let out after eighteen months. His wife had divorced him. He lived quietly in Florida until his death in 1952.

     The VA scandal was one of many that the Harding administration endured. It was costly in money and in neglected care of veterans. But the Veterans Bureau lived on and was reorganized to the modern Veterans Administration in 1930, though not thoroughly immunized against subsequent scandal.

Sources:

    Murray, R K: The Harding Era. 1969

    Ferrell, R H: The Strange Deaths of President Harding. 1996

    Werner, M R: Privileged Characters. 1935.

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