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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                                   THE GUAIAC TREE:

 From syphilis to blood detection

     In 1496 a new disease broke out in Italy, producing large, disfiguring, sores over the body. It emerged after an invasion by Charles VIII of France followed by a severe winter of heavy snowstorms and floods, destroyed crops, and a malnourished population. But the French troops got the blame, hence the name “the French disease”, though some called it the Spanish or the Neapolitan disease. It surged through Europe when the troops went home.

     Treatments varied, but were oriented toward removing morbific material by means of bleeding, purging and, quite prevalent, “sweating” in enclosed hot fixtures. Soon mercury, both topical and ingested, came into practice, with its attendant symptoms of mercury poisoning.

Eventually the idea surfaced that the disease originated in America and reports came of a concoction used by the natives of Hispaniola – an extract of the guaiacum tree – that produced miraculous cures.

guaiac tree 

News of the remarkable remedy soon reached the emperor Maximilian I who ordered his chancellor, Cardinal Matthew Lang, to send a commission to Spain to investigate. The members of this commission are not known for certain, but almost certainly one was Dr. Nicolaus Pol. Pol was court physician to the emperor, a theologian, and a bibliophile.

     Nicolaus Pol published a tract on the use of the guaiac wood that appeared between 1517 and 1519. In it he clearly stipulates, bowing to Galenic theory, that before taking the guaiac potion the body must be “purged of offending humors”, the exact methods left up to the physician. This to be followed by 3 days of reduced dietary intake. Then comes a 30-day course of twice daily ingestions of a liquid made from the wood. After the morning dose the patient should be in bed, covered with blankets, to sweat. Dietary intake is gradually increased and sexual intercourse forbidden. The wood went under many names, common ones being lignum vitae or lignum sanctum.

Patient with syphilis on left drinking extract of guaiacum. On right, chopping, weighing, and boiling of wood.
Line engraving by P Galle after J van der Straet, about 1600. (Courtesy Wellcome Library, Creative Commons license:

http://creativecommons.org/licenses/by/4.0/)

     To make the concoction a pound of guaiac wood was cut into small pieces and boiled in 12 pounds of water until half was boiled off. A dose of ½ pound of the liquid was administered twice daily, altogether requiring 5 pounds of the wood for a 30-day course. The foam accumulating on the top was skimmed off, dried, and used as a powder on the sores.

     Another, and more well-known treatise on the treatment was published by the German poet-laureate and humanist Ulrich von Hutten, appearing in 1519. (David Starr Jordan, first president of Stanford, was so 

Ulrich von Hütten (Wikipedia)

impressed by von Hutten that he wrote a short book about him – see below. A phrase of Hutten's, "Der luft der Freiheit weht" - the wind of freedom blows - is on the Stanford emblem.) Von Hutten had the French disease himself and describes the treatment in this widely read book, De guaiaci medicina et morbo gallico (English translation made in 1730). His recipe is basically the same except a little stronger - one pound of wood only lasts 4 days - and the diet stricter. Von Hutten’s book sold widely and boosted the use of guaiacum immensely. He intimates that doctors and vendors of the wood were in cahoots financially, and that could be so. Jacob Fugger, the richest man in Europe and

Jacob Fugger by Albrecht Dürer
(Wikipedia)

Maximilian’s chief banker, was a major trader in the wood. He erected 3 houses for the treatment of syphilis as part of a larger “Fuggerei” – colony of houses for poor people (which still exists in Augsburg). He promoted guaiacum treatment and no doubt profited well from it.

     Finally, Fracastorio, in his treatise on syphilis, also praised the benefits of the wood. The treatment was expensive, though, and over time fell out of favor, yielding once again to Mercury.

     There are 3 varieties of guaiacum tree, 2 of which were probably used. The wood is hard and heavy, sinking in water, and has been used for mallets, bowling balls, ball bearings, and for propeller shaft bearings in steamships (they outlast steel). It grows in the Caribbean and adjacent shores and is a good shade tree. An extract of the resin of the tree is the basis of the “Guaiac Test” for occult blood, something else that is fading into medical history.

Sources:

    Muinger, R S. Guaiacum: The holy wood from the New World. J   

        Hist Med All Sci 1949, 4: 196-249.

    von Hutten, U. De Morbo Gallico (English Translation), 1730.

    Fisch, M H. 1946. Nicolaus Pol Doctor 1494. 

    Arrizabalaga, J, et al. The Great Pox: The French Disease in 

         Renaissance Europe.1997.

    Record, S J. Lignum-Vitae: A study of the woods…., 1921.

    Jordan, D S. 1910. Ulrich von Hutten: "Knight of the order of 

         poets". 

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Alexander Hamilton to Rockefeller Center:

David Hosack MD

           Tension gripped the air as two men faced each other in a tragic duel. Alexander Hamilton had just arrived at a lonely spot amongst dense cedar trees on the New Jersey shore where Aaron Burr was awaiting him, early July, 1804. At a prearranged signal Burr fired, wounding Hamilton in the right side, the bullet lodging in his lumbar spine. Hamilton sank to the ground, partly supported by his second who shouted for medical help. Doctor David Hosack, waiting at the shore by the boat that had ferried them over, scrambled up to the site. The devastating scene is best

Scene of the Duel (Wikipedia)

recounted in his own words: “His countenance of death I shall never forget. He had at that instant just strength to say, ‘This is a mortal wound, Doctor', when he sunk away and became to all appearance lifeless…. His pulse was not to be felt; his respiration was entirely suspended: and upon laying my hand on his heart, and perceiving no motion there, I considered him irrecoverably gone…” (from a letter to the editor of The New York Evening Post). Hosack liberally applied spirits of hartshorn (an ammonia solution distilled from the horns and hooves of deer, later called smelling salts). On the skiff back to New York Hamilton regained consciousness, started breathing more normally and his pulse felt stronger. He complained that he had no sensation in his legs. He was placed in the house of a friend and given laudanum and other pain relievers. Hosack called in consulting surgeons, but none had more to offer and Hamilton expired in pain the following afternoon, a great loss to the young nation.

     Who was Dr. Hosack? He was, in fact, an important figure in the early history of medicine in New York. As physician to Hamilton’s family, he had watched over one son severely ill with scarlet fever, and had attended another son dying from wounds inflicted in a duel 3 years earlier. He had also been consulted by Burr in the past.

      David Hosack was born in 1769 on Manhattan, where he spent his childhood during the Revolution while British troops roamed the Island. He attended Columbia College (the name “King’s” College had been dropped) and the College of New Jersey at Princeton. He studied medicine at the Medical College of the University of Pennsylvania, where he befriended Benjamin Rush, followed by nine months at the University of Edinburgh and a year in London. In London he studied botany at the Linnaean herbarium under James Edward Smith and became a dedicated plant lover.

David Hosack by Rembrandt Peale (Wikipedia)

     Back in New York Hosack entered private practice and did well. He was on the faculty of the Columbia Medical School, and later partnered in practice with Dr. Samuel Bard, perhaps the best-known physician in New York. In 1795 and 1798 he and Bard worked through yellow fever epidemics, both contracting yellow fever in the process. As treatment he employed Glauber’s salts (sodium sulfate, a moderate laxative), bathed the patient with vinegar and cool water, and applied warm blankets while feeding liquids (called the “stove-room technique” by some). Aware of Benjamin Rush’s regimen of bleeding and violent purges he tried it in the 1798 epidemic. But after losing 40 patients he reverted to his milder method, with better results. The milder treatment also brought him many patients. He was a cofounder of the Medical and Philosophical Register, a respected medical journal, was the first in the U.S. to ligate the femoral artery for aneurysm, and innovated treatment of hydrocele by injection. He wrote many medical essays, and his practice included most of the luminaries of New York Society.

     Botany was little taught in New York and there were no large herbaria in the country. Hosack saw the need and purchased twenty acres of land between what is now 47^th and 51^st Streets to create the Elgin Botanic Garden (named after his father’s home town in Scotland). He poured his heart, and his money, into the garden,

Engraving, Elgin Garden. (Medical Repository 1810)

 ordering plants from around the world, quickly becoming recognized as an expert botanist. As Professor of Botany and Materia Medica at the College of Physicians and Surgeons he regularly took his medical students through the garden, teaching. 

     Hosack fostered the development of arts in New York. He was a founder of the New York Historical Society, the NY Academy of the Arts, and supported other organizations. He was an outgoing person, enjoying his students as well as social company. In 1825 he married a wealthy woman (2 other wives had died) allowing him to purchase a large estate at Hyde Park. There he built a large garden and entertained in style, hosting many notables of the day and giving up most of his practice. He died after a stroke in 1835.

     The Elgin Garden of his dreams had long before proved too expensive to maintain and he sold it to New York State in 1811. It was transferred to the College of Physicians and Surgeons, then to Columbia College. John D. Rockefeller Jr. leased the land in 1928 and built the giant Rockefeller Center on the site. Columbia sold it only in 1985. Now, strolling in Rockefeller Center on the way to the ice rink one can see a small plaque commemorating Dr. Hosack, part of which reads, “In memory of david hosack, 1769-1835, BOTANIST, PHYSICIAN, MAN OF SCIENCE AND CITIZEN OF THE WORLD”.

    

Sources:

   Robbins, C.C. David Hosack: Citizen of New York. 1964

   Hamilton, A.M.: The Intimate Life of Alexander Hamilton. pp 395-404, 1911.

   New York Academy of Medicine Site:  

   http://nyamcenterforhistory.org/2016/01/21/dr-david-hosack-physician-to-    hamilton-and-burr/

   Garrison, F. “David Hosack”. Bull N Y Acad Med 1925. 1: 167-71

To view the plaque:     http://blogs.nybg.org/science-talk/2014/07/rockefeller-center-botanical-history-underfoot/

BONES and WORMS

A WRITER ON PARSITES INVENTS  “ORTHOPEDICS”

     It is ironic that the term “orthopedics” denotes a surgical specialty, considering that the inventor of that word, Nicolas Andry, was a fervid enemy of surgeons. Andry was born in Lyon in 1658. He studied for the priesthood, left that path to teach humanities, then decided rather late on medicine and studied at the University

Nicolas Andry de Boisregard (courtesy Wellcome Library and
Wikipedia)

of Reims and the University of Paris, obtaining his degree at age 39. His thesis was “The relationship in the management of diseases between the happiness of the doctor and the obedience of the patient”, a subject not unusual at the time (and relevant today!). He rose to become a professor at the College de France and finally, in 1724, dean of the faculty.

     He wrote two important books. The first appeared at the start of his career, at age 42: An Account of the Breeding of Worms in the Human Body, a book that earned him the name “father of parasitology”. Though it is an early work on parasites, with several illustrations (some of them fanciful), its real importance lies in Andry’s strong stand against spontaneous generation. Belief in spontaneous generation of intestinal worms went back to Hippocrates and continued through Galen and Avicenna. But Leeuwenhoek’s

Tapeworm, from "An Account of Breeding..."
(from Haiti Trust)

microscope and Redi’s experiments with flies in the late 1600s shed doubt on that notion. Andry never experimented; he simply stated, “Worms breed in the bodies of men and other animals, by means of a seed that enters there, in which those worms are enclosed. For all animals are bred of a seed which contains them…” (Grove). He describes a patient with fever, chest pain, and coughing blood who, after a purgative, expelled a long tapeworm, complete with head. Andry was the first to illustrate the tapeworm head (see illustration), though they had been described previously.

     At the other end of his career, at age 82, he published Orthopaedia or the Art of Correcting and Preventing Deformities in Children (English translation). This book earned him the title “father of orthopedics”, and though that is a little off the mark, the  author introduced the word “orthopedics” by saying “As to the title, I have formed it of two Greek words, viz. orthos, which signifies straight, free from deformity, and paidos, a child. Out of these two words I have compounded that of Orthopaedia.” The word persisted and infiltrated many languages.

     The book was actually a manual for the use of parents to treat or prevent, in their children, deformities of the skeleton and in part 2, those of the head. Various massages and braces are recommended for crooked spines and limbs, and exercises, proper posture, etc., for prevention of deformities. The section on the head covers skin problems, smallpox, deafness, nasal deformities, and the like. Overall, measures are conservative.

     One remedy is of particular interest. If a child is becoming bow-legged (usually from rickets at that time) Andry advises placing an iron plate on the

Straightening the tree trunk, in Orthopaedia
(from Hathi Trust)

inner side of the leg and binding it with a linen bandage, tighter each day "as is used for making straight the crooked trunk of a young tree” (see  illustration). The famous tree image has been adopted by orthopedic associations around the world. The logo of the American Board of Orthopedic Surgery is one example:

Logo, Amer Board of Orthopedic
Surgery

An interesting variation was created by the Arizona Orthopedic Society - a curved cactus:

Logo, Arizona Orthopedic Society

     Andry was described by colleagues as irascible, scornful, jealous, and superb. As a critic for the Journal des Savants he carried on a prolonged campaign against barber surgeons, abolishing surgical positions at the school and requiring that surgeons operate with a medical doctor present. Ironically,

Jean-Louis Petit (from Wikipedia)

he unjustly targeted Jean-Louis Petit, a famous surgeon who invented the screw tourniquet, was the first to drain the mastoid bone, and wrote a highly regarded work on bone surgery, the first comprehensive orthopedic surgery text.

    

Sources consulted:

    Grove, D I. A History of Human Helminthology. 1990.

   “Eulogy of Jean-Louis Petit”. Chirurgie 126: 475-81, 2001

   “A History of the Ecological Sciences, Part 30”. Bull Ecol Soc

       America, Oct 2008, pp 407-433.

   “Nicolas Andry de Bois-Regard, the Inventor of the Word

       Orthopedics and the Father of Parasitology”. J Child Orthop

       4: 349-55, 2010.

   Kirkup, J R. “Nicolas Andry and 250 years of Orthopaedy”. J

        Bone Joint Surg (Br) 1991. 73-B: 361-2.

   Andry, N. De la Generation des Vers dans le Corps de

       l”Homme. 1700.

   Andry, N. Orthopaedia: or the Art of Correcting and Preventing

      Deformities in Children. 1741 (Eng trans 1743).

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Theodor Kocher and the Birth of Endocrinology 

     At one time almost everyone in the valleys of Switzerland was afflicted with goiter. Mark Twain remarked that the two principle sights in Switzerland were Mont Blanc and goiter. Large goiters were burdensome and could impinge on the trachea, impairing

goiter patient, from and side (from Wellcome Library)

breathing. But the medical world was ignorant of the thyroid's function. Claude Bernard declared in 1879, well after surgeons started removing the gland, that nothing was known of its importance. Iodine was perceived as helpful for goiter by some, but little used. Not surprisingly it was in Switzerland where progress was made.

     Theodor Kocher, a Swiss, played a leading role in revealing the impact of the thyroid on human physiology. His surgical skills and wide knowledge were legendary and attracted students from around the globe.

     He was born in Bern in 1841. After medical school he decided

Theodor Kocher (from NIH via Wikipedia)

on a surgical career. He rose quickly to be Professor of Surgery at Bern University (at age 31) and remained there for the rest of his career. His influence was enormous. Only a partial list of achievements would include: rapid adoption of Listerism, inventing the “Kocher maneuver” for reducing shoulder dislocations, using physiological saline to combat shock  (later taken up by George Crile), and introduction of “Kocher clamps” for hemostasis. His neurosurgical researches greatly influenced Harvey Cushing and his deliberate, careful surgical technique helped cement a friendship with William Halstead. He published the first complete chart of human dermatomes (1896). Between 1909 and 1914 an average of 40 Americans visited his clinic every year. His textbook of surgery went through five editions and was translated into six languages. His discoveries concerning the thyroid gland earned him a Nobel Prize, though not without heartache and strife.

     Removal of goiter by surgery had been risky. The famous Theodor Billroth had removed numerous ones, but with frequent

Goiter removal, from Kocher's Surgical Text, 2nd edition
(Hathi Trust)

 complications and significant mortality. But with careful study of anatomy and adherence to asepsis Kocher managed to render thyroid removal a safe procedure, using a horizontal incision whose scar was barely visible. He performed the operation frequently.

     In the fall of 1882, at a Congress in Geneva, Kocher met Jaques-Louis Reverdin, a Geneva-based surgeon, who had noted that two of his own thyroidectomized patients had developed features of cretinism. He asked Kocher if he had observed the same. Kocher abruptly realized that he had - once. A local practitioner had informed him eight years earlier that an eleven-year-old girl had become sullen and zombie-like after losing her goiter. Kocher tracked her down and was stunned to find the “ugly appearance of a half-idiot” before him. He halted further

Jacques-Louis Revedin 9from Wikipedia)

thyroidectomies, contacted former patients, and turned up many with hypothyroid features - but only those with total loss of thyroid tissue.  Though the record is unclear he must have been shaken by the damage he had inflicted. He reported the findings in a long paper in 1883.

     Reverdin referred to the clinical picture of his patients as “myxoedéme opératoire”, after the term “myxoedema” coined a few years before (1877) by William Ord in England for patients

William Ord (from Wellcome Library)

with adult onset of cretinism and atrophied thyroid glands. Reverdin also acknowledged William Gull’s earlier description of the same syndrome. Kocher invented the name “cachexia strumipriva” and initially thought the syndrome due to oxygen insufficiency related to removal of the thyroid and adjacent vasculature.

     Kocher attempted transplanting thyroid tissue to improve his sluggish patients, noted initial improvement, but was discouraged that it was transient. He tried isolating an active substance from thyroid tissue, in vain. In England George Murray gave injections of thyroid extract, with positive results, then switched to oral administration of thyroid extract, also effective. Trial and error led to a reasonably accurate dosage. Kocher and others adopted similar replacement therapy, starting with thyroid tissue spread on bread much as caviar would be, and moving on to extract.

     Kocher was awarded the Nobel Prize in 1909, the first surgeon to receive one, for contributions to the physiology, pathology, and surgery of the thyroid. In his acceptance speech he ungenerously neglected the work of Ord and Gull that had clearly described myxoedema (he had actually corresponded with Ord on the subject) and failed to admit Revedin’s priority (Revedin is remembered also for performing the first skin allotransplant).

     But Kocher’s achievements should not be diminished. He went on to perform over 4000 thyroidectomies (partial), with excellent results. In addition to the accomplishments noted above he pioneered new techniques in gallbladder and stomach surgery, neurosurgery, and head and neck surgery. He taught a whole generation of surgeons and left a great imprint on American surgery. And his thyroid work ushered in a new medical specialty – endocrinology.

Sources used:

World J Surgery 2000, 24:2-9. (Biography)

J Roy Soc Med 2014, 107: 376-7 (Biography)

J Roy Soc Med 2011, 104: 129-32 ( thyroid work)

BMJ Sept 29, 1923, pp 560-1 (transplants)

Nobel Lecture, available at: http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-lecture.html

 Wellbourn, R B: The History of Endocrine Surgery. 1990

Tröler, U. Der Nobelpreisträger Theodor Kocher, 1841-1917. 1984

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