ALBERT NEISSER AND HUMAN EXPERIMENTATION

     Medical experimentation on humans has a long and sometimes depressing history, brought into high relief by experiences in Germany and Japan during WWII. After the war numerous papers, declarations, and laws emerged, coalescing into a more definitive approach to human experimentation. Long before the war, though, the case of Albert Neisser aroused great interest in Germany and gave birth to what is thought to be the first governmental guidelines for human experimentation.

     Albert Neisser was born in 1855 in a small Silesian town to a physician father. He studied medicine at the pretigious Breslau University Medical School (where Robert Koch had given his demonstration of the cause of anthrax in 1876, probably while Neisser was there). After obtaining his MD degree he joined the Breslau University Dermatology Clinic. 

Albert Neisser (National Library of Medicine)

     Dermatology, in those days, dealt with venereal diseases, including gonorrhea. Bacteriology, the new, popular science, induced Neisser to seek a bacterial cause for gonorrhea. He had learned microbiology at Breslau and was familiar with Abbe’s condenser and oil immersion techniques, new in the 1870s, that improved the resolution of microscopic images. At the age of 24, using the latest microscopic equipment, he discovered, in urethral discharges, the paired cocci that bear his name (Neisseria gonorrhea), and cultured them shortly afterward – an important discovery.

     After a trip to Norway to work with Armauer Hansen on leprosy, that ended in a priority dispute, Neisser returned to Germany and rose to head the Breslau dermatology clinic after his chief died. Neisser was impressed with the recent demonstrations by Behring and Kitasato of the healing effects of antiserum in cases of diphtheria. He wondered if serum from people with syphilis, made cell-free for purity, could provide similar “passive immunization” against the disease. First he injected subcutaneously serum from a patient with early syphilis into four female patients, aged 10 to 24. None developed syphilis. Next, using cell-free serum from patients with syphilis in various stages, he injected up to 30cc intravenously into four prostitutes, aged 17 to 20. They all developed syphilis. None had given informed consent.

     News of the experiments reached the press, creating an uproar. Neisser wrote a statement defending his work, suggesting also that that the latter four women contracted syphilis because they were prostitutes and not because of his serum injections. Similar experiments were done by other physicians, and he was supported by the majority of his colleagues though one, the psychiatrist Albert Moll, who was writing a book on physicians’ ethics, spoke out against him. Neisser was fined by the Royal Disciplinary Court - because he had not obtained the patients’ consent, not because of questionable science.

     The Prussian Parliament took up the case and sought an opinion from the Scientific Medical Office of Health. Rudolf Virchow, Emil von Behring, and other prominent physicians were on the panel. Lawyers were also consulted. In 1900 the Minister for Religious, Educational, and Medical affairs issued a directive. All medical interventions other than for diagnosis or treatment were prohibited if the subject was a minor or not competent, or if consent was not obtained after proper explanation of possible negative consequences. All research interventions had to be authorized by the medical director of the institution and all details had to be documented in the medical record. The directive was not legally binding.

     Evidently similar cases subsequently came to light and in 1931, in the context of an overall reform of criminal law in Germany, the national government issued “guidelines for new therapy and human experimentation”. These guidelines distinguished between experimental new treatments and experiments intended to extend knowledge but without therapeutic benefit. In both cases minors and incompetents were excluded, and consent from a properly informed and autonomous subject was required for any experiment. The only exception was if a new treatment were desired in urgent cases and immediate consent was impossible. Experimentation on dying patients was prohibited and animal experimentation should precede that on humans. Exploitation of financial or social needs was prohibited. The physician’s special responsibilities in clinical trials should be emphasized in medical teaching. A form of institutional review board was discussed but the review and oversight function was left with the medical director. The complete guidelines (translated) are found at: file://localhost/Users/john/Documents/ history of medicine & science/ethics,GERMAN GUIDELINES ON HUMAN EXPERIMENTATION 1931.webarchive. They are believed to be the first such guidelines issued by a government. They were not annulled during the Nazi era but were certainly ignored. 

Fritz Schaudinn, co-discoverer with E. Hoffmann
of Treponema Pallidum
(National Library of Medicine)

     Neisser turned to monkeys for further syphilis research and moved to Java where monkeys were abundant. He clarified several aspects of syphilis, including showing 

Erich Hoffmann, co-discoverer of Treponema
Pallidum (Wellcome Library)

inability to arrest the disease by removal of the primary chancre (a common belief at the time), or to immunize monkeys. He published a book summarizing the work. While he was in Java the causative Treponema pallidum was discovered and on his return he and his assistants worked with August Wasserman to develop the Wasserman test (1906). 

August Wassermann (Wikipedia)

     Neisser took an increasing interest in public health aspects of venereal disease, advocating public health clinics and regulation of prostitution, all at a time when these subjects were seldom discussed in public. He died in 1931 from complications after surgery for bladder stone.

      Neisser’s career encompassed much of modern knowledge of syphilis. His one irresponsible experiment brought the issue of human experimentation into the German public arena, where the first governmental guidelines for human experimentation were formulated, well before similar rules existed in the United States.

 SOURCES:

Vollmann, J and Winau, R. “Informed Consent in Human Experimentation before the Nuremberg Code” 1996: BMJ 313: 1445-7

Oriel, J. “Eminent Venereologists, 1. Albert Neisser” 1989; Genitourin Med 65: 229-234.

Ligon, B L. “Albert Ludwig Sigesmund Neisser: Discoverer of the Cause

of Gonorrhea” 2005; Semin Pediatr Infect Dis 16: 336-41.

 Benedek, T G. “Case Neisser: Experimental Design, the Beginnings of Immunology, and Informed Consent” 2014; Perspect Biol Med 57(2): 249-67.

USHER PARSONS AND NAVAL MEDICINE IN

THE WAR OF 1812

     “The most outstanding naval surgeon in the War of 1812” is a generous tribute to a man who helped shape U.S. naval medicine. Who was he?

     His name is Usher Parsons, born in Maine in 1788. His father was a farmer and merchant, apparently with little money. After primary schooling through age 12 Usher worked clerking in stores, then at age 19 was apprenticed to a local doctor, attended anatomy lectures and read medical texts. Realizing he was still not well educated he studied Latin and Greek, then, in 1811, won an apprenticeship with Dr. John Warren, the founder of Harvard

Usher Parsons (National Library of Medicine)

 Medical School. The following year he was licensed by the Mass. Medical Society. After an unsuccessful try at private practice, knowing that war had come, he sought a commission in the Navy.

     The War of 1812 was in large part a naval war. When the United States declared war on England, the fledgling United States had almost no navy. President Madison, intending to invade Canada, built a naval force on the Great Lakes to support army troops. Two ships, the Lawrence and the Niagra, both 20-ton brigs (2-masted vessels), and numerous smaller vessels were constructed on Lake Erie. Parsons was assigned as surgeon’s mate to the Lawrence, named after the James Lawrence who had uttered the cry, “don’t give up the ship”.

     Three levels of medical personnel served on naval ships at the time: surgeon, surgeon’s mate, and the “loblolly boy”. The surgeon was responsible for the overall health of the ship, and duties included inspection of food and water, care of patients (and keeping records of care), surgeries when needed, and maintaining stores of medicines and instruments. The surgeon’s mate, having less education and experience, assisted in surgery (generally to restrain the patient) and performed routine patient care in sickbay (generally located forward on the gun deck in an empty gun space called a “bay”). The loblolly boy, named for a thick porridge (“loblolly”) doled out to sailors, fed and nursed patients, and performed leeching, cupping, and other duties.  

      The Lawrence engaged two British vessels. Moving in close it was severely damaged by the opposing ships and was saved only after the Niagra, holding off for unclear reasons, was finally brought in to defeat the British ships.

The dismasted center ship is the Lawrence, the large ship to the right is the Niagra, and the small craft is carrying
Commodore Perry to bring the Niagra into the battle.  British ships are on the left.
(Lithograph by J P Newell, courtesy Library of Congress) click on image to enlarge

     Wounds received by navy men were varied. Cannonball hits caused some injuries, but smaller shot and canister caused many more. A cannonball hit to a ship’s hull would send splinters flying inside the vessel, inflicting serious wounds, and if it hit at the waterline would open a hole to let water in. Sharpshooters were posted in the rigging to pick off men on enemy decks. The wounded were usually cared for in a room below waterline, to avoid shot and splinters.

     On the Lawrence the surgeon was ill, and Parsons took over. The wounded were carried to the wardroom (mess room for midlevel officers), a roughly 10 to 12 square foot room just above the water line. Occasional cannonballs sailed through as Parsons worked feverishly. He had no time for the usual amputations and simply applied tourniquets and pressure bandages to stop bleeding. The only immediate surgery, he noted in an account in the New England Journal of Medicine and Surgery, was when a “division was made in a small portion of flesh, by which a dangling limb that annoyed the patient was hanging to the body.” He labored until midnight to “administer opiates and preserve shattered limbs in a uniform position”. At dawn the next day he carried out the necessary amputations (no anesthesia), followed by treating fractures, dislocations, and superficial wounds. Out of about 100 men fit for duty, 21 were dead and 63 wounded.

     The next day he boarded the Niagra, whose surgeon he found ill in bed, with “hands too feeble to execute the dictates of a feeling heart,” and cared for the wounded. The number of wounded from both ships was 96, of whom only 3 later died, an extraordinary recovery rate for the times. Parsons cites three reasons: the wounded were kept on deck for two weeks, inhaling lots of fresh air; they were well fed with meat, vegetables, and eggs; and finally, they possessed “the happy state of mind which victory occasioned.” Pretty good results for someone freshly out of an apprenticeship and little practical experience.

The first book of Usher Parsons
(Hathi Trust)

     After the war Parsons earned his MD from Harvard and studied in Europe at Navy expense. Subsequent naval voyages took him to the tropics, the Middle East, and Europe, where he met many notables in science and medicine. From France he wrote, “Larrey’s manner of operating is pleasing…He is humane and solacing in his behavior to patients, differing in this respect very much from Dupuytren, whose behavior to them is savage.”¹ He later taught anatomy at Dartmouth and helped found the medical school at Brown University. He resigned his commission in 1823, opened a practice in Providence, and penned numerous papers. In 1824 he published Sailor’s Physician, a short handbook of naval medicine that recommended citrus fruits for scurvy and Peruvian bark for intermittent fever. The book later evolved into an important work: Physician for Ships, that went through at least 4 editions and was a

Section on sea-sickness from Physician for Ships, 3rd edition. (Hathi Trust) Click on image to enlarge.

leading text for naval doctors through the Civil War. Parsons, married to the sister of Oliver Wendell Holmes, died in 1868.

     Usher Parsons was a talented man who helped bring modern medicine to a fledgling American Navy.

     This essay was kindly reviewed and improved by Andre Sobocinski, Historian, Bureau of Medicine and Surgery, U.S.Navy.

    [1] Dominique Larrey was Napoleon’s prized army surgeon. Guillaume Dupuytren was the gifted chief of surgery at the Hôtel Dieu-Hospital in Paris.

SOURCES:

Cushman, P. “Usher Parsons MD” N Y State J Med 1971; 71(24): 2891-4.

Cushman, P. “Naval Surgery in the War of 1812”. N Y State J Med 1972; 72(14): 1881-7.

Pleadwell, F L. “Usher Parsons (1788-1868), Surgeon, United States Navy”, 1922; United States Naval Med Bull 17: 423-60.

Daughan, George. 1812: The Navy’s War. 2011. Basic Books.

Goldowsky, S J. Yankee Surgeon: The Life and Times of Usher Parsons. 1988.

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EINSTEIN TO DEBAKEY:

EVOLUTION OF ANEURYSM SURGERY

     Albert Einstein had a pain in his belly, not a new one, but worsening. Admitted to Brooklyn Jewish Hospital in December of 1948, his white hair defying gravity, he underwent surgery and was found to have a grapefruit-sized aneurysm of the aorta (an expanding section of the body’s major artery) that threatened to rupture. The surgeon, Rudolph Nissen, wrapped a piece of

Albert Einstein (Wikipedia)

polyethene cellophane around the visible part of the aneurysm, considering it too dangerous to raise the vessel for a full wraparound. Polyethene had irritant properties that caused a fibrous thickening of the aneurysm wall, hopefully strengthening it enough to prevent a rupture. Einstein recovered uneventfully and returned to work in Princeton, N.J.

     Though he had intermittent pains he did well until April, 1955, when he was readmitted with severe abdominal pain. Now a huge mass extending from the left lower rib cage to the pelvic brim pulsated visibly. It was his aneurysm, greatly enlarged and again in imminent danger of rupturing. Surgery was offered, this time to resect the aneurysm and replace it with a section of aorta from a cadaver. Einstein refused, saying it was time to go and “I will do it elegantly”. He expired five days later, and at autopsy a ruptured aneurysm was the reason. Did the cellophane wrapping prolong Einstein’s life? Based on statistics at the time, probably yes.   

    Fifty-one years after Einstein’s death, on New Year’s Eve of 2006, another celebrity of the scientific world had a similar problem. Dr. Michael DeBakey, age 97, suffering a fierce chest pain, diagnosed the pain as a dissecting aortic aneurysm. He

Michael DeBakey (Wikipedia)

would know, as he had operated on hundreds, maybe thousands, of aneurysms over the years. Dr. DeBakey refused hospitalization but consented to a CT scan, which confirmed a dissecting aneurysm of the ascending aorta (saccular enlargement due to a tear of the inner lining of the aorta, just above the heart, in danger of rupture and internal bleeding). He declined hospital admission and, pale and unsteady, gave a lecture three days later, followed by a luncheon. He grew weaker, ate little, and was finally admitted to Methodist Hospital, Houston, on Jan 23, where another scan showed “dangerous” enlargement of the aneurysm. His physicians advised surgery in spite of his age, but, like Einstein, DeBakey said no. By Feb. 9, with the aneurysm still expanding, DeBakey had lost consciousness. His surgeons, though, still felt he had a chance with surgery.

     As related by the noted physician-journalist Lawrence Altman, who knew DeBakey well, the family gave permission to operate, but the anesthesiologists of the hospital refused to anesthetize him, feeling they would be looked upon as aiding his death. Another anesthesiologist, an old colleague, was brought in. Heated discussions that included doctors, lawyers, and hospital

Methodist Hospital, Houston (Wikipedia)

administrators dragged into the evening. Complicating the issue were a note saying that he did not want surgery and a signed “do not resuscitate” order, both in DeBakey’s chart. But Mrs. DeBakey and the doctors, all long-time colleagues, felt that the situation had changed enough to make these wishes inapplicable. The ethics committee of the hospital was summoned to an emergency meeting at about 10PM. After an hour of inconclusive deliberation Mrs. DeBakey, waiting outside, burst into the room shouting that her husband would die if nothing were done soon. The ethics committee agreed to the surgery at 11 PM. No minutes were taken of the meeting.

     The operation lasted seven hours, with DeBakey placed on a bypass pump and his body temperature lowered. The aortic tear was resected and replaced with a Dacron graft, an operation DeBakey had pioneered himself years earlier. After a prolonged and “stormy” course, including dialysis, he recovered enough to resume work. One year after surgery he could walk unassisted but preferred a motorized scooter, on which he raced up and down hospital corridors. His mind remained clear. He said later that he was happy that his wish to avoid surgery was ignored. He passed away in July of 2008, cause not mentioned. The cost of his care was estimated at over $1 million. 

Aorta showing two aneurysms, a large one in
the thoracic portion and another, sectioned in two,
in the lower aorta (from Clinical Lectures on the Principles
and Practice of Medicine, by John H Bennett, 1860)

     Michael DeBakey was born in Louisiana of Lebanese immigrant parents and attended the Tulane School of Medicine. In WWII he helped develop Auxiliary Surgical Groups that provided surgical care close to the front lines, a predecessor of the MASH units of the Korean and Vietnam wars. He subsequently built the small Baylor College of Medicine department of surgery into a large, advanced, surgical training center and helped pioneer many innovative procedures, especially in cardiovascular surgery. He was also instrumental in forming the National Library of Medicine.

     In 1952 DeBakey did his first aortic aneurysm resection, replacing the aortic segment with cadaver aorta, the same operation offered to Einstein in 1955. Cadaver aortas were in short supply, however, and a synthetic material was sought. Nylon and related materials were tried but did not work well. One day DeBakey, looking for nylon in a store, was offered a new material, Dacron. Trying it in dogs, he found it performed well, and Dacron soon became the standard for aorta surgery. The gap between the surgeries of Einstein and DeBakey covers this period of major progress in aortic surgery.

     The debates around DeBakey’s surgery at age 97 clearly reflect today’s struggles over defining what is reasonable treatment for patients in advanced age, a problem all too common as our population grows older.

SOURCES:

Cohen, J R and Graver, M. “The Ruptured Abdominal Aortic Aneurysm of Albert Einstein.” 1990; Surg, Gyn, Obst 170 (5): 455-8.

L Altman. “The Man on the Table was 97 but He Devised the Surgery”. New York Times Dec 25, 2006.

L Altman. “Michael DeBakey, 99, Rebuilder of Hearts, Dies”. New York Times July 13, 2008.

Chunn, C F. “Treatment of Aneurysms by Polyyethene Wrapping”. Ann Surg 1954; 139:  751-9.

DeBakey, M E. “The National Library of Medicine: Evolution of a Premier Information Center”. JAMA 1991; 266: 1252-8.

Morris, Thomas. The Matter of the Heart: A History of the Heart in Eleven Operations. 2017; St. Martin’s Press. Chap. 3.

“The Michael E. DeBakey Papers”. Profiles in Science, National Library of Medicine. Online at: https://profiles.nlm.nih.gov/ps/retrieve/Narrative/FJ/p-nid/322

WILLEM EINTHOVEN AND THE FIRST

ELECTROCARDIOGRAMS

     Is there electricity in heart muscle?  No one knew until, by accident, two German scientists, Köllicker and Müller, in 1856, saw that when the end of a frog’s sciatic nerve was mistakenly laid on top of a living frog’s heart, every heartbeat caused a twitch in muscle attached to the nerve. In subsequent years the anatomic pathways conducting current through the heart were mapped out, laying the groundwork for further study.

     The knowledge was fascinating, but could a recording of the feeble electrical activity help people with heart disorders? Yes, as it turned out.    

     The first recording in a human appears to have been done by Alexander Muirhead at St. Bartholomew’s Hospital in 1869 or 1870. He used something called a Thompson siphon recorder, an instrument made to record telegraph messages and based on movements of a wire coil between two magnets. Muirhead left medicine, however, to become a telegraph engineer. Next was

Auguste Waller (Wellcome Library)

Auguste Waller, son of Augustus Waller, who discovered “Wallerian degeneration” (degeneration of a nerve fiber distal to the site of injury). Waller placed a capillary electrometer, a thin, capillary-like tube enclosing a column of mercury topped by sulfuric acid, on the human chest. The electricity of the heart passed through the tube, moving the mercury level up and down, the motion recorded by strong light passing through a magnifier to a moving film. Response time was slow and the recordings not very sensitive. (See figure 1) Waller did not foresee much clinical use for his device.

Waller's Mercury Column Tracings
Fig 1: Lower tracing is EKG, middle one is chest wall vibrations from heart beat,
and upper one counts time (From J Physiol 1887; 8: 229-34, Hathi Trust))

     For the transition to modern electrocardiography we owe thanks to a Dutchman, Willem Einthoven. Einthoven was born in 1860 in the Dutch East Indies, where his father was a military physician. He was educated in Holland after his father died and

Willem Einthoven (Wellcome Library)

received his medical degree at the University of Utrecht. With the help of his professor of physiology, Franz Donders (who made important advances in ophthalmology), Einthoven became professor of physiology at Leiden University in 1886, at age 26. Stimulated by Donders, he began to record electric currents from the human heart, employing the same mercury column used by Waller. Einthoven, however, was also a self-taught mathematician and devised formulas to extrapolate the sluggish EKG pattern into a more readable and remarkably accurate form. (See figure 2)

Fig 2. Upper tracing by Einthoven is from mercury column. Lower one is derived mathematically
from the upper, with PQRST labelling applied (from Arch ges Phys 1885; 60:101-23, Hathi Trust))

He also changed the lettering of the deflections to PQRST from the ABCD used by Waller, apparently following a mathematical convention for labeling curved forms. He experimented with leads placed in various combinations, ending up with the 3 conventional leads used today. The leads were obtained by submerging a hand or foot in a jar of electrolyte solution.

     Einthoven’s lab was located in an old building adjacent to a cobblestone street. Vibrations from horse-drawn wagons passing by outside frustrated his work with the electrometer. Digging a hole 10-15 feet deep and fortifying it with rocks did not help.

      As a way out, Einthoven took advantage of a new instrument invented by a Frenchman, Clement Ader, called a string galvanometer. Ader placed a thin metal wire, 20 microns thick, between 2 magnets, to record wiggles as a tiny current passed through. This ingenious man had devised the first stereo apparatus and gave the first stereo renditions of the Paris Opera. He also was the first to fly a motorized plane, uncontrolled (the Wright brothers' was controlled), and later wrote a popular book on aviation.

     Einthoven took the galvanometer a step further, using a string of only 2.1 micron diameter. The string was made by placing a piece of quartz on the rear end of an arrow attached to a crossbow.

Schematic of Einthoven's string galvanometer. String is vertically
placed between 2 magnets. A microscope and light pass through
horizontally to project onto film (Einthoven, 1906, Hathi
Trust))

The quartz was heated to near-liquid state and the arrow fired. The thin, floating, thread left behind was coated delicately with silver before use. Using a strong arc light, a 600-power magnifier, and sensitive rolling film, Einthoven recorded amazingly accurate tracings. They corresponded well to the renditions he had calculated from the coarse mercury tube records. Einthoven called his recordings “electrokardiograms”, soon 

Lead one EKG, string galvanometer, published 1906 (Einthoven, 1906, Hathi Trust)
The high quality is remarkable

shortened to “EKG”. Before long he was able to publish on various rhythm disturbances, including heart block, atrial fibrillation, and the like (see Figure). 

Atrioventricular block (Einthoven, 1906, Hathi Trust)

     Einthoven’s apparatus was so large it could not be transported to a hospital, but the Cambridge Scientific Instrument Company learned how to manufacture a moveable version. One of the company’s founders, Horace Darwin, youngest son of Charles Darwin, negotiated with Einthoven to put galvanometers on the market, giving Einthoven a percentage of the sales. Clinical

Subject with hands in jars of electrolyte
solution as leads (Einthoven, 1906, Hathi Trust)

electrocardiography was born.  

     For his discoveries Einthoven was awarded the Nobel Prize in 1924, a prize worth $40,000 dollars at the time. Feeling that he could not have won the prize without the help of his now-retired lab assistant, Van der Woerd, Einthoven wished to share the prize. He found that the former assistant had died but was survived by 2 sisters, living frugally in an almshouse. Einthoven awarded half of his prize to the sisters.

     When the Queen of Holland learned of Einthoven’s award she offered to replace his old building with a new, modern structure with a fine laboratory. Einthoven declined the building, asking instead for money to hire another assistant and purchase new research equipment. The Queen obliged.

     Einthoven was described as a generous, graceful, man of simple tastes, who spoke 3 languages, and was instrumental in maintaining good international scientific relations over the years, not an easy task through the World War One period. His contribution to cardiology speaks for itself.

SOURCES

Cooper, J. “Electrocardiography 100 Years Ago”. NEJM 1986; 315: 461-4.

Ershler, I. “Einthoven – The Man”. Arch Int Med 1988; 148: 453-5.

Burnett, J. “The Origins of the Electrocardiograph as a Clinical Instrument” Medical History Suppl 5, 1985; 53-76.

Waller, A. “A Demonstration on Man of Electromotive Changes Accompanying the Heart’s Beat”. J Physiol 1887; 8: 229-34.

Einthoven, W. “Über die Form des Menschlichen Electrocardiogramms”. Arch gesamte Physiol 1895; 60:101-23.

Einthoven, W. “Über das Normale Menschliche Electrokardiogramm und über die capillar-electrometrische Untersuchung Einige Herzkranken” Arch gesamte Physiol 1900; 80: 139-60.

Einthoven, W. “Über das Normale Menschliche Electrokardiogramm und über die capillar-electrometrische Untersuchung Einige Herzkranken” Arch gesamte Physiol 1900; 80: 139-60.

Acierno, L J. The History of Cardiology. 1994; Parthenon Publishing.

     

THE MUSICAL SURGEON: THEODORE BILLROTH

     One of the great figures of 19^th century medicine was Theodor Billroth, a skilled, inventive surgeon and a consummate musician. His accomplishments are too numerous to fit into a short essay but even a few comments will reveal his great breadth.

     Billroth was born on the island of Rügen, Prussia. His father, a Lutheran minister, died when he was five. Theodor took to music at an early age, but after a gymnasium education he was induced, for monetary reasons, to study medicine rather than music. He

Theodor Billroth (Nat Library of Medicine)

obtained his medical degree in Berlin followed by a period of study in Vienna. On return to Berlin he received an appointment as surgical assistant to the famous Bernhard von Langenbeck at Berlin University. Here, in addition to practicing surgery, he immersed himself in pathology, publishing on polyps, testicular tumors, the spleen, and other topics. In 1860 he was tapped for a professorship of surgery at the University of Zürich, where he published a textbook on surgical pathology and was the first to publish “total” results of operations, including complications and mortality rates. In 1867 he was called to Vienna as professor of surgery at the famous Vienna General Hospital (Allgemeine Krankenhaus). Here he remained until his death in 1894. Lacking experience in battle surgery he volunteered at field hospitals in the Franco-Prussian war, developing triage techniques and principles of ambulance service. He took an

                                        "Theodor Billroth Operating" by Adalbert Seligman, painted between 1880-90 (Wikipedia)
                                          Notice the resemblance to "The Gross Clinic" by Thomas Eakins painted years earlier.
                                    Notice also the gowns but no gloves or masks, lighting by sunlight, and open drop anesthesia.
         According to the artist the operation is a neurotomy for trigeminal neuralgia. The artist and the Duke of Bavaria (who enjoyed attending)                                                                                       are depicted in the audience. The painting was found forgotten in a closet at the Surgical Clinic in 1963 (LITMED:    http://medhum.med.nyu.edu/view/10332 ) 

interest in wound infections, developed important new operations,  published a surgical text, and authored numerous articles. His students went on to professorships in university centers around the world.

     One of his famous operations became known as “Billroth I”. Two of Billroth’s assistants had worked on dogs to see if partial gastric resection was feasible, and especially to learn whether gastric juice would dissolve an anastomosis. So he was ready when in January, 1881, a 43 year-old woman, Therese Heller, presented with over 3 months of regurgitation and vomiting. A tumor was easily felt through her wasted abdominal wall. Under chloroform, using Lister’s antiseptic principles (except the spray), and after washing the stomach with 14 liters of warm water, a horizontal incision exposed the moveable, apple-

Frau Heller's Excised Pyloric Tumor
(Billroth, T. Clinical Surgery: Extracts from
the Reports of Surgical Practice, 1860-76. Eng Trans, 1881.
New Sydenham Soc., Hathi Trust)

sized, pyloric tumor, which was resected. The greater curvature of the stomach was narrowed and a residual opening sutured to the duodenum. The operation lasted 1½ hours. Postoperatively Frau Heller had little pain and almost no fever. She took sour milk, then a soft diet, and finally beefsteak. She had no intravenous fluid or antibiotics. She died 4 months later from metastatic disease and with an intact anastomosis. It was the first successful partial gastric resection, after which the field developed rapidly.

     While in Zürich Billroth took time to indulge his musical interests. Already accomplished on the piano and violin, he taught himself the viola and became part of a quartet. He was taken on as a music critic by the local paper, Neuen Zürcher Zeitung. After an uncomplimentary review of the Zürich Symphony he was fired, but rehired when the orchestra musicians protested that they needed expert criticism to maintain good quality. In Zürich he met Johannes Brahms twice, once hosting him as a guest in his home. He surprised Brahms by recognizing his compositional ability before the public had appreciated him.

     Musical theory fascinated Billroth so much that later in life he attempted a complicated manuscript, combining science and esthetics, to explain what made a person “musical”.

     The Vienna that greeted Billroth was a major cultural center, where compositions of Johann Strauss, Liszt, Bruckner, Dvorak, and Robert Schumann were bringing audiences to their feet. Brahms was already resident there and he and Billroth formed a close friendship, often joined by the music critic Eduard Hanslick in extended conversations on music. Brahms came to appreciate Billroth’s musical judgment so much that he often tried out compositions in Billroth’s home, which had a sumptuous music room, before public performances. The two men carried on an extensive correspondence, largely about music.

Johannes Brahms, c 1872 (Wikipedia)

     Both men were disciplined workers, but in many ways they were not alike. Billroth was well educated, outgoing, gracious, and fond of social gatherings. Brahms had been born in poverty in a Hamburg slum. His father was a fiddler in local bars who taught him the violin and piano. Young Johannes had been forced to play piano in similar bars and in brothels to earn money. His education was self-acquired, he was more introverted, and could be rude or gruff with others. His friendship with Billroth was warm, however, and he sought Billroth’s opinions on many occasions.

     Shortly before Billroth’s death Brahms happened to see a letter from Billroth to Hanslick, mentioning that he, Brahms, was often abrupt and discourteous to others, “like Beethoven”, and

House of Brahms' Birth, destroyed in WW II
(Wikipedia)

hampered by the poverty of his youth and his lack of education. Brahms and Billroth continued to correspond, but their relationship thereafter was cooler. Billroth died 2 years later of heart failure, and Brahms died 3 years after that of liver disease. Both were honored by large funeral processions and both were buried in the Central Cemetery in Vienna, not far from the graves of Beethoven, Schubert, and a monument to Mozart.

     Billroth was a great surgical innovator and an inspiring teacher. He emphasized the importance of research for surgery and introduced the fashion of surgical statistics, along with 5-year survival rates, into surgical literature. He was also an accomplished and insightful musician with a refined esthetic sensibility. Brahms was his primary sounding board and major link to the world of music.

SOURCES:

Rutledge, R H. “A Musical Friendship: Billtorh and Brahms”. 2007; J Surg Education 64: 57-60.

Rutledge, R H. “In Commemoration of Theodor Billroth on the 150^th Anniversary of his Birth”. 1979; Surgery 86: 672-93.

Ellis, Harold. Famous Operations. 1984; Harwal Publishing. pp29-35.

Wangensteen, Owen. The Rise of Surgery.  1978; Univ of Minnesota Press. pp 142-57.

McLaren, N and Thorbeck, R. “Little-Known Aspect of Theodor Billroth’s Work: His Contribution to Musical Theory”. 1997; World J Surg 21: 569-71.

Buklijas, T “Surgery and National Identity in Late Nineteenth-Century Vienna”. 2007; Stud Hist Philos Biomed Sci 38: 756-74.

    

Billroth, T. Clinical Surgery: Extracts from the Reports of Surgical Practice, 1860-76. Eng Trans, 1881. New Sydenham Soc. pp 502-5.

Hemmeter, J C. “Theodor Billroth, Musical and Surgical Philosopher. A Biography and a Review of his Work on Psycho-physiological Aphorisms on Music”. 1900; Bull J Hopkins Hosp. 11: 297-317.

Nagel, M, Schober, K-L, Weiss, G. Theodor Billroth: Chirurg und Musiker. 1994; Regensburg.

VENEREAL DISEASE AND COMPULSION

     In the spring of 1916 the Mexican revolutionary Pancho Villa raided the town of Columbus, New Mexico, setting off a small war with the U.S. After General Pershing chased him back to Mexico numerous American troops remained encamped on the Mexican border. Saloons and brothels appeared almost instantly and the venereal disease rate among the troops soared, reaching close to 30%. As rumors of the “debauched” scene drifted out, Secretary of War Baker dispatched Raymond Fosdick, a

Raymond Fosdick (Wikicommons)

Progressive and social reformer, to investigate, and he confirmed the news. Baker ordered stricter discipline, which helped, somewhat.

     The very next year the U.S. military began preparing for war in Europe. The War Department formed the Commission on Training Camp Activities (CTCA), headed by Fosdick, to help keep STIs out of the military training camps. The goal was to create a wide perimeter around the camps, devoid of bars and brothels, encourage sporting and recreational facilities, and provide education about STIs with graphic lectures, pamphlets, and movies.

     But male-female contacts flourished anyway and the VD rate remained high. As a stopgap measure “chemical prophylaxis” was provided for recruits recently exposed: first urinate, then wash the genitals, follow with a mercury bichloride rinse, then an injection of protargol (a silver-albumin compound) into the urethra to be held for five minutes, then expelled. It seemed to be effective for gonorrhea prevention.

     Meanwhile, another group, the Committee on Protective Work for Girls (CPWG), headed by the social worker Maude Miner, was formed to patrol around bases, befriend nearby women, and try and talk them out of meeting recruits. This also had little impact, persuading the CTCA to turn to more repressive measures, initiating a dark chapter in public health history. Detention became the watchword.

     Subdivisions of the CTCA worked with Law Enforcement personnel. They approached young women found near training camps and, if suspicious, hauled them off for an examination for venereal disease. If any was found they were incarcerated for treatment. For syphilis this meant several weeks.

     State governments, fearful of losing lucrative military camps, cooperated in the effort by passing laws for the arrest of women “reasonably suspected” of having VD. In many cases there was no habeas corpus, bail, or legal recourse for arrested women. By March 1918, 32 states had passed such laws. Rockefeller money went into the CTCA. President Wilson allocated $250,000 for establishing “detention homes” where the women were held and treated (to keep them out of prisons), and states provided others. Congress passed the Chamberlain-Kahn bill authorizing one million dollars for the same purpose, though the money went for maintenance of existing ones. The homes were often pretty shabby. Many of the detainees were given IQ tests, part of the nascent eugenics movement seeking to sterilize mental defectives. Over 18,000 women were incarcerated in federally funded institutions, some of whom did not have VD. The total number incarcerated is estimated at 30,000 or more.

     A recent book describes the ordeal of Nina McCall, an 18-year-old woman in St. Louis, Michigan, thought to have been fraternizing with soldiers at a nearby base. Confronted with a choice of being quarantined in her house with a sign outside saying she had venereal disease or entering a treatment facility, she opted for the latter. She was treated for gonorrhea and syphilis

August von Wassermann

in a “detention hospital” – a former contagious disease hospital. Once inside she could not leave until treatment was complete, about 2 ½ months in her case.

     A cacophony of public opinions on venereal disease provided a backdrop. Many still saw it as a moral issue, preaching education and abstention. Others advocated legally regulated prostitution near camps, with regular inspection of women by doctors to weed out those with disease (This was done in Nashville and Memphis during the Civil War). Many, especially women’s groups, complained, rightly but in vain, that detaining women and suppressing prostitution implied that men had little responsibility for passing on infections. If women were to be arrested, why not

Poster for film on Paul Ehrlich played by
Edward G Robinson (Wikipedia)

men? In the military soldiers were seldom disciplined even though acquiring VD was a punishable offence. Strangely, condoms were seldom emphasized, partly because they were seen as an inducement for “loose behavior” and partly to avoid antagonizing the Catholic Church.

     Medically, progress had been made with VD. In the first decade of the twentieth century the spirochete causing syphilis was

Fritz Schaudinn (Wikipedia)

discovered by Schaudinn and Hoffmann, and August von Wasserman developed his serologic test for syphilis. In the next decade Paul Ehrlich’s lab discovered compound 606 (Salvarsan), then Neosalvarsan, both arsenicals, usually used with mercury, for treatment of syphilis. Side effects of arsenicals were significant and dose regimens unstandardized. Many underwent treatment for months. Urethral silver

remained the treatment for gonorrhea.

     After WWI most of the detention activities ceased as training camps dissolved and funding evaporated. Important too was a public reaction against detentions and the compromise of civil rights. Raymond Fosdick eventually became president of the Rockefeller Foundation. The US Public Health Service, filling the postwar void, assumed a greater role in STI prevention and education.

SOURCES:

Stern, Scott. The Trials of Nina McCall. 2018; Beacon Press.

Brandt, Allan. No Magic Bullet: A social History of Venereal Disease in the United States since 1980. 1985; Oxford Univ Press.

Parascandola, John. Sex, Sin, and Science: A history of Syphilis in America. 2008; Praeger Press.

Sartin, J S, Perry, H O. “From Mercury to Malaria to Penicillin: The History of the Treatment of Syphilis at the Mayo Clinic-1916-1955”. J Amer Acad Dermatology 1995; 32:255-61.

Kampmeier, R H. “Venereal Disease in the United States Army: 1775-1900”. Sexually Transmitted Dis 1982; 9(2): 100-03.

Kampmeier, R H. “The Continuous Treatment of Early Syphilis by Arsphenamine and Heavy Metals”. Sexually Transm Dis 1981; 8: 224-6.

Brown, MT and Fee, E. “Raymond D. Fosdick (1883-1972): Ardent Advocate of Internationalism” Am J Public Health. 2012; 102(7): 1285.