AMERICA’S FIRST GALLBLADDER SURGERY

 

     Mary E. Wiggins, a thirty-year-old seamstress, arrived in Indianapolis in 1867 to consult a surgeon about a severe pain in her right side. Four years earlier she had noted a lump near her right pelvic brim that grew in size and became tender. By the time of the consultation she had lost considerable weight and could not work. Eating and mere walking produced crippling pain. Her physician, Dr. Newcomer, thought she had a large ovarian cyst, as did other physicians that she consulted. Knowing that a number of these had been successfully removed, Newcomer brought her to see Dr. John S. Bobbs, a respected Indianapolis surgeon. 

Dr. John S. Bobbs (Ind Med J, Hathi Trust)

     Dr. Bobbs examined her carefully. He could only partially outline the mass and pelvic examination did not suggest any attachment to the uterus or its appendages. He told Mary that he doubted that this was an ovarian cyst. Desperate from pain, she begged for surgery, regardless of the diagnosis. Bobbs, uncertain, waited, but after a second examination revealed nothing new, he decided to operate. 

     He had Mary taken to a room on the third floor over a local drugstore, a room that he rented at times for surgery. Inside were a plain wooden table for operating, a bed, a chamber pot, and chairs. At the time there were no hospitals for private patients and no trained nurses available. Present at the surgery were Dr. Newcomer, five other physicians, and a medical student, the nephew of Bobbs’ wife. Chloroform anesthesia was given. 

     Dr. Bobbs made an incision from the umbilicus to the pubis. Because of numerous adhesions he had to push his gloveless fingers through to reach the mass. It was about five by two inches, had a thin, translucent wall, and appeared to be attached to the liver. He opened the lower end and clear, colorless fluid gushed out, ejecting several small concretions ranging in size up to that “of ordinary rifle bullets.” After removal of additional stones, Bobbs sutured the open end of the gallbladder to the abdominal wall to allow further drainage. Antisepsis was still unknown, but Bobbs was said to always wash his hands before surgery. 

Mary Wiggins, 38 yrs after surgery
(Ind Med J, Hathi Trust)

 An Englishwoman was hired to provide nursing care. Aside from a small stitch abscess, Mary Wiggins recovered uneventfully. Her portrait shown nearby was taken thirty-eight years after the surgery. 

     Dr. Bobbs was born in Green Village, PA, in 1809. He grew up speaking Pennsylvania Dutch, a German dialect, and learned English a little later. He was apprenticed to a Doctor Martin Luther, practiced a short time, and moved to Indiana in 1835. He later enrolled in a one-year course at Jefferson Medical College. Another pupil while at Jefferson was J. Marion Sims, later famous as a gynecological surgeon and important to this story. Bobbs returned to Indianapolis where, in 1854, he contracted cholera. His physician, as treatment, rubbed morphine on his tongue, gave frequent small feedings of crushed ice and champagne, and applied hot water bottles and massages to his cramping extremities. He survived.

     Dr. Bobbs was active in the establishment the Indiana State Medical Society and of the Indiana Medical College. He became professor of surgery at the College and later dean of the school. A medical colleague, while praising his surgical talent, added that “he was original and bold almost to recklessness.” He served with distinction in the Civil War, read widely, and served one term as a State Senator. He published a report of his innovative operation in 1869 and died in the following year.

     There appear to be no further cholecystotomies until 1878, ten years later. In that year his old schoolmate, J.Marion Sims, unaware

J Marion Sims (from Meine
Lebensgescgichte, Hathi Trust)

of Bobbs’ report in an obscure journal, performed a similar operation in Paris. The patient was a 45-year-old woman with pain and a palpable mass, complicated by jaundice and severe itching. Sims aspirated the tender mass, removing 32 ounces of dark fluid. This relieved the pain and itching, temporarily. When symptoms recurred, Sims opened the abdomen, employing the new Lister technique of carbolic acid washes and sprays. He removed 24 ounces of dark fluid and 60 gallstones from the gallbladder and sewed the edges of the empty sac to the abdominal wall. The patient did well for five days, then began to ooze blood from the wound, gums, and intestinal tract, dying of internal hemorrhage. (Possibly a clotting disorder?) At autopsy the wound was intact and the gallbladder was not distended. Sims concluded that the operation probably had a future as a remedy for painful gallbladder distension and possibly liver abscesses and hydatid cysts. He coined the word “cholecystotomy”, a mixture of Greek words for gall, bladder, and incision. 

     The following year, the English surgeon, Lawson Tait, reported another case of cholecystotomy to the Royal Medical and Chirurgical

   Lawson Tait  (from biography    
by McKay, Hathi Trust)

Society. This patient survived the surgery. In 1889 Tait reported on an extended experience with 55 cases, seven of whom died. Of interest, Tait, like Sims, was primarily a gynecological surgeon. 

     The first actual removal of the gallbladder was done by Carl Langenbuch, in Berlin. In 1882, after trial operations on animals, he removed the organ from a man whose chronic pain over years had reduced him to morphine addiction and a skeletal appearance. The day after surgery the man was reported to be pain-free and smoking a cigar. Modern gallbladder surgery was born.

 

SOURCES:

Brayton, A W. “John S. Bobbs of Indianapolis: The Father of Cholecystotomy.” 1905; Indiana Med J 24: 21-37.

Tinkere, M B. “The First Nephrectomy and the First Cholecystotomy, with a Sketch of the Lives of Doctors Erastus B. Wolcott and John S. Dobbs.” 1901; Johns Hopkins Hosp Bull 12: 247-51.

Bobbs, J S. “Case of Lithotomy of the Gall Bladder.” 1868; Trans Indiana State Med Soc 18: 68-73.

Sims, J M. “Cholecystotomy in Dropsy of the Gallbladder.” 1878; Brit Med J June 8, pp 811-15

Tait, L. “Case of Cholecystotomy Performed for Dropsy of the Gallbladder.” 1879; Proc Royal Med Chirurg Soc 9: 435-7.

McKay, W J S. Lawson Tait: His Life and Work. 1922; William Wood and Co.

Thorwald, Jurgen. The Triumph of Surgery. 1957; Pantheon Books.

             

Troops ready to land 
(Wikipedia)

WHAT HAPPENED TO THE TYPHUS                 VACCINE?

 

      America’s baptism of fire in WWII was “Operation Torch”, the code name for the invasion of North Africa. The troops faced numerous hazards. Among them was epidemic typhus, a louse-transmitted scourge in the local population, likely to infect troops that cannot easily bathe or change clothes. Acquired by rubbing the infected feces of body lice into skin during scratching, epidemic typhus had swept away millions during and after the previous World War. Fearing that another epidemic could ruin the upcoming invasion, planners reached for two weapons: insecticides and vaccination. 

     On the advice of the newly-formed U.S.A. Typhus Commission (USATC), directed by Brig. Gen. Leon Fox (chief military health officer for the North Atlantic) and Fred Soper (an epidemiologist instrumental in malaria and yellow fever control in South America), all invading troops carried two-ounce cans of MYL powder, a pyrethrin-based insecticide, and all received a new and as yet minimally-tested vaccine against typhus. 

     The journey to a vaccine began in 1909 with the discovery by Charles Nicolle, in Algeria, that body lice transmitted the unseen germ. The next year, studying typhus in Mexico, Howard Ricketts

Howard Ricketts (Wikipedia)

found the tiny organism in lice, a finding soon confirmed by others. Early in WWI, A Brazilian scientist working in Germany, Henrique da Rocha Lima, and a Czeck scientist, Stanislaus von Prowazek, both working in a camp holding Russian prisoners, many with typhus, visualized the tiny causative organisms inside the cells lining the louse intestine. Rocha Lima named the organisms Rickettsia prowazeki after Howard Ricketts and von Prowazek, both of

Stanislaus von Prowazek(Wikipedia)

whom died of typhus during their investigations (Rocha Lima also contracted the disease but survived). Attempts at culturing failed, however.

     Inability to grow the organisms hampered vaccine development. A Polish scientist, though, did produce a vaccine in the 1930s, used on a significant scale. The scientist, Rudolf Weigl, in Lvov, Poland, invented a technique to inject Rickettsia organisms into the rectums of sterile lice using a fine glass tube and operating under a binocular microscope. Lice were placed in small boxes strapped to the legs of humans for feeding, both before and again after anal injection, to

Rudolf Weigl (Wikipedia)

enhance growth of the Rickettsia. Weigl then delicately removed the infected intestines, ground them with phenol as a sterilizer, and used the material as vaccine fluid. Three doses over a month offered enough protection to modify or prevent illness or death. The vaccine was used in and around Poland and traveled to China, where it saved hundreds of missionaries. The Germans, after invading Lvov, realized the benefits of the vaccine for their troops. Ramping up production impelled Weigl to mechanize the louse injections, so that one operator could inject 50 lice at a time and about 1000 an hour. A skilled dissector 

Body louse feeding (CDC website)

could harvest 300 louse guts per hour and one person could feed about 25,000 lice a month.  During WWII Weigl, under a lenient German manager, also managed to smuggle 30,000 doses to ghettoes in Poland without discovery. A similar lab operated in Warsaw. Being a louse feeder or technician in the lab was a life-saving job for many where SS troops roamed the streets. 

Weigl vaccine, packaged (Wiki-Commons)

     After the war scientists attempted to grow the organism in animal tissues such as rodent lungs, with some success. French workers in North Africa developed such vaccines and tried another made from murine typhus organisms, a related Rickettsia that can cause mild human disease. More importantly, Herald R. Cox (after whom 

Herald Cox (Wikipedia)

Coxiella burnetii, the cause of Q fever, is named), of the U.S. Public Health Service, succeeded in growing R prowazeki in the yolk sac of chick embryos. Further steps, especially extraction by ether, led to a more potent and easier to make vaccine, eventually produced by Squibb and Lederle in the U.S. and Connaught Laboratories in Canada. Human trials undertaken in Bolivia and Spain gave indefinite results, but the U.S. military decided, to be safe, to vaccinate the troops invading North Africa. In spite of a severe epidemic in the area only a handful of troops came down with mild cases. Proper studies among subjects in Cairo proved that the “Cox vaccine”, as it was known, was effective in protecting against severe, though not all, disease. 

     The MYL powder eliminated lice from clothing easily but its potency died out quickly. The next year, though, DDT came into use. This seemingly magic chemical had been synthesized as early

Paul Müller (Wikipedia)

as 1874 but had no useful function. In 1939, Paul H. Müller, a chemist working at the Swiss chemical firm, J.R. Geigy, while looking for a good insecticide, discovered the superior properties of DDT. Compared to MYL it had a much longer duration of action and soon replaced it. It was in use in Africa by early 1943. For delousing, the military ordered the local population to remove their clothing. Moslem women refused, however. So, Army personnel employed spray guns to blow the chemical between the clothing and skin, with the sleeves and legs tied off. 

Spray gun for DDT (Wikipedia)

     Many millions of lives were saved with DDT. Paul Müller was awarded the Nobel Prize in Physiology or Medicine in 1948 despite the fact that he was neither a physician nor a physiologist.

     The Weigl vaccine, after the war, gave way to the easier “Cox vaccine” whose production continued until 1970. By then, the widespread use of DDT and the introduction of effective antibiotics had terminated typhus as a world problem. The former scourge of armies, prisons, ships, and famine presently exists only in isolated pockets. 

 

SOURCES:

Allen, Arthur. The Fantastic Laboratory of Dr. Weigl. 2014; W W Norton

Snyder, J C. “Typhus Fever in the Second World War”. 1947; California Medicine 66 (1): 3-10

Ecke, et al. “The Effect of Cox-Type Vaccine on Louse-Borne typhus Fever.” 1945; Am J Trop Med25: 447-62.

Lindenmann, Jean. “Typhus Vaccine Developments from the First to the Second World War.” 2002; Hist Phil Life Sci. 24: 467-485.

     

     

   

                 INTERNATIONAL MEDICAL CONGRESS OF 1876

 

     In 1876 the United States was 100 years old. To celebrate, Congress authorized a mammoth celebration, an international exhibition in Philadelphia, covering about 285 acres. The Exposition included a medical exhibit: a military hospital, fully built, with pathology specimens, books, instruments, etc. on display. In one room was a scale model of a medical railroad train, with beds and stretchers in some cars and an operating suite, kitchen, and baggage space in others. Such trains were used in the Civil War. Bright red paint on the smokestacks and other locations and red lights at night served as a signal not to attack it, and it never was.

 

Main building, Centennial, covers 21.5 acres (Wikipedia)

   The Philadelphia County Medical Society, not to be outdone, decided to hold an international medical congress concurrently with the Centennial. Doctors from Europe to Japan arrived, along with delegates from the AMA, state medical societies (delegates limited to the number of representatives in Congress), the three military services (Army, Navy, and Marines), the American Public Health Association, a mental hospital association, and the American Association for the Cure of Inebriates. It ran for six days in September 1876.

     The president of the Congress was Samuel D. Gross, the prominent Philadelphia surgeon, celebrated in a painting by Thomas Eakins. Joseph Lister chaired the section on surgery, where he

The Gross Clinic, by Thomas Eakins (Wikipedia)
It hung in the military hospital exhibit (paragraph 
one)

presented his new antiseptic approach to surgery. Alfred Stillé presided over the internal medicine section. He was professor of the theory and practice of medicine at the U. of Penn Medical School and had published an early American text of pathology but was lagging in his acceptance of germ theory.  Robert Barnes, of London, obstetric physician at St. George’s Hospital, presided over obstetrics. Various other specialties were represented, including “sanitary science” (public health, today) and mental illness. The program featured eighty-one papers.

     The Congress met at a time when new findings of bacteriology were upending long-held beliefs and practices. After Joseph Lister lectured on his antiseptic surgery technique, employing carbolic acid liberally as the key antiseptic, attendee comments made it clear that

Joseph Lister (Wikipedia and Wellcome Library)

those who had actually visited Lister in Scotland and seen his results were quite persuaded by the method, as were several more. Others were still doubters and professed to have good results with mere cleanliness. Samuel Gross, unconvinced by Lister, remained silent.     

     In the obstetrics section, puerperal fever was reviewed by William T Lusk, chief of obstetrics at Bellevue Medical College. He agreed on the presence of coccal bacteria in the tissues of puerperal fever victims but was unsure of the mechanism of sepsis. He discussed Semmelweiss’ successful trial of handwashing, adding that he had queried three attendings that did both autopsies and deliveries concurrently. Two had not encountered puerperal fever and one said his death record was “unusually low.” Lusk, conceding that bacteria played a role, concluded that puerperal fever did not have a single cause.

     In fact, there was no bacteriology laboratory in the United States at the time. Even in Europe the science was just beginning and confusion reigned over various bacterial species. Agar plates did not arrive until 1882, allowing more exact speciation. Petri dishes came a few years later.

     Dr. Thomas Satterthwaite, from New York, discussed the germ theory in relation to Sanitary Science (public health). He was equally confused, admitting some relation of certain bacteria to certain diseases, but noting that the air was full of bacteria, with no ill effects. Dr Woodworth, of the Marine Hospital Service, discussed quarantine. He referred to the “morbific causes of infectious diseases”, recommending overall hygiene, cleansing of ships and ports, as well as the presence of informants in foreign ports to report contagious diseases, an innovation later adopted.

     A few other items are of interest. Joseph Woodward, author of a medical and surgical history of the Civil War, noted an average mortality rate from disease (not wounds) among white volunteers in the Civil War of 55 per 1000 mean strength. Among blacks in the last two years of the War, the rate was 211 and 139.8 per 1000. The excess in blacks he attributed to their poor condition before enlistment. As fugitive slaves they were “literally naked and starving”, as he put it. 

     Mercury and potassium iodide remained the treatments for syphilis, with much discussion over dosage and regimens. Dr. George A. Ward, medical director of the Oroya Railroad in Peru, gave an interesting account of verrugas, a stage in what is now known as Bartonellosis, seen in railway workers in the Andes. The Railroad was a venture of Henry Meiggs, the builder of the huge gold-rush-era Meiggs Wharf in San Francisco (burned in the earthquake). He had fled to South America in 1854 to escape crushing debts, only to take up railroad building. 

     A paper on treatment of ulcers recommended taking milk, especially cow’s milk. For bleeding ulcers, better to swallow ice and apply it over the epigastrium. Other medical papers covered “typhomalarial fever” (still considered an entity), diphtheria and the history of American medicine and surgery. 

     Presentations on mental illness dealt with the histology of general paresis (syphilis of the brain) before the infectious cause was understood, the insanity defense in criminal cases, and institutions for care of the insane. Dr. Edward R. Squibb, founder of the Squibb company and an advocate of better drug purity, spoke on the hope of a “universal pharmacopeia”, to standardize medicines worldwide. He realized it was unrealistic at present.

     Except for that of Lister, there were no breakthrough papers at the Congress, and Lister’s presentation had a limited immediate effect on surgical practice. But the seeds of progress had been sown and soon sprouted in surgery's younger generation. 

 

SOURCES:

Ashhurst, J, ed. Transactions of the International Medical Congress, 1876. 

Rutgow, I. “Joseph Lister and His 1876 Tour of America”. 2013; Ann Surgery 257: 1181-7.

Maass, J. “When the New World Dazzled the Old” American Heritage, June 1976, pp 25-8.

Review of International Exhibition, 1876, Official Catalogue. 1876; Amer J Medical Sciences 72: 236-9.

 

     

     

     

 

DEATH AND MEDICINE: FORENSIC SCIENCE IN NEW YORK

 

 

     Before 1918, if a corpse turned up in a New York City apartment, an elected coroner, with physicians as advisors, determined the cause of death. But the coroner rarely carried out autopsies or investigations. The system was so inefficient and corrupt that the NY Governor ordered an inquiry. A summary of the inquiry included phrases such as, “…infanticide and skillful poisoning can be carried on almost with impunity” and “in criminal prosecutions the district attorney usually receives no adequate medical data whatever.” Coroners had no training and many had previously been undertakers, politicians, saloon keepers, and plumbers. The physicians appointed to help the coroner had been “chiefly known for their political activity.”

     New York State passed a law in 1915 mandating that a medical examiner replace the coroner in New York City. Tammany-connected N.Y. Mayor Hylan was forced to choose an experienced physician for the job and chose Dr. Charles Norris, a pathologist and director of laboratories at Bellevue Hospital. 

     Charles Norris, from a wealthy New Jersey family, graduated from the College of Physicians and Surgeons (P&S), then studied anatomy and pathology in Europe, including time with Virchow. He spent eighteen months in Vienna absorbing the teachings of Eduard von Hofmann. Hofmann was the first professor of forensic medicine at

Eduard von Hofmann (Wikipedia)

the University of Vienna, appointed in 1875 after the retirement of Carl Rokitansky (who had kept forensic medicine in his pathology department). Hofmann brought chemistry, experimental physiology, and microscopic work, including bacteriology, into the specialty. Norris, on his return, worked in bacteriology at P&S and later accepted a position as director of laboratories at Bellevue Hospital. Bellevue’s City Morgue was joined to the pathology department, whose new building boasted modern laboratories. The enlarged morgue was said to be the largest in the world.  

     Norris, with his training, was uniquely suited for the medical examiner's job. Though he was not the first American medical examiner (that honor goes to Dr. George Magrath, appointed medical examiner in Boston in 1877), Norris’ office became the most scientific and influential one.

     To investigate suspicious deaths, a knowledge of poisons and toxins was essential. Norris brought in Alexander Gettler, a young chemist (not an MD) and an instructor at NYU’s medical school. Unlike Norris, who was well-born and over six feet tall, Gettler was the son of a poor Hungarian immigrant and diminutive in size. He was a brilliant chemist and became America’s first professional toxicologist. He studied poisons, using samples from a local butcher shop to determine efficient ways to measure the levels of poisons in tissues and blood. With cyanide, he elaborated ways to quantify mere traces and found that decomposing human tissues did not produce cyanide de novo, as some defense attorneys asserted, and was not degraded after death. Ballistics, bullet trajectories, and many other subjects were explored. Before long the findings of the two men in murder and suicide cases made headlines.

Medical Examiner's Lab. Norris on left, Gettler on right (Wikipedia)

     Life was busy at the morgue. A bomb explosion on Wall Street, accidents on the new subways, suicides from the stock market crash, gangster wars during Prohibition, and other problems provided numerous bodies for investigation. Norris also aimed at broader issues. Automobile sales exploded in the early 1920s, and so did deaths from auto accidents. In 1920, 692 New Yorkers died in auto accidents, leading to a law in 1922 requiring a driver to be licensed. It did not help – in 1925 the number of deaths was 1272. By this time tetraethyl lead (TEL) had been added to gasoline to prevent engine knocking. In 1924 workers in a Standard Oil plant began suffering from psychiatric disorders and convulsions and five employees died. New Jersey officials called Norris for help. In four autopsied cases he and Gettler found high levels of lead in all tissues, including the brain. In fact, TEL had a particular affinity for the brain. New York City, New Jersey, and a few other cities banned TEL. But a conference held by the Surgeon General in 1925, influenced by

Alexander Gettler (Wikipedia)

industry, opined that there was no real evidence that TEL was harmful, though further study was recommended. Only in 1976 did the phaseout of TEL begin, finalized in 1996.

     Norris took on Prohibition as well. He and Gettler predicted that deaths and blindness would increase with Prohibition, and they were right. The toll was heavy. To deter drinking, industrial alcohol was poisoned, most commonly with methyl (wood) alcohol, a substance degraded in the body to formaldehyde and formic acid. Illegal distilling companies simply hired chemists to remove or lower the wood alcohol content from supplies stolen for resale. Congress responded by authorizing an increase in methyl alcohol content or introducing new poisons, including benzene and mercuric salts, into industrial alcohol. Alcohol-related deaths and blindness increased, mainly among the poor who could not afford the purer stuff. Norris, seeing the tragic results firsthand, was exasperated and cried out, “…the United States Government must be charged with the moral responsibility for the deaths that poisoned liquor causes…” Congress did not respond, and Prohibition was not repealed until 1933.

Scene in Bellevue's Morgue, late 1800s. (Wikipedia)

     Norris’ office was the origin of the specialty of forensic medicine in America. He and Gettler placed the investigation of poisonings, suicides, and criminal and accidental deaths on a scientific basis that became, over time, the norm throughout the nation. Medical examiners, many trained by Norris, replaced coroners in most cities and their work led to the formation of the American Academy of Forensic Sciences, certification in forensic pathology, and several journals.

    And many a mystery writer has profited from their discoveries!

 

SOURCES:

Ewing, James. “Charles Norris, M.D.” (obituary). 1935; Bull N Y Acad Med 11(10): 633-6. 

Oshinsky, David. Bellevue. 2016; Doubleday. Chapter 14.

Blum, Deborah. The Poisoner’s Handbook. 2010; Penguin Books

Bucholtz, Ann. “History of Death Investigation” 2015; Forensic Sci Sem 5(1): 15-19.

Eckert, William. “Medicolegal Investigation in New York City: History and activities 1918-1978”     

    1983; Amer J Forensic Medicine and Pathology 4(1): 33-54.

     

 

     

 

 

 Orthopedic Surgery Enters the Modern Age on          a Chance Observation

Roy A. Meals, MD

     For thousands of years, bone setters and doctors could not accurately diagnosis broken bones or differentiate such injuries from joint dislocations and torn ligaments. That changed with a chance discovery 125 years ago this month. Subsequently, doctors began using the new discovery to discount their long-held assumptions and were able to accurately diagnose skeletal diseases. 

     In his darkened laboratory on November 8, 1895, a German mechanical engineer and physicist, Wilhelm Röntgen, electrified a vacuum tube and happened to observe a strange glow coming from a nearby card coated with a photosensitive chemical. He placed his hand between the vacuum tube and the card and an image of his hand appeared. Over the following weeks he ate and slept in his laboratory and studied this unknown ray, which he labeled “X,” the mathematical symbol for an unknown. 

Wilhelm Röntgen (Wikipedia)

     Röntgen discovered that X-rays passed through books, no matter how thick, and that coins cast a shadow on the photosensitive board. Röntgen shared the secret with his wife, who allowed him to take a fifteen-minute exposure of her hand, the first orthopedic X-ray. When she saw the image of her hand skeleton, she exclaimed, “I have seen my death.” Far more broadly, she was witnessing the advent of diagnostic radiology and modern orthopedic surgery. 

     A week later, Röntgen presented his findings in a paper titled, “On a New Type of Rays.” This caught the immediate attention of physicists, who alerted the lay press. The discovery made the front-page headline news within a week of Röntgen’s public presentation. 

     At the time, vacuum tubes were well known and easy to make. After Röntgen’s discovery and announcement, many investigators contributed to the understanding and practical applications of X-rays. Interest was intense and advances were rapid. Less than three months after Röntgen’s public announcement, an enterprising electrical contractor and avid photographer opened a laboratory that offered diagnostic services. 

X-ray of Bertha's hand (Wikipedia)

     Röntgen received the Nobel Prize in 1901, the first one ever awarded for physics. Röntgen not only gave the reward money to his university, he also refused to take out patents on his discovery to allow for wide-spread application. 

     I suppose when X-rays were in their infancy, patients were asking, “Now that you have finished obtaining a thorough medical history, performing a careful physical examination, and telling me that you know with assurance what is wrong, aren’t you going to order an X-ray, Doctor?” This question implied a lack of trust in the doctor’s diagnosis unless he threw in a high-tech, oh-so-modern X-ray evaluation. Gradually, doctors and patients came to understand when an X-ray study could help make the diagnosis or plan treatment and when one would be superfluous. For instance, today it is intuitive that a sore tooth most likely deserves an X-ray while a sore throat does not. In general, X-rays reveal calcium-rich structures—those containing enough calcium to cast a shadow in the X-ray beam. Examples are bones, teeth, hardened arteries, and kidney stones.

     Doctors have learned to order X-rays with some caution because radiation damages living tissues and their DNA. That fact required discovery, and the harmful effects of early X-ray examinations were slow to reveal themselves. Since X-rays could not be seen or felt, investigators had no reason to consider them harmful. Both Nicola Tesla and Thomas Edison experimented with X-rays, and both observed that their eyes became irritated; but neither drew a connection between the radiation and their symptoms. 

     For convenience, dentists originally held the film inside the patient’s mouth with their fingers when shooting dental X-rays. Decades later the skin on their hands dried, cracked, and became cancerous. Nowadays the radiology tech steps behind a lead shield before shooting the film, and there are generally accepted standards for how much radiation a person can receive on an annual and lifetime basis without incurring undue risk. 

     Despite our best efforts, we cannot avoid radiation exposure entirely. Some comes naturally from the sun and some from the ground. We get more during a plane flight because the thinner air at high altitude blocks less of the sun’s radiation. This fact poses a major, unsolved problem for interplanetary travel because of the absence of Earth’s radiation-shielding atmosphere and because of the impracticality of armoring spaceships with lead. 

     Most would agree, however, that the potential benefits of a timely chest X-ray or mammogram far outweigh the risks.  Even an occasional and judiciously planned CT scan may help maintain or restore one’s health; but we should avoid advice such as, “I don’t have a clue about what’s wrong, so let’s get a CT scan.” A second opinion is safer. Remember, it took decades for the damaged DNA in dentists to turn into skin cancers. Similarly, we should avoid being our own doctor and proclaiming, “I would just feel better, Doctor, if you ordered a CT scan.”

     Röntgen discovered his new type of ray a few decades after the introduction of general anesthesia and the acceptance of aseptic surgical techniques. These developments, along with the invention of stainless steel, ushered into the modern era orthopedic surgery and the practicality of operative fixation of fractures. Looking ahead 125 years, fractures will still exist. Arthritis and osteoporosis may be fully preventable. Bone imaging techniques will be even more sophisticated than those in current use. X-ray imaging may be obsolete, replaced completely by magnetic resonance imaging, ultrasound, or some yet-to-be-discovered alternative. Nevertheless, Röntgen’s discovery and its enduring 125-year legacy deserves recognition and respect. 

Bradley, William. “History of Medical Imaging.” Proceedings of the American Philosophical Society 152, no. 3 (2008): 349–61​.

“Radiation Risk from Medical Imaging.” Accessed November 6, 2020. https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging

Röntgen, William. “Ueber eine neue Art von Strahlen. (On a New Kind of Rays.)” In Classics of Orthopaedics. Edited by Edgar Bick, 278–84​. Philadelphia: Lippincott, 1976.

Dr. Meals blogs at www.aboutbone.com and has recently published Bones, Inside and Out (WW Norton, 2020) 

 

 Presidential Disability: 

The Case of Grover Cleveland and the

Twenty-fifth Amendment

 

     On June 30, 1893, President Grover Cleveland called for a special session of Congress to meet on August 8. The economy was slumping badly and he urgently wanted Congress to repeal the Sherman Silver Purchase Act. But why wait until August? Because he had scheduled a leisurely cruise up the Hudson River to his summer retreat at Buzzards Bay, he said.

     The truth was different. In May, Cleveland had noticed a roughening in his mouth. An examination by Dr. Robert O’Reilly, his personal physician, revealed a quarter-sized, ulcerating lesion on the roof of his mouth. Dr. Joseph Bryant, from Bellevue Hospital

Dr. Joseph Bryant (Nat. Library of 
Medicine)

Medical College, took a biopsy and sent it to William Welch at Johns Hopkins. Welch considered the tissue malignant, and Bryant urged immediate surgery. Cleveland felt, considering the economic crisis, that news of an operation for cancer would be destabilizing. Accordingly, he chose to have the tumor removed secretly aboard a yacht, the Oneida, loaned by a wealthy friend. 

     On the morning of July 1, 1893, the Oneida left the New York pier. On board, beside the President, were the surgeon, Dr. Bryant, who had authored a textbook on surgery and had reported the world’s largest series of maxillary (upper jaw, roof of mouth) resections, John Erdmann, a surgeon who worked with Bryant, Dr. William Keen, a well-known neurosurgeon from Jefferson Medical College, Edward Janeway, a prominent

Dr. Edward Janeway (Wikipedia)

internist from Bellevue, Ferdinand Hasbrouck, a dentist and anesthesiologist, and Dr. O’Reilly, the President’s personal physician who was to administer ether.

     The surgery began at 12:50 PM. Anesthesia was a worry, as the President was fifty-six years old, was obese, and had a short, thick neck. Initially, under nitrous oxide and locally injected cocaine anesthesia, Hasbrouck extracted two teeth and Bryant made an initial incision over the hard palate. Then, as Reilly administered ether, almost the entire upper jaw was removed along with some soft palate. A large gelatinous mass in the maxillary sinus was diagnosed by Dr. Welch as carcinoma. Gauzes were applied and the patient awakened. The surgery lasted just over one hour, with about six ounces of blood lost. Just over two weeks later Cleveland returned to the Oneida for a resection of margins thought to harbor residual tumor.

     The President recovered at Gray Gables, his home in Buzzards Bay. His speech was muffled and indistinct and his left cheek hollow. The team requested Dr. Kasson Church Gibson, a New York dentist, to make a prosthesis. Gibson had studied with Dr. Norman Kingsley, known as the “father” of orthodontics. Kingsley was the first to use a vulcanized rubber obturator (an object to fill a gap) in a case of cleft palate. He founded the New York College of Dentistry and wrote the first text on orthodontics. His apprentice, Gibson, after dentistry school, opened a practice in New York and was on the faculty of the University of Maryland School of Dentistry. He had collaborated with Bryant on previous cases. Gibson produced an obturator so perfect that the President’s face and speech appeared normal, even to friends, and he had no difficulty eating.

Pres. Cleveland, 1904 (Smithsonian
Portrait Gallery)

Pres. Cleveland, 1888 (Library of
Congress)

     In 1980, pathologists from the University of Pennsylvania restudied the tumor, preserved in the Mutter Museum in Philadelphia. They decided that the tumor was a verrucous carcinoma, a slow-growing tumor not prone to metastasis. Cleveland was probably cured at the initial surgery. 

     To explain the President’s temporary weakness and weight loss, Cleveland’s staff gave out reports that he suffered from rheumatism and bad teeth. One reporter published a true account, obtained from an inadvertent slip by Hasbrouck, but the coverup was otherwise so complete that the report never gained credence and the full story did not emerge until after Cleveland’s death.

     Coverups of presidential illness have been fairly common. Concealing the illnesses of Wilson, Roosevelt, Eisenhower, and Kennedy are examples. Most recently, when President Trump was hospitalized, the issue of a temporary incapacitation arose. A mechanism to deal with incapacity of the president, temporary or otherwise, is contained in the 25^th amendment to the Constitution, written well after Cleveland’s time.

     The idea of a plan in case of temporary presidential disability originally came from President Eisenhower. Eventually, Lyndon Johnson formally asked Congress to address the issue with a constitutional amendment. The amendment from Congress was ratified in February 1967. But does it address a central issue?

     A radiologist at Stanford University, Herbert Abrams, has pointed out that Congress never solicited medical opinion (from the AMA, for example) when drafting the amendment. In addition, the amendment says nothing about obtaining medical consultation in cases where a president is unable to perform his duties but will not or cannot say so. It reads only that “the Vice President and a majority of the principal officers of the executive departments or of such other body as Congress may by law provide” transmit to Congress their written declaration of the President’s incapacity. Abrams felt that though medical advice would almost certainly be sought, the mechanism should be spelled out. He suggested a six-man panel of physicians consisting of two internists, two neurologists, a psychiatrist, and a surgeon to provide an objective medical opinion if needed. Each would serve a six-year term, with a rotational replacement schedule, the appointments to be made by a complicated process to ensure impartiality.

     Perhaps renewed discussions in Congress will lead to clarification of this issue. Meanwhile, since staffs are generally loyal to their presidents and a cabinet majority is needed to invoke the 25^th amendment, some degree of coverup may well be a feature of future presidencies.

     

SOURCES:

Ferrell, Robert. Ill-Advised: Presidential Health and Public Trust. 1992; Univ of Missouri Press.

Keen, W W. The Surgical Operations on President Cleveland in 1893. 1917; George Jacobs Co.

Seelig, M G. “Cancer and Politics: The Operation on Grover Cleveland” 1947; Surg Gyn Obst 85: 373-6.

Murray M, Pappas T, Powers D. “Maxillary Prosthetics, Speech Impairment, and Presidential Politics: How Grover Cleveland Was Able to Speak Normally after His “Secret” Operation.” 2020; Surg Journal 6: e1-e6.

Abrams H. “Can the Twenty-fifth Amendment Deal with a Disabled President? Preventing Future White House Coverups.” 1999; Presidential Studies Quarterly 29 (1): 115-33.      

     

                                        SAMUEL POZZI

FATHER OF FRENCH GYNECOLOGY

 

 

     In the summer of 1881 an up-and-coming artist, John Singer Sargent, was introduced in Paris to a rising French physician, Samuel Pozzi. The artist agreed to do a portrait of Pozzi,

Dr. Pozzi at Home by J S Sargent
(Wikipedia)

a strikingly handsome man. When Sargent visited Pozzi’s sumptuous home on the Place Vendome he found Pozzi in a bright red dressing gown and decided on the spot to portray him in this garment. The result was one of Sargent’s most arresting paintings.

     Who was Samuel Pozzi? Born in 1846 to a physician father in Bergerac (of Cyrano fame), he completed his medical education at the University of Paris. During the student years he lived in the Latin Quarter, where he met the young actress, Sara Bernhardt. The two were almost certainly lovers and remained close friends throughout life. 

     In 1870 the Franco-Prussian War broke 

Samuel Pozzi (Wikipedia)

 out. Pozzi, then an intern at the Necker   Hospital, enlisted and treated the wounded at  Sedan. After the war he completed medical school, writing a thesis on fistulas of the upper recto-pelvic space. His aggregation thesis, for a faculty position, was on fibroid tumors of the uterus. Pozzi then worked at the Pitié Hospital, whose director was Paul Broca, a noted anatomist, surgeon, and anthropologist, who had discovered the speech area of the brain, “Broca’s area”. At Broca’s encouragement, Pozzi and a colleague translated into French Darwin’s latest work, The Expression of the Emotions in Man and Animals. 

    To enhance his income Pozzi took locum tenens positions at several hospitals and  gradually built a private practice. In 1876, at a meeting of the British Medical Association, he visited Joseph Lister in Edinburgh. He learned his techniques and on return introduced them into his work at the Pitié, supported by Broca. He was one of the early users of antiseptic techniques in France. 

     In 1883 he was appointed chief of surgery at the Lourcine-Pascal Hospital (later called the Broca Hospital). Pozzi had been interested in medical and surgical problems of women since medical school, where he had been impressed at how neglected their problems were. Particularly distressing were fistulas, leaking urine or stool, seen after difficult childbirths. Pozzi converted a disused shack on the grounds into a specialized ward for gynecological patients, considered to be the first such unit in France. Pozzi also installed an operating room in the main hospital, something it was lacking, and acquired possibly

Pozzi operating at the Broca Hospital (Standing to right of patient) 
(Wellcome Library and Wikicommons)

the first autoclave in France. Believing in the healing power of art, Pozzi had murals painted on the ward walls and a ceiling painted by the artist Georges Clairin, entitled Health Restored to the Sick. Sarah Bernhardt was the model for “Health”. A new surgical assistant, Robert Proust, brother of Marcel the writer, joined him. Proust later

Robert Proust (Wikipedia)

made contributions to gynecological and urological surgery.

     Pozzi applied to the University of Paris to teach a course in gynecology but was refused, so he taught the first such course in France independently and free of charge. It was popular. Meanwhile he worked to accumulate material for a much-needed textbook of gynecology. He finally retreated to his mother-in-law’s house in Montpellier for six months of isolated labor to produce it. 

     The text, the first in France, published in 1890 in two volumes and comprising over 1200 pages with almost 500 illustrations, was immensely successful and was followed by a new edition two years later. New surgical instruments and techniques that Pozzi had introduced were important contributions. The work was translated

From Pozzi's Textbook, 1891
Translation (Hathi Trust)

into five languages, including more than one English edition and new editions followed. The text established the specialty of gynecology in France and enhanced it worldwide. Amazingly, it wasn’t until 1901 that a department of gynecology was established at the University of Paris, with Pozzi appointed to chair it. 

     In contrast, in the U.S. the American Gynecological Society was formed as early as 1876. In that year Ulysses Grant was president, Custer was killed at Little Big Horn, and Colorado was admitted as the 38^th state. 

     Pozzi’s practice expanded, though he never abandoned general surgery, and he served as personal physician to numerous patients, including celebrities. He removed a large ovarian cyst from his friend Sarah Bernhardt but deferred to a colleague when she needed a leg amputation later in life. He continued to mingle with artists and writers and traveled frequently, accumulating a significant art collection. The American Gynecological Society honored Dr. Pozzi in 1906, the one hundredth anniversary of Ephraim McDowell’s amazing kitchen-table ovariotomy, by inviting him to address the Society on the history of ovariotomy in France. 

     Pozzi was deeply involved in the Dreyfus scandal, acting as a vocal advocate for the wrongly accused officer. He was also elected as a Senator for his home area. When WWI came, Pozzi enlisted at age 68, operating again on wounded soldiers and writing papers on abdominal wounds.

     Pozzi’s end came suddenly in 1918 when a deranged patient in his office shot him four times in the abdomen. Rushed to emergency surgery, Pozzi insisted on remaining conscious, ordering the surgeons to use only local anesthesia, morphine, and atropine. Prime Minister Clemenceau, an old medical school friend, attended the surgery. Despite repairing the bowel perforations, Pozzi died from a sudden hemorrhage. 

     The death of Samuel Pozzi, the creator of gynecology in France, was mourned by thousands, both for his work as a physician and for his support of, and friendship to, the artistic community of France. The famous portrait by Sargent is now on display in the Hammer Museum in Los Angeles.

     

SOURCES:

De Costa, C and Miller, F. The Diva and Doctor God: Letters from Sarah Bernhardt to Doctor Samuel Pozzi. 2010, ExLibris Corp.

 

Barnes, J. The Man in the Red Coat. 2020, Knopf.

 

Pozzi, S. Treatise on Gynecology, Medical and Surgical. Trans from French under supervision of Brooks H. Wells. 1891; Wm Wood & Co.

 

Speck, R. “Robert Proust – an eminent doctor in the shadow of his famous brother Marcel.” 2001; World J Urol 19: 285-91.

 

Ricci, J. The Development of Gynecological Surgery and Instruments. 1949; The Blackiston Co.

 

Pozzi, S. “The Evolution of Ovariotomy in France.” 1909; Surg, Gyn, Obs 9: 417-26.

 

Taylor, E S. History of the American Gynecological Society 1876-1981 and American Association of Obstetricians and Gynecologists 1888-1981. 1985; C.V. Mosby Co. (available online at: https://www.agosonline.org/public/PDF/Taylor_AGOS_history.pdf )

 

Transactions of the American Gynecological Society.  1876; H O Houghton & Co. vol 1.