IMMUNOLOGICAL CAPITAL IN NEW ORLEANS

 

                Much has been written about the impact that disease has on the course of human affairs. Typhus, for example, decimated Napoleon’s army as it retreated from Russia. Plague ravaged Europe in the fourteenth century to such an extent that the population dropped by about one third. Malaria and cholera have crippled military campaigns. Influenza killed millions toward the end of the Great War.

                One more disease deserves mention: yellow fever. In 1802, when Napoleon sent an army to St. Dominique (now Haiti) to put down a revolution, yellow fever carried off so many troops that the effort failed. After the failed invasion, Napoleon decided to sell the French possessions in America to the new United States. Thomas Jefferson, suddenly responsible for the management of the Louisiana Purchase, acted to bring it and its most important city, New Orleans, under American governance. He filled the various administrative offices with men to whom he owed political favors.

                Before long, however, his appointees expressed reluctance to accept the new jobs. Their predecessors were dying of yellow fever. The fever season lasted from June to the end of October or early November and the mortality among the newcomers hovered around fifty percent. A new book, Necropolis: Disease, Power, and Capitalism in the Cotton Kingdom, by the Stanford historian Kathryn Olivarius, relates the dominance that yellow fever exerted on the rhythm of life in New Orleans during the antebellum years and the importance of “immunological capital.”

                The city, by all accounts, was filthy. Local government, controlled by the planter and merchant class, funded the most meager civic improvements possible. Sewage was virtually absent. Cesspools stank in the summer. Butchers slaughtered animals in the street and left the carcasses behind. Diseases of poor sanitation were common. All this was in spite of the predominant medical opinion that yellow fever was not contagious but arose from the miasmas produced during hot months. Travelers were astonished at the nonchalance of the inhabitants living among such foulness, stench, and, in the summer, death. Newspapers and publications, on the contrary, ignored the truth and painted the city as healthful and prosperous.

                Importantly, there were fortunes to be made in New Orleans (mainly on the backs of slaves) and new immigrants kept coming from both the United States and from Europe. Young, optimistic arrivals often felt they could weather a bout of the fever and then, being immune, seek greater opportunity. A man was much more likely to be hired after surviving yellow fever, especially in a job with long-term prospects. Surviving “yellow jack” is how he earned his “immunological capital.” Immunity to yellow fever was a ticket to a social and business world of privilege that tended to exclude those who had not crossed this threshold. An immune person could rise in business, hold office, be a member of clubs and associations, buy life insurance more easily, and even marry the daughter of a father who rejected any nonimmune suiter. It was common for employers and insurance companies to ask for a doctor’s certificate verifying immunity to yellow fever. The doctor, of course, had no laboratory test or visible sign to buttress his opinion. He relied on the patient’s history, focusing especially on how long the individual had lived in the city.

                It was almost a universal belief that the black population had a natural, inborn, immunity to yellow fever. Doctors believed it too. For slaves born in Africa that may have been partially true since they grew up in a yellow fever environment. But slaves and free blacks born in the United States were as susceptible as anyone else. Planters, of course, knew the truth. They lost slaves to the fever during epidemics, sometimes in large numbers, seeing it as a cost of business. Slaves known to have survived yellow fever commanded higher prices.

                Some residents profited from the epidemics. Doctors, for instance, charged a higher “yellow fever rate” during epidemics. They often became wealthy enough to invest in a plantation or slaves, prospects that attracted more doctors to town. Gravediggers, usually blacks, charged higher rates during outbreaks. Even so, they were often overwhelmed. Undertakers, coffin makers, pharmacists, and irregular practitioners all did well during epidemics. Residents of French and Spanish background usually called on French-trained physicians, who tended to prescribe baths, rest, and hydration. American-trained doctors, in contrast, were more aggressive, employing generous purges, copious bleeding, and blistering. Medical care for poor people was more haphazard. Charity Hospital, founded back in 1736, was overloaded with patients and lacked the money for decent nursing, bathing, and even adequate diet. Numerous private charities and the Catholic Church filled the gap for the poor as best they could. Irregular practitioners, even Voodoo doctors, were also active.

                The deadliest yellow fever epidemic in antebellum New Orleans came in 1853. Up to 1000 people a week were dying and an estimated 10% of the city population (of 120,000) perished, even as newspapers reported on everything except the epidemic. Amazingly, the deaths and misery of that terrible outbreak still failed to persuade the city to establish a permanent health department or a quarantine regimen. The filth, stench, and repeated yellow fever tragedies continued until the Civil War, when Union forces under General Butler cleaned up the city and enforced a quarantine. Yellow fever cases dropped dramatically, paradoxically reinforcing the general belief that the disease arose from filth and miasmas. It took a massive epidemic in 1878 to finally convince New Orleans to institute definitive measures. Mosquito transmission was not confirmed until 1900.

 

                                     A MIRACLE DRUG, MAYBE

       She was known only as Mrs. G, a twenty-seven-year-old woman with debilitating rheumatoid arthritis that largely confined her to a bed and chair existence. Grasping at straws, she had already undergone a trial of streptomycin, based on theories of an infectious cause for her arthritis, without any improvement. In July 1948, she journeyed to the Mayo Clinic after hearing about a possible new approach to the disease: inducing jaundice.

        The chief of the rheumatology service at the Mayo Clinic was Philip Hench. He had founded and directed the first rheumatology

Philip Hench (Wikipedia)

service at the Clinic. An alert clinician, Hench noticed that the pain and immobility of rheumatoid arthritis sometimes improved for weeks to months in patients who were jaundiced from various causes (except hemolysis). Sensing a treatment opportunity, he infused bilirubin in large doses into patients and even transfused blood from jaundiced individuals, but with little or no improvement (1938). Noticing that pregnancy also helped rheumatoid arthritis in women, Hench transfused blood from pregnant women and administered female hormones, but without success. Some women even deliberately became pregnant again, hoping to make permanent the improvement in pain and stiffness.

This time Hench gave Mrs. G, and another patient, lactophenin, a substance that induced jaundice. But Mrs. G never turned yellow, though her companion did, and was released from the study. She refused to leave, however, badgering the Mayo doctors for another possible therapy. 

Based on the jaundice and pregnancy results, Hench had proposed a “substance X” present in the blood in these conditions that rendered rheumatoid arthritis potentially reversible. Since it appeared not to be a sex hormone or released from the liver, attention turned to the adrenal cortex. During WWII, research on extracts from the adrenal cortex had accelerated. Rumors proliferated that German scientists had isolated a substance from the adrenal cortex that increased tolerance to oxygen deprivation in fighter pilots and that submarines were transporting large quantities of bovine adrenal

Edward Kendall (Wikipedia)

glands from Argentina to Germany. Edward Kendall, at the Mayo Clinic, who had already isolated thyroxine and glutathione, and a Swiss chemist, Tadeusz Reichstein, had both isolated compound E from the adrenal cortex in 1936. The procedures were laborious and the quantities small. Because compound E, unlike other isolates, kept adrenalectomized rats alive and might be valuable for stressed pilots, the U.S. prioritized efforts to synthesize it.

       Mrs. G’s pleas for another treatment touched Hench. He turned to Edward Kendall, who had isolated compound E, who persuaded Merck, the owner of the scarce

Tadeusz Reichstein (Wikipedia)

substance, to release 5 grams for use. Hench, not optimistic about the outcome, left the trial to two younger rheumatologists working on the service, Charles Slocum and Howard Polley. 

       Mrs. G received the first of twice daily injections of 50 mg of compound E on September 21. By the 23^rd she felt better and by the 24^th she was walking around and doing light exercise. By the 28^th she went shopping for three hours, saying “I have never felt better in my life.” Hench, stunned, was about to leave for London at this critical moment to give the prestigious Heberden Lecture. He swore everyone involved to complete secrecy until he returned. On the way to London, he detoured to New York to meet with Merck executives to swear them to secrecy and to obtain more of the scarce compound E.

       Meanwhile, Mayo doctors tried compound E (soon to be called cortisone) on more patients, including some with lupus and other rheumatic diseases, with equally startling results. Merck, before publicizing such extraordinary findings, wanted the security of involving experts beyond the Mayo group. Hench coaxed a group of five prominent rheumatologists from around the country to come to Rochester. One of them, Dr. Richard Freyberg, from New York’s Hospital for Special Surgery, recalled the event years later. Hench had turned his large house into a clinic, complete with X-ray viewers, microscopes, and movie projectors, and plenty of food. Two patients were examined carefully, then injected once with 300 mg of cortisone. Over the next three days the same miraculous transformation from an almost immobile status to a freely moving one amazed the onlookers. Back home, the experts tried it on their own patients, with the same astonishing results, but always with relapses after the cortisone ceased. 

       The rheumatologists reported their findings at the International Congress of Rheumatology. One of them, Walter Bauer from

Nobel Medal, showing a figure gathering water from a spring 
to help an ailing young woman (Wikipedia)

Harvard, recalling Boston’s ether story, declared, “Gentlemen, this is no humbug.” During the Congress, however, Hench received a phone call alerting him to side effects that were to mar cortisone’s reputation. In particular, Mrs. G had become bloated, developed a moon-like face, lost bone density, and suffered a depression and psychosis so serious she was transferred to a locked psychiatric ward. After recovery, she refused to take cortisone ever again. She died in 1954 of pulmonary edema during a course of ACTH in Indiana. 

Similar side effects from cortisone in others shattered the euphoria of the doctors and their arthritic patients. In the end, cortisone, used safely, offered little benefit over aspirin. Only the later introduction of prednisone provided a safer alternative.

       In 1950, two years after Mrs. G received her first dose of cortisone, the Nobel Prize in physiology or medicine was awarded to Hench, Kendall, and Reichstein. 

Was the Nobel prize premature? Maybe, since cortisone proved to be a disappointment. On the other hand, its use led to improved steroids and opened vast new avenues of research, considerably improving the lives of those with rheumatic diseases.

 

SOURCES:

Rooke, Thom, The Quest for Cortisone. Michigan State University Press, 2012.

 

Burns, C M, “The History of Cortisone Discovery and Development.” 2016; Rheum Dis Clin North Am 42: 1-14.

 

Warner, M E, “Witness to a Miracle: The Initial Cortisone Trial: An Interview with Richard Freyberg, MD.” 2001; Mayo Clin Proc 76: 529-32.

 

Hench, P S, “Effect of Spontaneous Jaundice on Rheumatoid (atrophic) Arthritis.” Brit Med J 1938; Aug 20: 394-8. 

 

Benedek, T G, “History of the Development of Corticosteroid Therapy.” 2011; Clin Experim Rheumatol 29(Suppl 68): S5-S12.

       

       

       

       

       

         

       

         FURTHER TALES OF ANGINA: 

A REMEDY AT LAST

 

         Last month’s essay outlined the first descriptions of angina pectoris and its relation to coronary artery disease. William Jenner was probably the first to notice the association of the syndrome with calcification of the coronary arteries. He withheld publication of his findings to avoid frightening his friend and former teacher, John

Caleb Parry (Wikipedia)

Hunter. In 1799, Jenner’s colleague, Caleb Parry, a physician in Bath, published a monograph on angina in which he reveals the story of Jenner’s discovery, details three more cases that show diseased coronary arteries at autopsy, and unfortunately confuses the picture by adding syncope as an accompanying symptom in some cases. 

         Osler, in his 1892 textbook, called angina a rare disease, reiterating its rarity in a series of lectures published in 1897. Regarding the cause of anginal chest pain, Osler noted that hardened coronary arteries are

William Osler (Wikipedia)

found in many cases with no angina, making it uncertain what actually caused the pain. He listed three main possibilities: a neuralgia of the cardiac nerves, a cramp in the heart muscle, or an extreme tension in ventricular walls (or in the associated nerves) caused by dilatation of the heart from insufficiency of coronary blood flow.

         Treatment since Heberden’s time and until the late 19^th century consisted in administration of spirits, plasters, bleeding (to relieve “plethora”), and sometimes opiates or chloroform. Removing a few ounces of blood often prevented recurrent attacks for a short period, probably related to a lower blood pressure. Details of the physiology involved, however, were far from clear. 

         Nitroglycerin, the “modern” treatment for angina pectoris, originated, strangely enough, in homeopathic practice. 

         Dr. Samuel Hahnemann, a well-trained German physician, began the homeopathy movement in 1796. It was based on his idea

Sanuel Hahnemann (Wikipedia)

that if the effects of a drug caused symptoms resembling those of a particular disease, then small doses of that medication would counteract the action of the same disease – “like cures like.” The idea proved attractive and, possibly because patients avoided the traditional bleeding and purging, the practice of homeopathy grew. 

         The chief founder and organizer of homeopathy in America was Constantin Hering. Born and educated in medicine in Germany, Hering was asked by a professor, while training in Leipzig, to write an essay against homeopathy. But when he studied the works of Hahnemann, he became a convert. He landed in America after a shipwreck near the New England coast. He decided to stay, opened a homeopathy practice in Philadelphia, and was instrumental in founding the first school of homeopathy in America. He devoted much time to “proving” medications. Proving was a method, initiated by Hahnemann, by which medications were tested systematically on

Constantin Hering (National Library of Medicine)

humans to observe and record their effects. It was perhaps the first such evaluation of items in the pharmacopeia, an advance over methods of regular physicians.

         Hering was aware of nitroglycerin. An Italian chemist, Ascanio Sobrero (whose face was scarred from an explosion and who knew Alfred Nobel), first synthesized nitroglycerin in 1847 while seeking a better explosive than the available “gun cotton.” Hering “proved” nitroglycerin as early as 1849 and noted that small doses on the tongue rapidly produced throbbing headaches and a rapid pulse, effects Sobrero had also noted. He gave the name “glenoin” to nitroglycerin and, in diluted doses, it became a treatment for headaches and sometimes palpitations. Occasionally it produced an oppressive feeling or even pain in the chest, but it was never promoted for angina, which homeopaths agreed was a rare condition.

         In England, homeopaths were also using glenoin. A British regular physician, Alfred Field, obtained the substance from a homeopathic chemist and reported, in 1858, a single case of a woman with angina-like chest pains who was relieved by nitroglycerin. Others with varied non-chest pains also had relief. The first to use it specifically for angina pectoris was William Murrell, a physician at the Royal Hospital for Diseases of the Chest. He had worked under Burton-Sanderson, one of England’s finest physiologists, and Sydney Ringer (of Ringer’s solution) and was thus trained in experimental techniques. Having read the papers of Sobrero and Field, Murrell made a 1% solution of nitroglycerin and placed a small amount on his tongue. He noted a headache and a sudden bounding of his pulse, so forceful that, just as a patient had entered his office, “I hardly felt steady enough to perform percussion” and, “The pen I was holding was violently jerked with every beat of the heart.” He took nitroglycerine many more times and began to administer it to others, recording pulse, symptoms, and the like. 

         Murrell was aware that the effects of nitroglycerine resembled those of amyl nitrate, an inhaled substance first described as a treatment for angina in 1867. In 1879, he published his experiments

Murrell's first article on nitroglycerine.

with nitroglycerin in a series of four articles, showing that its effects were similar to amyl nitrate but with faster onset of action and longer duration. As an attempt to prevent angina, he gave it as a small tablet to take four times a day. The frequency of anginal attacks in three patients tested diminished, as did the intensity. However, one patient found it easier to simply take a nitroglycerine tablet on the tongue when an attack came on, after which he obtained quick relief. This use of a former homeopathic remedy became the standard approach to managing angina up to the present time. Few medical remedies have enjoyed such a long life.

 

SOURCES:

Fye, B, “Nitroglcerin: a homeopathic remedy.” 1986; Circulation 73: 21-9.

 

Murrell, W, “Nitroglycerine as a remedy for angina pectoris.” 1879; Lancet v 1, 80-81, 113-15, 151-2, 225-7.

 

Osler, W, Lectures on Angina Pectoris and Allied States. 1897; Appleton & Co., New York.

 

Eastman, A M, Life and Reminiscences of Dr. Constantine Hering. 1917; reprint from The Hahnemannian Monthly, 1917, privately printed.

 

Field, A G, “Toxical and medicinal properties of nitrate of oxide of glycyl.” 1858; Med Times Gazette 16: 291.

 

       TALES OF ANGINA

 

            The oppressive chest pains induced by exertion, known as angina pectoris, have plagued sufferers for centuries. Even the hearts of ancient Egyptian mummies have revealed calcified coronary arteries, an anatomical change that restricts blood flow to the heart muscle that is the usual cause of angina. A full description of anginal pain, recognizing it as a distinct entity to be distinguished from other chest complaints, was first made by William Heberden in an address to the Royal College of Physicians in 1768. The address was published four years later in the Medical Transactions of the Royal Society of Physicians and in the periodical, Critical Review or Annals of Literature, a popular magazine aimed at an educated readership that frequently published medical news.

         Heberden describes angina in the following words: “Those who are afflicted with it are seized, while they are walking, and more

Article by Heberden in Medical
Transactions. (Hathi Trust)

particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away if it were to increase or continue: the moment they stand still, all this uneasiness vanishes. In all other respects the patients are at the beginning of this disorder perfectly well, and in particular, have no shortness of breath, from which it is totally different.” Heberden adds that he and another physician, whom he discussed the matter with, both noticed a high frequency of sudden deaths within a short time after the onset. Heberden speculated on some sort of “strong spasm” beneath the sternum as the cause of pain, not mentioning heart disease.

          William Heberden was one of the most sought-after physicians in London. Born in 1710 to an innkeeper, his early schooling was at a grammar school that emphasized the Classics. He entered St. John’s College at Cambridge at the age of

William Heberden (Wikipedia)

fourteen, obtained a Bachelor of Arts degree four years later, followed by further study and a medical degree after another eleven years. He taught physic and materia medica for several years at Cambridge and later opened a practice in London. He was a careful observer, taking extensive clinical notes that coalesced eventually into a book: Commentaries on the History and Cure of Disease. His description of digitorum nodi (Heberden’s nodes) appears there. He was a founder of the journal, Medical Transactions, published by the Royal College of Physicians. 

He was conservative regarding the multiplicity of medicines at the time, naming only Peruvian bark for ague, mercury for syphilis, sulfur for the itch (probably scabies), and opium as specific remedies. His broad education and gentle manner attracted many friends and patients, especially from the sphere of literature, such as Samuel Johnson, who dubbed him “ultimus Romanorum,” the last of our learned physicians. He was a friend of Benjamin Franklin, who persuaded him to write a pamphlet on the prevention of smallpox by variolation (inoculation of smallpox virus, a technique used prior to vaccination with cowpox-derived virus), which Franklin published in America on his own press in 1759. The pamphlet was distributed free of charge, the cost being absorbed by Franklin and Heberden. 

         One of Heberden’s patients suffering from angina had willed his body to be dissected when he died. Heberden asked the famous surgeon and anatomist, John Hunter, to perform the autopsy. Helping

Edward Jenner (Wikipedia)

him was Edward Jenner, his 23-year-old pupil in surgery. They found no particular cause of death. Fourteen years later, Jenner, now in practice in the town of Berkeley, autopsied a patient of his with angina pectoris who had died suddenly. While making a transverse section of the heart, Jenner’s knife encountered something hard and gritty. As he wrote to a colleague, Caleb Perry, he looked up at the old and crumbling ceiling, “…conceiving that some plaster had fallen down. But on a further scrutiny, the real cause appeared: the coronaries were become bony canals.” Jenner, sensing that the “bony canals” impaired cardiac circulation and might cause anginal pains, was anxious to publish his finding but hesitated. He had kept in close touch with John Hunter and knew that Hunter himself was having anginal pains. He worried that publication of the idea would have distressed his old mentor and friend.

Knowing Heberden was Hunter’s physician, Jenner wrote to him. He observed that patients with angina had a substantial layer of fat around the heart, and, “as these vessels lie quite concealed in that

John Hunter, by John Jackson (Wikipedia)

substance, is it possible this appearance has been overlooked?” He felt certain that the coronary arteries of Heberden’s previous case had not been examined and he feared that if Hunter learned of his theory of hardened arteries, “it may deprive him of the hope of a recovery.” Heberden agreed that it was best not to publish the findings as Hunter’s anginal attacks sometimes came when he was agitated.

Sadly, a few years later, in 1793, after a dispute at a hospital board meeting, Hunter suddenly collapsed and died. At autopsy, his coronary arteries were “in the state of bony tubes, which were with difficulty divided by the knife,” consistent with Jenner’s speculations.

Edward Jenner later achieved fame with the discovery of the immunizing effect of cowpox against smallpox. He had suppressed his seminal discovery of the hardened arteries in anginal patients out of concern for a friend, a generous act. Heberden and Jenner had opened the way to the study of coronary circulation and its relation to angina pectoris and myocardial infarction. Effective therapies were not to emerge, however, for many years. 

 

SOURCES:

Acierno, Louis J, The History of Cardiology. Parthenon Publishing Group, 1994.

 

Fisk, Dorothy, Dr. Jenner of Berkeley. Heinemann, 1959.

 

Finger, Stanley, Doctor Franklin’s Medicine. University of Pennsylvania Press, 2006.

 

Hart, F D, “William Heberden, Edward Jenner, John Hunter, and angina pectoris.” J Medical Biography, 1995; 3(1): 56-8.

 

Heberden, W, “Some Account of a Disorder of the Breast.” Medical transactions / Royal College of Physicians. 1772; v. 2: 59-67.

 

Heberden, W, Commentaries on the History and Cure of Diseases. London, 1802.

 

Beasley, A W, “A Story of Heartache: The Understanding of angina pectoris in the Pre-surgical Period.” J Royal Coll Physicians Edinb 2011; 41: 361-5.

 

 

 

                     BENJAMIN FRANKLIN’S GOUT

      Benjamin Franklin’s name is recognized everywhere. No American history course omits mention of his accomplishments. Less often referred to, though, is his struggle with gout and urinary stones, maladies that plagued him in later years. 

Benjamin Franklin in a fur hat he often wore 
in France (Wikipedia)

         Franklin first mentioned “a touch of the gout” in a letter to his sister when he was 56 years old. Gout appears off and on in later letters as an annoying but not serious impediment. Franklin, of course, was conversant with many medical and scientific matters, often corresponding with doctors. He knew the writings of Thomas Sydenham, considered the father of English medicine, who had published a treatise on gout in 1683. Sydenham noted that gout “generally attacks those aged persons who have spent most part of their lives in ease, voluptuousness, high living, and too free an use of wine and other spirituous liquors” and “…have

Thomas Sydenham, by Mary Beale
(Wikipedia)

large heads, are generally of a plethoric, moist, and lax habit of body…” When, less often, it attacks younger persons, they received it from gouty parents or occasioned it by “over-early use of venery.” Sydenham also recognized an association with urinary stones, and he discouraged bleeding, emetics, purges, and sweating agents in favor of certain herbal remedies. Leeuwenhoek had seen the needle-like crystals from gouty tophi but identification of uric acid as the important substance came after Franklin’s time.

         Franklin had been sent to France early in the American Revolution to enlist the aid of the French government in the revolt against England. He arrived in December 1776, at the age of seventy. He was well known there, as Voltaire had extolled him as the discoverer of electricity, a genius, a successor to Newton, and a scientist. He took up residence on an eighteen-acre estate in Passy, a wealthy commune near Paris, owned by an aristocrat sympathetic to the American cause. 

Franklin presented at court. Louis XVI and Marie Antoinette are seated on the right. The woman
in white next to Franklin is Diane Polignac, lady-in-waiting to the queen's sister. (Library of Congress)
(click on image to enlarge)

Franklin commuted to Paris for consultations with the French government, during which he faced numerous meals rich in fatty meats, pastries, and wines, many of the latter fortified. He became especially fond of Madeira and consumed generous quantities of it. His gout intensified and he believed that his new lifestyle was responsible. Lead was often present in wine at the time, entering during its production and seeping in from lead-containing wine vessels. Lead can promote gout by decreasing uric acid clearance and is believed to have contributed to Franklin’s case. 

Madame Brillon, by Fragonard (Wikipedia)

Near Franklin in Passy lived Madame Brillon, the wife of a much older and frequently absent man. Madam Brillon was quite attractive, and she and franklin flirted with each other. During one of Benjamin’s gouty attacks, she composed a poem, chiding him for bringing it on himself by eating too much, drinking too much, avoiding exercise, and “you pass your time with dames” (translated).  He subsequently composed a dialogue  between himself and "Madame Gout," who also berates him for dietary excesses and lack of exercise.

Colchicine, known to the ancients as a remedy for gout, seems to have fallen out of favor in Franklin’s time. He probably did not use it, but it was available in Paris as part of a secret formula called “Eau Médicinale.” Colchicine is derived from the plant Colchicum autumnale, or autumn crocus, found most abundantly in Colchis, an ancient tribal area, described by Herodotus, that covered a region corresponding to the western part of modern Georgia. The identity of colchicine as the secret ingredient in Eau Médicinale was revealed in 1814 and its use in gout subsequently reaffirmed.

Aside from gouty attacks in his feet, Franklin had passed “gravel” in his urine off and on, but it was not until he was 76 that he became aware of a bladder stone that would not pass. The stone troubled him principally when traveling in a coach or walking and he limited his activities to avoid excruciating pain. This hampered his negotiations over the Treaty of Paris of 1783 ending the American Revolutionary War. He medicated himself with large amounts of honey, molasses, and jellies, hoping that they would increase the specific gravity of the urine and allow the stone to be buoyed up and perhaps keep gravel from coalescing. His idea stems from a school of thought known as iatrophysical or iatromechanical medicine, seeking to explain physiological processes through the laws of physics. He could not know the modern conception of urine and stone formation.

Doctors advised another medication for the stone, Blackrie’s Lixivium, a solution of salt of tartar (potassium carbonate), quicklime (calcium oxide) from oyster shells, and water, which is basically a lye solution. Prescribers of this remedy, a remnant of the iatrochemical school of thought, hoped that the lye would dissolve stones. Surgery was discussed among his doctors but dismissed as unreasonable. The operation would have been a lithotomy, removing

John Jones, surgeon (National Library 
of Medicine)

the stone through an incision between the scrotum and the perineum, without anesthesia. Founding father and later chief justice John Marshall underwent this procedure in his sixties, successfully. His surgeon was John Jones, a prominent surgeon in the American Revolution, the first to perform a lithotomy in America, and one who could accomplish the surgery in a little over one minute, to minimize pain.

Franklin returned to America in 1785 in ever more pain from the stone. He finally resorted to opiates, which eased the agonies somewhat. He signed the new U.S. Constitution in 1787 but eventually, with John Jones attending him, succumbed to a lung abscess in 1790 at the age of 84. Alert to the end, he lived a remarkably long life for his era, and certainly a productive one.

 

SOURCES:

 

Corner, GW and Goodwin, WE, “Benjamin Franklin’s Bladder Stone.” 1953; J Hist Med Allied Sci8: 359-77.

 

Finger, S and Hagemann, IS, “Benjamin Franklin’s Risk Factors for Gout and Stones: From Genes and Diet to Possible Lead Poisoning.” 2008; Proc Amer Philosoph Soc 152 (2): 189-206.

 

Franklin, JL, “The Three Contraries of Benjamin Franklin: “the gout, the stone, and not yet master of all my passions.” 2021; Hektoen 13 (3).

 

Franklin, B. The Bagatelles from Passy. 1780; Facsimile by Eakins Press, New York, 1967 (Originally printed by B. Franklin on his personal press at Passy).

 

Griesemer, A D, et al, “John Jones, M.D.: Pioneer, Patriot, and Founder of American Surgery.” 2010; World J Surg. 34 (4): 605-9.

 

 

                                    EISENHOWER’S HEART 

      At about two AM on the morning of September 24, 1955, a severe chest pain awakened President Eisenhower. Thinking it related to a giant hamburger with onions eaten the day before, he got up to find some milk of magnesia. Mamie, hearing the noise, came in and, alarmed at her husband’s appearance, called their family physician, Dr. Howard Snyder. Dr. Snyder, residing nearby, arrived at about 3 AM at the home of Mamie’s mother, outside Denver, where the couple were staying. Eisenhower had suffered from abdominal

General Snyder, Eisenhower's personal
physician (Wikipedia)

pains for years, all through WWII in fact (with no clear diagnosis), and Dr. Snyder apparently thought this might be a manifestation of his usual disorder. He administered morphine which helped the pain. Events thereafter are confused due to differing reports, but it is safe to say that sometime in the late morning Snyder suspected a cardiac origin of the pain and called nearby Fitzsimons Army Hospital, requesting an EKG machine. The commander of the hospital and the chief cardiologist, Dr. Byron Pollock, came and quickly diagnosed an anterior myocardial infarction. 

         Ike was helped down the front stairs into the presidential limousine, driven by a circuitous route to avoid the press, and delivered to the back door of Fitzsimons Army Hospital. Once in bed, covered by an oxygen tent, he received more morphine, along with papaverine (thought to open up the coronary arteries), atropine (thought to help prevent arrythmias), and heparin, followed by Coumadin (for anticoagulation). Dr. Thomas Mattingly, chief of cardiology at Walter Reed Hospital and Dr. Paul Dudley White, who had been a mentor of Mattingly and was at the time probably the best-known cardiologist in the country, were called in for

Paul Dudley White, seated, next to Ancel Keys,
early advocate of Mediterranean diet, standing.
(National Library of Medicine)

consultation. They all concurred on the prescribed regimen. Eisenhower, unhappy about the previous cover-ups of the illnesses of FDR and Woodrow Wilson, ordered that the public be informed of events.

         Interestingly, during the previous few days Eisenhower had been fishing near the continental divide, at about 8900 feet, without any chest complaints. His blood pressure was known to be mildly elevated at times, especially when angry. His cholesterol was about 200, he was not overweight, he exercised regularly and, though previously a heavy smoker, he had given it up abruptly in 1949.

         The choice of Paul Dudley White (“P. D.” to friends) as the civilian consultant was a fortunate one. White was a founder of the American Heart Association, author of numerous books, including a standard textbook on cardiology, and a physician consultant to a number of celebrities. He had transported to the Massachusetts General Hospital their first EKG machine from the laboratory of Dr. Thomas Lewis, in London, in 1914. Equally important, White was smooth and tactful with the press.

         Eisenhower was not treated in a cardiac care unit at Fitzsimons. In fact, treating heart attacks at home was still a common and recommended practice. The first CCU in the world opened seven years later, in Kansas City in 1962. The essential components of a CCU, such as external pacemaking, electroshock for ventricular fibrillation, and closed chest massage for cardiac resuscitation were not worked out until 1960. Monitoring with oscilloscopes was possible, and drugs such as quinidine, procainamide, and digitalis were available, as was anticoagulation. CCUs proliferated worldwide once the necessary elements were in place. 

         Eisenhower’s clinical course was fairly smooth, though the infarct was a large one. Six weeks of bed and chair existence was the favored regimen at the time, followed by a gradual increase in exercise. Eisenhower left the hospital after seven weeks. About nine months later, he developed an intestinal obstruction, relieved by surgery, at which time the diagnosis of regional ileitis, or Crohn’s

Dwight Eisenhower during his second term
(Wikipedia)

disease, became apparent. It was certainly the reason he had had so much intestinal distress over the years. After a somewhat slow but steady recovery, Eisenhower ran for a second term as president and completed his time in office without major medical problems.

         In November 1965, now retired and in Georgia, Ike had another, milder, attack. After stabilization, he was transferred this time to a modern CCU in Walter Reed Hospital, where he stayed five weeks, still on the bed and chair regimen. Two and one-half years later, in California, recurrent chest pains landed him in the hospital at March Air Force Base from where he was flown back to Walter Reed. This infarction was complicated by multiple episodes of ventricular fibrillation, uncontrolled by drugs. It required a total of fourteen external shocks to Eisenhower’s chest before the rhythm settled down. “He died fourteen times,” it was said. Amazingly, he remained alert and calm through most of the ordeal. 

Walter Reed Hospital (Wikipedia)

But the old soldier’s time was running out. Before he could be discharged, another intestinal obstruction prompted a second operation that he endured successfully, though it weakened him. His heart failed to rally after the surgery, and he expired quietly on March 28, 1969. An autopsy confirmed extensive three-vessel coronary disease and scarring of the heart muscle. His final stay in Walter Reed Hospital had lasted for approximately ten months.

         Dwight Eisenhower’s staff generally reported his medical problems correctly, as he had asked, though sometimes minimizing their severity. And, importantly, Ike’s cardiac illness helped promote awareness and knowledge of heart disease among the general public.

P.S. Please visit the informative History of Medicine Museum of the Sierra Sacramento Valley Medical Society at: http://www.ssvms.org/museum.aspx

The exhibits and essays are well worth it.

 

SOURCES:

Lasby, Clarence G., Eisenhower’s Heart Attack: How Ike Beat Heart Disease and Held on to the Presidency. Univ of Kansas Press, 1997.

 

Diamond, E. Grey, ed., Paul Dudley White: A Portrait. Reprinted from Amer J Cardiology, 1965.

 

Fye, W. B., “Resuscitating a Circulation Abstract to Celebrate the 50^th Anniversary of the Coronary Care Unit Concept.” 2011; Circulation, 124: 1886-93.

 

Caswell, J.E., “A Brief History of Coronary Care Units.” 1967; Pub Health Reports 82 (12): 1105-7.

 

Herrick, J.B., “Concerning Thrombosis of the Coronary Arteries.” 1918; Trans Assoc Amer Physicians 33: 408-18.