THE DISEASE OF THE DEPOSED CHILD                                                                 

         In 1929, a 36-year-old Jamaican-born British physician, Cicely Williams, arrived by ship at the African “Gold Coast,” now known as Ghana. The inspiration for this assignment to a faraway place came from a Croatian professor of public health, Andrija Stampar, whom Williams had met on the way to work in a refugee camp near Salonika. He had shown her how to deal with with epidemics and nutritional problems at the community level using limited resources. Cicely determined to take up medicine in underserved communities as a way to confront these challenges. 

Gold Coast (Wikipedia) Click on 
image to enlarge.

 Dr. Williams, after her inspiring experience with Stampar, earned a Diploma at the London School of Hygiene and Tropical Medicine and was assigned by the British Colonial Medical Service to the town of Kumasi, in the Gold Coast. The area, formerly the land of the Ashanti empire, was now a center of cocoa production and extensive mining. 

While working in Kumasi and nearby stations, Dr. Williams encountered a clinical syndrome in young children that baffled her and did not appear in her medical texts. The afflicted children were edematous (puffed up with extra fluid), had orange hair, scaly and somewhat dry skin that was darkened in the creases, frequent diarrhea, and were mentally sluggish. Most of them died. Williams tried to obtain autopsies but was frustrated by mothers who whisked their children away before dying. After learning that the bus driver charged extra to transport a dead person, she paid the extra charge and autopsied several children. She found only an enlarged fatty liver, pallor, and edematous changes. Her first report of the disorder was in Gold Coast medical reports 1932. The local people called it “kwashiorkor.” 

Photos of kwashiorkor from Williams' first article (Wellcome Library)

Kwashiorkor was a tainted “ju-ju” word of the Ga language that locals were reluctant to pronounce. It referred to the sickness affecting a child after it is “deposed” from its privileged breastfeeding site to make way for a newborn child. The deposed child was put on a diet close or equal to an adult diet of ground maize, often laced with hot spices. The infants ate less and the reduced intake and lack of protein, sometimes mixed with parental neglect, led to what Williams determined to be a deficiency disease. She found that feeding the needy child with Nestlé’s canned, condensed milk produced a quick recovery, suggesting that protein deficiency was the main problem. Williams wrote a second report,
this one in a widely read pediatric journal, that brought the syndrome to broader attention.

Beginning of first article on kwashiorkor (Wellcome Library)

 Her second article caught the attention of the London physician, Hugh Stannus, who was an expert on pellagra, a disease due to niacin deficiency. Stannus felt that kwashiorkor was really pellagra, not a new disease. His authority held sway for a while, but eventually new evidence proved Stannus wrong. The work of Joseph Goldberger in the United States showing that pellagra was a dietary deficiency disease and the demonstration in 1937-8 that niacin alone, without a change in diet, could cure pellagra, established the difference between kwashiorkor and pellagra. 

Another champion of William’s ideas was Dr. Hugh Trowell, who worked in Uganda while Williams was in Ghana. Trowell found that medical missionaries in his area, back in the 1920s, had noticed a similar syndrome and described it in the first issue of the Kenya Medical Journal. They too had considered it a protein deficiency disease. Trowell had bowed before Stannus’ opinion but eventually joined Williams in considering it a new disease. The word “kwashiorkor” did not appear in textbooks of tropical medicine, however, until the 1950s.

Through the use of condensed milk and the encouragement of prolonged breast feeding many more children survived after abrupt weaning (though later findings showed that hypoglycemia could be a problem with condensed milk). Cicely’s work with children, mothers, and within the local communities lowered the child mortality rate, and resulted in women having fewer children. 

 A dispute between Williams and her chief led to an abrupt transfer to Malaya in 1936. Infant malnutrition in Malaya turned out to be generally due to insufficient breastfeeding from birth. Mothers, responding to European advertising and culture, had curtailed breastfeeding, feeding their infants condensed milk instead. Williams aroused controversy by campaigning to restrict the use of condensed milk and encourage milk from the breast. World War II, however, curtailed her efforts while she was incarcerated by the Japanese in the infamous Changi Prison in Singapore. After the war, still energetic, Cicely worked as head of a new Maternal and Child Health Division at WHO and was regarded as a specialist in child nutrition. After

Dr. Cicerly Williams (Wikipedia)

another stint in Malaya, she settled as a lecturer at the London School of Hygiene and Tropical Medicine. Her lectures and writings emphasized that to combat malnutrition it was necessary to investigate the social and behavioral causes, such as she had seen in Malaya, in addition to correcting the diet. She died in 1992, at the age of 98. 

Andrija Stampar, the public health physician who inspired Williams, was active in the League of Nations, and later presided over the conference convened to draft the constitution of the World Health Organization, where he served for many years.

The word kwashiorkor in textbooks now appears as part of a spectrum of nutritional disorders under the category of “Protein-calorie-deficiency” or “protein-energy-deficiency” disorders. They include kwashiorkor and marasmus, the latter characterized by severe wasting, absence of fat, and loose skin. Research work continues, as evidenced by finding distinct intestinal microbiomes in healthy and kwashiorkor-affected children. Cicely Williams’ work on nutrition lives on, as does her decades-long devotion to community maternal-child care.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

SOURCES:

 

     Williams, C, “Deficiency Disease in Infants: A Report by Miss C.D. Williams, Woman Medical Officer, Princess Marie Louise Hospital, Accra. Report of Medical Department, Gold Coast Colony, 1931-32. 1932; pp 93-99. 

     Williams, C D, “A Nutritional Disease of Childhood Associated with a Maize Diet.” Arch Dis Childhood. 1933; 8: 423-33.

     Craddock, S, Retired Except on Demand: The Life of Dr. Cicely Williams. 1983; Green College, Oxford.

     Trowell, H. “The Beginning of the Kwashiorkor Story inn Africa.” Central African Journal of Medicine 1975; 21(1): 1-5.

     Stanton, J, “Listening to Ga: Cicely Williams’ Discovery of Kwashiorkor on the Gold Coast.” Clio Med. 2001; 61: 149-71.

     Goodall, J, “Malnutrition and the Family: Deprivation in Kwashiorkor.”  Proc Nutrit Science. 1979; 38: 17-27. 

     Trowell, H, “Kwashiorkor, 1. Nutritional Background, History, Distribution, and Incidence.” Brit Med J.  Oct 11, 1952, 796-8. 

 

                               THE ORIGIN OF BLOOD BANKS

 

         For hundreds of years physicians and surgeons drew blood from sick patients to improve their health. Today’s doctors still remove blood, though now from healthy individuals, and transfuse it back to the sick. Sporadic attempts at transfusion go back at least to the 17^th century, but with little success. Transfusion service as we know it had to await further knowledge of the physiology of shock, the discovery of blood groups, the development of sterilization techniques, and the prevention of blood clotting.

         By the 1920s blood clotting was the primary unsolved problem. Clotting often frustrated the transfer of blood by syringe from donor to recipient. Devices to connect an artery of the donor directly to a vein of the patient prevented clotting but required a surgical

Kit for citrated transfusion, early WWII, used by Geoffrey Keynes,
surgeon, British Army, and brother of John Maynard Keynes. See diagram 
below (Courtesy National Archives, U.K.)

procedure. In 1914, Albert Hustin, in Belgium, announced the use of sodium citrate as an anticoagulant. In the U.S., Richard Lewisohn, working on the same problem, published on the use of a 0.2% solution of citrate in Surgery, Gynecology, and Obstetrics in 1915, a time when WWI was raging. Oswald Robertson, from the Rockefeller Institute, joined Harvard’s Base Station Hospital in France with the assignment to study shock. He noted the favorable results in shock of direct person-to-person transfusions by the British. He devised an apparatus to collect blood in a citrate and glucose

Robertson's apparatus for citrated 
transfusion (From History of the Great War
Gordon-Taylor, KB Walker, eds, Hathi 
Trust)

solution to prevent clotting, permit storage, and eliminate direct transfer. Transfusion centers, precursors of blood banks, were set up in underground bunkers where blood was drawn, cross-matched (though type O was used preferably), and sent to surgical stations. Direct transfusions became obsolete. 

         After the war, as doctors increasingly used transfusions, donors generally received money for their blood and hospitals tried to find healthy ones. Private collection agencies sometimes were less choosy. But there was always a cost, and if one could not afford a transfusion in a hospital, it often was not given. The depression of the 1930s worsened the financial issue. 

         Patients at Cook County Hospital in Chicago usually lacked financial resources. Those without family or friends as donors might die without needed blood. To remedy this, Dr. Bernard Fantus,

Bernard Fantus (Wikipedia)

director of therapeutics, instituted a novel approach. Blood transfusions fell under “therapeutics,” allowing Fantus to create a system that he termed a “blood bank,” a name deliberately chosen. Blood donors established an account, just as in a bank. If the donor needed blood for himself or his family, he could withdraw the amount deposited to his “account” at any time. Meanwhile, his deposited blood could be given to another person, who was then liable for repayment by him/herself or a proxy. Blood was drawn from healthy donors, patients in congestive heart failure (before taking digitalis!), healthy prepartum women, and elective surgery patients. The hospital kept ledgers with separate columns for debits, credits, and balances, the accounts maintained for each hospital department. The blood, typed and tested for syphilis, was stored in labeled citrated bottles and refrigerated. Febrile reactions, not uncommon and usually due to sterilization and cleaning defects, almost vanished with careful attention to detail. Other centers, the Mayo Clinic, for example, also stored blood for future use, but the “bank” concept began in Chicago.

         Fantus, often called the “father” of blood banks, published his experience in the JAMA in 1937, a widely read report that encouraged hospitals elsewhere to form similar banks, including the L.A. County and Detroit Receiving Hospitals. Eventually communities opted in. 

         As WWII began, England needed blood desperately as it coped with the blitz. An organization was formed in New York City to deliver blood and later plasma, called “Blood for Britain.” On the west coast, two San Francisco physicians, John Upton (born in England) and DeWitt Burnham, founded the Irwin Memorial Blood Bank in 1941 to collect blood for British and American use. It operated in the William Irwin mansion on Washington St. (Now replaced by Washington Tower Apartments.) Blood was collected in the mansion’s ballroom, most of it made into plasma that was stored in the wine cellar. Plasma was considered an adequate substitute for blood at the time and was much easier to ship.

Six months after Irwin Blood Bank’s founding, on December 7, the Japanese bombed Honolulu. Bernice Hemphill, a certified bioanalyst and the wife of a naval officer, volunteered the next day at the Honolulu blood bank, learning how it functioned. In 1943 she moved to San Francisco and volunteered at the Irwin Bank.

Bernice Hemphill (from her oral history,
see Sources, U.C. Library, Berkeley)

         The staff at Irwin, recognizing Hemphill’s talents, appointed her as managing director of the bank. When the war ended, the Red Cross, that had been the nation’s major blood-collecting agency, continued in this role, a function that overlapped with Irwin's. A turf battle erupted, Hemphill maintaining that the bank system, operating at a community level, was preferable to a broad, “quasi-governmental” (her term) organization. Working with Dr. Upton, the two stimulated the foundation of new community blood banks (one in Sacramento began in 1947), and worked to organize the national American Association of Blood Banks to resist the Red Cross and to coordinate business and scientific information on a national basis. Hemphill also conceived the idea of a “clearing house,” similar to that of money banks, where incoming and outgoing blood could be coordinated. It was headquartered at Irwin. Many have considered Hemphill as the “mother” of blood banking. 

         Blood banking is here to stay. Modern surgery could not exist without it. Although many factors contributed to its growth, blood banks could be said to have two “parents.” Bernard Fantus conceived the “bank” system and Bernice Hemphill expanded it to the broader community by creating the “clearing house.”

 

A link to an index of all the essays is available at:  

SOURCES:

 

Swanson, K W, Banking on the Body: The Market in Blood, Milk, and Sperm in Modern America. 2014, Harvard Univ Press.

 

Starr, D, Blood: An Epic History of Medicine and Commerce. 1999, Alfred A. Knopf.

 

“California Blood Bank Society: The Early Years.” At: https://www.cbbsweb.org/page/CCBSTheEarlyYears

 

The Mother of Blood Banking: Irwin Memorial Blood Bank and the American Association of Blood Banks. Oral History of Bernice M. Hemphill. 1998, Regents of the University of California. Accessible at: https://archive.org/details/motherbloodbank00hemprich/page/n5/mode/2up?view=theater

 

Fantus, Bernard, “The Therapy of the Cook County Hospital.” JAMA 109 (2): 128-131.

 

 Schneider, W H, “Blood Transfusion between the Wars.” J Hist of Medicine 2003; 58: 187-224.

         

         

 

                                                                       THERIAC

 

         If you are looking for a super-remedy that cures everything, reach for theriac, if you can find it. Theriac is one of the historical all-time greats of pharmaceutical success, used by emperors, kings, and anyone else who could afford it. Though it’s use has given way to the advances in pharmaceutical sciences, its history holds lessons for today.

         The origins of the theriac recipe are obscure. The story allegedly begins with Mithridates VI, king of Pontus, a large kingdom surrounding most of the eastern Black Sea. He believed that his father, Mithridates V, was poisoned (120 B.C.) and, in an attempt to head off a similar fate, he regularly took small doses of poisonous substances to build resistance. After Mithridates VI’s death, the ingredients he was taking were incorporated into a poison-preventive remedy known as Mithridatium that soon became a preventive for a number of illnesses unrelated to poisoning. Later, Andromachus, physician to Emperor Nero, modified the formula, most notably by substituting viper’s flesh for that of the lizard, in order to prevent poisoning by venomous bites. He also added opium and several other ingredients, including Lemnian earth (a red soil from the island of Lemnos), roasted copper, bitumen, additional herbal plants, and squills (a medicinal plant). The new formula eventually acquired the name “theriac,” derived from the Greek theriake, an adjective signifying “of a wild or venomous animal.” 

         Galen used both theriac and Mithridatium and wrote that he had tried theriac on roosters “with creeping poisonous beasts among

Galen (Wellcome Library)

them” and found it successful. In addition to anti-poison and antivenom effects, Galen modified theriac doses to take advantage of ingredients known to heat, dry, moisten, or cool the humors, according to the Galenic scheme. He used it for malaria with mixed results.

         The use of theriac survived the fall of the Roman Empire. After the Islamic takeover of territory east of Europe, recommendations for theriac surfaced in writings of Rhazes, Avicenna, and others and in some form was in use in medieval Europe. As the Renaissance dawned, the western world relearned theriac’s formula (or formulas, as by then pharmacists puzzled over the identity of certain ingredients or could not obtain them). Different formulas contained 40 to 60 ingredients, though numerous simplified versions of “theriac” flooded the market, prompting many cities to establish days when an official version was manufactured. Physicians, pharmacists, and government dignitaries supervised the process publicly, and certified it as genuine. 

Pharmacist making theriac under physician supervision (woodcut, Hieronymus Brunschwig,
approximately 1512. Wellcome Library)

    Modern study of old recipes shows variation in ingredients, some of whose names are no longer decipherable. The medicine developed a reputation as a cure or preventative for a variety of illnesses in addition to its actions on venoms and poisons. It was used extensively in plague epidemics both to prevent and to treat the pestilence and was considered effective for either. The ingredients, especially opium, could reduce diarrhea and cough and induce analgesia, sweating and sedation, adding patient satisfaction. Doctors gave it orally, usually in wine, or rectally, as a plaster, or by inhalation. 

Partial list of ingredients, 16th cent.
book (Wellcome Library)

         During Renaissance times the Republic of Venice enjoyed a booming pharmacy business. The state’s extensive trading with the East supplied many of theriac’s ingredients. The first chair of materia medica was established in Padua in 1533 and a botanical garden followed soon after. By 1565 there were 71 pharmacies in the Republic, organized into a Collegio, whose pharmacists underwent years of training and an examination to obtain licensure. The Collegio fixed pharmacy prices so that a pharmacist’s success rested on the quality of his products (especially theriac) and his relationship with physicians. Physicians could not own pharmacies but worked closely with favored ones. The Campana d’Oro in Verona, the most famous pharmacy, also maintained a natural history museum that was a known tourist attraction. Another one, the Farmacia Dell’Orso, still operates in Venice.

Photo of model of 16th century Italian pharmacy (Wellcome Library)

         Crowds gathered in the city every spring to witness the manufacture of theriac. Outside the licensed pharmacies benches supported numerous majolica jars containing herbs, spices, roots, gums, and other ingredients while larger jars on the top row held the snakes whose flesh was the vital component. Priors of the College of Medicine arrived to inspect the ingredients and spectators crowded in to witness the butchery of the vipers and watch the costumed workers grind and mix the herbs. Travelers sometimes came from afar to witness the spectacle. Up to 800 snakes (only females could be used) per month in some years disappeared into the concoction, eventually depleting the usual supply area near Padua.

Even at this time, arguments about the possible harms of “polypharmacy,” such as seen in theriac, appeared in print and they gained credence as botanical and pharmaceutic knowledge increased. A particular influence in the decline of theriac’s popularity in

William Heberden (Wellcome Library)

England was a publication by William Heberden, Antitheriaka: An Essay on Mithridatium and Theriaca (1745). The essay details theriac’s poorly documented recipes and debunks the agent’s supposed curative properties. Regarding its opium content, Heberden urged that if the doctor needs opium, he should prescribe it separately. Heberden was generally skeptical of reliance on ancient authorities.

In Paris, residents last witnessed a Venice-like, public theriac manufacture in 1798 and the French Pharmacopeia listed theriac until 1884. Theriac is now a historical curiosity. Why did it have such a long life? The significant opium content certainly contributed to public and medical acceptance. And no doubt heavy promotion by purveyors, from doctors and elite pharmacies to itinerant peddlers, influenced an expectant public. Not unlike purveyors of vitamins and immunity boosters today.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

SOURCES:

 

Eamon, William, The Professor of Secrets: Mystery, Medicine, and Alchemy in Renaissance Italy. 2010; National Geographic.

 

Heberden, W, Antitheriaka. An essay on mithridatium and theriaca. 1745. Available at: https://wellcomecollection.org/works/ty3m7h5g

 

Berman, A, “The Persistence of Theriac in France.” 1970; Pharmacy in History 12(1): 5-12.

 

Fabbri, C N, “Treating Medieval Plague: The Wonderful Virtues of Theriac.” 2007; Early Science and Medicine 12: 247-83.

 

Rankin, A, “On Anecdote and Antidotes: Poison Trials in Sixteenth-Century Europe.” 2017; Bull Hist Med 91 (2): 274-302.

 

Palmer, R, “Pharmacy in the Republic of Venice in the Sixteenth Century.” Chapter in The Medical Renaissance of the Sixteenth Century, A. Wear, R K French, I M Lonie eds. 1985, Cambridge Univ Press.

         

         

         

 

 

 

 

 

 

 

 

 

 

 TYPHUS AND REVOLUTION IN RUSSIA

         Russia and eastern Europe provided the setting of the largest outbreak of typhus ever recorded. Typhus had been a problem in Russia for centuries. The cold winter climate and a relative lack of bathing and personal hygiene were ideal for louse reproduction. A famine year, 1892, saw the largest outbreak of the disease before WWI, with 184,162 cases registered. The role of lice, under suspicion for some years, became clear only in 1909 when Charles Nicolle, working in Tunis, demonstrated louse transmission  of the disease, for which he received the Nobel Prize. The tiny, causative Rickettsia remained invisible. 

Charles Nicolle (Wikipedia)

         Medicine in the pre-revolutionary Russia, though lacking the organization and sophistication seen in Europe, was improving. Following the emancipation of the serfs in 1861, the government created “zemstvos,” self-governing units throughout the countryside whereby peasants had reasonable control over their own affairs. Hired “feldshers,” the rough equivalent of physician assistants, provided most of the rural medical care. The wretched living conditions faced by the zemstvos crystallized the need for a public health approach to disease control and a growing number of well-educated, liberal-minded physicians fostered this approach. World War One and the Bolshevik revolution,  however, changed everything.

Early in the war, typhus broke out among Russian soldiers imprisoned in a large camp near Cottbus, Germany. Two researchers assigned to the camp, Stanislaus von Prowazek, a brilliant Czech

Stanislaus von Prowazek (Wikipedia)

zoologist already known for his discovery of the agent of trachoma, and Henrique da Rocha Lima, a Brazilian physician working at the Bernard Nocht Institute in Hamburg, discovered that the typhus germ entered the body when louse feces were scratched into abraded skin, not during a bite. Tragically, both men contracted typhus, von Prowazek dying from it and da Rocha Lima surviving. Da Rocha Lima also found the offending organism under the microscope and named it Rickettsia prowazeki in honor of Howard Ricketts (who had succumbed to

Bust of da Rocha Lima (Wikipedia)

typhus while studying it in Mexico) and his deceased colleague at Cottbus. 

Typhus exploded in war-torn Serbia in 1915. The American Red Cross sent a commission, headed by Richard Strong from Harvard, to help. Strong was stunned by sights of extreme poverty, hospitals filled to over 400% of their capacity with louse-covered sufferers, virtually absent sanitary facilities, and crippled medical help (126 doctors had already died). The team constructed large steam generators, often using locomotives, and ovens of various types to sterilize clothing while the wearers of the clothing went into showers rigged in railroad cars or were doused with kerosene or benzene. These louse-killing measures, along with appropriate isolation practices, stemmed the epidemic, though only after about 150,000 deaths claimed by the disease.

Illustrations from Strong, et al, in Serbia

In Russia, the worst came a little later. Cases were apparent during the war, but real acceleration began in 1918, when Petrograd reported almost 11,000 cases and Moscow close to 7,000. Masses of troops were returning to their homes, either as deserters or released after the 1918 peace treaty of Brest-Litovsk, bringing lice and disease with them. The demilitarized soldiers who clogged the railroads, a subsequent civil war, a new and disorganized Bolshevik government, financial collapse, and subsequent famines, all created the conditions for a massive epidemic. Large numbers of city dwellers, escaping food and fuel shortages, moved to the countryside, spreading the germs further. The final tally is unknown but estimates of the total number of typhus cases run between 15 and 35 million (1918-22), involving the entire country from the Baltic to the Pacific. As an added calamity, scurvy, typhoid, tuberculosis, dysentery, cholera, and other diseases of social and economic collapse battered the population, along with a huge influenza epidemic.

Family living in boxcar, man lost legs to frostbite (Library of Congress)

Russian doctors, now down-graded as “bourgeois” in the new regime, knew the principles of control of typhus. Even Lenin knew, evidenced by his cry to attendees of the 1919 Party Congress, “All attention to this problem, comrades. Either lice will conquer socialism or socialism will conquer lice.” In fact, in the ensuing civil war, typhus was killing or incapacitating significant numbers of both the Red Army and the White Army as they battled it out for the future of Russia. Lenin’s government centralized medical services under the new “People’s Commissariat for Health Protection,” or NKZ, and provided crucial money for epidemic control. Gradually, as the Red Army prevailed, delousing activities similar to those employed in Serbia escalated and eventually gained the upper hand. Railroad stations and other public places, even railroad cars, where large numbers had gathered to escape the bitter cold, were especially targeted for delousing. Famines continued to plague the country and slow the efforts, but by 1923 typhus was under reasonable control. 

The American Red Cross played a role. Its mission to Siberia began in February 1919 as the “Inter-Allied Typhus Train,” partly as an anti-Bolshevik maneuver by the wartime allies and partly as a

American Red Cross Nurses, Russia (Wikipedia)

humanitarian effort. Departing from Vladivostok, the Train carried disinfection and delousing steam equipment, adopted from the Serbian experience, across a vast area. Along with their own medical personnel, the team hired Russian feldshers and other health workers and provided extensive educational materials about typhus transmission (sometimes resented by local doctors). In just over a year the Train covered 11,00 miles and treated over one million White Army soldiers and local civilians. The advancing Red Army made it dangerous to continue, however, and it terminated in May 1920.

Typhus had cemented its reputation as a disease of war, poverty, and famine. By World War II, in contrast, the advent of the insecticide DDT and awareness of the danger of lice served to prevent a massive recurrence of the scourge. It is now an uncommon disease and hopefully will remain so.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

SOURCES:

 

Patterson, K D, “Typhus and its Control in Russia, 1870-1940.” Medical History 1993; 37: 361-81.

 

Nachtigal, R, “Russian Public Health during the First World War.” J of Slavic Military Studies 2023; 36 (1): 73-95.

 

Sackmann, W, “Fleckfieber und Fleckfieberforschung zur Zeit des Ersten Weltkrieges.” Zeitschrift für Klinische Medizin 1924; 100(1): 203-22.

 

Irwin, J F, “The Great White train: typhus, sanitation, and U.S. International Development during the Russian Civil War.” Endeavor 2012; 30 (10): 1-9.

 

Jaenicke, L, “Stanislaus von Prowazek (1875-1915) – Prodigy between Working Bench and Coffee House.” Protist 2001; 152: 157-66.

 

Field, Mark G, Soviet Socialized Medicine: An Introduction. 1967, The Free Press, N.Y.

 

Strong, R P, et al, Typhus Fever with Particular Reference to the Serbian Epidemic. 1920, American Red Cross at Harvard Press, Cambridge, Mass.

 

 

 

 

 

         

 

    REVEALING THE AGENT OF SYPHILIS:

SCIENCE AND CONTROVERSY

      

         

         In late nineteenth century Germany, reforms in the attitude toward venereal diseases, in the form of better public education, improved statistics, and more government funding, ensured frequent headlines in the press. It was also a time when scientists were uncovering the role of bacteria in numerous diseases that previously defied understanding. Naturally, a search for the agent of syphilis was of great importance. 

One investigator, John Siegel, followed an oblique pathway. During an epidemic of an unknown disease characterized by ulcers in the mouth, Siegel, a general practitioner, wondered if the disorder was a human form of foot and mouth disease. Working in a home laboratory, he failed to find a bacterium behind foot and mouth disease and wondered about parasites. After further training under Prof. Franz Schulze, a respected parasitologist at the Zoological Institute in Berlin, he published papers claiming that protists in the genus Cytorrhycetes were the cause of foot and mouth disease as well the cause of variola/vaccinia, syphilis, and scarlet fever. Such broad assertions aroused skepticism, but the prominence of Schulze, his mentor, prevented outright disbelief. The Imperial Health Office (Kaiserliche Gesundheitsamt), alarmed by an increase in venereal disease in military troops, wanted confirmation of Siegel’s claim for syphilis and asked Fritz Schaudinn to investigate.

Schaudinn, born into a prosperous East Prussian farming family in 1871, had studied at the Friedrich-Wilhelm University in Berlin, where his talent in zoological studies attracted the attention of the same Franz Schulze who had mentored Siegel. Schulze encouraged Schaudinn to study protists and before long the latter earned a name for new

Fritz Schaudinn (Wikipedia)

 discoveries and superb microscope skills. He was asked to participate in a malaria project in the Dalmatian coast, where Germany maintained a marine research station at Rovigno. Schaudinn and his team, using quinine and anti-mosquito measures, cleared the area of malaria. While there, he founded a journal, the Archiv für Protistenkunde. Among other projects, he described new protozoa, distinguished  Entameba histolytica from Entameba coli  microscopically, and determined the pathogenicity of one ameba from the other by experiments on himself. It was a productive period (though he also made an erroneous microscopic observation that delayed knowledge of the malaria parasite’s liver stage).

He returned to Berlin as chief of a new department of protozoology in the Imperial Health Office, from where he was asked to assess the findings of Siegel. Schaudinn obtained the assistance of Erich Hoffmann of the dermatology service at the Charité Hospital (dermatologists were the syphilis specialists at the time). In March 1905, Schaudinn demonstrated, for the first time, slender spirochetes in syphilitic lesions and in lymph nodes adjacent to lesions, all carefully prepared by Hoffmann. Schaudinn saw the spirochetes both with and without staining, noting the pale blue coloring with Giemsa stain (thus the name Spirochaete pallida, later changed to Treponema pallidum). He did not say the organisms caused syphilis, only that he saw them, and in lymph nodes he saw no others. 

How did Schaudinn see what others had failed to see for so long? Two explanations have been offered. First, he was an expert microscopist, often known to spend all night peering through his instrument. Second, he had a new Zeiss apochromatic microscope (the lens corrected for three colors of light rather than the two of achromatic lenses, improving clarity). In later papers, after consistently finding spirochetes alone in syphilitic lymph nodes, he maintained that they were the causative organisms, though attempts at culture had failed. Schaudinn and Hoffmann presented their findings before the Berlin Medical Society in May 1905 and were surprised to be met with a hostile skepticism, one member huffing that spirochetes could be added to the 25 previous causes of syphilis that had been alleged.

Photos of treponema from Schaudinn and Hoffmann's original paper (Hathi Trust)

           Meanwhile, many other workers saw the organisms. Metchnicoff and Roux, recently able to transmit syphilis to apes, saw the slender organisms. Organs of infants born with congenital syphilis showed them. Robert Koch, informed while performing tropical disease research in Africa, wrote Schaudinn from Dar es Salaam, congratulating him. Mail applauding him came from the bacteriologist Carl Fraenkel, the dermatologist Karl Herxheimer, Aldo Castellani (the discoverer of the trypanosome of African sleeping sickness), and the chemist/bacteriologist Gustav Giemsa, whose stain Schaudinn had used.

Schaudinn received invitations from the Universities of London and Cambridge, but eventually accepted a position as protozoologist at the new Bernard Nocht Institute for Tropical Medicine in Hamburg. Shortly after this, the Kaiser invited him to attend the International Congress of Medicine in Lisbon in 1906. A committee of the Congress had unanimously chosen Schaudinn to receive a prize for his work, but the German medical establishment intervened, objecting that Schaudinn lacked an MD degree and was too young to qualify for such a prestigious award. The award eventually went to Alfonse Laveran for his discovery of the malaria parasite in 1880. He was 86. The dermatology section of the Conference, provoked, hosted an extravagant tribute in Schaudinn’s honor, which touched him deeply.

Schaudinn had suffered for some time from perirectal abscesses. Heading home by ship from Lisbon, he became quite ill with pain and fever, requiring emergency surgery aboard ship. After landing, his condition worsened. An abscess the size of a “small child’s head” was opened but he developed overwhelming sepsis, perishing in June 1906. He was 35 years old, his brilliant career cut short. 

Schaudinn left behind a wife and two children, whose grief may have been softened by the creation at the Bernard Nocht Institute for Tropical Medicine, his last research home, of the Schaudinn Medal, awarded every two years for excellence in protozoan research. 

 

Remember: A list of prior history of medicine entries with corresponding links is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

The website for the SSVMS History of Medicine Museum is: https://museumofmedicalhistory.org

SOURCES:

 

Kuhn, C, Aus dem Leben Fritz Richard Schaudinns. 1949, Georg Thieme Verlag, Stuttgart.

 

Mollenhauer, D, “Founder of Archiv für Protistenkunde: Fritz Schaudinn - his Unfinished Life.” 2000; Protist, 151: 283-7.

 

Lindenmann, J, “Siegel, Schaudinn, Fleck and the Etiology of Syphilis.” 2001; Stud Hist Biol & Biomed Sci, 32(3): 435-55.

 

Thorburn, A L, “Fritz Richard Schaudinn, 1871-1906: Protozoologist of Syphilis.” 1971; Brit J Vener Dis 47: 459-61.

 

Medina-de la Garza, C E et al, “Fritz Schaudinn: zoólogo y protozoologo.” 2012; Medicina Universitaria, 14(57): 231-8.

 

Risse, G, “Schaudinn, Fritz Richard,” Dict of Scientific Biog, 1981.

Schultz, O T, “Fritz Schaudinn: A Review of his Work.” 1908; Bull Johns Hopk Hosp 19: 169-173.

 

 

 

 

 

 

         

         

         

 

         

 THE CREATION OF THE AMERICAN 

MEDICAL ASSOCIATION

 

         By 1800, the still new United States could boast of five recognized medical schools, all in the eastern states. Over succeeding decades medical practitioners seized opportunities to form new medical schools, appoint themselves professors, and derive further income from student fees. Between 1830 and 1847 the number of medical schools doubled. To discourage dropouts, pre-med requirements were negligible, the two-year curriculum was reduced to 16 weeks a year (some going to 13 weeks), and final exams were geared to pass most of the students. 

         Many doctors saw this trend as damaging to the profession. Dr. Nathan Smith Davis of the New York State Medical Society was especially concerned. Smith, born in poverty in a log cabin, obtained a medical education at a long-since defunct school in Fairfield, N.Y., opened a practice in Binghamton, engaged in

Nathan Smith Davis MD 
(Wikipedia)

teaching, and became active in the State Medical Society. Learning about earlier unsuccessful attempts to standardize medical education, he worked to convene a national meeting to address the problem.

         Davis, through the N Y Society, invited delegates from every state medical society and each medical school in the country to attend a conference to establish educational standards and to consider the formation of a national medical society. In spite of opposition, the organizers met in the Medical Department of NYU on May 5, 1846. Eighty delegates attended, representing sixteen states (of 25 at the time). Efforts by naysayers to cancel the meeting were defeated decisively, ending further resistance to the idea of a national organization. 

         In short order, officers were elected, rules established, and, responding to the broadening interests of the group, committees were organized to report at future meetings on topics such as education, medicine, surgery, hygiene (public health), medical ethics, medical literature, and the like. Medical education remained a leading issue and the delegates were expressly asked to consider the thorny question of whether professors in medical schools could also issue licenses, a common practice at the time.

         The following year, 1847, delegates to the first “National Medical Convention” met in the Academy of Natural Sciences in Philadelphia to formalize the national association. The delegates

 Academy of Natural Sciences of Philadelphia (Graham's Magazine, 1852)

chose “The American Medical Association” as their name and drew up a constitution designed to be as representative as possible. Two classes of membership were adopted. The largest group consisted of delegates, some chosen by state and local medical societies (the number based on membership tallies), and others chosen by medical schools, hospitals of at least 100 beds, and other medical institutions (usually two per institution). Along with delegates from areas without medical societies, they comprised the voting members and served one-year terms. Another delegate class, permanent members, comprised those who wished to continue their association with the AMA as nonvoting members. Officers served for one year and the same city could not host the meetings twice in a row. The first president of the AMA was Nathaniel Chapman, Professor of the Theory and Practice of Medicine at the University of Pennsylvania. He was chosen because “of his age, his high attainments, and his

Nathaniel Chapman (Wikipedia)

position as one of the oldest and most eminent teachers in the Union,” and not because of medical innovations or research. His biographer describes him as a “friendly anachronism, venerated for his age and position but ignored as a medical theorist.”

The new AMA focused on medical education. The delegates passed resolutions extending the teaching period to three years, with at least two years of six-month lecture periods and three months of dissection, and stipulating attendance records. Pre-med requirements included adequate basic science and mathematics, proficiency in English, enough Latin and Greek to read medical tracts and write prescriptions, and testimony of good moral character. The question of using outside examiners for license qualification, furiously resisted by many medical school delegates, went to a committee for further study.   

The Convention adopted a medical code of ethics that was virtually a reprint of the widely known and valued 1803 work by the British physician, Thomas Percival. A resolution encouraging the registry of births, deaths, and marriages passed easily, various standing committees were assembled, and Baltimore fixed as the first annual meeting place for the new-born AMA. 

         The Baltimore meeting in 1848, the first annual meeting, opened with a speech by the new president, Nathaniel Chapman, who established the convention of serving a one-year term. The just-approved requirements for pre-med education were upheld in spite of complaints, even by Harvard faculty, that they were too severe (though there was no ability to enforce them). Furthermore, the delegates added hospital bedside teaching as another obligation. A report on the growing problem of adulterated drugs imported to the U.S. (after Europeans tightened their laws) startled participants. Major problems cited were Peruvian bark (sent after the quinine was leached out), adulterated quinine, rotten or spoiled rhubarb root, and diluted opium. Oliver Wendell Holmes reported on the sad state of American medical literature and the sparsity of translations of good European articles. 

Transcription of the first annual
meeting of the AMA (Trans of 
the AMA, v1, 1848,Hathi Trust)

         The surgical section devoted generous time to the new anesthetic agents, ether and chloroform, introduced in the previous two years. New developments in medicine, vital statistics, public health reports, and indigenous medical botany filled the remainder of the agenda. 

In spite of disputes over issues of education, reasonable harmony prevailed and leaders in medicine leant their support. The AMA endured. Nathan Smith Davis, the driver of the early efforts, had skillfully guided the organization through the birth process. He later accepted the chair of Physiology and Pathology at Rush Medical College. However, when the dean of the school refused to institute some of the AMA medical school requirements, Davis and sympathetic faculty left and founded a new school, the Medical Department of Lind University, which eventually morphed into Northwestern University Medical School (now the Feinberg School of Medicine). Davis later served as president of the AMA, editor of its journal, and wrote a history of the AMA up until 1855.

         

SOURCES:

 

Fishbein, M, A History of the American Medical Association 1847 to 1947. 1947; W.B. Saunders.

 

Davis, N.S., History of the American Medical Association from its Organization up to January 1855.1855; Lippincott, Grambo & Co.

 

The Transactions of the American Medical Association, Instituted 1847. v 1, 1848; American Medical Assoc.

 

Code of Ethics of the American Medical Association Adopted May, 1847. 1871; Turner Hamilton.

 

Leake, C. D., Percival’s Code: A Chapter in the Historical Development of Medical Ethics. 1923; American Medical Assoc.

 

Obituary (Davis), Science, 1904; 20 (NS): 237-40.

 

Richman, Irwin, The Brightest Ornament: A Biography of Nathaniel Chapman, M.D. 1967; Pennsylvania Heritage, Inc, Bellefonte.