Imagine you’re working the day shift at Bellevue Hospital in New York City–incidentally, since this is a history podcast, the oldest public hospital in the US. It’s hot outside, and it’s Monday, so we all know what that means–plus, let’s give you a little hint that this case isn’t that recent, so, you’re dealing with your standard poor sick person dumps, about six of them, from outlying private hospitals, when the ambulances bring you a case…a young, professional woman is brought in from one of the office buildings near-by with severe stomach pain. The ambulance crew says she was fine this morning, but now she’s got severe cramping pain, and severe gastric emptying. She says she has some tingling in her hands and feet as well. Blood pressure’s low, heart rate’s high…what are your thoughts?
Step one–questions from Max and Mike
mortality from abdominal pain in general–higher than chest pain
gastric emptying and pain out of proportion–mesenteric ischemia, cases in the literature of ‘sudden gastroenteritis’
You’re just one of the lowly house officers trying to take care of this sick patient at Bellevue, but then you notice a commotion and ask your senior what’s going on. Apparently there’s an office building about eight blocks away that’s in a bunch of trouble; while you’ve been caring for this patient, two more ambulances at least have come from the same place, with patients that have the same symptoms. There are many people sick, all with vomiting and diarrhea.
Does this change your differential? How so?
Let’s say it’s the early 20th century, so, no joke, your boss at Bellevue says, how about we grab the stomach pumps and go take care of these people in the office building itself? Sounds great!
The stomach pump, as a brief aside, was invented by Alexander Munro Secundus–Secundus to differentiate between his father, Alexander Munro Primus, and his son, Alexander Munro Tertius, all of whom held the chair of Anatomy at the University of Edinburgh in the 1700s. Munro Secundus was the most highly regarded, and, in 1767, along with the thinking of the time which fixated on emptying the bowels in one way or another, he invented the stomach pump, which is literally a hydraulic device about the size of a clarinet attached to a rubber tube that is used to manually empty the stomach.
Gentleman, have you ever pumped a stomach?
These were still in use into the last century; in this case, somehow or another it became clear that there was a huge emergency going on at this office building, with people literally on every floor just emptying themselves, and multiple teams of doctors running around with stomach pumps performing ‘patient care’ (in air quotes). Once the dust cleared, six people were dead, and dozens had become sick, with one of the deaths the original ‘index case’, as it were. What could have possibly happened?
The doctors on scene, once done administering care, compared notes, and the medical examiners and so on started to get involved and try to piece together what had happened. They were able to compare notes to the point that the found a common thread–all of the people that got sick had eaten at a local restaurant. Lunch counters and small diners were used frequently at the time and probably still are, and a small restaurant called the Shelbourne proved to have served lunch to all the people that got sick. The first woman who got sick, Lillian Goetz, was a stenographer who had a traditional lunch of tongue sandwich (omigod), coffee, and a slice of huckleberry pie. Although I would suspect the tongue sandwich, it proved to be the pie that was the problem; upon testing, the pie crust revealed traces of arsenic, not present in the flour or any of the basic ingredients.
They concluded that is was foul play, and the incident was later known as the Shelbourne Restaurant murders–after those who got sick, the Shelbourne was another victim, as it soon closed, and it was said restaurants around the city couldn’t sell Huckleberry pie to save their lives.
Arsenic has been on the pod before; white arsenic, which is a metallic powder, was used for ages as a poison mixed into drinks or food, toxic at low doses. Arsenic dissolves completely in water, and 90% of it is absorbed; it achieves peak concentration within an hour, which is really fast for something we eat or drink. Arsenic attaches really strongly to multiple enzymes in the body–enzymes are like little folded proteins that do stuff–and essentially suffocates cells internally so they die, all over, and then also happens to prevent sugar from being either absorbed or made, which is our back up energy system. It’s absorbed first and most in the guts, and then the liver, which causes the symptoms; because of the way it works, those body systems shut down, which is the main cause of death. Also, which such severe emptying, severe electrolyte abnormalities occur, and when your body gets super low on potassium or magnesium, for example, it’ll short-circuit the heart sometimes. Obviously that’s all a gross oversimplification.
This case was never solved with regards to the actual poisoner, but the fact that it was proven as arsenic poisoning at all owes to the story of two men who were instrumental in modernizing forensic medicine, especially in New York. It was overall not unusual at all that a poisoner walked away unscathed and was never caught, especially around this time. New York in the early part of the 20th Century was awash in poisons and not really up to speed on toxicologists or medical examiners.
A lot of this episode and the story of early forensic medicine in New York is covered really well in a book called ‘The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York’, by Deborah Blum, which came out in 2011–we’ll link it in the show notes. Prior to around 1917, medical examinations in New York were undertaken by coroners. There were not really stringent requirements for the job, and they got paid on commission based on examinations they did. Given politics at the time, which centered on Tammany Hall, famous for corruption, the coroner’s post was a revolving door of undertakers, politicians, and various other odd jobs; they also produced death certificates that listed the cause of death, and they worked on commission, so it was pretty easy to see how this got co-opted.
There were some other famous cases that put this in the spotlight–one chloroform case detailed in the book involved like a string of contradictory experts for days–and prosecutors would routinely avoid calling the coroner for murders because the testimony was so hit-or-miss.
So around 1917 the state government passed a law that medical examiners had to be qualified; a man named Dr. Charles Norris was second among three qualified applicants, and was the head of laboratory science at Belleview. The transition was NOT smooth; machine politicians in New York City wanted to use the medical examiner job as patronage, just like they had before, and tried to appoint their own applicant. Then, when there was uproar, they actually tried to arraign the three formal applicants including Dr. Norris for violating a law regarding autopsies. At the time, cadavers were supposed to go to medical schools; by performing the autopsy that was required for the medical examiner’s test, the mayor’s office accused the applicants of breaking the law.
This bold-faced power grab didn’t work; the mayor at the time chose Norris because he was second just as a last objection, and, luckily for all of us, chose a famously dedicated man who would go on to be known as one of the two dads of forensic toxicology in the US. Norris was famously dedicated, and often spent his own considerable inherited money on the office of the medical examiner; he was motivated by the old romantic belief of public service that sometimes shows up in the Gilded Age, and lived and breathed the improvements in the medical examiner’s office, along with Alexander Gettler, a pioneering chemist who happened to work at Bellevue as well. Gettler had an opposite path to Norris, immigrating from Austria-Hungary at the age of 7 and coming up through Brooklyn to get a doctorate at Columbia. He literally had to invent many of the toxicologic tests that the early medical examiner’s board used, and worked for decades with the office.
Silver Fox Doc
Cardiac procedures we take for granted had to be developed by somebody, somewhere. I don’t know how many times Mike or I have had a patient come to the ER having chest pain, diagnosed a “heart attack” knowing that some part of the heart needed more blood flow, called a cardiologist and had that patient whisked out of our department and onto a cath lab table within literal minutes, to have their heart plumbing fixed without surgery. It can certainly be more complicated than that depending on the scenario, but it was not always this way.
One of the interesting things that is discussed early in this chapter, is the fact that the heart was something of an afterthought or organ that was of less scientific interest in the 19th century, and it wasn’t until the 20th century that we made significant developments here. It wasn’t until 1912 until an internist named James Horrick even speculated to an assembly of physicians that blockage of the coronary arteries was probably a thing explaining sudden apparent death. Why did it take so long to figure this out and how was his theory received? (We can discuss some basic cardiac circulation and physiology here).
“Myocardial infarction,” the medical term for heart attack, was not really coined until 1918.
1929 - Werner Forssman boldly plays with catheters. Can you tell us a bit about this story and what the concerns of his colleagues at the time were?
1958 - Dr. Mason Sones at the Cleveland Clinic decides the venous system is too easy to put a catheter into. Can you tell us how his first foray into the world of sticking catheters into the arterial side of circulation went? Would you say swimmingly or no?
Once the ability to get catheters into arteries was established, how did we figure out how to fix the problems that were found? This could include a thrombus or blood clot, or a narrowing of the artery due to fat and calcium deposits in the walls (called plaques). I think this involves explaining what the verb “Dottering” is because, whether I was supposed to or not, this part of the book made me laugh.
I’m not a fan of balloons–too whimsical and noisy for my taste–but they are quite important to the history of cardiac intervention–fixing problems within the plumbing of the heart, especially. Can you explain what balloons have to do with saving lives?
Any time medicine can fix a life threatening problem without sawing through a ribcage under anesthesia, I’m all for it, but before balloons and catheters were used, one of the only options for fixing artery flow problems to the heart was surgical. Still in use in the right circumstances, “open heart surgery” is the term for going into the thoracic cavity and literally tying in new pipelines to the arteries of the heart, now typically using a big vein taken from the leg, the saphenous vein, to make nice new piping. It took a lot of steps to get to this point because, well, it’s hard to do surgery on a moving organ, especially when it’s kind of important to one’s life. What were the baby steps into cardiac surgery, so-to-speak?
Under ideal pre modern circumstances, I believe I read it’s about a 4 minute window to do procedures on the heart. Maybe 12 minutes with hypothermia. Now we can open a heart, replace a valve, ask poor medical students a bunch of questions until they sweat through surgical smocks while observing, and then have plenty of time to close. What made this possible and how was it discovered?
The last frontier of this chapter, fittingly, is heart transplantation. We can now take a heart from one person and give it to another in need. Can you talk about the first surgeons to figure out the steps necessary to do this, Drs. Christian Barnard and Dr. Norman Shumway?
Doctor with a mustache.