Thomas G. Benedek

Delayed traumatic vertebral body compression fracture; part II: Pathologic features

T HE DELAYED appearance of the clinical manifestations of traumatic compression of vertebral bodies, or Kiimmell disease, has not been reviewed in the English language literature since 1951.’ Much information bearing on the pathophysiology of this disputed and now rarely diagnosed ailment has been published since then. Recently having seen three patients to whom this diagnosis may apply, we have formulated a concept of the pathogenesis of Kiimmell disease and present up to date osteologic and biomechanical data in explanation and support of this hypothesis.

The ‘Tuskegee Study’ of syphilis: Analysis of moral versus methodologic aspects

The background and course of the prospective investigation of the “natural history” of syphilis which was conducted by the U.S. Public Health Service in Macon County, Alabama from 1932 to 1972 (the “Tuskegee Study”) is reviewed. Unpublished correspondence is cited to illustrate some of the attitudes and problems of the investigators. The relevance of certain other studies of syphilis to the interpretation of the Tuskegee data which were not discussed by the investigators is shown. The study is analyzed by the application of some general principles of scientific investigation set forth at the beginning of the article.

Delayed traumatic vertebral body compression fracture; part I: Clinical features

We have described three patient who sustained trauma to their spines followed by persisting pain. Initial radiographs were negative, but on subsequent examinations compression fractures were demonstrated. This sequence of events resembles the clinical picture described by Kümmell in 1895 with significant differences. A plethora of early written description with minimal radiographic documentation suggests that this is a relatively rare condition. It is appropriate, therefore, to present these cases with the suggestion that traumatic injuries with persisting thoracic or upper lumbar back pain should be followed up radiographically in order to demonstrate the occurrence of subsequent compression fractures. These fractures may be treated with simple braces.

Vaccination-Induced Syphilis and the Hübner Malpractice Litigation

This article examines smallpox vaccination in the 19th century as background for a notorious medical malpractice case that occupied Bavarian courts fromApril 1853 until May 1854. Dr. Georg Hübner, the defendant, was accused of having initiated a small epidemic of syphilis by using the lymph of a syphilitic infant to vaccinate 13 infants. The litigation and its published contemporaneous discussion demonstrate conflicts in the understanding of syphilis, the hazards of having to make a purely clinical diagnosis, the effect of obsolete legal wording in medical litigation, and the attitude of leading physicians to a guilty colleague. This case ultimately led to efforts to make arm-to-arm smallpox vaccination safer, and by 1898 to abandon the technique in favor of bovine sources that were sterilized and stabilized by various methods.

Case Neisser: Experimental Design, the Beginnings of Immunology, and Informed Consent

In 1892, Albert L. Neisser (1855–1916), the professor of dermatology and venereology at the University of Breslau (Prussia), undertook two series of clinical experiments: one to test whether serum from syphilitic patients had a prophylactic value against contracting syphilis, and the other to test whether such serum had a therapeutic value for syphilitic patients. The first experiment was based on the erroneous scientific hypothesis called “Colles’s law,” which posited that a fetus that was syphilitic due to the father’s disease could in utero immunize its mother against syphilis. Neisser acknowledged that neither experiment achieved its goal. However, when his work was published, Neisser was criticized not for the various errors of experimental design that should have been recognizable to him, but because of his failure to obtain the consent of his non-syphilitic subjects. The political furor that followed led to the first governmental edict to require informed consent of participants in clinical research. This essay examines how Neisser’s generally forgotten investigation into therapies for syphilis led to some of the first regulations about informed consent.

Frederic Edward Mohs, MD—The Pioneer of Chemosurgery

In 1910, Frederic Edward Mohs, MD, was born in Burlington, Wisconsin. Although initially he trained to become a radio engineer, Dr Mohs transitioned to medicine in college. While he attended medical school at the University of Wisconsin, he worked with Dr Michael Guyer, a cancer researcher, and cultivated an interest in preparing frozen tissue for histological study. Here, he made the vital discovery that zinc chloride paste could “fix” skin tissue for microscopic examination, setting the foundation for the Mohs micrographic surgery (MMS) technique. Dr Mohs began performing the procedure, initially dubbed “chemosurgery,” in 1936 on patients with skin cancer. During the procedure, he first applied dichloroacetic acid to the involved area to remove keratin from the epidermal layer. He then applied zinc chloride paste for fixation, which could take hours to days depending on how well the paste penetrated the sample. After adequate fixation, Dr Mohs excised a saucer-shaped layer of fixed tissue, followed by cross-sectioning the specimens into pieces that were 1 cm × 1 cm × 2 mm in size and mapping out slices to their corresponding anatomical locations. DrMohsmicroscopicallyexaminedeachsectionforthepresenceofcancer. Sections negative for cancer required no further workup, but sections positive for cancer led to continued surgery in the sections’ corresponding locations. Zinc chloride paste was reapplied to that region, and the entire procedure was repeated until the cancer was removed. Mohs micrographic surgery was a groundbreaking technique because it allowed the maximum sparing of healthy tissue while removing all cancerous cells. Despite its effectiveness, Dr Mohs’ technique initially faced great skepticism. The early to mid-1900s was rampant with cancer quackery, as numerous pills and potions claimed to “cure cancer.” Harry Hoxsey, one alternative medical proponent, used zinc chloride in pseudocancer treatments. As a result, zinc chloride, also present in Dr Mohs’ paste, was largely rejected by the medical community. Furthermore, surgeons then believed that cutting into a tumor caused it to spread, leading to further disbelief over the MMS technique. The technique gradually gained acceptance when Dr Theodore Tromovitch, a dermatologist who trained with Dr Mohs, transitioned Mohs’ fixed-tissue technique to a freshtissue one without the use of caustic zinc chloride. This, alongside Dr Mohs’ high cure rate, helped MMS gain full acceptance. Ultimately, Dr Mohs’ belief in the scientific rigor of his technique allowed him to persist through the strong skepticism. Countless patients have since been treated with MMS for basal and squamous cell carcinomas, including President Ronald Reagan in 1985. Dr Mohs died on July 2, 2002, but his legacy lives on through the American College of Mohs Surgery, which has over 900 members.

Harvey Cushing, MD—A Neurosurgeon’s Contributions to Cutaneous Pathology

Harvey Williams Cushing, MD, was born on April 8, 1869, in Cleveland, Ohio, as the youngest of 10 siblings. He attended Cleveland Manual Training School as a child, where he learned carpentry, metal work, and machinery skills that would later help him develop his technical abilities as a surgeon. Cushing came from a family with 3 generations of physicians, and he began his medical career at Harvard Medical School in 1891. Cushing trained at numerous institutions, including Massachusetts General Hospital, where he trained under John Wheelock Elliot, MD, who directed his attention to surgery of the brain. Through these experiences Cushing helped establish neurological surgery over the length of his career as a viable medical specialty and earned the title of “the father of modern neurosurgery.” He faced adversity from critics who did not believe in the viability of brain surgery; however, he found constant encouragement from William Osler, MD (1849-1919), whose mentorship helped him push the boundaries of surgical innovation. During his training at Johns Hopkins Hospital in 1910, Cushing encountered a 23-year-old woman who presented with an enlarged abdomen, mimicking that of a full-term pregnancy; she also had supraclavicular fat pads, a rounded face, and abnormal hair growth on the face, hips, and back. Cushing’s case report stated that her “skin during the past few years has become rough and dry and has a blue and dusky appearance. The body and extremities show an especial degree of cyanosis. There are a number of large subcutaneous ecchymoses over the lower extremities. The lineae atrophicae over the abdomen are of a deep brownish-purple color. There is considerable pigmentation, particularly of eyelids, groins, pubes, and areolae.” Although prior accounts had reported similar symptoms of adrenal etiology, Cushing was the first to connect the symptomatology to a pituitary basophil adenoma, grouping the findings as “polyglandular syndrome.” Suprasellar surgical techniques were still primitive, but Cushing performed a decompressive craniectomy with some symptomatic relief 1 month after the operation. His meticulous characterization brought new connections between endocrine pathology and cutaneous manifestations. Outside of medicine, one of Cushing’s long-standing hobbies was collecting and writing books. His book collection included a broad range of subjects, including books on herbalism, astronomy, general surgery, and anesthesia. He eventually donated his book collection, including a Brain Tumor Registry describing his interactions with his patients, to his alma mater, Yale University. In 1940, the university built the Harvey Cushing/ John Hay Whitney Medical Library to honor him. In appreciation for his mentor, Cushing wrote a Pulitzer Prize–winning biography of Dr Osler called The Life of Sir William Osler. Cushing died at the age of 70 years on October 7, 1939, as the result of a posterior coronary myocardial infarction.

Of Wine Stains and Vases—William Allen Sturge’s Diverse Legacy

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