Sunday, September 24, 2023

A Technological But Also Inevitably Political and Medical Appendix to Postblogging Technology, June 1953, I: Diagnosing Presidents


Leaving aside the unintentional, dark irony of an ad exalting modern diagnostic practice and focussing on peptic ulcers,  this post was only secondarily inspired by this ad. It actually mainly has to do with my nephew, C.'s, enrollment in a doctoral programme in medical physics. No, that's a lie. It has mainly to do with my company put roasting chickens on two for one last week. I spent entirely too much time on Tuesday and Friday cooking them, so Postblogging June, II is stuck two-thirds of the way through 15 June. 

And that is why my attention is very much focussed on the already reported 10 June 1953 press conference in which Senator Robert Alphonso Taft announced that he was ill and would be temporarily resigning as Leader of the Senate, with William F. Knowland as his interim replacement. "The Senator from Formosa" would end up remaining as Majority and Minority Leader, until 1959. 

Taft had first sought treatment at Walter Reed in May after a round of gold with the President was interrupted by the increasing severity of hip pains which the Senator had been suffering for some time. At the time the pains were dismissed as arthritis. It was not until a late May visit to Holmes Hospital in Cincinnati that nodules were removed from his neck and abdomen and biopsied, coming back malignant. It was for some reason found necessary to hospitalise Taft again in New York on 7 June to finally confirm the cancer diagnosis, and a final diagnosis of metastatised cancer of unknown origin was made on the basis of exploratory surgery on 4 July. As The Periscope will report next week (around here), by 15 June, there were rumours that Taft's condition was life-threatening, but he was only officially put on palliative care in July, and died of a brain hemorrhage on 31 July some hours after a final visit from his wife, a detail that I assume Wikipedia offers in a spirit of "Do I have to paint you a picture"? 

The man who almost won the Republican nominations in 1948 and 1942 was dead, within months of beginning his first or second term, depending on which alternative history you prefer. This is something that has struck me as somehow significant ever since I read the grief-stricken Time obituary of 1940 Republican candidate Wendell Willkie in October of 1944. At the time and since it has been my lively suspicion that one of the problems with Willkie is that Henry Luce had such a massive crush on the man, but I think we can all agree that it is a bigger problem that in some alternate history he would have dropped dead at the climax of WWII, just a month away from contesting the 1944 Presidential election. In other words, pick your alternate timeline carefully, and you'll get three Republican Presidents dying in office in thirty years.   
Okay, maybe he could have lost some weight.
As far as the events of June, 1953 go, I would like to blame "Mr. Conservative" here. The ultimate nepo baby with frankly ludicrous foreign politics, we can finger him, as people have fingered Warren Harding, for allowing himself to be nominated for President while nursing an ultimately fatal disease. Unfortunately for easy partisanship, Taft was always a supporter of education, public housing, and welfare, and as cynical as I have become about the amount of corruption involving the Air Force and Ohio society and politics, it's hard to see any serious downside to the long term outcomes, and pancreatic cancer doesn't work that way. Also, Harding was more-or-less an accidental candidate after the near-simultaneous deaths of Theodore Roosevelt and Woodrow Wilson led to his nomination and that of Governor Cox. But why would anyone be interested in a scenario in which two giants of their respective parties "cleared the field" of serious alternative candidates and then died of the predictable frailties of aging just ahead of the election? What relevance would it have today? How could I lay it on thicker?

It was, unlike Eisenhower's May, 1955 heart attack, just one of life's little, incomprehensible tragedies. Dwight Eisenhower first complained of discomfort while playing golf in Denver on 23 September 1955. Returning, in the words of this often bizarrely sloppy article posted online from The New England Journal of Medicine, "to the house where he was a guest," actually that of  his Doud in-laws in Colorado Springs, he awoke at 2am with acute chest pains. His wife summoned his personal physician, un-named in the linked article as Howard McCrum Snyder, who reached the President's bedside at 3am, where he administered multiple shots of morphine "while hoping the diagnosis was indigestion." I wish the people who wrote these kinds of things would put more emphasis on the fact that presidents went on vacation in places like Denver in 1953, to places like their parents-in-law's house, and that the President's personal doctor could be a 71-year-old crony. Actually, that hasn't changed, so never mind, but we really do need to go back to taking "Domeliner" vacations to exotic locations like "British Columbia" and "the Puget Sound region."

The President woke at 1pm on Saturday, 24 September, and an ECG was immediately administered, showing a cardiac issue, of which more below. The President was permitted to walk downstairs to a waiting car, and taken to Fitzsimmons Army  Medical Centre, where he was placed in an oxygen tent and given additional morphine, the antispasmodic papaverine, atropine to hopefully prevent arrhythmias, and heparin and warfarin to reduce blood clots. The first bypass surgery being still eight years away, there was little that the medical staff at Fitzsimmons could do otherwise, apart from manage the press. Wall Street famously shed $14 billion in value, although it is not clear to me when that happened, as in these quaint old days, stocks did not trade on the weekends. The mortality rate among myocardial patients who reached the hospital was 30 to 40% in 1955, and there were a lot of them, as one of the key subtexts of this story was the epidemic of smoking, PTSD and substance abuse in the wake of WWII. A crack doctor from Boston was flown in to give what the medical profession deems to be  a masterpiece of a press conference 

that is, notwithstanding Dr. White's decision to talk about the President's healthy bowel movement, which was controversial at the time in spite of Dr. White's quite accurate observation that contemporary America (and Canada) was "bowel-obsessed." (Let me tell you about the time that I tried to add Macleans to the postblog roll. That is some ad content!) The real issues here being perhaps the President's well-documented bowel issues, which would culminate in a very risky (you didn't just go cutting up cardiac patients on a whim in those days) 1958 surgery for Crohn's Disease and more saliently the pain management treatment involving copious amounts of constipating morphine. It would not do to imply that Dr. Snyder thought he was easing the President's path into the next world on Saturday morning!

 Dr. White also handled questions from the press about whether or not the President had had a previous, minor heart attack which had been covered up, which gratifies me in my speculation about his 1953 "flu." It may or may not have been anything more than flu, but I'm not the only one with a suspicious mind! If the President had a history of heart attacks, Dr. Snyder's actions become even more salient.

In retrospect, this cynical question gets at the heart of the problem, which was, not as is often suggested, Dr. Snyder's delay in diagnosing a heart attack from 3am to 1pm. There was no point in such a diagnosis. It is not as though there was any treatment recourse. An ECG was arranged for when, and if, the President woke up. Diagnosis in situ at the Doud House revealed ventricular and superventricular premature beats indicating "extensive anterior myocardial infarction." All this medical jargon indicates the presence of a skilled diagnostician to interpret the test results on site, but even in the absence of the test, Dr. Snyder was well aware that the only treatment that worked for the feared infarction was plenty of rest, which the President wgot from 3 to 1. The issue the press picked on (apart from the bowel movement remark) was that the President was being allowed to physically exert himself at the altitude of Denver, including allowing him to walk to downstairs to the car. That was a real risk to the President, and almost certainly done in an attempt to conceal the gravity of the President's condition from photographers staking out the house. A great deal of the question lies in whether Eisenhower's entourage was taking an informed risk or not, so let's by all means look at ECGs, because they make for some pretty interesting medical physics! 

It turns out that "ECGs" have been in use since the Nineteenth Century, at least per Wikipedia's potted history. This isn't wrong in the sense that the heart is an electrical organ and putting an electrode to the chest will tell you something about what is going on in there. Given that opening up the thoracic cavity, was a Very Big Deal even in the Fifties, this was obviously something worth following up on, but the terse description of the technology, again per Wikipedia, shows how much follow up was required.An ECG circa 1953 consisted of ten to twelve electrodes attached around the heart. By running electrical currents of different frequencies through each electrode, requiring a slightly fancy signal generator, picking them up at the receiving electrodes, and superimposing input and output waves, data about impedances on various pathways through the heart can be obtained. Mathematically, this is 12!, or 479 million signals, so obviously a lot of them were filtered out before processing, at least in 1953. There is also the problem of making sense of them, which was accomplished by mathematically transforming these into waves, and outputting them, as of 1951, to an inkjet printer. Given a portable analyser and printer, you could send a clinician on site could come to a fairly complete picture of what was going on in the heart. In this case, it was determined that the infarction was over, and that the damage was not so severe as to require the President to be moved in a stretcher and ambulance. 

Dr. Zoll could have had a good career at Hammer Films
From there it was a management issue. Arrhythmia was a likely and inevitably fatal sequel of an attack. When we use the Eisenhower case as an index of improvements in cardiac care management, it is often noted that defibrillators were available at the time of his final series of heart attacks, which began in 1966. It turns out that defibrillator pioneer Paul Zoll was one of those medical entrepreneurs with a technique looking for a use. He first demonstrated "chest surface pacing of an arrested heart" in 1952, a technique that was discontinued because of the excessive pain it caused, then improved it with the first description in the literature of a successful demonstration of defibrillation in 1956, and finally financial/humanitarian success in the early 1960s. (He also had to fight off what sounds like a small army of competing inventors of defibrillation with inferior engineering.) 

Of course we are here talking specifically about a technology that was not used in 1955, and would not have helped. That it might have been used after 1965 is cold comfort. Eisenhower had four heart attacks in four years after 1965 and died after last ditch surgery. He was not young at the time of his 1969 death, being 79. There was a spate of ex-Presidential deaths in these years, with Herbert Hoover dying at 90 in 1964, three Truman at 88 in 1872, and Lyndon Johnson's 65 in 1973. You can't turn this number of events into a pattern, but, combined with the mortality of the 85th Congress, discussed around here before, you can see the Fifties as a sickly season for American politicians and wonder about diagnosis. Our blogging year of 1953 saw "the first description of M-mode echocardiography" by Inge Edler and his engineer/physicist, Hellmuth Hertz (nephew of the big guy). The NIH is all about promoting knowledge, which is what we do around  here when we aren't making shallowly cynical comments about long-dead politicians, so let's steal some graphics!


It's one thing to shoot the heart with interacting, predictable and recordable transient phenomena; it is quite another to transform the returns into a picture of what is going on in the heart that is accurate enough that you can take the risk of letting the President walk downstairs in Colorado Springs. Which does leave me wondering of Dr. Snyder was winging it. It's okay, though, it's just the President.  

Movie critic Michael Medved wrote a book on Presidential aides called The Shadow Presidents, that stated Adams was probably the most powerful chief of staff in history. He told of a joke that circulated around Washington in the 1950s. Two Democrats were talking and one said "Wouldn't it be terrible if Eisenhower died and Nixon became President?" The other replied "Wouldn't it be terrible if Sherman Adams died and Eisenhower became President!"

Fun fact: According to the Mayo Clinic, about one in five heart attack survivors experience serious depression, Dr. Zebra, whom I have linked to before as giving perhaps the most serious and thorough version of Eisenhower's medical history I encountered writing this blog, says that this group included Eisenhower, "For example, he was observed to be depressed in Gettysburg toward the end of 1955, but not to have signs of it such as psychomotor retardation, early morning awakening, constipation, and decreased appetite." Nevertheless, Eisenhower put himself forward as the Republican nominee in 1956, something his biographers see as characteristic of his masterful "behind the scenes" leadership. 

Yeah, I don't know about that. Assuming that the revisionist picture of Jack Kennedy's health isn't overstated, the United States spent the tumultuous Fifties and Sixties under a series of sickly Presidencies. This was not the first time, either. Harding's blood pressure was too high for him to realistically function as an executive, while Wilson's invaliding is still the prime example of the dangers of sick President. Better diagnosis is clearly valuable; it isn't just luck that Harding was the last President to die in office unexpectedly. (Roosevelt was quite obviously sinking as early as the Teheran Conference). But it isn't going to help if the political structure insists on taking a gamble on a clearly ill candidate. 


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