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First planned nephrectomy for kidney stones
HISTORY
FIRST PLANNED
NEPHRECTOMY
PETER
M.D.
Savannah,
L. SCARDINO,
STONES
Georgia
Gustav Simon performed the first recorded planned nephrectomy at the University of Heidelberg in 1869.’ His first planned nephrectomy for kidney stone disease was done August 8, 1871, on a woman from Savannah, Georgia, in the same surgical amphitheater that had been the scene of his first spectacular feat.’ Mary Helen Williams was born in Savannah, Georgia, in 1840, the daughter of Thomas F. and Mary Jane Williams. Since age 18 Mary Helen had experienced dull pains in the area of her left kidney, made worse when she rode horseback. Often the attacks were accompanied by bouts of chills and fever. By the age of 24 she suffered six to eight hours of renal colic every five to six weeks. In the interludes of well-being she was sufficiently attractive to have wed a modestly successful Savannah, German, immiWilliam Phillip Schirm, on grant merchant, November 3, 1869. During the first twenty-four months of her marriage she became pregnant at least twice, but each was interrupted during renal colic attacks, one at four weeks and one at four months of gestation. During her attacks she passed calculi about the size of a pea.2 Her stone disease encroached heavily on Mary Helen’s stamina. In the face of her failing health her husband and her family arranged a trip to the “old country,” Germany, to “build her up.” While visiting Obernhof, Mary Helen continued to have kidney colic. After one of the more severe episodes she and her family decided to place her in Simon’s hands. The epochal trip to Germany was made possible because William Schirm was employed by the Savannah firm of Wilcox-Gibbs, whose shipping business included merchandise to and from Germany. The port of Savannah in 1871 enjoyed a prosperity in cotton and rice. Founded in 1733 it had survived the Revolution
and Civil Wars without much more than a brief battle. On May 21, 1819, with the launching of the first steamship to cross the Atlantic, the “Savannah,” the prosperity of the port reached new heights of success. Somehow the identity of this surgical celebrity, Mary Helen Schirm, had not been revealed as had that of her predecessor, the woman whose ureteral fistula led to the first planned nephrectomy (Margaret Kleb). The History of Urology published in 1933 by the American Urological Association refers to the removal of Mary Helen Schirm’s kidney on August 8, 1871, as the first planned nephrectomy for kidney stones on a lady from Savannah.’ No further description of the patient or her hospital course is given. Additional clues to the lady’s identity or the date of her death were not available. It seemed reasonable that an affluent citizen who might finance a trip to Germany or be able to engage a surgeon of Professor Simon’s fame would merit recognition in the Savannah newspaper. Surely an obituary notice. The microfilm obituary files of the Savannah newspaper repository was searched from January 1 to October 2, 1871, where the following notice was seen: Died at Heidelberg,
/ JANUARY 1979 / VOLUME
XIII,
NUMBER
Germany,
7 September
1871,
Mary Helen Schirm, the beloved wife of William P. Schirm of Savannah, daughter ofThomas F. and Mary Jane Williams.
The identity of the heroine was established to some degree; circumstantial evidence, perhaps, but not the hard evidence required. Since Simon’s patient had died at the University hospital it could be assumed that an autopsy had been performed. In the summer of I975 a young pathologist3 working in the Heidelberg laboratory was contacted and agreed to search the archives of the University’s Pathology Department. Under the date of 7 September, 1871, the description of the remains of Mary Helen Schirm was located. The details of the patient’s history, physical examination, laboratory findings, operation, progress notes, and
Presented at the Forum of History of Urology, Annual Meeting of American Urological Association, Inc., Washington, D.C., May 21-25, 1978.
UROLOGY
FOR KIDNEY
1
111
autopsy examination are meticulously described by Professor Simon.’ He does not reveal the patient’s name, but his historical description combined with the pathology records and the Savannah records leave no doubt as to her identity. Simon’s record is a scientific literary model. On August 2, 1871, Mary Helen visited him for the first time. She related her long history of recurrent bouts of colic, of her abortions associated with kidney colic. She had headaches, was both anemic and underweight. She had passed many stones during colicky attacks. During one such episode Simon saw that she voided thick and yellow urine. Between attacks her urine was clear. He analyzed the stones. They were “phosphor acid.” He was probably confronted with infected struvite stones. Flushed with the success of his earlier achievement, Simon was anxious to prove his theory of stone disease. “Even the most vigorous proponents of the stone diathesis believe that the phosphor acid stones do not develop on a constitutional basis. They have a local causation, in particular inflammation of the mucosal membrane of the kidney pelves.“2 Having observed the clear urine Mary Helen voided after her left renal colic attacks, he recorded: “Therefore it could be assumed that the right contralateral kidney would not be likely to develop kidney stones.” He could see no contraindication to extirpation of the left kidney. Simon was a surgical entrepreneur with the style of Barnum and Bailey. Word was “leaked” that at 2:00 p.m., August 8, 1871, he would perform a nephrectomy for kidney stones. There was great excitement. A large audience of students, physicians, and professors gathered in the surgical amphitheater at Heidelberg University to watch the historic event. Simon describes the operation: “The lumbar incision of the kidney went quickly and without bleeding. The fatty capsule of the kidney was tighter than normal.” He was concerned about this thin layer of tissue, suspected it to be the peritoneum. After identifying the renal capsule he opened the pelvis and inadvertently cut a branch of the renal artery, probably that notorious posterior segmental branch that continues to trouble the surgeon today. Simon, the good anatomist, gained control of the bleeding in ten minutes. The kidney was out and the wound closed in thirty minutes. The postoperative documentation is a model for all surgeons. Each day he penned his obser-
112
vations. The patient’s fluid intake and urine output were recorded. Significantly her first day’s urine was found to be clear. By the fifth postoperative day she managed an oral diet and voided more than 0.5 L. of a concentrated urine with a sp, gr. of 1.026. Improvement was rapid and she was afebrile and off opiates by the eighth postoperative day at which time her gastrointestinal tract began to behave well. Each day the wound was irrigated with a carbolic solution. On the eighteenth postoperative day he wrote, “the patient is in an excellent mood, and writes letters almost daily. She takes wine and bouillon and meat. The wound granulations are healthy.” On the twenty-first day during a bandage change, Simon carefully examined the wound with his little finger so that he might get some information about the depth of the wound which he found to be 2 to 2.5 cm. deep and 7 cm. in length. In the afternoon of the same day the patient experienced chills and fever and began what proved to be a progessively downhill course. After ten days of nausea, vomiting, chills, fever, rapid pulse, dyspnea, and orthopnea, the patient died on September 7 at 8:00 a.m., thirty-one days after her historic surgery.* Simon indicated that his finger probing of the wound, her ingestion of unripe pears and peaches, and the unhygienic conditions of the hospital led to her death. The autopsy revealed peritonitis and pleuritis. The cause of death was septicemia. The right kidney was enlarged, possibly compensatory hypertrophy. It is unlikely that Simon’s irritation of the wound with his finger probing of August 29, 1871, could have produced the chills and fever of the afternoon of the same day. The peritonitis and pleuritis were more likely an extension of infection from the undrained wound site. Mary Helen Schirm might have returned triumphantly to her beloved city when the first steamship to cross the Atlantic returned to Savannah after a Russian visit, had Simon simply drained the wound. Instead our heroine lies buried on German soil in her husband’s native village of Obernhof. 2515 Habersham Street Savannah, Georgia 31401 References 1. Ballinger EG, Frontz WA, Hamer HG, and Bransford L: History of Urology, Baltimore, Williams and Wilkins Co., vol. 1, 1933, pp. 293-297. 2. Simon G: Chirugie der Nieren, Stuttgart, Verlog van Ferdinand Enke, vol. II, 1876, pp. 148-165 3. Manegold C: Personal communication, 1975.
UROLOGY
/
JANUARY
1979
/
VOLUME
XIII,
NUMBER
1
FIRST PLANNED
NEPHRECTOMY
PETER
M.D.
Savannah,
L. SCARDINO,
STONES
Georgia
Gustav Simon performed the first recorded planned nephrectomy at the University of Heidelberg in 1869.’ His first planned nephrectomy for kidney stone disease was done August 8, 1871, on a woman from Savannah, Georgia, in the same surgical amphitheater that had been the scene of his first spectacular feat.’ Mary Helen Williams was born in Savannah, Georgia, in 1840, the daughter of Thomas F. and Mary Jane Williams. Since age 18 Mary Helen had experienced dull pains in the area of her left kidney, made worse when she rode horseback. Often the attacks were accompanied by bouts of chills and fever. By the age of 24 she suffered six to eight hours of renal colic every five to six weeks. In the interludes of well-being she was sufficiently attractive to have wed a modestly successful Savannah, German, immiWilliam Phillip Schirm, on grant merchant, November 3, 1869. During the first twenty-four months of her marriage she became pregnant at least twice, but each was interrupted during renal colic attacks, one at four weeks and one at four months of gestation. During her attacks she passed calculi about the size of a pea.2 Her stone disease encroached heavily on Mary Helen’s stamina. In the face of her failing health her husband and her family arranged a trip to the “old country,” Germany, to “build her up.” While visiting Obernhof, Mary Helen continued to have kidney colic. After one of the more severe episodes she and her family decided to place her in Simon’s hands. The epochal trip to Germany was made possible because William Schirm was employed by the Savannah firm of Wilcox-Gibbs, whose shipping business included merchandise to and from Germany. The port of Savannah in 1871 enjoyed a prosperity in cotton and rice. Founded in 1733 it had survived the Revolution
and Civil Wars without much more than a brief battle. On May 21, 1819, with the launching of the first steamship to cross the Atlantic, the “Savannah,” the prosperity of the port reached new heights of success. Somehow the identity of this surgical celebrity, Mary Helen Schirm, had not been revealed as had that of her predecessor, the woman whose ureteral fistula led to the first planned nephrectomy (Margaret Kleb). The History of Urology published in 1933 by the American Urological Association refers to the removal of Mary Helen Schirm’s kidney on August 8, 1871, as the first planned nephrectomy for kidney stones on a lady from Savannah.’ No further description of the patient or her hospital course is given. Additional clues to the lady’s identity or the date of her death were not available. It seemed reasonable that an affluent citizen who might finance a trip to Germany or be able to engage a surgeon of Professor Simon’s fame would merit recognition in the Savannah newspaper. Surely an obituary notice. The microfilm obituary files of the Savannah newspaper repository was searched from January 1 to October 2, 1871, where the following notice was seen: Died at Heidelberg,
/ JANUARY 1979 / VOLUME
XIII,
NUMBER
Germany,
7 September
1871,
Mary Helen Schirm, the beloved wife of William P. Schirm of Savannah, daughter ofThomas F. and Mary Jane Williams.
The identity of the heroine was established to some degree; circumstantial evidence, perhaps, but not the hard evidence required. Since Simon’s patient had died at the University hospital it could be assumed that an autopsy had been performed. In the summer of I975 a young pathologist3 working in the Heidelberg laboratory was contacted and agreed to search the archives of the University’s Pathology Department. Under the date of 7 September, 1871, the description of the remains of Mary Helen Schirm was located. The details of the patient’s history, physical examination, laboratory findings, operation, progress notes, and
Presented at the Forum of History of Urology, Annual Meeting of American Urological Association, Inc., Washington, D.C., May 21-25, 1978.
UROLOGY
FOR KIDNEY
1
111
autopsy examination are meticulously described by Professor Simon.’ He does not reveal the patient’s name, but his historical description combined with the pathology records and the Savannah records leave no doubt as to her identity. Simon’s record is a scientific literary model. On August 2, 1871, Mary Helen visited him for the first time. She related her long history of recurrent bouts of colic, of her abortions associated with kidney colic. She had headaches, was both anemic and underweight. She had passed many stones during colicky attacks. During one such episode Simon saw that she voided thick and yellow urine. Between attacks her urine was clear. He analyzed the stones. They were “phosphor acid.” He was probably confronted with infected struvite stones. Flushed with the success of his earlier achievement, Simon was anxious to prove his theory of stone disease. “Even the most vigorous proponents of the stone diathesis believe that the phosphor acid stones do not develop on a constitutional basis. They have a local causation, in particular inflammation of the mucosal membrane of the kidney pelves.“2 Having observed the clear urine Mary Helen voided after her left renal colic attacks, he recorded: “Therefore it could be assumed that the right contralateral kidney would not be likely to develop kidney stones.” He could see no contraindication to extirpation of the left kidney. Simon was a surgical entrepreneur with the style of Barnum and Bailey. Word was “leaked” that at 2:00 p.m., August 8, 1871, he would perform a nephrectomy for kidney stones. There was great excitement. A large audience of students, physicians, and professors gathered in the surgical amphitheater at Heidelberg University to watch the historic event. Simon describes the operation: “The lumbar incision of the kidney went quickly and without bleeding. The fatty capsule of the kidney was tighter than normal.” He was concerned about this thin layer of tissue, suspected it to be the peritoneum. After identifying the renal capsule he opened the pelvis and inadvertently cut a branch of the renal artery, probably that notorious posterior segmental branch that continues to trouble the surgeon today. Simon, the good anatomist, gained control of the bleeding in ten minutes. The kidney was out and the wound closed in thirty minutes. The postoperative documentation is a model for all surgeons. Each day he penned his obser-
112
vations. The patient’s fluid intake and urine output were recorded. Significantly her first day’s urine was found to be clear. By the fifth postoperative day she managed an oral diet and voided more than 0.5 L. of a concentrated urine with a sp, gr. of 1.026. Improvement was rapid and she was afebrile and off opiates by the eighth postoperative day at which time her gastrointestinal tract began to behave well. Each day the wound was irrigated with a carbolic solution. On the eighteenth postoperative day he wrote, “the patient is in an excellent mood, and writes letters almost daily. She takes wine and bouillon and meat. The wound granulations are healthy.” On the twenty-first day during a bandage change, Simon carefully examined the wound with his little finger so that he might get some information about the depth of the wound which he found to be 2 to 2.5 cm. deep and 7 cm. in length. In the afternoon of the same day the patient experienced chills and fever and began what proved to be a progessively downhill course. After ten days of nausea, vomiting, chills, fever, rapid pulse, dyspnea, and orthopnea, the patient died on September 7 at 8:00 a.m., thirty-one days after her historic surgery.* Simon indicated that his finger probing of the wound, her ingestion of unripe pears and peaches, and the unhygienic conditions of the hospital led to her death. The autopsy revealed peritonitis and pleuritis. The cause of death was septicemia. The right kidney was enlarged, possibly compensatory hypertrophy. It is unlikely that Simon’s irritation of the wound with his finger probing of August 29, 1871, could have produced the chills and fever of the afternoon of the same day. The peritonitis and pleuritis were more likely an extension of infection from the undrained wound site. Mary Helen Schirm might have returned triumphantly to her beloved city when the first steamship to cross the Atlantic returned to Savannah after a Russian visit, had Simon simply drained the wound. Instead our heroine lies buried on German soil in her husband’s native village of Obernhof. 2515 Habersham Street Savannah, Georgia 31401 References 1. Ballinger EG, Frontz WA, Hamer HG, and Bransford L: History of Urology, Baltimore, Williams and Wilkins Co., vol. 1, 1933, pp. 293-297. 2. Simon G: Chirugie der Nieren, Stuttgart, Verlog van Ferdinand Enke, vol. II, 1876, pp. 148-165 3. Manegold C: Personal communication, 1975.
UROLOGY
/
JANUARY
1979
/
VOLUME
XIII,
NUMBER
1