The Rebirth and Blooming of Forensic Medicine
Milton Helpern Lecture
Sidney Kaye, Ph.D.
Medical School Univ. P.R.
P.O. BOX 365067
San Juan, P.R. 00936-5067
This features a presentation by Dr. Sidney Kaye on the occasion of the Milton Helpern Lecture at the annual meeting of the National Association of Medical Examiners near Fort Myers in Florida in 1989. The author experienced the "golden age" of forensic medicine as a student and associate of Dr. Alexander Gettler in the New York Medical Examiner's Office.He also worked with Dr. Rutherford Gradwohl in the St. Louis Police Department and was one of the founders of the American Academy of Forensic Sciences. He was the toxicologist in the Virginia medical examiners' system before moving to Puerto Rico. His discussion is a historical review of his experiences in developing forensic sciences.
Key Words: Forensic pathology- Forensic sciences
INTRODUCTION (WILLIAM G. ECKERT)
The Milton Helpern Award in Lectureship is presented
in honor of Milton Helpern, one of the founders of the National Association
of Medical Examiners (N.A.M.E.), and the awardee is known as the Milton
Helpern Laureate. The qualities that we look for in a speaker for this
event should include a long-standing career in the forensic sciences, outstanding
contributions to the medical examiner investigative system, the professional
recognition and respect of fellow scientists, adherence to the high principles
and standards set by N.A.M.E., and contributions to its goals. The speaker
should also have been an administrator among his or her colleagues. These
are the rather lofty qualifications that I think today's awardee meets
and even exceeds. The purpose of the award is to have such a speaker, to
honor annually the founders of N.A.M.E., and to enable its members to partake
of the expertise of the speaker's philosophy, knowledge, and experience.
COMMENTS (WILLIAM Q. STURNER, N.A.M.E. MEETING CHAIRMAN)
It is a great honor for me, as the Chairman of the Helpern Committee, and a great personal privilege, to introduce our speaker, Dr. Sidney Kaye, whose presentation chronicles the blooming of modem forensic medicine.
Dr. Kaye earned his Bachelor of Science in Chemistry at New York University (NYU) in 1935, his Master's Degree at NYU in 1939 (with Alexander Gettler), and his Ph.D. in Pharmacology from the Medical College of Virginia in 1956. He was a research associate of toxicology at the Office of the Chief Medical Examiner in New York City from 1938 to 1940. Among the many medals that he was awarded while in the U.S. Army were a Commendation Medal from the Second Service Command Army Medical Laboratory and the Legion of Merit (when he was the commandant of the U.S. Army Reserve School in San Juan, P.R., 19641970). He was the toxicologist and deputy director of the police laboratory in St. Louis from 1946 to 1947, and an instructor in pathology at Washington University School of Medicine from 1946 to 1947. Dr. Kaye spent 15 years at the Medical College of Virginia, where he wrote extensively, and was the state toxicologist and the director of the Chief Medical Examiner's laboratories. He was lecturer in legal medicine throughout the Medical College of Virginia system as well as at the University of Virginia School of Medicine. During this time, he was a guest lecturer at the Armed Forces Institute of Pathology and the chief of the Scientific Crime Detection Laboratory for the police of both the city of Richmond and the state of Virginia. He has been a founding member of many organizations, including the American Academy of Forensic Sciences, the Toxicology Society, and the Sigma Xi Honorary Research Society, of which he was the Founding President at the University of Puerto Rico. He was the Associate Director of the Institute of Forensic Medicine, and Chief Toxicologist, from 1962 to 1982, and has been a consultant for the U.S. Army, the Air Force, the Navy, the Veterans Administration Hospital, and the Poison Control Centers during his years at the University of Puerto Rico, where he remains a Professor (Emeritus now) in Toxicology, Pharmacology, and Pathology.
His meritorious awards include a Medal of Achievement in the Forensic Sciences from the University of Ghent, Belgium, in 1983. He has been awarded two citations from the American Academy of Forensic Sciences, including the Gettler Medal in Toxicology in 1985, and he received the Medal of Appreciation from the Armed Forces Institute of Pathology.
He has been the chairman of meetings, which have included the Ninth International Conference on Alcohol, Drugs, and Traffic Safety in San Juan, Puerto Rico, 1983, and has been the president of the Third International Pan-American Conference of Forensic Sciences held in Wichita, Kansas, in 1987. Among his 127 published works is the Handbook on Emergency Toxicology, the fifth edition of which was published in 1988.
Particularly pertinent to the Milton Helpern Lectureship
was his receipt of the Milton Helpern Medal, the first awarded at the Third
International Meeting of the Pan-American Association of Forensic Sciences.
SIDNEY KAYE'S PRESENTATION
This is indeed an honor. I did not know there was an award associated with this lecture, but what a pleasure for me to be here with you today to pay homage to a man of the caliber of Dr. Milton Helpern, who was an outstanding pathologist, teacher, and, above all, a wonderful human being.
Furthermore it will be fun for me to talk about the
"rebirth of toxicology," the "good old days," and the better times yet
to come with the blooming of modern forensic sciences.
I first met Milton Helpern in 1936, more than 50 years ago, in New York City, where he was an Assistant Medical Examiner in the old morgue at Bellevue Hospital, and I, a Teaching Fellow in Chemistry at New York University and a graduate student of Alexander Gettler, was sharing a laboratory with Joe Umberger. Those were good days. We had a big lab next to the office and laboratory of Dr. Alexander Wiener of Rh fame. Joe Umberger chewed tobacco and had a spittoon in our laboratory. He was working on the detection of alcohol at the time, and I was working on the determination of lead poisoning.
Thomas Gonzalez was then Chief Medical Examiner, assisted by Morgan Vance, Milton Helpern, and others, including Dominick Di Maio. I didn't get to know Dr. Helpern well, and I was pretty sure that he didn't know me, until 1944, during World War II. He had been appointed as a consultant to the U.S. Air Force in England and intended to visit London in the winter.
How could he keep warm in London, however, and yet not be conspicuous as a civilian? I was chief toxicologist at the Army Service Command Laboratory in New York City at the time, and offered to accompany him to Governors Island, where I helped to rig him up with long johns and military khakis. I got to know him better then, but still wouldn't dare call him Milton.
When the war ended, I set up a laboratory with Rutherford Gradwohl in St.- Louis, and later moved to Virginia and set up a laboratory with Herb Breyfogel and, later, continued with Geoff Mann. I finally settled where I am now in Puerto Rico. Over this time-a period of 50 years-our paths did cross and, although he was 10 years older than I, the difference in our ages mattered less and less as the years went by. Then I dared call him Milton.
His untimely death in San Diego was a shock to us
all. We lost one of the giants in the rebirth of forensic pathology and
one who nurtured the beginning of the bloom that we are enjoying today.
Those of us who knew him as a friend miss him dearly.
Forensic Medicine dates back to our early times, but progress was slow during the past 5,000 years following Hammurabi up to about 50 years ago. With the origin of man and woman, which of the sciences emerged first out of immediate necessity? I think it was toxicology. Adam and Eve had to eat and yet had to avoid the poisonous fruits and vegetables. They had to learn fast what was fit to eat.
Can you imagine the courage of the first person to bite into a ripe tomato or to swallow a fresh oyster? Can you also imagine the wisdom needed to learn how to use the fire produced millions of years ago by a bolt of lightning hitting a fallen tree? Now they could see at night, keep warm, keep predators at bay, and make food tastier, easier to chew, and easier to preserve for another day, especially if it was smoked. But they had to learn fast that it is deadly to bring fire deep into their cave without a chimney. They did learn some toxicology because early men and women survived by trial and error.
As time went by, their knowledge increased and some persons used it to gain wealth and power. The Borgias (1492), the Medicis (1600), and others probably used arsenic. It was available and is odorless, colorless, tasteless, and deadly in small amounts. Even more important, smaller doses can have a cumulative effect that can mimic food poisoning and other common disorders. Since diagnosis was not easy, arsenic poisoning was usually written off as gastroenteritis.
Today this would not be permitted (I hope). In Virginia during the 1950s, a beautiful young woman was found guilty of slowly poisoning her husband. He was being treated by a physician for gastroenteritis. Unfortunately for the wife, when he died his doctor was up north skiing and thus not available to sign the death certificate. The medical examiner who was called (Hal Beddoe) asked some questions. Somehow he was not completely satisfied and ordered an autopsy.
To everyone's surprise, arsenic was found in large amounts. A complete investigation that was initiated disclosed that this was her third husband in recent years who had died of gastroenteritis. Since arsenic could still be reliably determined in embalmed and putrefied bodies, exhumations of the other husbands' bodies were called for. Now, to no one's surprise, they too were positive for arsenic. Gastroenteritis as a cause of death that does not result in an autopsy or complete workup is very unusual today (I hope).
Up until the late 1880s, most advances in forensic medicine came out of Western Europe, but in 1887 a major breakthrough occurred in Massachusetts. The "Old Coroners System" was replaced by a medical examiner who was a skilled physician. This was a big step forward.
In 1918, this was followed by New York City's efforts to correct the many abuses practiced-one of which was to ferry a cadaver from Brooklyn to Manhattan or vice versa and thus certify two fees for the coroner's investigation of the same cadaver. Dr. Charles Norris, a skilled pathologist, was appointed Chief Medical Examiner for the city of New York. This was a perfect choice. He was a very dignified gentleman in his frock coat and was strong-minded and firm in his decisions.
He selected Dr. Alexander 0. Gettler, a biochemist at Bellevue Hospital, as his toxicologist. This again was a very fortunate choice. Laboratory space was arranged on the third floor of the Morgue Building on First Avenue and 29th Street. Tests were set up to do "routine screening" and further testing was done for some of the common poisons.
Dr. Gettler's early assistants were Abe Freireich and Henry Siegel and later included Harry Schwartz, Leo Goldbaum, and Joe Umberger. Gettler used the methods available at the time, such as the Stas-Otto procedure for separation of poison from tissue or fluid and further purification. This proceeded to color reactions, crystal formation, melting or boiling-point measurements, or titration. He modified or developed tests to help him determine or confirm identification.
Around 1932, Gettler, who was now also a Professor of Chemistry at New York University, started to take on graduate students in an effort to help train future toxicologists and also to help him develop newer, better tests. I was fortunate to be one of those students. Preceding me were Lester Ellerbrook, Louis Weiss, Henry Freimuth, Joe Umberger, and Leo Goldbaum. Abe Stolman and Milton Feldstein came on shortly after.
There were very few active toxicologists at the time, but I can remember Clarence Muehlberger, Ray Abenathy, and Rollo Harger. I hope that I haven't left anyone out. I must also mention Irving Sunshine, Fred Rieders, and Leo Dal Cortivo, who followed me at Gettler's lab, and Kurt Dubowski, who took his graduate course. They are still very active and I am happy to say are a great influence on the present development of modern toxicology.
In January 1940, with the threat of war looming, I was given a direct commission as First Lieutenant (Toxicologist) in the Army Reserve Corps and was called to active duty June 1941 and assigned to Puerto Rico to help set up the Caribbean Defense Command Laboratory. I believe at the time I was the first professionally trained toxicologist in the army.
The same old standard procedures of the time were implemented. Blood alcohol was the most frequent test requested. We used a modified Bogen oxidation-reduction procedure and a quantitation was made by measuring the green color produced. It was necessary to modify the preservation with fluoride to allow shipment in the tropics. A field test kit to monitor and enforce the taking of quinine (which is very bitter) was devised to minimize the risk of malaria. Both of these methods were later published.
During my Puerto Rican tour, it was my good fortune to have been associated in our laboratory with Gus Dammin (later a professor at Harvard), Tommy Aitken (later a professor at Yale), and Tommy Weller (later Nobel Laureate in Medicine, also at Harvard).
In 1944, my next assignment was to establish a toxicology laboratory at the Army Service Command Laboratory in New York City. The same old standard methods with few modifications were the procedure of the day. There were no great breakthroughs-yet. Again it was my good fortune to be able to get Abe Stolman as my partner and to be associated with Ed Smith (later Secretary of the American Boards of Pathology) and Frank Townsend (later director of the Armed Forces Institute of Pathology).
With the war over, I left the army in 1946 to join forces with Gradwohl in St. Louis to establish a toxicology laboratory and reorganize the police crime lab. I was also given an appointment in the Pathology Department of Washington University School of Medicine and worked with Herb Breyfogle, who was Coroner's Pathologist for St. Louis County.
Using the same old standard procedures, we were able to be of assistance to the community by dealing with various toxicology problems involving common poisons. The Reinsch test had become a very useful simple screening test since Gettler and I had expanded it to include not only arsenic but also mercury, antimony, bismuth, selenium, and sulfides.
Gradwohl and I kept busy planning a future medicolegal conference in St. Louis. In 1948, with Gradwohl as chairman, Israel Castellanos as cochairman, and myself as secretary-treasurer, the First Congress of Legal Medicine was convened with such dignitaries as Milton Helpern, Henry Freimuth, Leo Goldbaum, Abraham Freireich, John Wood, Charles Joseph Umberger, Alexander Wiener, Lemoyne Snyder, Ralph Turner, Briggs White, Leonarde Keeler, Milton Feldstein, Walter Camp, Charles Wilson, Frank Dutra, George Swett, and Herbert Breyfogle all presenting papers. The group was small, but very enthusiastic. This was the beginning of the American Academy of Forensic Sciences.
In another part of the United States, however, another important event was taking place in 1946. Virginia was planning to replace the antiquated coroner's system with a statewide medical examiners' system. Russell Fisher, an honor graduate of the Medical College of Virginia, was sent to Harvard to train under Dr. Alan Moritz for 2 years and then return to become the first Chief Medical Examiner.
Meanwhile, at the same time, since the state legislature met only every 2 years and to save time, the medical community submitted a detailed well documented proposal to the legislature for study, hoping that the legislature would be ready to pass it in its next 1948 session. The proposal submitted was so convincing and the need for a change was so well-documented that, to everyone's surprise, it passed "as is" on the first vote in 1946 before adjournment. A medical examiners' system was created under the guidance of a Post Mortem Commission and ample funds were allocated to start "at once. "
Since they could not wait 2 years for Russell Fisher, they had to seek a recent trainee of Alan Moritz, and Herb Breyfogle was suggested. He readily accepted and asked me to join him and set up a statewide toxicology network involving 100 counties. This would be my fourth experience in setting up a toxicology lab and training the staff.
Up to now, the methods were mostly the old standard procedures, but in this postwar period more people were becoming interested in legal medicine and toxicology and new methods and procedures were beginning to be developed. Several other medical examiners' offices were being established. In fact, there was a general awakening in all of the sciences in 1947, and the rebirth of toxicology and forensic sciences was budding into adolescence.
We set up the offices and laboratories of the Chief Medical Examiner on the campus of the Medical College of Virginia and were able to start one of the early graduate programs in toxicology with Ramon Morano in 1950 and then later with Elmer Gordon and Reggie Hall. Even Doug Wilder was one of my early trainees in toxicology who later became a lawyer and is now the Lieutenant Governor of Virginia and slated to be the next Governor. (I am very proud and happy he was later elected governor.)
The bloom (long overdue) had started. Especially exciting was the DU Spectrophotometer of Arnold Beckman. This was an extremely sensitive instrument and now the old Stas-Otto long, tedious procedure, which required a large amount of specimen, was replaced. A 5-ml sample of blood was now adequate. The DU's original source of energy was an auto storage battery. This DU was later replaced by an automatic DK2-A, which could scan not only in the UV range but also in the near infrared. Leo Goldbaum started with the DU to identify the barbiturate group and Russell Fisher later developed a similar procedure while still in training at Harvard.
Identification of strychnine could be elusive because it is so rapidly removed from the blood prior to death, even fatal cases may only show traces in the blood, and the liver also has to be analyzed. The UV spectrophotometer proved to be a very useful test for strychnine and an early paper that I published added to the UV spectrophotometer's effectiveness.
When another excellent screening technique became available with paper chromatography, many drugs could be identified within 18 hours. This was greatly improved with thin-layer chromatography (TLC), whereby most common drugs could be identified at very low concentrations within 1 hour.
Supplementing these two excellent procedures is gas chromatography, which can be used to detect many drugs and chemicals. Reggie Hall was using an early model when he was working on his alcohol determination by gas chromatography for his Master's thesis in early 1960 in our lab. My 15 "years in Virginia were good ones and I was in the midst of a scientific explosion. The many wonderful new developments eliminated the use of the old standard procedures, and new and better ones were still to come.
After 3 years, Herb Breyfogle moved to California and Geoff Mann was appointed Chief Medical Examiner. He was a very able administrator who established an early resident training program in forensic pathology and expanded our services with regional offices in Norfolk, Roanoke, and Fairfax. Early in his career, Bill Eckert was in charge of our Norfolk office. A statewide poison control and information center was set up following the pattern used by Edward Press in Chicago, Irving Sunshine in Cleveland, and Kurt Dubowski in Oklahoma City.
After 15 years in Richmond, I still had fond memories of Puerto Rico during the war, and so I planned to move to San Juan. Virginia's Office of the Chief Medical Examiner was still expanding under the leadership of Geoff Mann. A new building was being planned and the facilities in the forensic sciences were to be expanded and made more available to the entire state. The resident training of forensic pathologists was in full operation. I fully enjoyed the daily sessions that I had with Earl Rose and Peter Lardizabal during my last year in Richmond.
Robert Blanke was then appointed State Toxicologist and later, when Geoff Mann moved to Florida, David Wieking, who also had a law degree plus an M.D., was named Chief Medical Examiner. While the rebirth of toxicology and the dignity and prestige of a trained forensic pathologist were being established, off I went to the Caribbean to join forces with Dr. Raul Marcial Rojas (the outstanding young pathologist in Latin America), who was Chairman of the Department of Pathology at the Medical Sciences Campus of the University of Puerto Rico and also Director of the Institute of Legal Medicine.
I was appointed Professor of Toxicology and Legal Medicine with joint appointments in Pathology and Pharmacology. I was given a free hand to set up a modern toxicology Laboratory. We were now in the "bloom and rebirth of toxicology." In Virginia, we had one of the early graduate training programs in toxicology and now, in Puerto Rico, I could continue and expand to Central and South America, Mexico, and Africa. It was in the best of times-the time of hope, time of plenty (of money in grants). People became interested in toxicology.
The institute took on a new life with the availability of modern techniques and equipment. What used to take 1-2 days to prepare a specimen now took a short time for a complete and more reliable determination. The analysis of toxic heavy metals, which is important for our health, is only one example of the new techniques. Modern electronic equipment is being developed rapidly. The competition is keen.
The Institute of Legal Medicine in 1985 took on more responsibilities and expanded into the Institute of Forensic Sciences. Dr. Pio R. Rechani is the present Executive Director who inaugurated our new building in the summer of 1992.
It is like an amazing impossible dream that began 50 years ago when I started shaking test tubes and waiting for a reaction. This can be compared with the transition from the horse-drawn trolley to flying off into space. Even with all of these wonderful things happening during the past 50 years, far exceeding all advances during the past million years-there is no "free lunch."
The cost of technology has been high in the pollution of our planet. Although our life expectancy today is about 75 years compared with much less a century ago, we must think of the potential dangers to our children's future health. This should be within your domain in developing your subspecialty of environmental pathology and chemical injuries (toxicologic pathology), not only for the dead but also for the living.
The "bloom" that Professor Milton Helpern helped to initiate is here. He loved to teach and to share his knowledge and experiences with his friends and colleagues. I guess he believed that knowledge is like fertilizer and is best effective when you spread it around.** It is really a blessing when you love to teach.
Before I stop, I want to thank you for the honor and privilege of receiving the Milton Helpern Lectureship and for allowing me to relive the last 50 years. Yet better things are ahead of us. You young ones are our future! There seems to be no limit to your capacity and ingenuity for even more amazing acomplishments. The future belongs to you.
**Modified from Hello Dolly.