Chapter  Walter G. J. Putschar (1904–1987) Andrew E. Rosenberg, Donald J. Ortner, and Bruce D. Ragsdale

alter G. J. Putschar (fi gure 12.1) was concentrated in zoology and developed a special Won the staff of the Department of Pathol- interest in planktons, and he hoped to become a ogy of Massachusetts General Hospital (MGH) zoology teacher. His curriculum included eight from 1959 to 1984. His unique attributes left an years of Latin and six of Greek. During this indelible impression on all who worked with period he was awarded a two-year scholarship at him. He lived his life with purpose, insatiable Kremsmünster, a Benedictine abbey founded in curiosity, and personal sacrifi ce and fulfi llment. the eighth century, to which a school was added His many qualities and diverse interests made in the sixteenth century. Th e school possessed him a remarkable physician and an extraordi- collections of rocks, crystals, preserved animals, narily gifted pathologist. botanical specimens, and bones, as well as an Walter Putschar was the son of a civil engi- astronomical observatory. Walter excelled as a neer who helped construct bridges and build- student and advanced through his coursework a ings. Born on January 9, 1904, in Graz, Austria, year ahead of his peers. he was raised during much of his adolescence by Upon graduation, he matriculated at the his much-loved uncle, Dr. Arnold Wittek, after University of Graz to begin his medical train- his father died in 1917. Dr. Wittek was an accom- ing, which he later completed at the Univer- plished orthopedic surgeon at the University of sity of Vienna. During his medical education Graz who founded the fi rst orthopedic hospital he requested advanced studies in histology and in that city (1914) for the rehabilitation of those received instruction at Josef Schaff er’s Institute wounded in war and industrial accidents, and of Histology, where he learned the principles of he also created therapeutic centers for crippled scientifi c investigation and the art and science children and patients suff ering from musculo- of accurate and precise observation. His peers at skeletal tuberculosis (1). His papers covered many the institute included two other Austrians who areas of orthopedic surgery, and he was the fi rst later became leaders of German pathology: Her- to coin the term “Ollier’s disease” for the disorder wig Hamperl, who became recognized for his of enchondromatosis. His hard work led to his research on the oncocyte, a word he coined, and being named an Honoured Citizen of the City of Friedrich Feyrter, who discovered the argentaffi n Graz; his portrait adorns the city hall alongside cell system. Th e next year he studied pathology those of other legendary leaders of the town. He at Wieden Hospital, part of the Vienna hospital had a lifelong infl uence in shaping the character, system, where he studied under Professor Carl interests, and pursuits of his nephew. Sternberg, a privilege granted only to outstand- In high school the young Walter Putschar ing students. Th ere he published three articles on

154

pathology_chap12.indd 154 8/16/11 10:18 AM Walter G. J. Putschar (–)

the complications of arsenic in the treatment of requested that each staff member choose a sub- syphilis and the signifi cance of cartilage within specialty to focus on. When asked, “Do you want vertebral bodies (3–5); he received his medical lung, kidney, what?” Walter interrupted, “Put on degree at the end of 1927. my desk that which no one else wants.” Th e next He then completed a practical year at the Uni- day bones and eyes covered his desk and became versity Hospital Vienna, including six months his main purview. His interest in these organs, in ophthalmology. In 1928 he was appointed particularly the skeletal system, had already been an Assistant in Pathology by Professor Georg stimulated no doubt by his well-known uncle, Gruber, Chief of Pathology at the University of and this opportunity helped foster its becoming Göttingen, one of the fi nest German universi- one of his lifelong passions. ties, and home of many Nobel Prize laureates. During this time Dr. Putschar married a Putschar taught anatomic pathology there for woman named Eva, who was from a Hungarian seven years, and was the fi rst to describe glycog- Jewish family. Th ey had two daughters, Elga and enosis (Joannes C. Pompe described it the same Eva, and the family bonds were strong. As the year), a genetic enzyme defi ciency that results political scene of Germany changed and Nazism in heart failure (7). In 1931 he was promoted to grew, Dr. Putschar became an outspoken critic of the equivalent of an American assistant profes- its philosophic tenets. On more than one occa- sor. During his tenure his department chairman sion he commented that Germany was not big enough for both himself and Hitler. Not long thereafter, he became concerned about the safety of his family, so in 1935 he decided to forfeit his promising career, and he and his family overcame diffi cult bureaucratic obstacles in Germany and immigrated to the United States. In the 1930s the United States provided expe- dited entry and permanent resident status to immigrant professionals and their families if they were qualifi ed for teaching posts at Ameri- can institutions of higher learning. By the time Dr. Putschar arrived in the United States, many academic positions in pathology had been fi lled by central European pathologists, and in 1935 he accepted a temporary position as Assistant Pro- fessor of Pathology on the faculty of the Univer- sity of Buff alo medical school. Th e off er had been extended by the chairman, Dr. Kornel Terplan, who had known Dr. Putschar in Vienna in the 1920s. Dr. Putschar remained at the University of Buf- falo for one year, until a disagreement between Dr. Terplan and a senior hospital administrator ended the arrangement. In 1937, Dr. Putschar accepted an off er to become the Director of Lab- Figure 12.1 Walter G. J. Putschar as a young man oratories at the General Hospital in Charleston,

155

pathology_chap12.indd 155 8/16/11 10:18 AM Keen Minds to Explore the Dark Continents of Disease

West Virginia. Beginning with only a small room Armed Forces Institute of Pathology (AFIP) in in the basement at Charleston General Hospital, Washington, D.C., during his Charleston years, Dr. Putschar single-handedly created and staff ed and this affi liation played an important role for a new pathology laboratory that became an the rest of his career. Colonel James E. Ash, the important center for the training of both pathol- director of the AFIP, had trained in Vienna before ogists and laboratory technicians. Th e program World War I, and he appreciated the expertise of included a two-position pathology residency in European pathologists. Accordingly, he recruited combined anatomic and clinical pathology and Dr. Hans Smetana as Chief of the AFIP. Dr. Sme- an outstanding 18-month school for laboratory tana had known Dr. Putschar in Vienna, and he technicians. Dr. Putschar ran a “tight ship” and, invited him to become a Civilian Resident Con- according to Dr. Arturo Michelena, one of his sultant for the AFIP in 1949. Th ere Dr. Putschar residents from that period, autopsies were per- began a productive, 30-year-long collaboration formed promptly upon arrival of the deceased, with Dr. Lent C. Johnson, Chief of the Ortho- under his supervision, even if that happened to pedic Pathology Department. Dr. Putschar also be midnight. arranged for Dr. Erwin Uehlinger, a distin- Life in Appalachia during the Great Depres- guished pathologist from Zurich who had a spe- sion was dramatically diff erent from that in cial interest in orthopedic pathology, to become a the intellectual milieu of Göttingen, but Dr. consultant at the AFIP. Subsequently, Uehlinger, Putschar had the motivation and self-discipline Editor of Virchows Archiv, dedicated one of its to build his own academic and cultural environ- issues to the centenary celebration of the AFIP, ment. During his tenure at Charleston he did not to which Putschar contributed. Putschar in turn collaborate with his former German colleagues dedicated his last major work (on gross skeletal who had acquiesced to Hitler’s regime and who paleopathology) to Uehlinger, whom he recog- by then had become leaders of German pathol- nized as the dean of European pathologists. ogy. Instead, he transformed the pathology pro- Dr. Putschar’s recruitment to the MGH was gram at the hospital and helped bring culture to initiated by Dr. H. Robert Dudley Jr. Dr. Dudley the city. He loved classical music and founded a was a young MGH pathologist who was interested chamber music society. in bone pathology; he often visited Dr. Johnson Dr. Putschar remained at Charleston General at the AFIP to strengthen his diagnostic skills. Hospital for 21 years, until 1958. Only near the end It was there that Dr. Dudley met Dr. Putschar of his time there did he hire an associate patholo- and was impressed by his breadth of knowl- gist, Dr. Willis Garrer, who was primarily a clini- edge and expertise. Dr. Dudley arranged for Dr. cal pathologist. In the late 1950s Dr. Putschar’s Putschar to meet Dr. Benjamin Castleman, the wife died suddenly of complications from giant Chief of Pathology at MGH (fi gure 12.2). At the cell myocarditis while traveling in Europe. Eva, “interview,” Castleman was impressed with Dr. the younger of his two daughters, had died from Putschar and in 1959 hired him as a consultant leukemia, and these two losses were devastating pathologist. Dr. Putschar accepted the position for him. When Dr. Putschar resigned from his without discussing salary, but the agreement gave position at Charleston General Hospital in 1958, him the opportunity to have six months off each he was depressed, although he had accomplished year for consulting and working at other institu- all he had set out to do at the hospital. He was tions. Th is arrangement made his position diff er- fi nancially secure and ready for a new personal ent from those of the other faculty; nonetheless, challenge. during his time at the hospital he had responsi- Dr. Putschar developed an association with the bilities of routine sign-out of both surgical and

156

pathology_chap12.indd 156 8/16/11 10:18 AM Walter G. J. Putschar (–)

Figure 12.2 Walter Putschar (left) and Benjamin Castleman, conferring at the microscope

autopsy pathology, and he was present in the attended the daily surgical pathology “outs” con- laboratory throughout most of the day. ferences. In addition, he was routinely consulted Soon after he joined the staff at the MGH, on diffi cult cases regarding matters of biology, Dr. Putschar met Florence Freestone, his future anatomy, embryology, and pathophysiology, as second wife, on a bus during a travel tour of the well as challenging diagnostic interpretations. He Near East. He was immediately taken by her was an endless source of information on speci- and after several months they married. Th e two mens from the simplest to the most complex, and became inseparable—her nickname for him was he was approachable—as long as the requesting “Pappy”—and she often accompanied him to resident was prepared with the details of the case. work, where she helped with his projects. Flor- Dr. Putschar’s background in zoology, embry- ence felt at home in the department and devel- ology, and developmental biology, combined oped close friendships with many staff members with his interpretive skills, made him legendary and residents. Years later, when the Putschar as an MGH pathologist. At slide sessions and Conference Room was dedicated (fi gure 12.3), gross pathology reviews, while others discussed the most prominent photograph placed on the statistical probabilities and diagnostic criteria on wall in his honor was a picture of him and Flor- a diffi cult case, he would harvest the overlooked ence sitting face to face at a partners desk, work- details and then give a crisp, concise evaluation ing on a manuscript (the picture remains there that went directly to the core of the problem. today). His opinions were given in a refreshingly direct At the MGH Dr. Putschar helped with the manner, without ifs, ands, or buts. He was not, Orthopaedic Pathology Service, supervised many however, reluctant to admit, “I don’t know, let’s of the daily autopsy conferences, and regularly look it up.” He emphasized a strong foundation

157

pathology_chap12.indd 157 8/16/11 10:18 AM Keen Minds to Explore the Dark Continents of Disease

Figure 12.3 Walter Putschar (left) shakes hands with Robert McCluskey at the dedication of the Putschar Conference Room, Warren Building, 1984

in normal anatomy, histology, and physiology as Dr. Putschar’s talents and persona were dis- a requirement for the understanding of pathol- played daily at the MGH morning autopsy con- ogy. On one occasion, a patient with a testicular ference, where organs from the previous day’s cases mass and brain tumor was undergoing surgery were passed around on small metal trays with a pair to remove both lesions; the clinical diagnosis of forceps. By the time a tray came to Dr. Putschar, was of a testicular malignancy that had metas- several speculations or shrugged shoulders about tasized to the brain. Th e testis was removed fi rst fi ndings were swept aside by a brief, confi dent pro- and its dissection in the lab revealed a circum- nouncement that left everyone thinking, “Why scribed tomato-red mass. When it was shown didn’t I see that?” Th is often included the staff and to Dr. Putschar, he declared: “Th is has nothing resident on the case. Dr. Putschar had very high to do with his brain tumor. It is merely sple- standards, and he was known to express his dis- nogonadal fusion. A piece or strand of spleen content and disappointment when they were not may descend with the testis in the embryo and met. (Some noted that he was more politic with enlarge as a conjoined component.” Th e resident the opposite gender.) He was once participating didn’t know it at the time, but Dr. Putschar had in an autopsy and was dissecting a knee joint with in fact authored a paper detailing a series of cases a resident when a prominent internist-rheumatol- of splenogonadal fusion in which he recognized ogist with his entourage of residents came to the that the continuous type could be associated autopsy table. Th e clinician gave a short lecture with micrognathia and the partial or complete on the description of the knee as it appears in the failure of limb formation; excellent drawings of Henke-Lubarsch reference textbook, and then the abnormalities are included in the publication asked Dr. Putschar if he had ever read that descrip- (13). Not surprisingly, the slides confi rmed his tion. Putschar looked up from his dissection for a intraoperative gross diagnosis. moment and replied, “I wrote it.”

158

pathology_chap12.indd 158 8/16/11 10:18 AM Walter G. J. Putschar (–)

Residents assisted Dr. Putschar in his prepara- alveolar bone that was most prominent on one tion for MGH orthopedic conferences, especially side. Th e biopsy specimen was suboptimal, but it the one held for the skeletal radiologists. Prepara- revealed squeezed mononuclear cells with abun- tion entailed gathering X-rays, glass slides, and dant cytoplasm. After review, Dr. Putschar indi- specimen photographs. Dr. Putschar would pre- cated that it must be Gaucher’s disease because of sent the material in great detail, always carefully the clinicopathological fi ndings and then ordered correlating the radiographic manifestations with special histochemical stains and a clinical evalua- the gross and microscopic fi ndings, and identify- tion that confi rmed his diagnostic impression ing changes that gave clues to the time course of Th e collaboration between Dr. Walter Putschar the disease. Although Dr. Putschar was skilled in and Dr. Donald Ortner, a biological anthropolo- diagnosing bone neoplasms, he was most inter- gist at the Smithsonian Institution, began in 1970 ested in evaluating inherited, metabolic, devel- when Ortner was planning a special course on opmental, and infectious disease of the skeletal human skeletal paleopathology (fi gure 12.4). It system. One time a case was sent in to him to was to be off ered at the Smithsonian and based evaluate tissue that came from the mandible of a on the human skeletal collection of the National middle-aged male. A panorex fi lm showed “fl oat- Museum of Natural History. Dr. Ortner con- ing” molars associated with widening of the man- sulted with Dr. Lent Johnson about the course, dibular canal, and endosteal resorption of the and Johnson suggested that Dr. Putschar partici- pate and give a series of lectures on bone pathol- ogy. Dr. Putschar was invited and accepted the opportunity, and in 1971 he was appointed a Research Associate of the Smithsonian Institu- tion. Th e course was highly successful and off ered yearly between 1971 and 1974, and once more in 1985. Together, Drs. Putschar and Ortner con- tinued to study the institution’s large collection of archaeological human skeletal remains during Putschar’s many visits to the Smithsonian, and this helped cement a productive scholarly asso- ciation, leading ultimately to a pioneering and comprehensive book on the topic that was pub- lished in 1981 (2). In addition to his regular institutional appoint- ments at the AFIP, Smithsonian, and MGH, Dr. Putschar worked as a consultant pathologist for the World Health Organization, Fulbright Exchange, and the U.S. Department of State. Under their aegises he traveled to help improve health care, and he benefi ted as well because he was always as eager to learn as to teach. He com- pleted seven “ambassadorships” in Taiwan, Th ai- land, Egypt, India, Iran, Indonesia, and Iceland, Figure 12.4 Walter Putschar in his later years, and during these trips he often had to improvise: engaged in paleopathology he once built a microtome from razor blades and

159

pathology_chap12.indd 159 8/16/11 10:18 AM Keen Minds to Explore the Dark Continents of Disease

old pieces of machinery and personally cut and and challenging times in his personal and profes- stained routine histologic sections, as he had in sional life (8, 9). Schaff er’s institute. Additionally, he built an opti- In 1960, Dr. Putschar published a substan- cal bench to prepare gross and microscopic pho- tial chapter in English on the general pathology tographs to document untreated disorders rarely of the musculoskeletal system (10). His study of encountered in Western medical practice. Some orthopedic pathology provided a foundation of of these images are still being used in lectures and knowledge that would enhance his understanding published in medical reference textbooks. of and contributions to human skeletal paleopa- Dr. Putschar’s published investigations were thology. His fi rst publication on this topic was generally focused on the fi elds of congenital and a chapter entitled “Problems in Pathology and metabolic disorders and the pathology of the Paleopathology of Bone” in a book on the subject skeletal system and bone tissue. His interests in edited by Saul Jarcho, a physician and medical skeletal pathology were broad and included meta- historian (11). His next-to-last publication was a bolic disorders (vitamin D defi ciency), infectious brief summary of the paleopathology of devel- diseases such as leprosy, syphilis, yaws, and tuber- opmental disorders and dysplasias that aff ect the culosis, as well as developmental and degenera- skeleton (14). tive disorders. His fi rst publications were related Dr. Putschar’s experience at the Smithsonian to spine disorders, and are dated 1927, the year he highlighted the need for a major reference work completed his medical degree at the University on the subject of human skeletal paleopathol- of Vienna (3, 5). At a major meeting the German ogy. With the support of Ortner’s grant from the pathologist Christian Georg Schmorl presented Smithsonian Institution, the two began to write the original gross description of the vertebral a manuscript in the summer of 1974 based on body “node” (herniation of the annulus fi brosus a careful review of skeletal remains housed in through the hyaline cartilage endplate) for which European medical museums. Th ey meticulously he is known. Following Schmorl on the same examined collections from England, Scotland, program was none other than Putschar, his topic Czechoslovakia, Austria, France, and Switzerland being the histopathology of herniated disc mate- to document the range of skeletal manifestations rial through a fractured vertebral body endplate. of various diseases. During this research tour, In 1931 he published a major work on the devel- they studied and carefully photographed hun- opment of the pelvis with a particular empha- dreds of cases, and in some cases it was possible sis on the changes that occur during pregnancy to obtain plain-fi lm radiographs of the aff ected and childbirth (6). In a collection of celebratory bones. None of the museums had radiographic writings honoring T. Dale Stewart, a distin- facilities, and therefore the roentgenograms guished biological anthropologist at the National had to be squeezed in between patient exams at Museum of Natural History and the Smithson- radiology units of local hospitals. Th is research, ian Institution, he published an updated version, along with that performed on materials from the and it remains an important reference (12). National Museum of Natural History, provided His chapters on bone and urologic pathol- the gross and radiographic materials for what ogy in the handbooks for special and general would become the classic text of skeletal paleo- pathology, known by pathologists as the “Henke- pathology that Drs. Putschar and Ortner coau- Lubarsch,” have stood the test of time and are thored (2). still considered to be classic references. Th ese Dr. Putschar was always active and remained were published in 1934 and 1937 and therefore sharp, but he became aware of his increasing must have been prepared during very turbulent fragility as he entered his late seventies. While

160

pathology_chap12.indd 160 8/16/11 10:18 AM Walter G. J. Putschar (–)

attending professional meetings in Edinburgh in 28. Washington, D.C.: Smithsonian Institution late 1984, he slipped and fell during a walk with Press, 1981. Florence on a stony path en route to a medieval 3. Putschar WG. Cartilage islands in the vertebral castle. Weeks later he diagnosed himself as hav- bodies. Verhandl d Dtsch Path Ges 22:262–266, ing a chronic subdural hematoma, which was 1927. confi rmed by a subsequent CAT scan. Despite 4. Putschar WG. Extensive myelomalacia of the grey substance seemingly caused by Salvarsan. Vir- the complications from this injury, he insisted chows Arch 265:403–413, 1927. on giving the lectures he had scheduled for the 5. Putschar WG. Studies on the cartilage islands in special course in human skeletal paleopathol- the vertebral bodies. Beitr z Path Anat u Allgem ogy held at the Smithsonian Institution in 1985. Path 71:150–165, 1927. Florence developed pancreatic cancer and passed 6. Putschar WG. Development, Growth and Pathol- away soon thereafter, which was a terrible burden ogy of the Pelvic Joints of Man with Special Study for Dr. Putschar to bear. In 1986 he was preparing of Changes Caused by Pregnancy, Actual Birth and the keynote lecture for the International Acad- Consequences. Jena: Verlag von Gustav Fischer, emy of Pathology congress in Vienna on the past, 1931. present, and future of pathology, and he planned 7. Putschar WG. Congenital glycogen-storage dis- to use an analogy of white light dissected into ease of the heart. Beitr z Path Anat u Allgem Path its multitude of colors by a prism, but he had to 90:222–232, 1932. cancel his presentation because of medical com- 8. Putschar WG. Th e infl ammatory diseases of the urinary tract and the renal capsules, including plications that led to his death in April 1987. pyelonephritis and pyonephrosis. In Handbuch His professional peers regard him as one of der Speziellen Pathologischen Anatomie und Histolo- the world’s outstanding pathologists, possess- gie. Lubarsch O, Henke F, eds. Berlin: J. Springer, ing a breadth of knowledge that very few, if any, 1934. could match. Th ose who were fortunate to social- 9. Putschar WG. Functional adaptation of the skel- ize with him outside the hospital knew him as a eton and the so-called “strain and stress deformi- renaissance man of diverse interests and avoca- ties.” In Handbuch der Speziellen Pathologischen tions. Walter Putschar is fi rmly entrenched in the Anatomie und Histologie. Lubarsch O, Henke F, memories of those whom he mentored and who eds. Berlin: J. Springer, 1937. became his colleagues. He will forever be a part 10. Putschar WG. General pathology of the muscu- of MGH Pathology: every day medical students, loskeletal system. In Handbuch der Algemeinen residents, and staff walk in to the conference Pathology. Buchner EL, ed. Berlin: Springer, 1960. room named in his honor; every year the depart- 11. Putschar WG. Problems in the pathology and paleopathology of bone. In Human Paleopathol- ment celebrates his achievements in an annual ogy. Jarcho S, ed. New Haven: Yale University lectureship; and every time we learn, we celebrate Press, 1965. his spirit. 12. Putschar WG. Th e structure of the human sym- physis pubis with special consideration of parturi- References tion and its sequelae. Am J Phys Anthropol 45 (3, pt. 2):589–594, 1976. 1. Ehatt W. Austrian Orthopaedic Society. J Bone 13. Putschar WG, Manion WC. Splenicgonadal Joint Surg 40:490, 1958. fusion. Am J Pathol 32 (1):15–33, 1956. 2. Ortner D, Putschar WG. Identifi cation of Patho- 14. Putschar WG, Ortner D. Zur palaeopathologie logical Conditions in Human Skeletal Remains. der skelettmibildungen und dysplasie. Verhdlg Smithsonian Contributions to Anthropology, vol. Dtsch Ges Pathol 66:141–150, 1982.

161

pathology_chap12.indd 161 8/16/11 10:18 AM