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Home , Anything Goes, Begin the Beguine, Cole Porter, Fifty Million Frenchmen, High Society (musical), I Concentrate on You

ole orter’s C P orthopaedic odyssey

Cole Porter playing the piano at auditions for the musical “Wait for Baby,” July 7, 1936. © Bettmann/CORBIS.

James G. Gamble, MD, PhD The author (AΩA, University of Maryland, 1974) is professor rap, and New Age smooth . In 2004, a biographical film in the Division of Orthopaedic Surgery at Stanford University entitled Delovely, starring and , was School of Medicine and Packard Children’s Hospital at released and is available now on DVD. A 1964 article in the Stanford. He is a previous contributor to The Pharos and is New York Times noted that, “The hallmarks of a typical Porter a member of its editorial board. song were lyrics that were urbane or witty and a melody with a sinuous, brooding quality. Some of his best-known songs in this vein were ‘What Is This Thing Called Love,’ ‘Night and long with Jerome Kern, Richard Rogers, George Day,’ ‘Love for Sale,’ and ‘.’ ” 1 Gershwin, and , wrote some Cole Porter’s life was remarkable from the musical, so- of the most memorable music of the twentieth century. cial, and medical standpoints. For more than thirty years, he HisA songs and lyrics remain popular even in the age of hip hop, was an international star, at home in Hollywood, New York,

20 The Pharos/Winter 2007 Year Production 1928 Song Title 1930 “Let’s Do It, Let’s Fall in Love” 1933 “Love for Sale” 1934 “Experiment” 1935 “” 1936 “Begin the Beguine” Red, Hot and Blue 1936 “It’s De-Lovely” 1937 “I’ve Got You Under My Skin” 1938 “In The Still of the Night” Leave It to Me 1939 “My Belongs to Daddy” DuBarry Was a Lady 1940 “But in the Morning No” Broadway Melody 1941 “” Let’s Face It “Make a Date with a Great 1943 Psychoanalyst” “Hey Good Looking” 1944 1948 “I Love You” Kiss Me, Kate 1950 “” Out of this World 1953 “Use Your Imagination” Can-Can 1955 “” 1956 “All of You” “True Love”

Cole Porter playing the piano at auditions for the musical “Wait for Baby,” July 7, 1936. © Bettmann/CORBIS.

London, Paris, and Venice. Charles Schwartz, in his biography ­sustained bilateral open of Porter, wrote, “His name conjured up all the accouterments leg fractures in a horse- [sic] of international glamour: elegantly dressed people, sump- back riding accident. tuous houses, fancy cars, many servants.” 2p2 Married to Linda These injuries occurred Lee Thomas, the two were the darlings of the Café Society before the availability of intravenous in the years between the two world wars. The Porters were a antibiotics and modern techniques of fracture “must have” for any party, and the night was sure to be a suc- management, and he developed the dreaded complication cess if Porter could be persuaded to sit down at the piano to of chronic osteomyelitis with a draining sinus that plagued play and sing. Although their marriage appeared conventional him for the next twenty-one years. Scarcely a day went by that from the outside, Cole and Linda Porter had a special relation- he was not in pain. He underwent at least thirty-three opera- ship. Cole was a lifelong, promiscuous homosexual. tions in a futile attempt to get the bones to heal and eradicate At forty-six, during the height of his career, Porter the infection. The osteomyelitis was so severe that in 1958

The Pharos/Winter 2007 21 Cole Porter’s orthopaedic odyssey

Porter’s right leg was amputated above the knee. The ampu- The urbane francophile tation prolonged his life for almost six years but completely married a wealthy beauty extinguished his creativity. No condition highlights the dramatic advances of ortho- paedic surgery more than the management of open fractures and the prevention of chronic osteomyelitis. Porter’s obituary in tells us that “Porter was a trim, slight, dark man, groomed in subdued, elegant Porter’s parents—weak father, taste. He usually sported a boutonniere in the lapel of his well-tailored suits. His speech was quiet, reserved, almost determined mother clipped.” 1 His wealth permitted him to travel and live abroad at will, and he had a special love of Paris and things French. It was while he was in Paris in 1918 that he met his future wife, Cole Porter was born in the small town of Peru, , Linda Lee Thomas, a tall, slender divorcée with blond , on June 9, 1891. His father, Samuel, was a marginally suc- light blue eyes, and finely chiseled features. Schwartz writes, cessful pharmacist and a passive, ineffectual husband. His “She has been described as one of the outstanding beauties mother, Kate, was a strong-willed and determined woman. of her time; she was also bright and amusing, had impeccable She was the cherished daughter of one of the wealthiest manners and exceptional taste.” 2p52 She was also indepen- men in Indiana, J. O. Cole, who had obtained his fortune dently wealthy. Linda Lee was fifteen years older than Porter, from smart land investments that yielded coal, timber, and and it was rumored that her previous husband, newspaper heir oil. J. O. had had great expectations for his only grandchild Edward R. Thomas, had abused her. Perhaps this partially ac- in the business world, but Kate had different ideas. She counts for her tolerance of Porter’s behavior. She fostered his nurtured and encouraged Cole’s interest in music, im- creativity while overlooking his excesses. From the outset, the mersing him in violin, piano, and composition. At Kate’s two seemed to have an understanding about the limits of their insistence, Cole was sent East for a primary education at marriage. Porter, like others of his generation, hid his homo- Worcester Academy and then to college at Yale. Biographer sexuality behind a façade of heterosexuality. Nonetheless, the William McBrien wrote that Porter “had an utterly charm- couple was emotionally bonded, and in all his homosexual love ing Leprechaun . . . personality, which coupled with his gift affairs, Porter encouraged friendship between his lovers and of song, endeared him to everyone.” 3p55 After graduation his wife.3p103 Their marriage lasted for thirty-five years, until from Yale in 1913, Porter entered Harvard Law School, Linda’s death from emphysema in 1954.4pxv essentially to placate his grandfather. His interest in law was minimal and his exposure was brief. At the dean’s sug- gestion he transferred to the School of Arts and Sciences, Crushed legs . . . should where he took two music courses before abandoning cam- they amputate? pus life for the glitter of . He was determined to make a career as a popular . His first professional musical, , opened on March 28, 1916. It was a certified flop, closing after only In 1937 Porter returned to the United States while Linda fifteen performances. Discouraged and depressed, Porter remained in Paris. It was a difficult time for Linda, and she left for Paris, where he served for a time as a volunteer was contemplating divorce due to Porter’s increasingly indis- ambulance driver for the French Armed Forces. However, creet homosexual affairs.5p109 On his first weekend back in the he could not stay away from music for long. McBrien States, Porter accepted an invitation from Countess Edith di tells us that Porter’s experiences at Worcester, Yale, and Zoppola to stay at her estate in Mill Neck, near Oyster Bay on Harvard gave him a unique stylistic overview and versatil- Long Island.5p111 On October 24, while riding in the woods, ity that no other composers could challenge.3p76 He could his horse shied, reared, and fell on its side, crushing his leg. compose and arrange beautiful music, and he could write In attempting to rise, the frightened horse fell again, this time unforgettable lyrics. Dale Harris wrote, “All [his songs of- on Porter’s other leg, resulting in bilateral open fractures. He fer] sophisticated views of love; they express erotic feeling was taken to the hospital in Glen Cove. He was in shock and rather than tenderness or exhilaration.” 3p135 His career got unconscious for two days.5p112 Dr. Joseph B. Connolly, the a needed boost in 1928 when he wrote “Let’s Do It” for attending surgeon, observed such severe fractures that he the Broadway production of Paris. He continued to write recommended bilateral amputations in a telephone conversa- unforgettable scores for Broadway and Hollywood for the tion with Linda.2p180 Both Linda in Paris and his mother Kate next thirty years. in Indiana rejected the idea of amputations, knowing that

22 The Pharos/Winter 2007 Porter’s vanity could not withstand such mutilation. After Personal communication with Dr. Allen Silverstein, the Dr. Connolly promised to delay amputation, Linda rushed director of the Medical Records Department of New York back to the States and consulted with Dr. John J. Moorhead, Hospital, indicates that Porter’s medical records at Doctors an orthopaedic surgeon from New York City. Dr. Moorhead Hospital and many of the records from Columbia have been agreed that amputation was probably the best treatment, but lost. However, we can deduce what his treatment must have acquiesced to Linda’s plea to try to save Porter’s legs. been by consulting the contemporary literature and reviewing Porter’s left leg had sustained an open fracture of the tibia the history of open fracture treatment. and fibula. On the right he sustained an open, severely com- minuted fracture of the tibia and fibula with damage to the Open fracture treatment common peroneal nerve. Today we would call this a Grade Hippocrates: Grave prognosis III fracture or a mangled extremity.6p626 Porter was eventu- By the time Cole Porter had his accident in 1937, surgeons ally transferred to Doctor’s Hospital in Manhattan, where he had inherited a long and distinguished history of fracture treatment, but open fractures were still life-threatening. Hippocrates (460–377 BC) wrote about open fractures and discussed their grave prognosis. Death typically resulted from tetanus, gangrene, or septicemia.7p86 Ambrose Paré (1510– 1590) advocated amputation of limbs with open fractures, particularly fractures that had occurred during battle. In 1564 Paré introduced the use of ligatures to control the hemorrhage from such amputations.7p90

The Civil War: Amputations The next significant advancement in the treatment of open fractures was the introduction of debridement and mechani- cal cleansing of the wound attributed to Pierre-Joseph Desault (1738–1795).7p91 In 1786 John Hunter (1728–1793) recommended either amputation or treatment with a splint and a poultice of subacetate of lead, depending on the severity of the injury.7p90 However, amputation of open fractures continued to be the treatment of choice during the Napoleonic Wars, the Crimean War, and during the American Civil War. Following any major battle, a mound of extremities could be seen near the surgeon’s tent.8p296 Dominique-Jean Larrey (1766–1842), the greatest French military surgeon of his time, is said to have performed as many as two hundred amputations in twenty-four hours at Borodino during Napoleon’s Russian campaign.9pp487–88

Courtesy of the author Lister: Carbolic acid Joseph Lister (1827–1912) revolutionized the treatment of needed around-the-clock Dilaudid injections for the pain. His open fractures and wounds by applying Louis Pasteur’s (1822– right leg had such massive swelling that large blebs formed 1895) work on microorganisms to injured patients. Lister used on the skin, requiring treatment with Amertan, the ointment carbolic acid (phenol) to treat open fractures. On August 12, used that same year to treat burn victims of the Hindenburg 1865, Lister first employed carbolic acid in a case of compound dirigible explosion. Porter’s toes were numb, and he began to fracture, and the patient healed without complications.9p590 have excruciating paresthesias. He underwent two operations Lister’s first paper, “On a New Method of Treating Compound and remained heavily narcotized to control the pain. Fractures, Abscess, etc., with Observations on the Condition Despite the operations, the pain, the narcotics, and the of Suppuration,” appeared in 1867. In this paper, Lister re- general debility associated with immobility, Porter’s sense of ported on his satisfactory results of treatment of eleven cases humor and his rich imagination remained active. When Elsa of compound fractures.7p99 Maxwell and visited him a few days after the accident, he whispered to Miss Maxwell, “It just goes to show : Tetanus antitoxin and Dakin’s that can’t be wrong—they eat horses Despite these advances, open fractures continued to be instead of riding them.” 5p114 devastating injuries for the troops during World War I.

The Pharos/Winter 2007 23 Cole Porter’s orthopaedic odyssey

Fortunately, two discoveries greatly improved prognoses: the have been scrubbed with solvents such as benzine, alcohol, use of tetanus antitoxin injections, and the use of Dakin’s so- or ether, and flushed out with gallons of normal saline.11p1622 lution for wound irrigation. Bacteriologists Emil von Behring The wound edges would have been debrided, loose pieces of (1854–1917) and Shibasaburo Kitasato (1852–1931) discovered bone removed and discarded, and then the wounds closed and prepared tetanus antitoxin serum in 1891. This was the with silk sutures or left open to drain if the swelling prevented first successful treatment for “lockjaw.” Dakin’s solution, per- closure. Porter’s legs would have been placed in metal splints fected by organic chemist Henry D. Dakin (1880–1952) and or plaster casts because plates or screws were not then used in surgeon Alexis Carrel (1873–1944), is a mixture of 0.45 percent the treatment of open fractures.11p1624 After the operation, he sodium hypochlorite and 4.0 percent boric acid that is gentle would have been wheeled on a stretcher directly to his room. on the tissues but has excellent antibacterial properties. Intravenous fluid replacement was not used until after World War II, but it was common to administer a liter of fluid rec- 1935: Sulfa drugs tally after a patient returned from surgery, a procedure called The first clinically successful antibiotic was the sulfa drug proctoclysis.12p8 Prontosil, introduced by Gerhard Domagk in 1935.7p110 Sulfa drugs could be sprinkled on wounds, injected, or taken by His legs: Geraldine and mouth, but could not be administered intravenously. It was not until 1943 that penicillin became available for military use, Josephine and it was not sold commercially until 1945, much too late to influence the outcome of Cole Porter’s fractures. It is difficult for us to imagine Porter’s agony. He did get frequent injections of Dilaudid, but that only served to take 1937: Primitive the edge off his pain and had little effect on the paresthesias. emergency response Dr. Moorhead suggested that Porter write to distract his mind. Taking the cue, Porter wrote a collection of notes entitled, “A Few Illusions Caused by an Injured Anterior Popliteal In the autumn of 1937, when Porter was lying on the ground Nerve.” 5p114 Porter named his legs Geraldine, on the right, and in the forest with shattered and bleeding legs, organized Josephine, on the left. While Josephine was a sweet and oblig- emergency medical response was primitive at best. Regional ing leg, reflecting the good response to treatment, Geraldine Level I trauma centers with twenty-four-hour medical evacu- was “a hellion, a bitch, and a psychopath.” 3p213 He said, “There ation and home base surgical teams were forty years in the are about a thousand little men in these legs with sharp knives future. Porter’s riding friend, Benjamin Moore, had to ride and they’re jabbing all over,” 3p213 and wrote, back to the clubhouse to make a frantic call to the local North Country Hospital, only to learn that an ambulance was not the right foot is doing its best to fit into a shoe that is much available. Fortunately, he was able to get the Locust Valley Fire too short for it, but it persists and persists until some one Department’s ambulance to take Porter to the hospital.2p179 inserts, inside the cast, a jagged glass shoe-horn. Porter would have been brought to the hospital on the Fire A procession of little men with picks over their shoulders Department stretcher. His legs would have flopped and jolted choose a spot on the inner side of the instep of my right foot, the entire way because they would not have been splinted. In near the ankle, and start digging a hole.” 2p184 1937 application of a splint was considered a medical proce- dure, and laymen were prohibited from doing them.10p643 The As with the lyrics from many of his songs, Porter’s words from ambulance driver probably had to ring the doorbell beside the the hospital bed make his feelings almost palpable. emergency room door to gain admittance. A nurse would have Porter was discharged from the hospital around Christmas, come from the ward to let them in. She would have initially and his casts were removed on January 17, 1938, at which inspected Porter, and then had to call the doctor to come in time he wrote to a friend about his “coming out party.” 12p7 from his home. In February he re-fractured his left leg in a fall. He had been Porter would have been given 0.25 grain of morphine by drinking heavily (as he had for most of his life), and he also mouth for pain, 1500 units of tetanus antitoxin and 1000 was using narcotics and sleeping pills,3p215 which certainly units of perfringens and vibrion septique antiserum by must have compromised his balance and his judgment. In the injection.11p1620 Shock would have been treated with warm summer of 1938, he tripped again on a stair and refractured blankets and externally applied hot-water bottles. His wounds his left leg.3p217 From his correspondence we can tell that he would have been sprinkled with sulfanilamide (if available) and went on to develop an infected malunion of the left tibia, an covered with a dressing saturated with Dakin’s solution. When equinus contracture of the left ankle, an infected nonunion he eventually got to the operating room, his wounds would of the right tibia, and a decubitus ulcer on the right heel. In a

24 The Pharos/Winter 2007 letter to Nelson Barclift in March 1945, he wrote, services system, in-hospital multi-specialty trauma team, antibiotics, and orthopedic procedures. His riding partner On my left leg, Moorehead first had to break both bones would call 911 from his cellular telephone, and a Life Flight again, take out the jagged ends, splice the tendon of Achilles helicopter would be on the way within minutes. At the scene, and then further up on the tibia cut eight inches of bone to the paramedics or flight nurses would secure his cervical spine take the marrow out and graft over the fracture. . . . Luckily with a collar, immediately start intravenous fluids, and cover he didn’t find streptococci but staphylococci, which are less the open wounds with sterile dressings. Air splints would dangerous germs. . . . Then he operated on the right heel in be applied to immobilize the extremities, and he would be order to get the scar tissue out . . . I walk on crutches, short strapped to a backboard and immediately evacuated. As the distances, but the wheel-chair is used a great deal.3p29 helicopter was in flight, the trauma team would assemble and immediately descend on him as he entered the trauma bay. He was unaware that the staphylococcus osteomyelitis would Within minutes, he would have a secure airway delivering not be eliminated from his body until the amputation. one hundred percent oxygen, a pulse oximeter attached, and an arterial line inserted, as well as a large bore central venous Progress line and a Foley catheter. He would receive a complete physical examination, a hemogram, and urine and serum electrolyte and toxicological analyses. All of his vital signs would be stabilized and continuously monitored. His wounds would be cultured, and he would receive tetanus immunization. He would receive intravenous fluids to combat shock, and intravenous cephalosporin and aminoglycoside to prevent osteomyelitis.6p624 He would have a computed tomography of his body to rule out chest and abdominal injuries fol- lowed by a complete set of radiographs to look for other fractures of the spine, pelvis, and extremities. He would go immediately to the operating room where his soft tissues would be managed with debridement and high volume irrigation using at least three liters of normal saline per ex- tremity. His fractures would be anatomically reduced with ­intra-operative fluoroscopic control and rigidly fixed either with internal or external fixation, or a hybrid fixator. His wounds might be closed or left open, as they would have been in 1937, except that if they were left open, they would be covered with vacuum assisted closure device. Porter’s postoperative course would be much differ- ent in 2005. He would recover from surgery in the post- ­anesthesia recovery unit, where pain management would begin with narcotics and neuroleptics as necessary. He would continue to receive intravenous fluids, electrolytes, and antibiotics for up to five days as necessary. His legs would be elevated to reduce swelling, but the rigid skeletal fixation would permit early ankle and knee motion. His open wounds would continue to be managed with vacuum- ­assisted closure followed eventually by skin grafts, or soft tissue flaps when the wounds were ready. Porter would be mobilized out of bed and into a wheelchair within three to five days and discharged home by seven to ten days, to Cole Porter after his amputation, 1958. be followed as an outpatient in the orthopaedic clinic. © Bettmann/CORBIS. He would be fitted with a plastic ankle foot orthosis on the right side to control his foot drop, and he would be If Cole Porter had sustained his riding accident on October weight bearing with crutches by three to four weeks, and full 24, 2005, the outcome of his fractures and his life would have weight bearing by eight to ten weeks. Most likely, his fractures been much different, thanks to 2005’s emergency medical would heal primarily, but at the first sign of delayed healing,

The Pharos/Winter 2007 25 Cole Porter’s orthopaedic odyssey

he would undergo either a bone graft procedure or be fitted with an electromagnetic bone stimulator to facilitate fracture union. By six months, he could at least contemplate getting back on a horse, should he desire, with painless, intact lower extremities. Today’s combination of intravenous antibiotic therapy, soft tissue management, fracture stabilization, and early bone grafting has greatly improved the prognosis of open fractures. In 1937, Porter was left with a lifetime of pain, the necessity of undergoing thirty-three operations, the debility of chronic draining osteomyelitis, and ultimately, an above-knee amputa- tion in 1958. Considering his disability and chronic pain, Porter’s contin- ued musical activity is impressive: during this time he wrote the wonderful scores for Leave It to Me, , Kiss Me Kate, Can-Can, and Silk Stockings. It makes us appreciate References even more his creativity and joie de vivre. 1. Cole Porter is dead; songwriter was 72. New York Times 1964 Oct 16. 2. Schwartz C. Cole Porter: A Biography. New York: Dial Press; From “The Physician” 1977. 3. McBrien W. Cole Porter: The Definitive Biography. New Once I loved such a shattering physician, York: HarperCollins Publishers; 1998. Quite the best looking doctor in the state. 4. Gill B. Cole. Kimball R, editor. Woodstock (NY): Overlook He looked after my physical condition, Press; 2000. And his bed-side manner was great. 5. Grafton D. Red, Hot & Rich: An Oral History of Cole Porter. When I’d gaze up and see him there above me, New York: Stein and Day; 1987. Looking less like a doctor than a Turk, 6. Olson SA, Schemitsch EH. Open Fracture of the Tibial I was tempted to whisper, “Do you love me, Shaft: An Update. In: Ferlic DC, editor. AAOS Instructional Course Or do you merely love your work?” Lectures. Volume 52. Rosemont (IL): American Academy of Ortho- He said my bronchial tubes were entrancing, paedic Surgeons; 2003: 623–29. My epiglottis filled him with glee, 7. Peltier LF. Fractures: A History and Iconography of Their He simply loved my larynx Treatment. San Francisco: Norman Publishing; 1990. And went wild about my pharynx, 8. Ward GC. The Civil War: An Illustrated History. New York: But he never said he loved me. Alfred A. Knopf; 1990. 9. Garrison FH. An Introduction to the History of Medicine: He said my maxillaries were marvels, With Medical Chronology, Suggestions for Study and Bibliographic And found my sternum stunning to see. Data. Fourth Edition. : W. B. Saunders; 1929. He did a double hurdle, 10. Bancroft FW. Application of fixed traction for transporta- When I shook my pelvic girdle, tion of patients with fractures. Surg Gynecol Obstetrics 1936; 62: But he never said he loved me. 643–44. He said my vertebrae were “sehr schone,” 11. Walkling AA. Contaminated wounds and compound frac- And called my coccyx “plus que gentile,” tures. Surgical Clin N Am 1937; 17: 1619–24. He murmured “molto bella,” 12. Millam D. The history of intravenous therapy. J. Intravenous When I sat on his patella, Nurs 1996; 19: 5–14. But he never said he loved me. 13. Silverstein A. The brain tumor of and the legs of Cole Porter. Seminars Neurol 1999; 19 Suppl 1: 3–9. He lingered on with me until morning, Yet when I tried to pay him his fee, The author’s address is: He said, Why, don’t be funny, Department of Orthopaedic Surgery It is I who owe you money,” Stanford University Hospital and Clinics But he never said he loved me. 300 Pasteur Drive, Edward R144 Stanford, CA 94304-5341 Written for Nymph Errant (1933) 5pp118–19 E-mail: [email protected]

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