Vascular surgery: is our name Mudd or Quasimodo?

Abstract

Sic semper tyrannis (Thus always to tyrants) was the phrase uttered by John Wilkes Booth as he leaped 10 feet to the stage floor below from the Presidential box at Ford Theater after firing the fatal bullet into the brain of President Abraham Lincoln on Good Friday, Apr 14, 1865. Booth, an accomplished actor, was known for daring jumps and leaps during his performances, but on this occasion, after struggling in the Presidential box and stabbing Major Henry Rathbone, Booth was off balance and caught his spur in an American flag draped over the balcony, and landed awkwardly on the stage. This misstep resulted in a fractured fibula, and although Booth was mobile, he was now in need of medical attention. The resulting treatment of this fracture dramatically altered the life of one of our early medical colleagues, Dr Samuel Alexander Mudd. Dr Mudd was born on Dec 20, 1833, in Charles County, Maryland, where he became a farmer and a practicing physician after attending Georgetown College in Washington, DC, and ultimately graduating from the University of Maryland in Baltimore in 1856 after studying medicine and surgery. Times were hard because the country was in a depression, but Dr Mudd developed a successful medical practice and married his childhood sweetheart, Sarah Frances Dyer, on Nov 26, 1857. When shots were fired at Fort Sumter in Charleston Harbor on Apr 12, 1861, additional southern states seceded to join the fledgling Confederacy, but Maryland was not among them. Maryland was a border state, with a large number of Confederate sympathizers, including Dr Mudd. He continued his life as a physician and farmer during the ensuing Civil War, but was most likely a member of the Confederate underground and subsequently became acquainted with some soon-to-be famous people. In fact, Dr Mudd had met John Wilkes Booth on at least 3 previous occasions. Six months earlier, on Nov 13, 1864, Booth had attended St Mary's Church near Bryantown and was introduced to Dr Mudd, and possibly spent the night in his home. On Dec 18, 1864, in the Bryantown Tavern, and again on Dec 23, 1864, Dr Mudd had meetings with Booth, and introduced him first to Mr Thomas Harbin and later to John Surratt, both known Confederate Secret Service operatives with extensive local knowledge of the countryside, which Booth would need to aid him in a grand scheme to kidnap President Lincoln and take him to Richmond, Virginia, as a hostage to exchange for Confederate prisoners of war or to force a peace treaty favorable to the South. Booth recruited additional help for his abduction plan, including David Herold, Louis Payne, George Atzerodt, Michael O'Laughlin, and Samuel Arnold. An initial plan for abduction of Lincoln on March 17 failed when President Lincoln changed his schedule, and some of the conspirators lost heart and abandoned the group. Booth, however, had previously confided to his friends a desire to kill Lincoln. After the surrender of General Robert E. Lee to General Ulysses S. Grant on Apr 9, 1865, Booth began to organize a new plan, one of assassination. The evening of Apr 14 was selected for George Atzerodt to assassinate Vice President Andrew Johnson; Lewis Paine and David Herold were to kill Secretary of State William Seward; and John Wilkes Booth made plans to assassinate President Lincoln. (It is interesting to note, considering today's world, that Booth was able to visit the President's box on the afternoon of the assassination to drill a peephole in the door of the box and to later enter the box unchallenged because the single guard, Mr John Parker, had left the area to get a better view of the play!) During a key moment of laughter in the play, Our American Cousin, Booth entered the Presidential box, fired a single shot from his .44-caliber derringer into Lincoln's head behind his left ear, stabbed Major Rathbone, and leaped to the stage. Atzerodt had done some heavy drinking, but still lost his courage, and abandoned the attack on Vice President Johnson; Lewis Paine had seriously wounded Secretary of State Seward with a knife. David Herold was outside guarding Paine's mount, but subsequently fled on hearing screams from the Seward household. Herold and John Wilkes Booth met each other en route to Lloyd's Tavern in Surrattsville, Maryland, which was owned and operated by Mary Surratt (the mother of John Surratt). Whiskey was retrieved for self-medication, along with a package containing field glasses and a Spencer rifle that had been previously stored. Whether the original escape route was to proceed to Dr Mudd's home or was required because of Booth's injury is the subject of continued debate. At 4:00 am on Apr 15, 1865, Dr Mudd and his wife Sarah were awakened by 2 men banging loudly on the door of their home near Bryantown, Maryland. The horsemen identified themselves as “strangers from St Mary County” who were on their way to Washington, DC, when one of the men's horses fell and the rider's leg was broken. The injured man had a mustache and long chin whiskers. Dr Mudd later told interrogators that he did not recognize either man. He cut off the patient's boot, and after examining the leg concluded that the patient had a simple fracture of the fibula, 2 inches above the ankle. Dr Mudd set the fracture, and cut up a wooden box to fashion a splint for it. The injured man was put to bed, and Dr Mudd and the other traveler went to Mudd's father's farm and subsequently to Bryantown in search of a carriage or wagon to transport the patient. When none was available, the stranger returned to Mudd's farm while Mudd stayed in Bryantown to do some shopping. Soldiers were bustling about, and there was news of the assassination of President Lincoln, possibly by a man named Booth. The soldiers, however, had inadvertently picked up fliers with a picture of Edwin Booth, John Wilkes Booth's brother, and Dr Mudd would later testify that while in Bryantown he did not recognize the face on this flier as anyone he knew. On later returning to his farm around 5:00 pm, Mudd found the 2 men saddling their horses and preparing to leave. He directed the riders on a route through the Zekiah swamp. Mudd had his handyman make a pair of rough crutches for the injured man, and was paid $25 for his “global” services to the patient, but later testified he would have been willing to accept a lesser fee. On his return to the house, Sarah informed him that the injured man's beard was a disguise. The Mudds later testified that they were shocked at the realization of the possible identity of their visitors, but inasmuch as night was approaching, Sarah was afraid for her husband to leave, lest the 2 men might return. (What Sam knew and when he knew it would later become a significant issue). Sam waited until the next day, after Easter Sunday mass, to report the information to his cousin, another practicing physician, Dr George Mudd, who was a strong Union supporter. George agreed to pass the information along to the military, but did not do so until the next day, Monday. The soldiers in turn waited another day before coming to Sam Mudd's farm on Tuesday, Apr 18. Dr Mudd provided the valuable information of the route through the Zekiah swamp that the 2 had taken, and also that 1 of the men had a broken leg. The army officers searched the area and rode off, but returned 3 days later to conduct a further search. At this time Sarah presented the soldiers with the patient's cut boot that she had found, and in it was inscribed “Henry Lutz, Maker, 445 Broadway, New York, J. Wilkes.” Now the identity of the injured man was confirmed, and the officer, Lieutenant Alexander Lovett, abruptly changed his demeanor and “invited” Dr Mudd to accompany him to Bryantown for further questioning. The questions continued through the weekend, and on Monday, Apr 24, Sarah received news that her husband had been arrested for participation in the murder of President Abraham Lincoln! The assassin, John Wilkes Booth, was still at large. While Dr Mudd was in jail and the other conspirators were being rounded up, the search intensified for David Herold and John Wilkes Booth. Booth and Herold had traveled to the home of Samuel Cox, where they were given food and hid in the woods for 3 days before crossing the Potomac River to the presumed safety of Virginia. There was, however, a $100,000 reward on their heads, and Union soldiers were searching everywhere. Despite the reward, their escape attempt was aided by many southern sympathizers, and they arrived at Richard Garrett's farm south of the Rappahanock River near Port Royal on Apr 24. Time was running out, however, because a fellow passenger on the river ferry tipped off the Union soldiers, who on Apr 26 surrounded the Garrett tobacco barn in which Herold and Booth were hiding. The soldiers threatened to burn the barn, and David Herold surrendered. Booth refused to come out, and the barn was set on fire. As Booth hobbled within the burning barn, he was shot in the neck by Sergeant Thomas “Boston” Corbett and sustained a fatal spinal cord wound that severed the cord at the C4-5 level. He was paralyzed, but lived for 3 more hours, and stated before dying, “Tell my mother that what I did, I did for the good of the country.” Herold was returned to Washington and imprisoned with the other accused conspirators: Atzerodt and Paine, who had come to the boarding house (and frequent conspirator meeting place) of Mary Surratt while she was in the process of being arrested; Ned Spangler, who had aided Booth's escape from the theater; O'Laughlin and Arnold, who had abandoned the group after the failed abduction; and our own Samuel Mudd. The trial that followed for the defendants began on May 9, and was a military tribunal with 7 generals and 2 colonels sitting on the court, and a prosecutor who had served as the Secretary of War and had recently turned down the job of Attorney General. Things did not look good for the accused, who were granted legal counsel only 1 day before the trial began and were denied the opportunity to testify in their own defense! The first witnesses were heard on May 12, and the trial was completed on July 5. The prisoners were notified of the findings on July 6. All were declared guilty, and Herold, Atzerodt, Paine, and Mary Surratt were condemned to die the next day. Spangler was sentenced to 6 years at hard labor. Arnold, O'Laughlin, and Dr Mudd were sentenced to life in prison. Dr Mudd was spared the death penalty by 1 vote. The next day, July 7, the 4 condemned prisoners were hung in the penitentiary courtyard. Appeals and a plea for mercy to President Johnson on behalf of Mary Surratt were unsuccessful, and he was quoted as saying she “kept the nest that hatched the egg.” The 4 remaining prisoners were shackled in irons and chains and sent by boat to Fort Jefferson, an island prison in the Dry Tortugas, between Florida and Cuba, likened to Alcatraz or Devil's Island, from which escape would be difficult, as would communication with friends, family, and legal counsel. They arrived on July 24, 1865, and their spirits were not brightened by threats of punishment in the dungeon portion, where the door bore a quote from Paradise Lost: “Whoso entereth here leaveth all hopes behind.” Sam Mudd would have an opportunity to pass through this portal in chains after a botched escape attempt on Sept 25, 1865, 2 months after arriving, as he attempted to stow away on an outgoing vessel, the Thomas A. Scott. Back in Washington, DC, Sarah Mudd obtained an audience with President Johnson and asked for a pardon for her husband, protesting that his guilt had not been established, that he was merely a treating physician and had no knowledge of the assassination at the time of the treatment, and was the victim of a military court that was “out for blood.” In truth, though he almost certainly was a conspirator in the original abduction plot, there was no evidence that Dr Mudd was aware of the assassination when Booth arrived at his house. Also, he provided the information to the authorities that Booth had come to his home and had given information as to the direction Booth was traveling. In addition, briefs and appeals were filed in the courts to protest the trial of civilian defendants by military tribunal as unconstitutional. Dr Mudd's health had been failing while he was chained in the dungeon, but improved after a communication from President Johnson relaxed his punishment. Dr Mudd initially had hospital duties when he arrived in July 1865, but lost them after his escape attempt and was working in the carpenter shop, until Sept 1867 when an epidemic of yellow fever struck the mosquito-laden island prison and claimed the life of the post commander and the post surgeon, Dr Joseph Sim Smith, who had been a classmate of Dr Mudd at Georgetown College, and who enlisted Dr Mudd's help during the epidemic. Mudd took over the hospital, inasmuch as he had some understanding of yellow fever because he had encountered it while in medical school during an 1855 epidemic. This was a frustrating disease, because the manner of contagion was unknown and treatment options were limited. Sam Arnold and Dr Mudd both contracted the disease, but survived, whereas Michael O'Laughlin died of it. Two hundred seventy of 300 people at Fort Jefferson contracted yellow fever, and 38 died. It was the feeling of the entire prison that Dr Mudd's skills, knowledge, courage, and willingness to treat these patients saved many lives. Of significance, he now had the run of the fort and was looked up to as a gentleman and a physician. A petition to President Johnson was signed by all, and Major Andrew Stone, the post commander was going to Washington to help in the effort to free Dr Mudd; however, Major Stone contracted the disease, and died in Key West, Florida. The new commander, Major George P. Andrews, had not suffered through the epidemic, and he put Dr Mudd and the other conspirators back into a cell, in chains. The guards, however, remained grateful to Dr Mudd for his efforts, and thanks to his medical skills and dedication, life was much better than before the epidemic. President Johnson had political problems of his own, having survived potential impeachment by only 1 vote, on May 26, 1868, but the next year, on Feb 13, 1869, he kept an old promise to Sarah Mudd and wrote an official pardon for Dr Mudd. Dr Mudd returned home in March 1869, and resumed his medical practice and farming. He and Sarah had 5 more children in addition to their previous 4. He ran for Maryland state legislature, but lost in the primary, and the nation that had previously pardoned him never really forgave him. The derogatory term “Your name is Mudd” became an accepted, widespread phrase, and he and his family were subjected to threats and verbal abuse for decades. Sam remained dedicated to his medical practice, but on New Year's Day 1883 he contracted pneumonia after making a house call on a cold, rainy night. He took to his bed, and died on Jan 10, 1883, and was buried at the same St Mary's Church Cemetery in Bryantown, Maryland, where he had first met John Wilkes Booth 19 years previously. Dr Mudd's family has never been satisfied with the unconditional pardon granted by President Johnson, and have been working for more than 130 years to exonerate the name Mudd. A 1936 biography entitled The Prisoner of Shark Island won many friends for Sam Mudd and gave him American folk hero status. Numerous television productions about him have aired, a grade school was named after him, and in 1959 Congress established a memorial to him at Fort Jefferson. Presidents Jimmy Carter and Ronald Reagan wrote letters expressing their belief in Dr Mudd's innocence, but these were moral victories only. Finally, Senator Joseph Biden of Delaware asked the Secretary of the Army to reopen the Mudd case. A 5-member board of the Army Board for Correction of Military Records (ABCMR) was convened in 1992, and all 5 members agreed that Dr Mudd's trial had been a gross miscarriage of justice. The ABCMR concluded that the military commission that tried Dr Mudd did not have jurisdiction over civilians, and recommended that his conviction be set aside. The Assistant Secretary of the Army was William Clark, and he denied this recommendation on the basis that it is not the role of the ABCMR to attempt to settle historical disputes or to act as an appellate court. This was appealed, but 4 years later in 1996 the denial was upheld. In 1997 Congressman Hoyer of Maryland introduced a bill (HRR1985) in the House of Representatives to seek relief for Dr Mudd. When this bill stalled, the Mudd family filed a suit in the US District Court in 1998 and were successful in having the denial remanded back to the Secretary of the Army for review, but there has been no recent change in the status of this case, and as of this writing the family has never received any official notification from the Secretary of the Army exonerating the name Mudd.1McHale J.E Dr Samuel A. Mudd and the Lincoln assassination. Dillon Press, Parsippany (NJ)1995Google Scholar, 2Steers Jr, E His name is still Mudd. Thomas Publications, Gettysburg (PA)1997Google Scholar, 3Jones J.P Dr. Mudd and the Lincoln assassination the case reopened. Combined Books, Conshoken (PA)1995Google Scholar Now, what does all of this have to do with vascular surgery? Probably very little, but let's review some recent vascular history, and perhaps we will note some similarities or parallels. Denied on the basis of a “totality of criteria” was the response received from Dr Stephen Miller, Secretary of the Liaison Committee for Specialty Boards (LCSB) on Dec 22, 2002, in response to a request from Drs James Stanley, Frank Veith, Robert Smith, and the Board of Directors of the American Board of Vascular Surgery (ABVS) asking for an accounting of the committee's decision to deny the application of the ABVS to become a new examining board in medical specialties.4Hubson II RW. Presidential address: the American Association for Vascular Surgery: advocate for independence. J Vasc Surg 2002;35:1-7Google Scholar Since the early 1970s, prominent leaders in vascular surgery have strived for appropriate recognition of vascular surgery as a separate specialty. This issue has been ably addressed by several distinguished presidents of our most prestigious vascular societies, and began in Sept 1996 with incorporation of the ABVS to include the presidents, president elects, immediate past presidents, and secretaries of the Society for Vascular Surgery and the then current International Society for Cardiovascular Surgery, North American Chapter, 5 of which are current members of the Southern Association for Vascular Surgery (SAVS).5Stanley JC. Presidential address: The American Board of Surgery. J Vasc Surg 1998;27:2Google Scholar This action was not viewed favorably by the American Board of Surgery (ABS), because vascular surgery was at that time deemed a primary component of general surgery training and the ABS leadership was not inclined to consider modifying the then current training regimen. They did, however, acknowledge the need for additional expertise in the construction of vascular examinations, determination of standards of certification, and oversight of the certification process. Accordingly, in 1998 the Vascular Surgery Board (VSB) of the ABS was created to help address these issues. The VSB-ABS consists of 2 directors of the ABS nominated respectively by the joint council of the vascular societies and the Association of Program Directors in Vascular Surgery (APDVS), and 3 additional members appointed respectively by the American Association for Vascular Surgery, the APDVS, and the Society for Vascular Surgery, each of whom serves for 3 years. An additional ad hoc member can be added by members of the board at the wish of the board. The current VSB-ABS board includes 3 members of the SAVS, Drs Bruce Gewertz, past President James Seegar, and Jonathan Towne. The immediate previous chair was our past president, Dr Pat Claggett. These 2 boards, the ABVS and the VSB of the ABS, share a common goal to maintain and continue to improve the quality of care available for patients with vascular disease. This care includes the broad spectrum of medical management, noninvasive and invasive diagnosis, open vascular reconstruction, endovascular procedures, and critical care.6Vascular Surgery Board of the American Board of Surgery NewsletterGoogle Scholar The issues are related to how best to train for and deliver these services. It is my belief that our colleagues and teachers in the 1970s—Jack Wiley, Jessie Thompson, Sterling Edwards, James Deweese, our first SAVS President, John Foster, and others—were already on the right track in trying to define vascular surgery as a distinct specialty.7Wylie E.J Vascular surgery a quest for excellence.Arch Surg. 1970; 101: 645-648Crossref PubMed Scopus (32) Google Scholar, 8Cannon J.A Surgical judgment in vascular surgery.Arch Surg. 1971; 103: 521-524Crossref PubMed Scopus (11) Google Scholar, 9DeWeese J.A Blaisdell F.W Foster J.H Optimal resources for vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (45) Google Scholar, 10DeWeese J.A Vascular surgery is it different?.Surgery. 1978; 84: 733-738PubMed Google Scholar The ongoing efforts of the ABVS are correct in their intentions. In the interim between incorporation of the ABVS in 1996 and the present, dramatic changes have occurred across the spectrum of the treatment of vascular disease that make the issues even more relevant. Vascular surgeons have the best training and skills for evaluation and appropriate treatment of vascular disease. The recent technologic advances availing the improved diagnostic and endovascular treatment methods should become an integral part of every vascular surgeon's armamentarium and, more important, enjoy a major role in future vascular surgeon training. Herein lies the major conflict: how this can best be accomplished. Vascular training paradigms need to be altered to provide additional training for the expanded evaluation and treatment roles of endovascular therapies. Initial responses from the ABS and the Residency Review Committee for Surgery proposed an unacceptable training route, adding extra length to the current paradigm already considered by many as too long. This course was chosen to “protect” the large role of vascular surgery within the realm of general surgery training. However, with time, changes in some of the previous ABS personnel, and of importance, with appropriate input from the VSB of the ABS, progress has been made. Specifically, recertification in general surgery by certified vascular surgeons was made optional. The Board no longer requires that general surgeons perform a specific number of aortic procedures. Two vascular surgeons were added to the Residency Review Committee for Surgery, and an additional vascular surgeon appointed by the APDVS was added to the ABS. An early specialization program has evolved that will enable chief resident rotations in surgery during the fourth clinical year, as well as 2 years of vascular training with the candidates eligible for dual certification. They would be eligible for general surgery certification after the fifth year, and vascular surgery certification after the sixth year.11Expanded board sponsorship. Vascular Surgery Board of the American Board of Surgery Newsletter. Spring 2002. p. 3Google Scholar This is somewhat akin to the old joke, “What do you call a busload of lawyers at the bottom of the ocean? A good start.” Certainly, dual certification is an important, if not mandatory, concept for anyone who will need to practice or cross-cover call for general surgery patients. However, the new complexity of vascular surgery is such that a more desirable paradigm for many would be a 3 year plus 3-year program or possibly even later a 5-year vascular program, resulting in a fully trained vascular surgeon who does not desire to practice general surgery. The ABS previously changed vascular surgery from a “primary component” to an “essential content area” of general surgery training, and there will likely be a continuation of the current national trend toward decreasing numbers of vascular surgery procedures being performed by general surgeons. Whether any or all of this can be accomplished under the auspices of the ABS remains to be seen. Certainly, it would be desirable to have the prestige and numbers of the spectrum of the ABS on our side, because as vascular surgeons we are few, whereas the physician groups with whom we will compete to provide vascular care in the future are many. Primary sticking points are the issues of certification standards and the potential creation of a Residency Review Committee for Vascular Surgery to evaluate and approve training programs as desired by the ABVS. The ABS has scheduled a retreat this month to discuss these important issues, as well as the American Board of Medical Specialties (ABMS) key issue of inability to grant board certification in a subspecialty without the applicant having certification from the primary board; that is, is a separate vascular surgery board mandatory to accomplish our goals? In 2002, the ABVS expanded its original board of directors to include representatives from 1111Expanded board sponsorship. Vascular Surgery Board of the American Board of Surgery Newsletter. Spring 2002. p. 3Google Scholar of the remaining national and major regional professional organizations representing vascular surgery in North America. All 13 sponsoring organizations approved the now denied ABVS application that was submitted to the ABMS.12Board of Vascular Surgery Newsletter, Spring 2002Google Scholar This action had been approved in a 2001 independent poll of North American vascular surgeons conducted by DeLoite and Touche, which asked, “Should vascular surgery seek an ABMS-approved independent specialty board at this time? Sixty-six percent of respondents answered yes, including 79% of those in practice less than 10 years.4Hubson II RW. Presidential address: the American Association for Vascular Surgery: advocate for independence. J Vasc Surg 2002;35:1-7Google Scholar On June 18, 2003, Dr Jim Stanley filed a notice of appeal regarding the denial of the ABVS application to the ABMS. The language of this notice is strongly worded, and relates the ABVS frustration with the LCSB failure to communicate any definitive deficiencies in the completed massive application document. It delineates the grounds for appeal and expresses the desire for an appropriate open dialogue and forum with the ABMS to state the ABVS ideas and position on the issues. I was told by personal communication with SAVS past presidents Dr Robert Smith (Atlanta, Ga; Dec 2003) and Dr James C. Stanley (Ann Arbor, Mich; Dec 2003) that this appeal has been postponed pending information forthcoming from the scheduled ABS retreat. The intentions of the ABVS are well placed, and the members recognize the importance of working within and the potential “hazards” of working outside the guidelines of the ABMS.13Stanley JC. Letter to Stephen H. Miller. The American Board of Vascular Surgery Newsletter; Spring 2003. p. 1-3Google Scholar The members of these two boards, the ABVS and the Vascular Board of the ABS, represent the best and the brightest of our specialty, and I am hopeful they will find the appropriate common ground that will enable our societies to act in a unified manner toward our common goal of providing the best possible training for the treatment of vascular disease. As for Quasimodo, in Victor Hugo's Hunchback of Notre Dame I find many parallels with the beast we know as vascular surgery. On the surface, our specialty is not so “glamorous” as that of some of our colleagues. Often the persons in positions of authority, such as the LCSB, have been a little hard on us and made it difficult to achieve our goal as an independent board. To this point, we have been unable to garner much support from our colleagues on the ABS, and we may need to gather more positive public interest and support to aid our cause. The efforts of the ABVS have been worthwhile, as desperate times call for desperate measures, and someone must act to change the course of events. As vascular surgeons we are fortunate in that we love what we do. During many cases over the past 25 years, I have often told vascular fellows and residents that vascular surgery is to me what Notre Dame's bell, Big Marie, was to Quasimodo. It made him deaf, but he obviously enjoyed his work. My comment regarding vascular surgery is that “I love her, but she is killing me.” I have not mentioned the issues of limitations on residency training work hours or the problems related to access to training opportunities for continued development of endovascular skills, but these issues are critical components of our current training program dilemma. It appears that the leaders in our specialty are making significant progress in attaining our goal of, if not complete independence, at least control over the credentialing, training, and recognition of expertise required for vascular certification in the future. Like Sam Mudd, if we persevere in using our skills and dedication we may gain appropriate government support to gain our freedom and continue our practice. Or, like Quasimodo, we may have to be a bit more forceful and take matters into our own hands to achieve our goal. Either will require a unified effort from all concerned, and I urge each of you to stay abreast of these issues as they evolve, and be ready and willing to contribute time and resources to aid our vascular surgery leaders. I thank you for the honor of serving as your president this year and for the opportunity of speaking to you today.