Allen Buckner Kanavel: Surgical proteus and founder of hand surgery

Abstract

Allen Kanavel possessed a protean skill set, excelling as an anatomist, clinical surgeon, surgical leader, surgical educator and surgical investigator. His investigations led to the foundation of a new surgical specialty, that of surgery of the hand. Additionally, he was a prolific author (>80 scientific articles, seven editions of his textbook Infections of the Hand). He also served as Chairman of Surgery at Northwestern University, President of the American College of Surgeons, of which he was a founding member, and he was also a charter member of the Society of Neurological Surgeons. In addition, he was a kind and humble person, and a devoted husband and father.

Keywords

Hand anatomy history of hand surgery history of surgery hand infections

Introduction

Allen Buckner Kanavel, MD, possessed a protean skill set, shifting from one role to another, with each role assumed in a masterful way. Kanavel was a surgical innovator, founding a new surgical discipline, Hand Surgery. He was a surgical leader: Founding member of the American College of Surgeons (ACS; 1913), ACS president (1931), Chairman of Surgery at Northwestern University Medical School (1919–1929), and a Charter Member of the Society of Neurological Surgeons (The Senior Society), 1920. Kanavel was a surgical scholar who authored more than 80 scientific papers, and served as founding member of the editorial board (1905) of Surgery, Gynecology and Obstetrics (SG&O; now Journal of the American College of Surgeons), and as Editor of SG&O 1935–1938. Kanavel was the author of Infections of the Hand, the definitive hand surgical text from 1912 until World War II, going through seven editions—the sourcebook for the new specialty. Kanavel was a multimedia educational pioneer: helped produce one of the first medical education movies, on hand infections, in collaboration with Eastman Kodak (1927). Clinically, he was a versatile surgeon, skilled in general surgery, orthopaedic surgery, plastic surgical procedures, neurosurgery, endocrine surgery, and gynaecology.

Figure 1 is a photograph of Allen Kanavel.

Figure 1.

Allen Buckner Kanavel MD FACS (1874–1938).

Allen Buckner Kanavel was born in Sedgwick, Kansas on 2 September 1874. His father was George Washington Kanavel (1845–1931) and his mother was Mary A. Kanavel, nee Paugh (1848–1915). G.W. Kanavel was a veteran of the U.S. Civil War, having served 1862–1865 in the 80th Ohio Regiment, under the command of William T. Sherman in the Western Theater. After the war, George settled with his family in Sedgwick, Kansas and became a farmer.^1–4

Allen grew up on the family farm. Allen was an excellent student, as review of his transcripts confirms, with averages for his classes ranging from 90 to 96, with an outlier of 85 in drawing. After completing high school, he journeyed to Chicago to enroll at Northwestern University (NU), matriculating 9 September 1892, commencing a lifelong association with NU (Northwestern University Archives, University library Evanston Illinois). He was an undergraduate there 1892–1896 and then enrolled in Northwestern University Medical School (NUMS) for one of the final 3-year cycles before the medical school converted to a 4-year cycle of study.⁵ Kanavel is listed in the Class of 1899 in the directory of Cook County Hospital Internes’ Alumni Association, 1866–1933 edition. Figure 2 is the Class of 1899 composite.⁶ Kanavel remained a loyal Northwestern Wildcat the rest of his life, even while later residing for much of each year in Pasadena, California. I speculate Kanavels’ proximity to Cal Tech prompted Robert Millikan, of the Cal Tech faculty, to solicit a donation to the Pasadena institution. Millikan had won the 1923 Nobel Prize for “work on the elementary charge of electricity and on the photoelectric effect.” Millikan wrote: “Dear Dr Kanavel, Would you not like to have me lay before you the associates scheme of the Institute?”. Kanavel politely demurred, “ I still have my association with Northwestern University Medical School, and feel that any interest I would have with any educational institution would naturally continue to be with the one I have been interested in all my life…” (nobelprize.org, winners in physics, accessed 20 May 2024, California Polytechnic Institute, Institute Archives, Millikan Papers 19–12).

Figure 2.

Northwestern University Medical School Class of 1899.

Per WW Chipman, after finishing at Northwestern University Medical School, Kanavel studied in Vienna for 6 months, possibly with surgical associates of the recently deceased Theodor Billroth (d. 1894), such as Eduard Albert and Anton von Elsenberg.^7,8 Following his study in Austria, Kanavel completed the prestigious 18 month internship at Cook County, with faculty luminaries such as Christian Fenger, John B. Murphy and Franklin Martin, to name just a few.⁹ The NU College of Arts and Sciences Directory of 1903 documents “…Interne Cook County Hospital 1900–1901, graduate study in Vienna, Austria 1899 …”. He joined the staff of NUMS in 1901.¹⁰ The Alumni Record of Northwestern University Medical School lists him as “instructor in surgery” as of 1901.¹¹ Initially, Kanavel was granted an outpatient clinic at Wesley Hospital.

Near Wesley were the Chicago Stockyards on Halsted Street. The slaughterhouses provided a hungry and growing nation with beef and pork, such that millions of animals were slaughtered yearly in a mechanized and rather chaotic fashion, as documented in the lurid Jungle of Upton Sinclair, and more recently by Dominic Pacyga. This assembly line production method led to high output of product, but also allowed for horrendous work-related injuries for the employees.^12,13

In the meantime, advances in anaesthesia (William Morton, Crawford Long),¹⁴ introduction of the anaesthesia record (Harvey Cushing and E.A. Codman),^15,16 antisepsis (Baron Joseph Lister)¹⁷ asepsis (Christian Fenger, W.S. Halsted),^18–20 allowed exploration into areas of the body previously out of reach. Where an open procedure was a virtual death sentence, usually due to infection, prior to these advances, by 1900, a patient could have a reasonable expectation of surviving an operation. In turn, enhanced awareness of functional aspects of anatomy allowed anatomically precise, anatomically respectful operations for breast cancer, thyroid abnormalities, and appendicitis,²¹ to name a few. Specialization of surgeons into various anatomic and functional areas followed. In Baltimore, to name just one locus, William Halsted encouraged trainees to concentrate on a single body system. In response to “encouragement from ‘The Chief,’” Harvey Cushing was a pioneer in neurosurgery, Hugh Young in urology, and William Baer in orthopaedic surgery, as examples of this trend.²² Similar changes were occurring simultaneously in other major medical centres in the USA and Europe, and Chicago was no exception. Led by J.B. Murphy, Christian Fenger and Nicholas Senn, the standards and range of surgery in Chicago advanced steadily during this time.²³

Kanavel came along at the onset this flowering of effective surgical subspecialization. From the outset of his career, Kanavel was mentored by Weller van Hook, NUMS surgery chair, and became van Hook's deputy with unrestricted privileges at Wesley by 1902. As Kanavel began his clinical career, he encountered severe hand infections, mismanaged, or not managed at all, leading to loss of productivity, loss of limb and even loss of life. Flexor sheath infections of the digits and infections of the deep spaces of the hand were poorly understood and were prone to propagate, often rapidly and disastrously, by unknown mechanisms.²⁴

In the Wesley laboratories, using his surgical and anatomic insight, Kanavel undertook a set of injections of radio-opaque barium paste into cadaveric digits and hands, thereby solving the mystery of synovial fluid drainage in the digits and hands. Using the new (1895) Roentgen rays, Kanavel mapped and demonstrated the anatomic parameters of digital tendon sheaths, and deep spaces of the hand.^25,26

Franklin Martin stated in 1934 that Kanavel, as a young man, may have been confined to bed for a time with a hand infection, perhaps adding a degree of urgency and personal insight to his studies.²⁷ Regardless of the precise genesis of the idea, the knowledge gained from Kanavel's patho-anatomic studies was the key that unlocked the door to anatomically appropriate and clinically effective treatment for hand infections. This work led to a set of landmark articles, the first of which appeared in 1905. Surgery, Gynecology and Obsterics was short of material for its third issue, and the associate editor (Kanavel) had to be persuaded to overcome his reluctance in order to submit to his own journal.^28,29 In his 1963 book Fellowship of Surgeons, Loyal Davis, former Kanavel resident, later NU Surgery Chair and neurosurgical pioneer, described the moment:

“…it was to be the beginning of an entirely new area to which surgeons were to devote themselves…”.²⁹ In a 1938 tribute following Kanavel's death, Davis commented further: “It is but given to a few to make such a fundamental addition to surgical knowledge.”³⁰ This marked the dawning of the surgical discipline of surgery of the hand.

Making the most of the constrained circumstances of the start of his surgical career, Kanavel was on his way. Demonstrating his protean talents, Kanavel was establishing himself clinically and in the laboratory. Administratively, he was involved in the Surgical Department of NUMS, and its educational and clinical missions, from the outset of his career.

At this point in time, surgical care in the US was not standardized, and quality of care varied widely, from proficiently administered, scientifically up to date, to technically inept, out of date treatment. Loyal Davis vividly documented such a situation in an abortive foray as apprentice to a general practitioner in his home town of Galesburg, Illinois. Davis became disgusted and discouraged by the situation, and returned to Chicago and NU to undertake advanced surgical training with Kanavel.^31,32

One of the problems pertaining to the advancement of surgical care was inadequate representation of surgical care, scientific and clinical, in journals of the day. This deficiency distressed Franklin Martin, an ambitious obstetrician/gynaecologist from Wisconsin who practiced in Chicago. Kanavel's abilities caught the eye of Martin, and Martin became a long-time mentor for Kanavel.

The lack of surgical representation in medical journals of the day led Martin to take matters into his own hands: the time had arrived for a new surgical journal. Kanavel was one of the four doctors summoned by Franklin Martin in September 1904 to launch this new journal, designed for the practicing surgeon, with current clinical and scientific content. The other doctors were carried along by Martin's enthusiasm and lofty rhetoric. The well-grounded Kanavel “…asked how the first issue would be financed, how large a journal it should be and how much a subscription should cost…He (Martin) knew that Kanavel was the most logical one of the four, the most practical, and the one least likely to be affected by his oratory…”.³³ From the outset, Kanavel was installed as Secretary of Surgery Gynecology and Obstetrics.³⁴ Kanavel owned 20 shares of the new corporation Surgical Publishing Company of Chicago, based out of Martin's office at 31 North State Street.³⁵

The new journal proved a success. Hand in hand with the efforts to expand and standardize the US surgical data base via Surgery, Gynecology and Obstetrics, a demand arose for in person surgical education. The Society of Clinical Surgeons was a 1903³⁶ step in this direction, and this inspired Martin, in 1910, to conceive of a plan to invite practicing surgeons to Chicago to experience in-person, “clinics” in surgery, staffed and taught by Chicago luminaries of surgery . Around this same time, Abraham Flexner's damning 1910 report on the state of medical schools in the US imparted additional urgency to raising the overall standards of surgical education and surgical care.^37,38

In November 1910, 10,000 invitations to the November 1910 Clinical Congress were issued. 200 responses were expected, and 1300 showed up.³⁹ Based on this gratifying response, and inspired by the English Royal College of Surgeons, Martin was motivated to consolidate this concept into the American College of Surgeons, founded in 1913 to advance the art and science of surgery. Kanavel was a charter member, later serving as President of the ACS in 1931–1932.^40,41

At Northwestern, Kanavel continued to advance academically, ultimately assuming the Chair of Surgery at NUMS in 1919, serving in that role until 1929. Documents from Northwestern University Archives in Evanston chart his academic course: Instructor in Surgery 1901–1902, Instructor in Clinical Surgery 1902–1907, Associate in Surgery 1907–1908, Associate Professor of Surgery 1908–1918, and Professor of Surgery, 1919–1938 (Northwestern University Archives, University Library, Evanston Illinois “Allen Kanavel”).

Kanavel's most prominent Northwestern surgical resident, Loyal Davis, undertook post-residency neurosurgical training at Harvard with Harvey Cushing. Davis later succeeded Kanavel as NUMS Surgical Chair (1933–1963).³¹ In turn, Davis taught, influenced, and trained numerous luminaries, including Thomas Starzl, father of the liver transplant, and architect of a 2300 paper CV.^42,43 Starzl, in a 2009 letter, commented on his time at Northwestern University Medical School and the influence of Kanavel's acolyte, Loyal Davis: “ By the time I came to Northwestern as a student in 1947, Dr Kanavel was no longer operating…As for Loyal Davis, the best I can do is send you the enclosed copy of The Puzzle People, an autobiography that I wrote18 years ago after my retirement from clinical (work) . In the index…you will find twelve separate entries under the name Loyal Davis—more than just about anyone to whom I referred…” (Thomas Starzl, letter to author, 27 May 2009).

For Kanavel, academic output commenced early, with his first paper, “An Inguinal Binder”, appearing in JAMA in 1904.⁴⁴ Papers followed on acute hand infections (1905)²⁸ varicosities of the female pelvis (1905),⁴⁵ splinting for fractures of the leg (1906),⁴⁶ surgery for leontiasis ossea of the skull (1907),⁴⁷ chronic hand infections (1907)⁴⁸ torsion of the greater omentum (1908),⁴⁹ fracture of the scaphoid (1908),⁵⁰ tenosynovitis of the hand in two parts (1909),^51,52 and surgery of the pituitary (1909).⁵³ Papers continued up to his death, including but not limited to: depressed scars, empyema, laminectomy, sympathetic nervous system and surgical anatomy of the trigeminal nerve.⁵⁴ As a testament to his neurosurgical skill, Kanavel was a charter member of the Society of Neurological Surgeons; the 19 founding members met in New York in 1922.^55,56

Away from work, Kanavel, Frederic Besley and Harry Richter, three young NUMS surgeons, shared bachelors’ quarters at 6027 Prairie Avenue on Chicago's South Side during ABK's early career (Chicago Medical Blue Book Citations via email, Galter Historical Library, Northwestern University Medical School⁵⁷). Kanavel met Olive Rosencrantz of Evansville, Indiana, and they were married in her hometown 8 October 1907.⁵⁸ Figure 3 is a 1904 photograph of Olive Rosencrantz. Kanavel and Olive were engaged by spring 1907, as the Kanavel family has a diary given by Allen to Olive “Given to Olive Rosencrantz by Allen Kanavel 1907 on the occasion of her trip to Europe before her marriage.”

Figure 3.

Olive Kanavel, circa 1904.

Before Kanavel embarked for Europe in WWI, he gave Olive another diary, with his address listed as “A.P.O. 731, Col. M.C., A.E.F., France.” Kanavel served in the Army Medical Corps, ultimately attaining the rank of Colonel during WWI. He was “attached to the Surgeon General's Office in Washington, and served as Surgical Consultant to the AEF”. An alumni survey for NU documents service as Lieutenant Commander in the Naval Reserve from 23 February 1911 until 2 May 1913. In 1912, he was made a Captain in the Army Medical Corps, thence to Major in October 1917, Lieutenant Colonel in May 1918, and Colonel in August 1918, with discharge 31 January 1919 (Olive Kanavel, 1917 Diary, Northwestern University Archives, University Library, Evanston Illinois).

After the war, Kanavel returned to Chicago, and by 1922, his address was listed as 924 E. 46th St on Chicago's South Side. Richard A Davis, MD, Loyal Davis's son, recalled meeting his stepsister Nancy Davis (later Reagan), and Dr Kanavel at the Parkway Tea Room near the intersection of Michigan Avenue and Superior Street. Richard spoke of Dr Kanavel's “…deep voice and kind manner.” Nancy also commented on Dr Kanavel's kindness⁵⁸ (Richard A. Davis MD, telephone interviews May 2009, Nancy Reagan email interview summer 2009).

Allen and Olive wanted a family, but were unable to have children themselves. In 1923, Kanavel and Olive adopted a set of newborn triplets. The mother of the triplets died shortly after giving birth, and the stunned father, with two children already at home, gave up the triplets for adoption. Kanavel and Olive assumed this challenge with ABK aged 49, and Olive aged 45.

Allen and Olive doted on the children. Olive lovingly recorded details of her children in a baby book: “…Date of birth October 30, 1923…weight … at birth: Patricia 4 lb, 12 oz., David 3 lb. 2 oz., Richard 4 lb., 6 ¾ oz….Came to Windermere East Hotel December 9, 1923. Miss Christiansen measured Patsy for auto basket, 22 inches, Apartment 516.” Timothy Kanavel reported that the triplets’ biological father, Dr Earl Stanton, came to visit the triplets, in the guise of a family friend, and the five biological children of Dr Stanton connected in the 1970s and celebrated holidays together as adults.⁵⁸ (Timothy Kanavel interview February 2017, Olive Kanavel baby book, Mary Woolsey Stanton Ancestry Search in US/Illinois Death index 1916–1947, Image of Newspaper Clippings attached to Ancestry file on Mary Woolsey Stanton)

At work, Kanavel was heavily involved with in person surgical teaching: Northwestern University Medical School hosted live surgical clinics and conferences. These meetings took place over a period of days. Alumni Week 1909 took place 31 May to 5 June 1909. “There will be practical demonstrations of the newer methods of Anaesthesia, including local anaesthesia, scopolamine and morphine, gas and ether, rectal administration of ether…In addition, there will be medical and surgical clinics held at Mercy, Wesley, St Luke's, Michael Reese, and County Hospitals….”. ABK was responsible for a surgery clinic at Wesley, Tuesday 1 June 1909 from 3 to 5 PM, with JB Murphy, Frederic Besley, and Harry Richter also carrying out clinics that same week.⁵⁷

To expand the reach of surgical education, Kanavel and the American College of Surgeons undertook a collaboration with Eastman Kodak to produce an educational motion picture on “Diagnosis and Treatment of Infections of the Hand.” Anatomic drawings were undertaken by Chicago artist Tom Jones, and animations created at Carpenter Goldman Laboratories in Long Island City NY in summer 1927. By January 1928, it was complete and ready to show: $$40.00 for 35 mm, $$15 for 16 mm. For outright purchase, $$250.00 for 35 mm, $$125.00 for 16 mm (Committee on Medical Motion Pictures, Box 5 Kanavel, Allen B “Infections of the Hand Correspondence 1927–1946", American College of Surgeons Archives).

For his most notable and enduring educational outreach, Kanavel consolidated his hand studies into a book, Infections of the Hand, in 1912. Charles Elliott commented: “During the early days a soap-box in his apartment was the repository of notes and observation on infections of the hand. From this soap box finally emerged the monograph that made its author world famous.”⁵⁹ Published by Lea and Febiger (L & F), with editions coming out in 1912, 1914, 1916, 1921, 1926, 1933 and 1939, the book was the definitive hand surgery resource until superseded by Sterling Bunnell's 1944 text.⁶⁰

The Historical Society of Philadelphia has records for L & F from 1815–1992. In these records are sales figures for the book: 30 June 1912, 1000 copies printed, by 31 December 1912, 313 copies were on hand. Royalty for 1912: $391.50. By 30 June 1913, 24 copies were on hand, and by 31 December 1913, 0 copies were on hand, and the 1913 royalty was $117.38.⁶¹ The press run of the 2nd edition, 2000 copies, sold out by 31 December 1915, with a royalty of $241.13⁶² The 5th edition sold out by 31 December 1933.⁶³ The book continued to increase in popularity, such that the 1933 sixth edition had a press run of 5000 copies, with a run of 3000 copies for the seventh and final edition.^64–66 The book became famous and gave rise to the eponymous Kanavel's signs of flexor tenosynovitis: from the 1912 edition: “1. Exquisite tenderness over the course of the sheath, limited to the sheath. 2. Flexion of the finger. 3. Exquisite pain on extending the finger, most marked at the proximal end. The fourth cardinal sign appeared in the 1926 edition: 4. Symmetrical swelling of the entire finger.”^67,68

Henry Marble and Edward Flynn, in an introductory chapter to the 1991 edition of Flynn's Hand Surgery, document that “…Surgery of the hand seemed to be almost completely neglected until the advent of Dr Allen B. Kanavel of Chicago.” Marble and Kanavel were able to cross paths, and Marble documented: In the second and third decades of this century infections of the hand were so common in the Massachusetts General Hospital that the senior author was able to demonstrate to each resident every type of infection of the hand, and every resident under his direction during his term of service had an opportunity to treat each type of infection as described in the Kanavel book (Early in their training the house staff complained that Kanavel's book was intricate and complex, but as greater knowledge of these infections unfolded during their term of service they found that it was much easier to digest. At one time the senior author told this to Dr Kanavel, saying: “My house staff finds your book hard to read”. To this Dr Kanavel replied, “You tell your house staff that I found it a much harder book to write.”⁶⁹).

Domestically, Allen and Olive were reportedly interested in property in Glencoe, Illinois, but, were always renters in Chicago. George Kanavel had had a California connection with business interests in banking in Riverside, California.⁷⁰ Allen and Olive purchased a lot in Pasadena, California and had a house constructed for themselves at 1015 South El Molino, built to the design of Wallace Neff, a prominent architect of the time (Compass.com : listing for 1015 South El Molino, Pasadena California, accessed 19 May 2024). They spent considerable time there as the years passed, with a vacation home at Big Pine, Inyo County, California. Figure 4 shows Allen and Olive at Big Pine. In 1935, Olive succumbed to leukemia. Allen had curtailed scrubbing by that time, limited by radiation burns of the hands, and by glaucoma as well.⁵⁷

Figure 4.

Olive and Allen Kanavel at Big Pine, Inyo county, California, circa 1929.

In May of 1938, the widower Kanavel was taking his sons Richard and David, along with a school friend, to the family lake house at Big Pine. Kanavel's car became entangled with another car and exited the road. The car rolled, ejecting Kanavel and killing him with a blow to the head. The boys were protected by fishing and camping gear in the car and were unharmed. Olive's sister Gertrude Hurst, and her husband W. Randolph Hurst, became guardians of the now-adolescent Richard, David and Patricia. The Kanavel triplets, and their offspring, have stayed in the Western USA (Timothy Kanavel interview February 2017).⁷¹

With his premature death at 63, Kanavel was prevented from participating in the management of hand care for US military personnel during World War II. World War II hand surgery care for the United States went to the expert guidance of Sterling Bunnell, the founder of organized hand surgery in the United States. Bunnell oversaw a well—structured set of hand hospitals during World War II, staffed by young surgeons with an interest in hand care. These doctors, with Dr Bunnell, went on to found the American Society for Surgery of the Hand (ASSH) in 1946, cementing the arrival of Hand Surgery on the stage of surgery and its various subspecialties. While the 1946 founding of the ASSH was a signal moment in the progression of Hand Surgery, it must be said that Allen Kanavel was there first. Bunnell was a sophomore medical student in 1905 when Kanavel's initial hand infection paper appeared. Multiple additional ABK hand infection papers were forthcoming in the years to follow, culminating in the 1912 release of the first edition of Infections of the Hand, the effective announcement of the birth of a new surgical discipline.

Allen Buckner Kanavel died in 1938, but his legacy lives on and looms large.

His text is still used as a teaching reference for resident (and attending) surgeons, and his protean talents help lay the foundation for powerhouse surgical, neurosurgical and orthopaedic surgical training at Northwestern University Medical School to this day, and his presence is felt every time a clinical examination of a patient with a hand infection occurs, at any location around the world.

Footnotes

Acknowledgements

Many thanks to those who contributed to the research that went into this study: Ron Sims, Sue Sacharsky, Susan Rishworth, Kevin Leonard, Richard A. Davis MD, Timothy Kanavel, Pinal County Arizona, Timothy Kanavel, Potomac, Montana, Harry Richter MD, Frank Milloy MD, Daniel Nagle MD, and the tireless Deborah Dobeisz.

ORCID iD

David Tate

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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