TO REACH THE HEART:

CARDIAC CATHETERIZATION 

         

           In the operating room of a provincial Red Cross hospital in Eberswald, Germany, on an afternoon in 1929 a young intern, Werner Forssmann, stood behind the operating table, where a surgical nurse, Gerda Ditzen, was lying, unable to see him. Forssmann injected novocaine into his right elbow area, made a small incision, and

Werner Forstmann (Wikipedia)

inserted a needle through which he threaded a narrow ureteral catheter, 65 cm long, pushing it up a vein to the level of his shoulder. The nurse had initially volunteered for the catheterization and was awaiting the procedure, but Forssmann, having used her primarily to access the operating room, catheterized himself instead.

         To document the catheter’s position, Forssmann, catheter in place, and the nurse, furious but curious, headed down a flight of stairs to the X-ray room. Behind a fluoroscope, Forssmann viewed his thorax in a mirror held by Gerda as he pushed the catheter up until it reached his right atrium. Another doctor burst into the room, enraged, and tried to pull out the catheter, but the technician had already taken a few shots. 

         The general surgeon supervising Forssmann, Dr. Richard Schneider, had previously refused a request by Forssmann to perform the catheterization either on himself or a moribund patient and was now obliged to discharge him. Schneider saw, however, the importance of the experiment and helped Forssmann write a paper, published by the prestigious Klinische Wochenschrift.

X-ray published in Klinische Wochenschrift, 1929, of Forssmann with first documented
catheter placement. See reference below. (Courtesy Hathi Trust)

         Forssmann had prepared himself. As a student, he learned that French physiologists had catheterized animals for years without ill effects. Claude Bernard, for example, to settle an argument about whether most of the metabolism of the body (and the source of heat) took place in the lungs, the opinion favored by Lavoisier, or in peripheral tissues, the idea promoted by Gustav Magnus (who had shown that venous blood contained more CO2 and less oxygen than

Claude Bernard (Wikipedia)

 arterial blood). Bernard, using horses and    dogs, introduced thermometers on catheters   through the carotid artery into the left  ventricle and through the jugular vein into  the right heart, confirming a temperature  difference that favored Magnus’ opinion. 

         To settle arguments over the timing of the contractions of atria and ventricles a veterinary physiologist, A. Chauveau, and a Parisian physician interested in blood pressure, E. J. Marey (see last month’s essay), had also introduced catheters into animal hearts to produce tracings of the timing and the force of the contractions. 

         Additionally, Adolf Fick, a German physiologist in Würzburg, established in 1870 a formula for determining cardiac output: the amount of oxygen taken up by the lungs per unit time divided by the difference between arterial and venous contents of oxygen. This required the simultaneous collection of mixed venous and arterial blood coupled with measurements of gas exchange in the lungs. Mixed venous blood is found in the right atrium. 

         In Forssmann’s 1929 report he claimed that he had first tried catheterization on a cadaver and that a colleague had introduced the catheter into his arm but became uneasy and refused to continue, obliging Forssmann to finish the attempt alone. Both statements were false, as documented by the medical reporter, Lawrence Altman. It was a true self-experiment without preliminary trials. The medical community missed the significance of catheterization, however. His action aroused severe criticism and his surgical career suffered. Undeterred, a short time later Forssmann reported self-injections of contrast material through a catheter into his right heart to visualize the chambers. The medical community had little reaction. Overall, Forssmann catheterized himself nine times.

         Catheterization efforts were few and far between for several years. A young French physician, André Cournand, aiming to

André Cournand (Wikipedia)

practice pulmonary medicine, enrolled in 1932 as a resident on the Columbia Chest Service of Bellevue Hospital in New York. While there, he accepted an offer from Dickinson Richards to collaborate on research on pulmonary gas exchange. 

Richards, a graduate of Columbia’s College of Physicians and Surgeons, had begun a career in pulmonary physiology.  He and Cournand, studying emphysema, established abnormalities in the mixing of gases but for precision needed to measure blood flow through the lungs, a step requiring samples of right atrial blood. Cournand consulted a colleague in France, Pierre Ameuille, who had catheterized the right heart in over

Dickinson Richards (Wikipedia)

100 cases, introducing contrast solution to visualize the pulmonary circulation. Cournand reviewed the cases and, after trials in animals, he and Richards proceeded gingerly, in 1941, to catheterize humans. 

War influenced all three men. Forssmann had joined the Nazi party and served in WWII, spending three years near the eastern front treating wounded soldiers. After the war, barred from hospital posts as a former member of the Nazi party, he practiced urology in a small town. Cournand, when a first-year medical student, served in WWI as a medic, applying first aid and retrieving wounded from no-man’s-land between trenches. The two, from former enemy countries, first met in 1952 and Cournand later wrote the introduction to Forssmann’s autobiography. 

Richards served in WWI as an artillery officer and during WWII he and Cournand, using cardiac catheterization, worked on the wartime problem of the physiology of shock.  The three shared the Nobel Prize in 1956 for their contributions to cardiac catheterization. Research seemed to be a criterion for the prize.  As the Nobel Committee, speaking of Cournand and Richards, put it: “…the main point was that a well-known research group at a distinguished clinic had set their seal of approval on the method, which then made its triumphant entry into the world of clinical medicine.”

Cardiac catheterization is now a routine procedure, essential for modern cardiology and cardiac surgery.

         

 

 SOURCES:

 

Weibel ER, “Andre Frederic Cournand, 1895-1988: A Biographical Memoir.” Nat Acad Sci, Biographical Memoirs, 1995.

 

Cournand A F and Ranges HA, “Catheterization of the Right Auricle in Man.” Proc Soc Exptl Biol Med 1941; 46: 462-6. 

 

Buzzi A, “Claude Bernard on Cardiac Catheterization,” Amer J Cardiol 1959; 28: 405-9.

 

Altman L, Who Goes First: The Story of Self-Experimentation in Medicine. 1987, Random House.

 

Ameuille P, et al, “Remarques sur Quelques Cas d’Artériographie Pulmonaire chez l’Homme Vivant.” Le Concours Médical 1936; 58: 3308. (The report contains little information of a physiologic nature.)

Forssmann W, Experiments on Myself: Memoirs of a Surgeon in Germany. New York: St. Martin’s Press; 1974.

Cournand A F, From Roots to Late Budding: The Intellectual Adventures of a Medical Scientist. Gardner Press, N.Y; 1986 

Cournand A F, “Cardiac Catheterization.” Acta Medica Scandinavica 1975; 198 (issue S579): 7-32. (A history of cardiac catheterization).

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

 

 

 

 

 THE SOUNDS OF KOROTKOFF

         Inflating a cuff on the arm and applying a stethoscope to record the blood pressure as the cuff is deflated is a routine procedure in any medical office. So routine that one rarely thinks about how it began.

         The idea of measuring the pressure impelling blood through the body arose primarily out of physiologic curiosity. Stephen Hales, an eighteenth-century clergyman, investigated it by inserting a cannula

Stephen Hales measuring a horse's 
blood pressure (from Haemastatics,
third edit)

into a major artery of animals, most notably a horse, and measuring the height to which the blood ascended in a calibrated tube. Other investigators followed suit, using mercury columns and other measuring devices. 

Was the blood pressure in man medically important? This was not understood for some time. In 1836 Richard Bright, at Guy’s Hospital in London, noted a “hard pulse” in cases of “albuminous urine” (chronic kidney disease) that were often associated with hypertrophy (thickening) of the left ventricle.

But many patients with ventricular hypertrophy turned out to have normal kidneys. Frederick Akbar Mahomed, also at Guy’s Hospital, picked up on the findings of William Gull and Henry Sutton who had described cases of normal or near-normal kidneys and ventricular hypertrophy that showed thickened walls of small arteries. Mahomed reported additional patients in 1881 as “Chronic Bright’s Disease without Albuminuria.” The report by Mahomed seems to be the first to describe the clinical picture recognized today as essential hypertension, a silent disease progressing from nosebleeds to heart failure and cerebral hemorrhages. Determining blood pressure became medically important.

Meanwhile, measurement techniques progressed. One of several investigators, Étienne-Jules Marey, a French

Étienne-Jules Marey (Wikipedia)

physician/cinematographer, had designed a varying pressure pad applied to the radial artery, recording the pulse curves on a tape and defining the systolic pressure as the level of compression to obliterate the pulse on recorded tracings. Marey was actually more famous as a developer of movies and “animated photography.” His technique revealed that all four hooves of a horse were raised briefly off the ground during a gallop, later confirmed by Eadweard Muybridge at Leland Stanford’s ranch. Mahomed, using a device similar to Marey’s, skipped the recordings and felt, below the pad, the onset of a pulse as the pad pressure loosened. 

Mahomed's blood pressure device, based on model of Marey, attached to wrist or arm.
(Med Times Gazette 1872)

Several other devices appeared but were impractical for clinical use. The earliest that resembles the modern cuff was designed by Scipione Riva-Rocce, an Italian physician. The use of a wider,

inflatable cuff attached to a mercury manometer, was the major improvement. The systolic pressure was still obtained by feeling the onset of a pulse below the cuff as it loosened. 

Riva-Rocci BP apparatus (Zimmerman
 instrument catalogue, 1903, Bauhaus
Universität Weimar)

The modern approach, determining systolic and diastolic pressures by using a stethoscope, was invented by Nicolai Sergeevich Korotkoff. Korotkoff began life in Kursk, the capital city of the region invaded recently by Ukraine. He studied basic sciences at Kharkov University and medicine at Moscow University, followed by postgraduate work at Moscow’s Alexander

Nicolai Korotkoff (Wikipedia)

Bobrov Surgical Clinic. In 1903, one of Russia’s finest surgeons, Sergei Fedorov, invited him to a residency in the Imperial Military Medical Academy in St. Petersburg, the most prestigious medical center in Russia. Fedorov was the founder of the urological association in Russia, a friend of William Mayo, and eventually “life-surgeon” to the imperial family. 

Korotkoff interrupted his studies at the Bobrov clinic in 1900 to join the Red Cross as a surgeon in a Russian military expedition to China to quell the Boxer Rebellion. He found traumatic arterial aneurysms (ballooning of the vessel after trauma) to be relatively common. He volunteered again during the Russo-Japanese war of 1904-5, going to Manchuria as chief surgeon in a Red Cross unit and encountering more post-traumatic aneurysms. A dictum of Nikolai Pirogov, perhaps Russia’s most famous surgeon (see essay of Dec 11, 2016) had been to always auscultate aneurysms, or lumps that might be aneurysms. Korotkoff heeded this advice in Manchuria. In addition to placing the stethoscope on aneurysms he applied Riva-Rocce inflatable cuffs to limbs and was able to determine with a stethoscope that the transmitted sounds corresponded to the palpable pulse felt below the cuff, thus correlating the palpated pressure with audible sounds. This allowed him to assess whether there was sufficient collateral circulation to preserve the involved limb. It also established a diastolic level that correlated with laboratory determinations.

Imperial Military Medical Academy, Saint
Petersburg (Wikipedia)

Korotkoff reported his experience in a brief (207 words) paper to the Military Medical Academy in December 1905. The method was validated in the hospital’s therapy department and adopted in Russia and elsewhere in Europe. In 1916 the American physiologist, Joseph Erlanger (who later shared a Nobel Prize for work on nerve

Joseph Erlanger 
(Wikipedia)

fiber functions) published detailed studies of the Korotkoff method, confirming its accuracy and ensuring its adoption in America.  

In 1910 Korotkoff published his thesis for Doctorate in Medicine on estimating collateral circulation. Unfortunately, Korotkoff, like his compatriot Anton Chekhov, whose stories he frequently read, had developed tuberculosis. Believing that cold, dry air would benefit him, he signed on for two years as physician at a gold mine facility in Siberia. On arrival, he was shocked and distressed at the workers’ desperate conditions, overworked and poorly fed. His protests led nowhere. During a strike many workers were massacred, a tragic event publicized worldwide. When his contract was up, he resumed hospital work in surgery, continuing through WWI and the 1917 Revolution. But his health deteriorated steadily and in 1920 he suffered a massive hemoptysis and died of the same disease that had felled his literary companion, Chekhov, in 1904. 

Korotkoff’s simple method of determining blood pressure, devised under battle conditions for reasons unrelated to general health, is now the standard method used worldwide.

 

SOURCES:

 

Fishman, A P, and Richards, W R, Circulation of the Blood: Men and Ideas. 1964, Oxford Univ. Press. Chapter VIII.

 

O’Rourke, M F, “Frederick Akbar Mahomed,” 1992; Hypertension 19 (2): 212-17.

 

Segall, H N, “How Korotkoff, the Surgeon, Discovered the Auscultatory Method of Measuring Arterial Pressure.” 1975; Ann Int Med 83: 561-2.

 

Konstantinov, I E, “Nikolai S Korotkov: A Story of an Unknown Surgeon with an Immortal Name.” 1998; Surgery 123 (4): 371-81.

 

Booth, J, “A Short History of Blood Pressure Measurement.” 1977; Proc Roy Soc Med 70: 793-99. (contains translation of original paper.)

 

Lewis, W H Jr, “The Evolution of Clinical Sphygmomanometry.” 1941; Bull N Y Acad Med 17: 871-81. (contains translation of original paper.)

  

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

 PHOTOGRAPHY AT THE SALPÊTRIÈRE: GUILLAUME-BENJAMIN DUCHENNE 

         The tumult of the French Revolution of 1789 swept away the existing structure of medicine. A new feature was the utilization of “hospices,” institutions where the poor, aged, and mentally ill were housed, as places of medical instruction. The Salpêtrière, for example, grew into an important teaching institution, made especially famous by the astute and flamboyant neurologist, Jean-Martin Charcot. 

         Charcot had served an internship at the Charité Hospital on the service of Pierre-François Rayer, a prominent physician and the first to see the anthrax bacillus. At the Charité, Charcot met a curious,

Jean-Martin Charcot (Wikipedia)

quiet man usually carrying a wooden box containing a battery pack and electrodes. His name was Guillaume-Benjamin Duchenne de Boulogne (de Boulogne added to distinguish him from other Duchennes) and he was a fervent believer in electricity as a diagnostic agent and treatment modality. While most doctors eyed him with skepticism, Charcot saw value in his work and befriended him.

         Guillaume-Benjamin Duchenne was born in Boulonge-Sur-Mer in northern France in 1806. His father was a ship captain and corsair during the Napoleonic Wars. Guillaume turned to

Guillaume-Benjamin
Duchenne (Wikipedia)

medicine, studying in Paris under notable teachers such as the surgeon Guillaume Dupuytren and pathologist Jean Cruveilhier, graduating in 1831. He returned home, prospered in private practice, and married. His wife died of sepsis after childbirth and, because he had been involved in the birth, his wife’s family considered him responsible and refused him custody of the surviving son. Duchenne remarried a few years later and, at about this time, became intrigued by the possibilities of electricity in medicine. Jean-Baptiste Sarlandière, a collaborator of the experimentalist Magendie, advocated a technique of enhancing acupuncture treatments by introducing an electric current through the needle. Duchenne sought a less painful approach and designed a portable apparatus that employed small surface electrodes to the skin. He soon found that by stimulating individual muscles he could study their function. Though a quiet man, Duchenne had a determined will and, to employ his new invention on a larger scale, he moved to Paris.

Diagram of Duchenne's apparatus ( from De L'Électrisation
Localisée, Internet Archive)

         Being unknown in the Paris medical scene, Duchenne survived by working long hours in charity hospitals, carrying his batteries and electrodes with him. Quietly, he mapped muscular function and could show exactly which muscles functioned poorly or not at all in various conditions. Contrary to his general reception, he was appreciated by Armand Trousseau at the Hôtel Dieu and by both Rayer and Charcot at the Charité. When Charcot became a professor at the Salpêtrière in 1862, he brought the much older Duchenne with him, offering him freedom and funds to pursue his studies among the over 5,000 residents, primarily elderly women.

         Duchenne found much to study. He combined detailed clinical observations with careful electrical stimulation data to describe several new conditions. At the time, knowledge of the neural connections behind movements was still incomplete and Duchenne’s inveestigations added much to clarify various points. His work influenced Charcot in his decision to focus on neurology. Duchenne eventually published a large tome on the results of his studies, revised in two further editions.

          Though he was not the first to describe it, his name is associated with the childhood disorder of pseudohypertrophic

Child with pseudohypertrophic 
muscular dystrophy, photo by
Duchenne (Album de photographies pathologiques)

muscular dystrophy, or Duchenne muscular dystrophy. He added much clinical detail and, probably based on an instrument used in Germany to biopsy cases of trichinosis, invented a smaller, relatively painless needle for in vivo biopsies. He also described a variant of amyotrophic lateral sclerosis, other muscular dystrophies, the consequences of syringomyelia, and found through electrical studies that “essential paralysis of childhood,” now called polio, was a motor neuron disease (unknown at the time). He investigated a common gait disorder, locomotor ataxia (tabes dorsalis), already described by Moritz

Duchene's biopsy 
needle (De L'Élect-
risation Localisée,
3rd edit., Bib Nat Paris)

Romberg, providing additional clinical detail and, by demonstrating the integrity of the muscles through electric stimulation, showed that the disorder was spinal in origin. Neither he nor Charcot associated tabes with the true cause, syphilis.

         Another great medical contribution of Duchenne was the use of photography. His cameras recorded pathology specimens, including histologic sections, and photographed neurons for the first time. Most impressive was a publication showing that the stimulation of various facial muscles produced expressions of emotional states. For this he was assisted by Adrien Tournachon, brother of Felix Tournachon (famous as Nadar, famous portrait photographer). Duchenne applied his electrodes many times to an elderly, obliging ex-cobbler (less often to other subjects) to reproduce emotional facies.

Creating a grimace with electrodes
(Mécanisme de la Physionomie Humaine)

The publication, Mechanisms de la Physionomie Humaine, generated wide admiration, especially in artistic circles. Charles Darwin used samples when he wrote The Expression of the Emotions in Man and Animals. He discusses several known works of art in which the facial expression, in his opinion, does not match the emotional situation. He cites, for example, the Laocoön (a copy in Brusssels), whose large, struggling figure had, he felt, a “physiologically impossible forehead.” It is significant that Duchenne left his personal photograph album to the École de Beaux Arts.

       

The Laocöon in the Vatican. Duchenne referred to a copy in Brussels (Wikipedia)

  Duchenne’s talents and discoveries became widely appreciated. He received the Chevalier de la Légion d’Honneur and honors from abroad, though he never had a university appointment. Tragedy darkened his last years. In 1870, after the Franco-Prussian War broke out, his estranged son, who had joined him in Paris in 1862 and opened a practice in neurology, succumbed to typhoid fever and his wife also died that year. Duchenne carried on, keeping company with medical friends, until 1875 when he suffered a stroke, dying shortly thereafter. Charcot, who frequently declared how much he learned from Duchenne and shared an interest in art, was at his bedside in his final hours.

 

SOURCES:

 

Parent, A, “Duchenne De Boulogne: A Pioneer in Neurology and Medical Photography.” Canad J Neurol Sci. 2005; 32: 369-77.

 

Nelson, K R, Genain, C, “Duchenne de Boulogne and the Muscle Biopsy.” J Child Neurol 1989; 4: 315.

 

Borg, K, “The Man Behind the Syndrome: Guillaume Duchenne.” 1992; 2: 145-54.

 

Duchenne (de Boulogne), G.-B, Mechanisms de la Physionomie Humaine ou Analyse Électro-Physiologique de l’Expression des Passions. 1862, Paris.

 

Berry, D, “Pierre-François Olive Rayer: Biography.” Medical History Suppl. 2005; 24: 7-13.

 

Siegel, I M, “Charcot and Duchenne: Of Mentors, Pupils, and Colleagues.” Perspect Biol Med 2000; 43 (4): 541-47.

 

Goetz G G, Bonduelle M, Gelfand T, Charcot: Constructing Neurology. 1995, Oxford Univ Press.

 

Duchenne de Boulogne, G-B, Album de Photographies Pathologiques Complémentaires du Livre Intitulé De l’Électrisation Localisée. 1862, Baillière, Paris.

 

Cuthbertson, R A (Editor and Translator), The Mechanism of Human Facial Expression by G-B Duchenne de Boulogne. 1990, Cambridge Univ Press.

A full index of past essays is available at: 

https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

THE SALPÊTRIÈRE AND THE BEGINNING OF PSYCHIATRY

         Some of Paris’ largest hospitals originated with far different purposes than medical care. France was exhausted after the Thirty Years’ War, ending in 1648, and a subsequent civil war that further ruined the economy and drove thousands of impoverished citizens into the capital. To prevent public unrest, leading members of the Parlement won a royal edict from the young Louis XIV to create the Hôpital Général, a group of buildings to shelter the poor and to provide both religious and work-oriented instruction. In relation to medical history, three buildings of the Hôpital Général stand out: the Bicêtre (for men), La Pitié (for children), and the Salpêtrière (for women). The Salpêtrière occupied the old city arsenal, its name derived from the saltpeter used to manufacture gunpowder. 

The Salpêtrière shortly after the chapel tower was added (Wikipedia)

A large chapel, whose dome dominates the structure, went up in the later 1600s as part of an overall expansion. 

         The poor and disabled filled most beds. Those with medical/surgical problems went to the Hôtel Dieu, Paris’ central hospital. Mentally ill and epileptic women, categorized at the time as custodial problems, lived in separate divisions, often enchained and ill-treated. In 1684 a prison was added to house prostitutes and other female “undesirables” and soon earned a bad name. 

Prostitutes on the way to the Salpêtrière, by Etienne Seurat, 1755 (Wikipedia)

        In the early 1700s the government dispatched hundreds of women from the prison to populate French colonies in the New World, settled by men. In 1792, during the French Revolution, a drunken mob entered the prison, dragged 45 women out and massacred them. Order was eventually restored and in 1795 authorities abolished the prison.

Medicalization of the Salpêtrière began only in 1780 with the inauguration of an infirmary, followed by a resident doctor in 1783, thereby reducing the number of sick previously dispatched to the Hôtel Dieu.     

         The Revolution brought about extensive changes in the medical world. The new government founded medical schools that accepted students and faculty based on merit. The hospices assumed new medical functions, offering abundant patient material for teaching and study. Autopsies revealed new information on disease processes and bedside teaching flourished. Introduction of the stethoscope and the rediscovery of percussion opened new methods of premortem diagnosis. At the Salpêtrière, an important step was the appointment of Dr. Philippe Pinel as medical director in 1795.

         Philippe Pinel was born in 1745 in the Department of Tarn,

Phillipe Pinel (Wikipedia)

southern France. His father and both grandfathers were physicians. At the University of Toulouse, he studied mathematics and obtained a degree in medicine. He moved to Montpellier to further his medical studies, supporting himself by tutoring in mathematics and Latin. Next, he moved to Paris, surviving at first by tutoring. He advanced slowly, partly due to extreme shyness, wrote medical articles, became editor of the Gazette de Santé, translated William Cullen’s Institutes of Medicine, and met important physicians who appreciated his learning. After the French Revolution, in 1793, he received an appointment as “physician of the infirmaries” at the Bicêtre Hôpital, a hospice similar to the Salpêtrière but reserved for men. 

In Ward 7, containing 700 mentally ill men, Pinel he found the “governor” (administrator), Jean Baptist Pussin, managing the patients without chains or beatings, contrary to the usual practice at the time. Pussin penned a summary of his experience, probably at the request of Pinel, in which he noted that patients responded well to gentle treatment. For those who persisted with violent behavior he used what is now called a straitjacket, allowing the patient some movement without risk to others. Pinel, impressed, presented the novel method of care to the Society of Natural History, a politically neutral haven for physicians during the chaotic revolutionary days, in 1794, acknowledging the work of Pussin.

         The next year, Pinel was transferred to the Salpêtrière as “physician in chief,” and brought Pussin with him. Imbued with scientific sentiments of the enlightenment, Pinel embarked on a study of over 1,000 patients to help plan treatments. He combined statistics and probability techniques and emphasized the value of experiments. He wrote that experiments must “fairly report the proportion of positive and failed results, all of which are instructive. It must therefore be based on the theory of probability which must henceforth be basic to medical therapies.” (Weiner, “Philippe Pinel in the Twenty-First Century”) The historian Edwin Acknerknacht has called him the “actual father of the numerical method in medicine.” 

For the mentally ill, Pinel instituted a kind, though firm, rehabilitation program that included a detailed history of the illness and the patient’s background and usually advised a work program. He reduced bleeding and many medicines as treatments.

1857 Lithograph by Armand Gautier:  Personifications of dementia, megalomania, acute mania, melancholia, idiocy, hallucination, erotic mania and paralysis at la Salpêtrière. (Wellcome Library)

    He found time to write texts, including a book on mental illness and one on internal medicine and taught at the University. His

Pinel's text on mental illness,
first ed.,1801 (year 9 in
Revolution calendar)

students included Xavier Bichat and René Laennec. After the restoration of the monarchy, the liberal Pinel was dismissed from the Salpètriére in 1822. Though an important figure in many ways, he is primarily remembered today as a father of modern psychiatry. Pussin’s role is under-appreciated. Similar approaches to the mentally ill were also underway in England, the German states, and America.

Two striking paintings commemorate Pinel’s work. The first, commissioned in 1849 by the Académie de Médecine, shows Pinel dramatically gesturing toward an attendant, presumably Pussin, who is removing chains from an emaciated, elderly man in the Bicêtre, a depiction that distorts the role of Pussin. (Painting and information on artist viewable at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/207397

        The other, set in the Salpêtrière, shows Pinel supervising the release from chains of a somewhat dazed woman, again ignoring Pussin. It hangs now in the Salpêtrière.

 Pinel at la Salpêtrière (1876) by Tony Robert-Fleury (Wikipedia)

The Salpêtrière today is a huge hospital complex, particularly famous for its neurology center, created by the famous Jean-Martin Charcot. But that story is for another time.

Front entrance of the Salpêtrière today. The chapel dome is behind entrance. (by author)

SOURCES:

 

Ackerknecht, E, Medicine at the Paris Hospital 1794-1848. 1967, J Hopkins Press.

 

Foucault, M, Madness and Civilization: A History of Insanity in the Age of Reason. 1965, Random House.

 

Weiner, D B, “The Apprenticeship of Philippe Pinel.” Clio Medica 1978; 13 (2): 125-33.

 

Weiner, D B, “Philippe Pinel in the Twenty-First Century.” Chapter in Wallace, E R and Gach, J, History of Psychiatry and Medical Psychology. 2008, Springer.

 

Weiner, D B, “The Madman in the Light of Reason: Enlightenment Psychiatry.” Chapter in Wallace, E R and Gach, J, History of Psychiatry and Medical Psychology. 2008, Springer.

 

Kushner, I, “The Salpêtrière Hospital in Paris and Its Role in the Beginnings of Modern Rheumatology.” J Rheumatology 2011; 38 (9): 1990-93.

 

Hurwitz, L J, “L’Hôpital de La Salpêtrière, Paris.” BMJ 1962; Apr 28, 1196-7.

 

Ruiz-Gomez, N and Liebrenz, M, “The Ties that Bind Past and Present: Tony Robert-Fleury, Philippe Pinel and the Salpêtrière.” Forensic Science International: Mind and Law 2021; 2: 1-7. 

 

McHugh, T J, “The Hôpital Général, the Parisian Elites and Crown Social Policy During the Reign of Louis XIV.” French History 2001; 15 (3): 235-53.

 

         

          

 

         

         

 THE ORIGINS OF BYSSINOSIS 

         In February 1842, the relatively new town of Lowell, Massachusetts welcomed Charles Dickens during a tour through America. A business group in Boston had founded Lowell in the 1820s, aiming to create a “model city.” The principle business, the Lowell textile factory, employed young women from nearby farms who lived in company residences equipped with a piano, a library,

Charles Dickens at the time of his
visit (Wikipedia)

and facilities to publish their own magazine. A nearby hospital provided medical care. After some two or three years of work the women returned to their homes, presumably to contemplate marriage.

Dickens, familiar with the poor working conditions in textile mills in England, was surprised by the healthy appearance of the Lowell workers. He wrote, “They were healthy in appearance, many of them remarkably so, and had the manners and deportment of young women, not of degraded brutes of burden.” This, despit a twelve-hour workday. A local physician, Dr. Elisha Bartlett, also the town mayor, agreed, saying, “the manufacturing population of this city is the healthiest portion of the population.” The young Elisha Bartlett became influential. After a

Elisha Bartlett (Wikipedia)

stint as itinerant professor, he studied with Pierre Louis in Paris. On return, he produced important works on fevers in the U.S. and promoted Louis’ statistical approach to medicine, eventually rising to a professorship at the College of Physicians and Surgeons in New York.

         Dickens and Bartlett would have rendered a different opinion of cotton factories a few decades later. After the Civil War, as America’s industrial revolution accelerated, the machinery in the mills became larger, noisier, and created more dust. Immigrant labor replaced local farm girls, living quarters were more crowded, water supplies became contaminated, and epidemics sprouted. “Consumption” was widespread in and out of the mills. The relation of inhalation of cotton fibers to symptoms of tuberculosis was not clear.

         Within the mills cotton dust filled the air, both from processing cotton and a process known as sizing. To improve the quality of fibers, jets of warm water sprayed into the rooms. The result was a mixture of heat, moist dust and loud noise. One physician described the factory air as “one floating mass of cotton particles, which none but those accustomed to it can breathe…” How harmful this was aroused controversy, since some workers seemed unaffected over years of exposure. As more complicated machinery developed, the noise became so loud that hearing impairment was a risk. The noise level reached 94 to 103 decibels. This compares to 90 decibels for a pneumatic drill at 10 feet or the 97 decibels of a 1992 disco. The heat of the workplace added to the strain.

         

Textile mill, Lancashire. Imagine the noise and dust. (Wikipedia)

         The discovery of the tuberculosis bacillus by Koch in 1882 settled the debate on whether tuberculosis was communicable. In Massachusetts, post-Civil War cotton factory workers frequently developed tuberculosis. Separating its effects from the effects of dust proved difficult. The workers lived in confined home conditions, often had marginal diets, and labored in crowded factory rooms, all conducive to tuberculosis spread. Studies showed that tubercle bacilli were more numerous in dust samples from rooms moistened with sprays. The item of greatest contention, though, was the shuttle. The mechanical looms shot shuttles back and forth at lightning speed that unraveled the weft as they went. When a length of weft ended, a

Shuttle. Weft in center, sucked 
through hole near top (Wikipedia)

worker would rearm the spindle and suck the new thread through a hole in one end, a maneuver called “kissing the shuttle.” The spindles were not cleaned or substituted between aspirations, leading to claims that tuberculosis and other diseases were transmitted by this route. 

The growth in population, increased disease outbreaks, and mounting sewage problems in Lowell and elsewhere persuaded the state to commission the famous Report of the Sanitary Commission of Massachusetts by Lemuel Shattuck, issued in 1850. Following recommendations in the report, Massachusetts created, in 1869, the first public health department in the U.S. that remained permanent. California followed a year later.

        

"Shuttle Girl" Drawing by Winslow Homer, from The Song of the Sower by
William Cullen Bryant (Internet Archive) Wefts are in the box below. 

     High tuberculosis rates in mill workers and strikes over wage issues prompted the new Massachusetts Board of Health to inspect mill premises and examine personnel. Workers, though, often did not disclose symptoms to doctors or asked them not to identify them as tubercular, fearing an ensuing loss of wages. Despite that, health department findings led to laws that improved ventilation, regulated humidity levels, and ensured clean water and better sewage in the towns. In 1911 the suction shuttle was banned. Non-contagious disease, such as lung conditions due to cotton fibers, received little attention.

Workers still complained of tightness of the chest, especially on Monday evenings following a weekend of breathing clean air. Many long-term workers developed chronic lung disease, including nonsmokers. The term that emerged to label these conditions was “byssinosis.” The word byssus refers to a very fine, silky cotton or flax fiber. Ludwig Hirt, a German author of an 1871 book on occupational disease, applied the name lyssinosis pulmonum to cotton workers’ lung complaints. A few years later (1877), Adrien Proust, a prominent French public health official and father of the writer

Adrien Proust (Wikipedia)

Marcel Proust, pointed out that Hirt should have written byssinosis since lyssa was the German word for rabies. To Proust, then, we owe the current name for a collection of pulmonary symptoms related to working in textile mills. X-ray and pathology findings have been inconsistent, making the diagnosis primarily clinical.

By the time byssinosis was being seriously investigated, the textile industry had moved to the southern U.S. Today much of the current literature on byssinosis comes from Pakistan, Bangladesh, and other sites where the textile industry has concentrated in recent years. 

No essay next month, I am traveling. See you in November.

 

         

SOURCES:

 

Greenlees, J, When the Air Became Important: A Social History of the New England and Lancashire Textile Industries. 2019; Rutgers Univ Press.

 

Rooke, G B, “The Pathology of Byssinosis.” Chest 1981; 79 (4) Suppl: 67S-71S

 

CDC, NIOSH, Criteria for a Recommended Standard…Occupational Exposure to Cotton Dust. 1974; US Dept Health, Education, and Welfare.

 

Massoud, A, “The Origin of the Term ‘Byssinosis.’” Brit J Industr Med 1964; 21: 162.

 

Dickens, C, American Notes for General Circulation and Pictures from Italy. 1913 edit. of 1842 version.

 

Louttit, C, “Lowell Revisited: Dickens and the Working Girl.” Dickens Quarterly 2007; 24 (1): 27-36.

 

Huntington, E, An Address on the Life, Character, and Writings of Elisha Bartlett, MD, MMSS. 1856; S J Varney, Lowell.

 

Corn, J K, “Byssinosis – An Historical Perspective.” Amer J Indust Med 1981; 2: 331-52.

 

Greenlees, J, “Stop Kissing and Steaming!: Tuberculosis and the Occupational Health Movement in the Massachusetts and Lancashire Cotton Weaving Industries.” Urban History 2005; 32 (2): 223-246.