DID A NOVEL HELP CREATE THE NATIONAL HEALTH SERVICE? 

         A.J. Cronin’s medically oriented novel of 1937, The Citadel, was one of the world’s greatest publishing successes of all time. The author, a physician himself, wove a tale of an idealistic and hard-working young physician at odds with a crusty, decaying British medical establishment. Over time, the novel sold millions of copies and was even popular (and allowed) in the Soviet Union and its satellites, probably because of its criticisms of British health services. Many cite the work as influential in the formation of the British National Health Service. 

First edition of Cronin's novel (Wikipedia)

        The hero of the novel, Andrew Manson, a young Scottish doctor with a Bachelor of Medicine (BM) degree, fresh out of school with no internship, takes work in a Welsh mining town. After an unhappy time there, Manson moves to another mining town, Aberalaw. In Aberalaw medical care of the miners is paid through funds in part deducted from the miners’ pay and in part contributed to by the mine owners. 

        While working in Aberalaw, Manson crams at night, earns an MD degree and acquires a membership in the Royal College of Physicians. He notices several miners coughing and laboring to breathe and begins a research project, including research on mice, to determine the role of inhaled particles. After being criticized for experimenting on animals, he leaves in anger and accepts a position on a government board that oversees safety in mines. But he is disillusioned by the laziness, neglect, and lack of progress shown by the board. Andrew then buys a private practice in London. Soon he is mesmerized by his high income and the swanky social circles he inhabits but in time is troubled by pandering to hypochondriacs for large fees, fee splitting, and the coverup of a botched surgery. There are more twists to the plot but eventually Manson and two others, one a skilled surgeon and one an American tuberculosis specialist, who is not an MD, depart London to set up a multispecialty group practice in a small middle-class town. Some former colleagues, angry and slighted, charge him with practicing with a non-physician and abducting a patient from a decaying TB hospital to receive a new and unproven treatment. In the finale, an impassioned speech, announcing his good intentions, saves Manson from losing his license. 

Scene from movie version starring Robert Donat (Wikipedia)

        Throughout the drama, the novel is quite critical of several aspects of British medicine of the time and is said to have been a driving factor in the introduction of the British National Health program. Was this so, and did Cronin advocate a National Health Service? 

        The novel is highly autobiographic. Cronin was born in 

A J Cronin (Wikipedia)

Scotland in 1896. Like Andrew Manson, Cronin received his medical education in Glasgow and began practice in a Welsh mining town as assistant to a general practitioner. Cronin next moved to Tredegar, a nearby mining town, given the name Aberalaw in the novel. As in the fictional Aberalaw, Tredegar’s distinction was a well-functioning medical system, financed by modest deductions from the workers’ pay and by contributions from the Tredegar Iron and Coal Company and other employers. It provided medical, including hospital, care for some 20-25,000 inhabitants. Cronin portrayed this type of practice, private and communal at the same time, as an optimal approach, as did his fictional hero, Andrew Mason. And, like Mason, Cronin studied in late hours to earn his MD and FRCP honors. 

Tregedar Cottage Hospital, taken 2017 (Wikipedia)

        Aneurin Bevin, the principle driving force behind the formation of the National Health Service, was born in Tredegar in 1897, one year after Cronin. His father, a miner who had embraced socialism, died of pneumonoconiosis. Aneurin worked in the mines, became active in labor politics, and attended college on a scholarship. He spent two years on the management committee of the Tredegar Cottage Hospital, where he had a close look at the medical system. He joined the Labor Party, remaining on its left wing. During WWII he criticized Churchill and Army leadership and felt that England should cultivate closer ties with Russia. 

     

Aneurin Bevan (Wikipedia)

   Bevin promoted the idea of national health care, funded on a tax-based model rather than private organizations. Bevin struggled with fierce resistance from the medical profession and the British Medical Association and eventually made concessions, such as higher pay for consultants and allowance of private practice alongside work in the NHS. As Minister of Health in the post-war Atlee government, he shepherded The National Health Care Act into law in 1946. 

         Although Bevin created a socialist framework for national health services, he may well have been influenced by his association with the similar, but private, scheme in Tredegar. Cronin’s direct influence on Bevin is probably slight, as no meeting is recorded. Cronin’s Andrew Mason praised the Tredegar system, but Cronin himself was silent on the program promulgated by Bevin and did not take part in the politics of health care. 

         In The Citadel and in other fiction, Cronin criticized the custom of beginning practice without hospital experience (such as an internship), urged more complete postgraduate medical education, and frowned on various practices such as fee-splitting as dishonest and unbecoming. And he portrayed public health officials as lazy and incompetent. This suggests a suspicion of governmental management in health matters and Cronin, through his fiction or elsewhere, never advocated a government-run health service. In The Citadel, Manson’s dream follows the lines of the Tredegar plan. While there is a connection between Aneurin Bevin, the miner’s life, and the hospital at Tredegar, Bevin’s ideological ties to socialist thought in his crusade for equal health care for all probably were the dominant factors in designing the NHS. 

         Apologies for missing June. I was traveling again. 

 SOURCES: 

 Dunn, Francis Gerard, A. J. Cronin’s Career and Fiction with Specific Reference to The Citadel and the Context of the Foundation of the National Health Service. MPhil(R) thesis, University of Glasgow, 2022. 

 McKibbin, Ross, “Politics and the Medical hero: A.J. Cronin’s The Citadel.” English Historical Review 2008; 123: 651-78. 

 Davies, Alan, A. J. Cronin, The Man Who Created Dr. Finlay. Alma Books, London, 2011. 

 Cronin, A J, The Citadel. Victor Gollancz Ltd., London. 1937. 

 Cronin, A J, “Dust Inhalation by Hematite Miners.” J Indust Hygiene 1926; 8 (7): 291-4. 

 Richardson, Ruth, “The Art of Medicine: A J Cronin’s Citadel.” Lancet 2016; 387 (June 4): 2284-5. 

 A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

           PROSPER MENIÈRE AND HIS DISEASE

 

         On a bitter, cold night, sometime before 1848, a young menstruating woman riding in an open carriage suffered an attack of severe vertigo, vomiting, and hearing loss. She was admitted to the service of Auguste François Chomel at the Charité hospital in Paris where she died five days later. Details of the illness are sparse but, because of the deafness, Dr. Prosper Menière, chief of the National

Prosper Menière (Wikipedia)

Institute for the Deaf and Dumb in Paris, was consulted. He opened the temporal bone and described the semicircular canals as “filled with a red, plastic matter, a sort of bloody exudate, a few traces of which were discovered with difficulty in the vestibule and which did not exist at all in the cochlea.” Dr. Menière gave two accounts of this event, thirteen years apart. The first, an annotation in an 1848 translation he made of a German textbook, did not mention vertigo. 

The second account, quoted above, he read at the Imperial Academy of Medicine on a rainy day in 1861 before a limited audience. The following week, Armand Trousseau,

Armand Trousseau (Wikipedia)

 physician-in-chief at the Hôtel Dieu, read a paper on “apoplectiform cerebral congestion.” That term applied to any condition involving change in level of consciousness, fits (except established epilepsy), or paralysis, and was considered a sign of impending or actual cerebral hemorrhage. Trousseau argued that this wordy diagnosis was a grab bag of conditions that should be classified individually and he cited Menière’s case as an example. Comprehension of brain and nervous system disorders at the time was primitive and Jean-Martin Charcot, who virtually created the field of neurology, began his studies at the Salpêtrière only the following year. Menière eventually published four papers on the syndrome that bears his name: noise in the ear, vertigo, and deafness.

Prosper Menière was born in Angers, France, in 1799, as Napoleon was coming to power. A bright student, he finished secondary school and primary medical education near home and at age 20 secured a position as externe at the Hôtel Dieux in Paris. Three year later, he secured an internship and over time served as assistant, and chief of service, under three famous staff physicians: Paul Dubois, an obstetrician, Auguste Chomel, the internist 

Guillaume Dupuytren (Wikipedia)

mentioned above, and the famous surgeon, Guillaume Dupuytren. Menière received his doctorate in 1828. Two years later, serving as assistant to Dupuytren, the “July revolution,” a rebellion against the repressive regime of Charles X, exploded in the streets. Menière, Dupuytren and others in the Hôtel Dieux worked non-stop caring for about 800 casualties received over a few days. Ironically, Dupuytren was chief surgeon to the deposed king, but did not follow him into exile.  

Menière grew in reputation, publishing several papers on assorted topics. In 1833, at the recommendation of Mathieu Orfila, dean of the Faculty of Medicine, the new king, Louis Philippe, dispatched Menière on a unique mission.

Duchess de Berry (Wikipedia)

The widow of the deceased son of the deposed king Charles, the Duchess de Berry, who was the mother of the king’s grandson, had stealthily reentered France to promote the child as a future heir to the throne. But rumors abounded that she was pregnant again. Menière’s task was to sniff out her true intentions. Surprisingly, the two enjoyed each other’s company. Menière saw that she was indeed pregnant, and delivered the child, a girl. The duchess had been secretly married to an Italian count and discretely returned to Italy, abandoning royal aspirations.

In 1835 Menière led a commission to combat an outbreak of cholera in southern France for which he received the Legion of Honor.

He was passed over for two prestigious posts, despite having better qualifications than his competitors, probably because of academic politics. In 1838 the head of the National Institute for the Deaf and Dumb died. Menière’s friends helped him secure the vacant post over the protests of respected experts in ear diseases. 

The National Institute of Deaf Youth of Paris, the same building where Menière worked.
The statue depicts the Abbé de l'Épée, the Institute's founder. (Wikipedia)

 The year of his appointment, 1838, he married Anne Pauline Becquerel of the Becquerel family of physicists (Henri Becquerel shared the Nobel Prize in physics in 1903 with Marie and Pierre Curie). The union produced one son, who became a specialist in ear diseases and eventually published Prosper’s diaries.

In later years, Menière devoted more time to literary pursuits. He wrote a 500-page book on medical studies of Latin poets, corresponded and mingled with literary and artistic lights of the day, including Balzac, Victor Hugo, and Franz Liszt, and kept a voluminous diary. He frequented the opera and theater and was welcome in Parisian salons. He never became a member of the Faculty of Medicine and never achieved a full professorship, in spite of apparent qualifications. Menière was 61years old when he saw the young woman with the syndrome bearing his name. 

In 1862, only a year after his innovative publications on vertigo, Menière met a sudden end, felled rapidly by an aggressive “influenza pneumonia.” 

It was left to the British otologist, Charles Hallpike, aided by neurosurgeon Hugh Cairns, to elucidate more details of the pathology of the swelling within the semicircular canals in Menière’s disease. They decalcified,

Charles Hallpike (Wikipedia)

 fixed, and sectioned the temporal bone of two patients deceased after surgery on the acoustic nerve. Almost simultaneously a Japanese investigator, Kyoshiro Yamakawa, published similar findings. Both had studied with the German ENT professor, Karl Wittmaack, in Hamburg, applying his innovative techniques for processing the temporal bone.

The name “Menière’s disease” persists to this day, though it is considered by many to be a syndrome rather than a disease.

 

 

SOURCES:

 

Atkinson M, Acta Laryngologica 1961; 53: Suppl 162, pp 7-78. (Contains several articles on Menière, including translations of four original papers)

 

M’Kenzie D, “Menière’s Original Case.” J Laryngol Otol 1924; 39(8): 446-9.

 

Maranhao P, Prosper Menière: the Man WHO Located Vertigo in the Inner Ear.” 2021; Arquivos Neuro-Psiquiatr 79 (3): 254-6.

 

Hawkins J E, “Sketches of Otohistory Part 5: Prosper Menière: Physician, Botanist, Classicist, Diarist and Historian.” 2005; Audiol Neurootol 10: 1-5.

 

Beasley N J P, Jones N S, “Menière’s Disease: Evolution of a Definition.” 1996; J Laryngol Otol 110: 1107-13.

 

Barsky H K, Guillaume Dupuytren: A Surgeon in His Place and Time 1984; Vantage Press.

 

Baloh R W, “Charles Skinner Hallpike and the Beginnings of Neurotology.” 2000; Neurology 54: 2138-46.

 

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

         

 

         

 

 

 BIRTH OF THE ARTIFICIAL KIDNEY

 

         On May 10, 1940, the German Army invaded the Netherlands. At the University Hospital in the city of Groningen, twenty-nine-year-old Willem Kolff, nicknamed Pim, was finishing his training in internal medicine. He realized that specialization made him less liable to be arrested or deported and quickly obtained certification in internal medicine. A new hospital in the small city of Kampen, out of the way of most German officials, hired him as chief of the medical service. Kolff, previously disturbed by a young patient dying of renal failure, had already been thinking of ways to substitute for kidney function.

Willem Kolff and his wife Janke, 1941 
(National WWII Museum and Marriott
Library, University of Utah)

         In Groningen, Kolff had befriended the professor of physiological chemistry, Robert Brinkman, who was attempting to dialyze plasma through a cellophane membrane. Attracted by Kolff’s thoughts on artificial renal function, Brinkman contributed ideas on using cellophane as a membrane to imitate the kidney's filtering activity. 
         The idea of artificial kidney function was not new. As early as 1912, the famous pharmacology professor at Johns Hopkins, John Jacob Abel, with colleagues Roundtree and Turner, had run animal blood through tubes of celloidin, a semipermeable substance, submerged in watery solution, to remove urea. They demonstrated the process, in fact, at a Congress in Groningen in 1914. World War I, however delayed further work.

John J Abel, later years (Wikipedia)

         In the 1920s, after seeing many soldiers in World War I dying of renal failure due to a new condition called “trench nephritis,” German physician Georg Haas, at University Hospital in Giessen, knowing the work of Abel, assembled an artificial kidney apparatus consisting of several 1.5 meter collodion membrane tubes suspended in solution. He employed the newly discovered heparin as an anticoagulant, safer than hirudin, an anticoagulant used by Abel that was derived from leeches. Haas drew half-liter amounts of blood and pushed it through the tubing. Although urea levels dropped, the few patients so treated only marginally improved and soon died. This, and discouraging comments by colleagues led Haas to abandon the project.

Georg Haas, right, dialyzing a patient (Kidney Intl Repts 2025; 10: 964, Creative Commons License)

         In Kempen, Kolff, under German surveillance, teamed up with an engineer, Hendrik Berk. They used cellophane previously obtained from American supplies in Amsterdam, to make narrow tubing thirty meters long wrapped around an aluminum drum. The drum was lined with aluminum slats to elevate the tubing off the surface, allowing solution to surround it. The drum was suspended in an enamel tub that contained water with sugar and salt. The cellophane tubing wound diagonally over the drum so that as a sewing machine motor rotated it, the blood flowed through the thirty meters of tubing and back to the patient without a pump. Aluminum for the drum came from an airplane that had been shot down, some parts came from an automobile, and when the cellophane supply ran out, Kolff used sausage skins.       

    Work went slowly. Spare parts needed to be scavenged and Kolff had other pressures. Sometimes he admitted people on the run from Nazis, giving them false names or diagnoses to protect them. In one instance he gave a hunted man a diagnosis of intestinal bleeding. To make it look genuine, he bled a liter of blood from him and artificially colored his stools black.

        Kolff found a laboratory technician and a physician assistant. The assistant, Jacobus van Noordwijk, had spent eighteen months in jail for anti-Nazi activities as a medical student. On release, forbidden to enroll again in medical school, he found no rules against taking the examinations. He tutored himself and passed the licensing exam. Kolff had him wear a blue smock rather than a white one to disguise his role as a physician. Jacobus also typed for him, something Kolff, a dyslexic, found difficult.
        Kolff’s first use of the artificial kidney was on an elderly man dying with prostate cancer and failing kidneys. Kolff, with agreement from his staff, dialyzed him in a comatose state. The sewing machine motor malfunctioned, there were leaks, and the patient did not improve, dying days later. Repairs and tinkering improved the apparatus, however, and between March 1943 and July 1944, fifteen people underwent treatment with the artificial kidney. In many, the clinical picture and blood chemistries improved, but in time all but one died because they had irreversible kidney disease. The one survivor probably had a condition not benefitted by the dialyzer. As in Haas’ case, Kolff’s physician colleagues felt that putting patients through such an ordeal when they died soon after was not helpful. Kolff still saw a future for the procedure, though, and refusing to publish in a German journal, he published his results in both a Dutch and a Swedish journal, the latter in English, announcing the technique to a wider community. 

(From "History of Dialysis in the U.K," Witness Seminars, v 37, 2009, published by Wellcome Trust
for History of Medicine)

        In April 1945, the Allies freed Holland. In the aftermath, Kolff treated another patient, a woman imprisoned for Nazi collaboration. She was the first patient to have meaningful survival, having had a reversible kidney disease. She lived to the age of seventy-three.
        After the war, in 1950, Irving Page at the Cleveland clinic hired Kolff. There he developed a membrane oxygenator, a forerunner of the heart-lung machine, and became an American citizen. He went on to develop an artificial heart and, of course, to see many improvements in the artificial kidney. Developments in shunts were a vital step allowing repeated dialyzing with minimum discomfort and dialysis procedures gained in efficiency. 
        For his achievements with artificial organs, Kolff received numerous international awards, society memberships, and honorary degrees. He earned four Nobel Prize nominations, but not the Prize. Kolff passed away in 2009 at the age of 97. Georg Haas died in 1971 and was posthumously honored with the establishment of the Georg Haas Dialysis Center in Giessen. He is buried in the local cemetery near Wilhelm Conrad Röntgen.

SOURCES:
 
Broers, Herman, Father of Artificial Organs: The Story of Medical Pioneer Willem J. Kolff. 2020, AERIE Publishers, Kempen, NL.
 
Abel, J J, et al, “On the Removal of Diffusible Substances from the Circulating Blood of Living Animals by Dialysis.” 1914; J Pharmacol Exptl Therapeutics 5: 275-16 and 611-23.
 
Wizemann V, Benedum, J, “70^th Anniversary of Haemodialysis – The Pioneering Contribution of Georg Haass (1886-1971).” 1994; Nephrol Dial Transplant 9: 1829-31.

Husain-Syed, F, et al, "Celebrating 100 Years of Hemodialysis and the Legacy of Georg Haas." Kidney Intl Repts 2025; 10: 964-5.
 
 Kolff, W J, et al, “The Artificial Kidney: A Dialyser with a Great Area.” 1944; Acta Med Scand 117 (2): 121-134.
 
Haas, G, “Über Blutwashung.” 1928; Klinische Wochenschrift 7 (2): 1356-62.
 
Morrissey, M, “Willem J Kolff (1911-2009): Physician, Inventor, and Pioneer.” 2012; J Med Biog 20: 106-138.
 
A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md
 
 
         
         
         
 
 
 

 

 THE STORY OF SAFE MILK 

         Milk “is usually drawn… from cows which often have flaking excrement all over their flanks, by milkmen who are anything but clean. It is drawn into milk pails which are seldom or never thoroughly cleansed…” 

         This was the 1892 message of William T. Sedgewick, professor of biology at MIT and later co-founder of the Harvard-MIT School for Public Health Officers. Milk, the principal source of nutrition for the majority of infants and young children at the time, was also a purveyor of death. In New York City, from 1890-2, infants under one year of age accounted for one-fourth of all human deaths and children under 2 years for one third of the total, numbers that had been rising since mid-century. 

AMA prizewinning cartoon (from Straus, Disease in Milk)

         As noted above, the unsanitary conditions of milk provision and its transport fostered the presence and growth of bacteria. Milk transmitted such varied infections as typhoid fever, streptococcal infections, diphtheria, diarrheal pathogens, and tuberculosis (from tuberculous cows), all of which could kill children in an age without antibiotics. Secondly, dairies in large cities were often placed next to distilleries to take advantage of throwaway fermented grain, called swill, to feed their cows. Cows fed on swill, however, produced milk that was thin and bluish, lacking fat and other basic ingredients. Lastly, milk, especially swill milk, was frequently adulterated with chalk, flour, or other ingredients to render it whiter. 

Cartoon, Frank Leslie’s Illustrated News May 29, 1858 showing central figure
 trying to arouse swill-fed cow too weak to stand (Internet Archive)

         Public protest and shaming of local governments were major forces that persuaded cities to put curbs on swill and adulterants. Newspapers, particularly Frank Leslie’s Illustrated News, published damning reports accompanied by vivid cartoons exposing the practice. The famous cartoonist Thomas Nast weighed in as well.

Thomas Nast cartoon, "Swill Milk" Harper's Weekly, Aug 17, 1878
 (Hathi Trust)

         The discoveries of bacteriology in the late 1800s brought the realization that terrifying scourges of the past, such as typhoid fever and diphtheria, were preventable. In the case of milk, just eliminate the bacteria and milk should be safe to drink.

A physician in Newark, New Jersey, Henry Leber Coit (he went by “Leber”), took one approach. After spending five years visiting dairies in New Jersey, Coit, at a local medical association meeting,

Henry Leber Coit (Wellcome Library)

he outlined a process to produce milk under hygienic conditions. He assembled a group of volunteer doctors, won approval of the N. J. legislature, and created the first American medical milk commission. The commission found a dairyman, Stephen Francisco, who was subsidized to maintain a sanitary dairy that used only tuberculin-negative and well-fed cows (tuberculin testing of cattle began in 1892 in the U.S.). In 1893, Francisco began to release milk “certified” by the commission and is said to be the first to sell bottled milk. After initial resistance by the farming industry, certified milk became popular. Similar milk commissions sprouted elsewhere, and eventually a national American Association of Medical Milk Commissions emerged, with Coit as president. By that time, certification required the bacterial count of milk to be 10,000 bacteria per cubic centimeter or less. Certified milk was twice the price of “regular” milk, limiting its use by penny-pinched families.

         Another, more certain, approach to clean milk was pasteurization. Since Louis Pasteur’s discovery that heat treatments would prevent spoilage of beer and wine, enthusiasts for safe milk applied similar techniques. Sheffield Farms Dairy in Bloomville, New Jersey was the first dairy, in 1891, to use a pasteurizer, one imported from Germany. As with certification, resistance came from the dairy industry. Dairy spokesmen claimed it was too expensive, that foreign particles would not be screened out, that it changed the chemistry of the milk, leading to rickets or scurvy, and that it ruined the taste. These claims, after investigation, proved to be baseless. The benefits were obvious, especially the precipitous fall in infant death rates in every large city that made the transition. Pasteurization killed harmful bacteria, leaving numbers of the remainders well below those of certified milk. So even without home refrigeration, milk might spoil but seldom led to disease.

Henry Koplik (Wikipedia)

As early as 1889, while Coit was seeking his first dairy, a New York City physician opened a small clinic for young children in Manhattan’s lower east side. He supplied heated milk, sterilized
rather than pasteurized. The physician, Henry Koplik, ironically earned more fame for his discovery of the small red intra-oral spots diagnostic of measles that bear his name than for his work for poor children. Koplik received funding for the clinic, named the Good Samaritan Dispensary, from a philanthropist, Nathan Straus. Nathan, who was a co-owner with his brother of Macy’s, was aware of the large number of poorly nourished children in New York, many of whom had mothers who toiled long hours in sweatshops. In 1891 he opened a string of milk dispensing stations, staffed by nurses. Concentrated in poor areas of New York, the stations sold cheaply, or gave away if needed, a new

Nathan Straus (Wikipedia)

product, pasteurized milk, processed in Straus’ own pasteurizers. By 1915, Straus dispensaries were distributing over 2 million bottles annually of milk and infant milk formulas in New York. Infant and child mortality rates fell rapidly. 

         The work of Nathan Straus in reducing infant mortality was widely recognized by medical and public health authorities. Milton Rosenau, Professor of Preventive Medicine and Hygiene at Harvard, in 1912 wrote a summary of milk, its chemistry, bacteriology, and processing. He dedicated the book to Nathan Straus, whose dispensaries must have saved tens of thousands of young lives. Strangely, despite the ease and efficiency of pasteurization, Dr. Coit doggedly promoted certified raw milk for many years, though eventually the superiority of pasteurization won out. Major cities like New York, Chicago and Boston legislated requirements for pasteurization before the 1920s.

     Unpasteurized milk is still available, though not without risk. Pasteurization is here to stay and has proven safe for over 100 years. 

 

Straus pasteurizer of bottled milk (from Straus, L G, Disease in Milk: The Remedy Pasteurization, Internet Archive)

SOURCES:

 

Kurlansky, M, Milk: A 10,000-Year Food Fracas. 2018; Bloomsbury Publishing, N.Y.

 

Greer, F, “One Hundred Years Later – Milk Safety Revisited.” 1999; Ped Res. 454: 124-5.

 

Koplik, H, “The History of the First Milk Depot or Gouttes de Lait with Consultations in America.” 1914; JAMA 63 (18): 1574-5.

 

Waserman, M J, “Henry L. Coit and the Certified Milk Movement in the Development of Modern Pediatrics.” 1972; Bull Hist Med 46 (4): 358-90.

 

Hygienic Laboratory, U.S. Public Health and Marine Hospital Service, Various Authors, Milk and its Relation to the Public Health. 1909; Government Printing Office.

 

Straus, L G, Disease in Milk: The Remedy Pasteurization. The Life Work of Nathan Straus. 1917; E. P. Dutton, New York.

 

Rosenau, M J, The Milk Question. 1912; Houghton Mifflin Co., N.Y.

 

Markel, H, “Henry Koplik, MD, the Good Samaritan Dispensary of New York City and the Description of Koplik’s Spots. 1996; Arch Pediatr Adolesc Med 150 (5): 535-9.

 

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

 

, 

         

         

 

 THE BIRTH OF NUCLEAR MEDICINE:

RADIOIODINE

 

         The decade of the 1930s was a heady time in the world of physics. Among other achievements, including atom splitting, Irene Curie and her husband Frederick Joliot, in 1934, used polonium (discovered by Irene’s mother, Marie Curie, as a source of alpha particles, or helium nuclei) to bombard a strip of aluminum foil. They discovered small amounts of a radioactive byproduct: an isotope of phosphorous. Hearing of this, Enrico Fermi, in Rome, used neutron bombardment to create, in a burst of modern alchemy,

Ernest Lawrence (Wikipedia)

fourteen isotopes in one year. Meanwhile, Ernest Lawrence and several colleagues were building particle-hurling cyclotrons at the University of California in Berkeley, enabling them to create isotopes almost at will. 

         One of the first isotopes to emerge from Lawrence’s lab was radioactive sodium: Na²⁴. He used it as a “tracer” element, given in quantities small enough to produce negligible radiation but sufficient to be traced to various tissues. The principle of radioactive tracers was first described by George de Hevesy, a Hungarian scientist, in 1913, a technique that revolutionized the study of physiology and biologic chemistry. Lawrence’s brother, John, a physician interested in medical possibilities for the new isotopes, and Joseph Hamilton, a chemist with a medical degree from San Francisco, 

John Lawrence (Wikipedia)

teamed up to investigate the medical uses of the new isotopes. In addition to Na²⁴, they studied radioactive phosphorous, P³². Phosphorous concentrates in bone and, reasoning that lying in bone it could radiate bone marrow, they tried large doses as a treatment for leukemias, though to no avail. Radioactive phosphorous served well, however, as a “tracer”.

         Iodine isotopes found the greatest medical use. Ingested iodine travels almost exclusively to the thyroid gland. Thus, radiation from an isotope would be limited primarily to the gland itself. The idea of thyroid radiation by isotopes originated at a luncheon conference at the Massachusetts General Hospital (MGH) in 1936. Karl Compton, President of MIT, was speaking on applications of physics in 

Saul Hertz (Wikipedia)

medicine and biology. Dr. Saul Hertz, in charge of a thyroid unit at the hospital, had seen efforts at direct radiation treatment of “toxic goiter,” an old name for thyrotoxicosis, a disorder due to abnormally high production of thyroid hormone by the gland. The usual treatment at that time was surgery to remove most of the gland, leaving just enough to produce a more normal level of hormone. It was a difficult operation and Hertz was looking for a less invasive therapy.

He asked if radioactive iodine could be made artificially. The answer was yes, and the MIT laboratory produced Iodine¹²⁸, whose half-life, however, is only 25 minutes. The short half-life forced Hertz and a young physicist, Arthur Roberts, to bring their test rabbits to MIT and feed the isotope quickly before the radioactivity ran out in two or three hours. They established that I¹²⁸ 

Joseph Hamilton (Wikipedia)

indeed concentrated in the thyroid gland, publishing the results in May 1938.

         Meanwhile, in Berkeley, Joseph Hamilton, thinking along the same lines, asked a chemist at Lawrence’s “rad lab,” Glenn Seaborg, if he might produce an iodine isotope with a longer half-life. In short order, Seaborg, using the cyclotron, bombarded tellurium with deuterons to produce I¹³¹, an isotope with a half-life of 8 days. Seaborg, in a brilliant career,

Glenn Seaborg (Wikipedia)

 discovered (or co-discovered) ten new elements, for which he won a Nobel Prize. He produced an iron isotope allowing George Whipple and colleagues, using it as a tracer, to flesh out the metabolism of iron in humans. Seaborg he was instrumental in the Manhattan Project and served as chairman of the U.S. Atomic Energy Commission for a decade.

         Hamilton recruited Mayo Soley from the thyroid service at the U C San Francisco Medical Center, who had trained at the MGH and knew Hertz. They investigated I¹³¹ in patients with various thyroid problems, mainly to work out how iodine was processed and excreted, much as Hertz had done earlier with rabbits, and published their similar results in 1939.

         Back in Massachusetts, scientists at MIT, to catch up, quickly assembled a cyclotron, and produced a mixture of predominantly I¹³⁰ (1/2 life 12 hours) and traces of I¹³¹. With that mixture, Hertz and Roberts began to treat patients with hyperthyroidism, sending the radioactive iodine to the overactive gland. The radiated gland released less hormone, resulting in reduced tremor, palpitations, and anxiety in patients. In San Francisco, Lawrence and Soley, using predominantly I¹³¹, obtained similar results, both teams reporting favorable results in 1942. 

Scintillation scan of radioactive iodine in thyroid gland (Wikipedia)

The following year, having treated twenty-seven hyperthyroid patients without surgery, Hertz joined the Navy. He postponed a report on the full series to be sure the treatment was successful. His vacancy at the thyroid service was filled by Earle Chapman, an internist who regularly attended the thyroid conferences. Chapman continued treating hyperthyroid patients, experimenting with various dose regimens.

         With the war over, Hertz returned to Boston to find that Chapman had submitted his new series of cases to the Journal of the American Medical Association for publication. Angry that he had not been notified, Hertz rushed his own series to the same journal. Perplexed at receiving two similar studies from the same institution, the editor, Morris Fishbein, wrote secretly to the chief of the medical service at the MGH, Howard Means, asking what was going on. Means satisfied him that the papers represented two distinct, reliable studies and Fishbein published them back-to-back in the same 1946 issue. Bad blood between Hertz and Chapman was never resolved, however, another unfortunate instance of wrangling over scientific recognition.

         Radioactive Iodine has become the therapy of choice for most patients with overactive thyroids and for some forms of thyroid cancer that preferentially take up iodine. Other radioactive isotopes have enjoyed widespread use as well, utilized in bone scans, PET scans, and others. The ancient art of alchemy, transmuting elements, has made a comeback.

         

The Polish alchemist and physician, Michael Sendivogius (1566-1636), demonstrating
alchemy to Polish King Sigismund III. Painting by Jan Matejko, 1867 (Wikipedia)

SOURCES:

 

Creager, ANH, Life Atomic: A History of Isotopes in Science and Medicine. 2013; Univ of Chicago Press.

 

Anon, “Donner Laboratory: Fifty Years of Nuclear Medicine Innovation.” J Nuclear Med 1968; 29 (4): 431-37.

 

Sawin, CT, and Becker, DV, “Radioiodine and the Treatment of Hyperthyroidism: The Early History.” Thyroid 1997; 7 (2): 163-176.

 

Anon, editorial, “Celebrating Eighty Years of Radionuclide Therapy and the Work of Saul Hertz.” J Appl Clin Med Physiol 2021; 22 (1): 4-10.

 

Hertz, S and Roberts, A, “Radioactive Iodine in the Study of Thyroid Physiology.” JAMA 1946; 131 (2): 81-86.

 

Chapman, EM and Evans, RD, “The Treatment of Hyperthyroidism with Radioactive Iodine.” JAMA1946; 131 (2): 86-91.

 

Daniels, DH and Ross, DS, “Radioactive Iodine: A Living History.” Thyroid 2023; 33 (6): 666-673.

 

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md