GET THE LEAD OUT!

Alice Hamilton and Industrial Toxins

(Thanks to Prof. Paul Blanc, Occupational Medicine Dept, UCSF, for help with this blog)

     A popular consumer item in the early 1900s was the cast iron, enameled bathtub. Probably few users knew how it was made.

     The tubs were first sandblasted to roughen the surfaces, bombarding workers with silica dust. The tub was then heated red-hot, to allow the enamel to spread evenly. Two men greeted the emerging red-hot tub, one handling a heavy apparatus that sprayed powdered enamel onto the tub, the other manipulating a turntable to expose it on all sides. Both men inhaled the enamel powder whirling around them, which contained about 20% lead.   

Alice Hamilton (from Wikipedia)

     The above description was rendered by Alice Hamilton, the founder of occupational medicine in the U.S. and a remarkable woman. Born into a fairly affluent family in Fort Wayne, Indiana, she and her four siblings were largely schooled at home. She attended medical school at the University of Michigan (14 of her class of 47 were women). Following an internship, study in Europe, and a year at Hopkins studying pathology she obtained a post teaching pathology at Northwestern Univ. Medical School. She chose to live at Hull House, a settlement house run by the future Nobel Peace prize winner Jane Addams in a poor area of Chicago. Here Hamilton encountered

Jane Addams (from Five Colleges &
Manuscript Collections)

impoverished immigrants ill with work-related diseases such as lead poisoning, carbon monoxide poisoning (steel workers), and silicosis. Having never been taught these disorders, she educated herself in the library.

     Her interest caught the attention of a sociologist, Charles Henderson, who had her appointed in 1908 to a new “Occupational Disease Commission”, formed to do research for a possible State insurance program. Hamilton was assigned to investigate lead poisoning, which led her to the tub factory. She documented the hazards of lead intoxication in this and several other areas, especially the lead smelting and paint industries. Company doctors under-diagnosed the disorders and no compensation was paid to sick workers.

    World War I brought a huge expansion in munitions manufacturing. TNT, picric acid, and fulminate of mercury (a detonator) were major products. Nitric acid was used almost universally to produce them. Hamilton, working for the Bureau of Labor Statistics, uncovered numerous problems. Nitric acid fumes damaged lungs, TNT caused liver damage and anemias, and fires and explosions occurred frequently. Workers were often unskilled and poorly trained. All of this Hamilton documented in a 1917 report. Soon after, she was appointed to the faculty at Harvard Medical School, the first woman on their faculty

     Next she investigated stone cutters. The recently invented air hammer produced 3000 strokes a minute, causing workers’ hands to become numb and bloodless and producing ever more silicate dust.

     Her work took her to mines, quarries, and factories. She investigated silicosis and poisoning from aniline dyes, carbon monoxide, mercury, and other toxicants. Her efforts culminated in the first American text of its kind, Industrial Poisonings in the United States, published in 1925 (available on line). She followed it  with Industrial Toxicology (1934). She was concerned over the occupational risks of tetraethyl lead in gasoline and advocated for the protection of workers made ill from painting radium on watch dials. Hamilton was well connected and highly influential in

Radium dial painters   (from Wikipedia)

improving industrial practices. To bring changes she tended to favor tactful persuasion by facts rather than blunt instruments, and supported legislation for worker compensation.

     Dr. Hamilton was a product of the Progressive Era. She was deeply involved in peace movements and social activism, though she was hesitant about an early equal rights amendment movement fearing it might lead to worsening work conditions for women. After WWI she helped in feeding programs in Europe. She visited the Soviet Union in 1924 and was saddened by its oppression and lack of freedom, though she generally favored socialism and was impressed by Russian attention to workers’ protection. She was a vocal anti-Fascist and personally assisted colleagues fleeing Europe. Her sister, Edith, was a classical scholar who authored The Greek Way and other works.

     Dr. Hamilton’s impact on industry practice was enormous. She has been honored by the establishment of the annual Alice Hamilton Lectureship at UCSF (http://oem.ucsf.edu/about/hamilton.html), the creation of the Alice Hamilton Award by the American Industrial Hygiene Association, and other lasting recognitions.

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 Sources:

Exploring the Dangerous Trades: The Autobiography of Alice Hamilton, 1943.

Alice Hamilton: A Life in Letters, by Barbara Sicherman, 1984.

Industrial Poisons in the United States, by Alice Hamilton, 1925

         A SAN FRANCISCO NEUROSURGICAL FIRST.

                                   by Arthur Lyons, MD

     In the fall of 1884 the news here was that Grover Cleveland, a Democrat from New York won the first of what would turn out to be his two elections as President of the United States but in Britain there was a major medical event to be reported. To the consternation of vocal and often violent English anti-vivisectionists, a neurologically diagnosed brain tumor was successfully diagnosed operated upon for the first time in history. It was removed from a 25-year-old farmer at the Maida Vale Hospital, London.  The case was diagnosed and the tumor localized in the brain based primarily on experimental work on dogs and monkeys carried out over the previous decade by Dr. David Ferrier (1843-1928) augmented by the clinical investigations of epileptic seizures

David Ferrier    (from Wikipedia)

by Dr. John Hughlings Jackson (1835-1911). Ferrier had used electrical stimuli as well as localized ablations to determine the main motor and sensory areas in monkeys, the findings published in a book, The Localization of Cerebral Disease, in 1879. Although the man’s tumor was highly malignant and the patient did not survive more than a few months, it was hailed as a remarkable achievement and widely reported in the medical as well as in popular press. Cerebral localization was still being argued and prominent investigators continued to hold that the brain acted as a whole and that localization of the various brain functions was largely a myth.  The patient’s personal physician was Alexander Hughes Bennett MD (1848-1901) whose father also a prominent doctor had died of a potentially removable brain tumor.  It was he who made the clinical diagnosis and urged surgery. The reputation

Rickman Godlee     (from Wikipedia)

of the surgeon, Rickman Godlee (1849-1928), lent legitimacy to the case. He was nephew of the famous Joseph Lister, his office partner, future president of the Royal College of Surgeons and ultimately was knighted by King George. The significance of the Godlee-Bennett case was well appreciated. Besides being an example of the then recent remarkable advances in surgical technique, it was tangible evidence of the concept of brain localization and it particularly dramatized the value of animal experimentation.

     In San Francisco in early 1886, two years later, a young man was admitted to the Lane Hospital on Clay and Webster Streets suffering from severe headache and focal epileptic seizures,

progressing in severity over eighteen months. Joseph Oakland Hirschfelder MD (1850-1922), the admitting physician made the diagnosis of brain tumor near the contralateral motor strip.  All the tools that we now consider routine in such cases, lay far in the future. X-Rays for example, had to wait another ten years before Wilhelm Roentgen made their discovery.  Hirschfelder depended on clinical signs alone. Like Bennett in London he relied on the character his poor patient’s seizure disorder and his post-ictal palsy. The San Francisco surgeon involved was Hirschfelder’s colleague John F.

Morse MD (1856-1898). The finding of the tumor in their case after opening the intact skull, again helped vindicate the still controversial concept of cerebral localization. The description of the tumor, soft and infiltrating was consistent with a glioblastoma as fatal now as it was then. Their patient died three weeks later of post-operative infection, a not uncommon outcome at the time in spite of the stifling carbolic acid mist of antiseptic surgery. Hirschfelder and Morse were aware of the Bennett-Godlee surgery as a first. The Hirscfhelder-Morse case was the second successful attempt at removal of a non-apparent tumor from the brain and the first in the United States. It was to become the forerunner of many such cases in this country.

     Joseph O. Hirschfelder, born in Oakland, was a well-known highly trained San Francisco doctor. A U.C. graduate, he took his

J. Hirschfelder (top), Levi Cooper Lane (bottom
courtesy Art Lyons

medical training in Germany and was Professor of Clinical Medicine at the Cooper Medical College, recreated as Stanford after the 1906 earthquake.  Among other things he was one of many investigators who carried out early laboratory experimentation on tuberculin in hopes of finding a cure for the scourge of tuberculosis.  He was the first of at least three generations of men who became prominent in American science. A son, Arthur, was the first to use the electrocardiogram in the U.S. Hirschfelder was also a president of the San Francisco Medical Society.

     John F. Morse was born in San Francisco, the son of a pioneer physician. He graduated from the Medical College of the Pacific

courtesy Art Lyons

and from the Frederich Wilhelm University in Berlin, subsequently spending a year in Heidelberg. With that extensive training behind him he established his surgical practice in San Francisco in 1882.  Beside his pioneering brain tumor surgery he carried out many of the earliest appendectomies here and was the first in this country to successfully operate on abdominal aortic aneurism utilizing copper wire. He was very active in medical politics and he too was a president of the San Francisco Medical Society. Surgery lost a giant when he died suddenly of apoplexy at 41.

     Although far from what were considered the medical centers of the world at the time: Philadelphia, New York London, Paris and Berlin, San Francisco had a remarkably sophisticated medical community in the late19th Century. In spite of the presence of many quacks and unlicensed practitioners most doctors had a good education for the time and many of the physicians here had extensive European training. The HIrschfelder-Morse case is a good early example of pioneering skilled medical and surgical practice in San Francisco. The groundbreaking step in the practice of neurosurgery carried out here in 1886 is a case in point.

                                                          Arthur E. Lyons MD

Sources:

Bennett, A. H. & Godlee, R. Case of Cerebral Tumor. Med.-chir. Trans. 1885, 68: 243-75

Hirschfelder,, J. O. Removal of a Tumor of the Brain. Pacific Med.and Surg. J. 1886, 29:210-16

Thorwald, Jürgen. The Triumph of Surgery. Pantheon Books. 1987, 434 pp.

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                                                                                                   GF.

                                

Oscar Wilde’s Father:

A Noted, and Knighted Surgeon

     Oscar Wilde’s humorous one-liners had many targets, though seldom doctors. Perhaps that’s because his father was one, and a famous one at that.

Robert J Graves

     William Wilde was born in Roscommon, western Ireland. His father was a country doctor and William saw disease and trauma early in life. He was raised as a Protestant, was not too studious in school but befriended people easily, learned Gaelic, and took an interest in Irish history and folklore. His father decided on a medical career, and had William apprenticed for three years to Abraham Colles (known for Colles’ fracture, Colles fascia, etc) at Dr. Steeven’s Hospital in Dublin. He also studied medicine at the Park Street School, where teachers included Robert J Graves (of Graves’ disease) and William Stokes (Cheyne-Stokes breathing, Stokes-Adams attacks). The three professors were a formidable trio.

Abraham Colles

     Shortly after receiving his degree Wilde accompanied a wealthy, but sick man on a recuperative trip to the Holy Land. Stops on the way included Egypt where he encountered extensive trachoma, probably influencing him to take up eye surgery later. His extensive notes on climate, geography, customs, and medical matters became a two-volume work published after his return, selling well and giving him an entrée into Irish literary circles.

     William decided on eye and ear surgery as a specialty, going to London, Vienna, and Berlin for further training (he picked up languages quickly). At Vienna he spent several months at the famous Allgemeine Krankenhaus, studying eye disease under Anton von Rosas. 

Vienna General Hospital (Allgemeines Krankenhaus) 1784

He spent time too on the maternity wards where he befriended Ignatz Semmelweiss, several years before the latter instituted hand washing. This journey too resulted in a successful travel book.

     Back in Dublin Wilde opened an eye and ear hospital. He wrote a book on ear surgery that became a standard text for several years. Students came to him from great distances and over time he became the most famous eye and ear surgeon in Ireland, eventuallybeing appointed Surgeon Oculist to the Queen in Ireland.

      He accepted the position of medical consultant to the Irish Census of 1841, providing causes of death and other medical information. Of interest is that measles accounted for 30,739 deaths in 10 years, whooping cough for over 36,000, and homicide for 4,000 (1/4 were infanticide). Tbc, of course, was the biggest killer. Wilde included a history of major diseases in Ireland, and the work was such a success and generally ahead of its time that he was kept on for the following 10 year censuses through 1871, expanding the data each time. He was eventually knighted for this work. He lived through the terrible potato famine of 1845-9, causing thousands to escape to the U.S., and his statistics on the 1851 census reflected the deadly toll it took on the population.

     In 1851 he married Jane Francesca Elgee, a separatist poetess who took the name of Speranza. She was a good deal taller than William and possibly older. When married she curtailed her separatist tendencies, hosted numerous late night parties crowded with artistic and Bohemian types, wrote books, plays, and poetry, and was fond of irreverent witticisms, traits that Oscar surely got from her.

      Apart from medicine Wilde became one of the most important

Sir William Wilde

archeologists of old Gaelic ruins, publishing books and articles on the subject. He was a brilliant conversationalist, a public personality, and something of a philanderer, with at least three illegitimate children.

     In 1864 tragedy struck. An an-tagonistic young woman, Mary Travers, who had been a mistress of Wilde’s and had offended Speranza, sued for libel on the grounds of a bitter letter Speranza had written to the girl’s father. William was included, con-sidered responsible by law for his wife’s behavior. The suit dragged on for months and resulted in a win for Travers but an award of only a farthing.

     Nevertheless the trial took a lot out of Wilde. He retreated to the country and practiced less and less medicine and more archeology. An illegitimate son, Henry Wilson, had followed his father in ophthalmology and gradually took over his practice and modernized it (he was treated like a legitimate son and included in his father’s will). William completed work on the 1871 census in 1874, and died in 1876. His estate had been impoverished, however, and Speranza struggled on her own, with only desultory help from Oscar who had his own troubles.

     In his life Sir William made contributions to eye and especially ear surgery, epidemiology and vital statistics, Celtic archeology, and travel writing, a full life.

Some works consulted:

Wilson, T G. Victorian Doctor, Being a Life of Sir William Wilde. 
    1946

White, Terrence dV, The Parents of Oscar Wilde. 1967

Froggatt, P. “The Demographic Work of William Wilde”. Irish J   
    Med Sci.1965, May. pp231-8.

Froggatt, P. “Sir WilliamWilde and the 1851 Census of Ireland”. 
    Medical History 9(4), 1965,pp 302-27.

Story, JB. “Sir William Robert Wills Wilde (1815-1876)”. Brit J 
    Ophth 1918, Feb, pp 65-71.  

Review of Census Report of 1841. In Dublin J Med Sci, pp 142-59.

    

QUAKER, DOCTOR, DRUG CRUSADER

 Does anyone remember Squibb toothpaste?

Edward R Squibb.

     Edward Robinson Squibb never sold or made toothpaste but this unusual doctor-founder of the Squibb Co. was an important pioneer in medicine and pharmacy. Born in Wilmington, Delaware, in 1819 into an established Quaker family, he served an apprenticeship to a pharmacist, acquiring early skills in compounding medicines. He then obtained a medical degree at Jefferson Medical College, a three year curriculum. At the onset of the Mexican-American War he enlisted in the Navy, a move that forced him to leave the Society of Friends. He didn’t see combat but served almost two years in the Mediterranean aboard the frigate Cumberland, an experience he published (Amer J Med Sci 1852, 23: 54-68). The article provides a unique window on naval medicine in the mid-eighteenth century. Cholera, other diarrheal diseases, and venereal disease topped the list of problems. More important for our story is that the medicines he used in the Navy were almost invariably adulterated or of bad quality due to the Navy custom of purchasing them from the lowest bidder without regard to purity.

     On his return he was assigned to the Brooklyn Naval Hospital under Dr. Benjamin Franklin Bache, great-grandson of the founding father and nephew of Dr. Franklin Bache, professor of chemistry at Jefferson Medical College (chemistry had been one of Squibb’s favorite subjects). There Squibb was provided with a laboratory allowing him to make drugs of high and consistent quality for the Navy.  He made several medications but focused on ether. Surgeons were unsettled by inconsistent effects of the newly discovered ether, and Squibb found this to be related to variations in its purity. He invented a steam distilling process that avoided the dangers of distilling the alcohol-sulfuric acid mixture by flame, attended to caliber of ingredients, and produced a reliable, pure product. He never patented the process, feeling it wrong to patent something of such human value. He also made pure chloroform (from chloride of lime and alcohol) and did extensive testing of available drugs, measuring and documenting their impurities such as straw, chalk, and plaster of Paris.

Steam distilling apparatus, diagram. From Internet Archives

     Meanwhile he had married the sister-in-law of his boss and, unable to support her on his Navy pay, resigned from the Navy in 1857 and briefly entered, with partners, a drug-making concern. But with civil war looming on the horizon the Army told Squibb that if he could put together his own lab they would keep him supplied with orders. He accepted, raised the money, and resigned from his other firm. The new lab was again in Brooklyn and was soon busy. But tragedy struck.

     One day a young employee, dizzy from pouring ether into small bottles, knocked one over. The volatile liquid ran down the long table toward a candle at the end. Flames leapt up, larger bottles exploded, and a sheet of flame roared up between where Squibb was and the exit stairways. Squibb ran for all his books with notes on experiments, formulas, and the like (his life’s work), dropped them, picked them up again, then charged through the flames, setting his hair and clothing on fire. As he burst out onlookers wrapped his torso to put out the fire on his clothing and gaped at his absent hair and his blackened face and hands.         

     Recovery was slow. Although he retained his vision his eyelids were so damaged that he had to wear protective goggles when going outside and tape his lids shut at night. His hands were severely scarred as was his face, inducing him to grow a beard to partly cover it. But Squibb was undaunted. A group of local physicians and pharmacists raised money (beyond insurance funds) to rebuild the lab, this time done with concrete. Squibb paid all the money back even though it had been intended as a gift. He was soon back to work.

     The Civil War did indeed keep the Squibb Company busy and the firm expanded. Medical supplies often were not readily available to battlefront surgeons since they were transported in large wagon trains, so Squibb developed a “medical pannier” – a smaller container for medicines, dressings, etc, that was small enough (up to 88 pounds) to be carried by a horse, mule, or ambulance directly to the front. (It can be seen at: http://www.civilwarhome.com/medicalstaff.html) Eventually the Army opened its own manufacturing facilities as Squibb became overwhelmed.

     One of Squibb’s best friends from medical school, George White, a physician then practicing in Georgia, asked Squibb during the war to provide food or aid to certain southern soldiers in northern prisons. Squibb readily did so, lamenting the bitterness of the war. During this time his wife developed epileptic seizures, another worry. She even went through a couple of pregnancies with seizures, though they ceased after menopause.

     After the war his lab’s reputation for high quality products continued to rise, leading to orders from as far away as Japan. He was rigid in his manufacturing demands, and people knew it. As late as 1899 The Boston City Hospital could state that of the ethers used, “Squibb’s is still preferred by most house officers” (Bost Med Surg J v 141: 312, 1899). The lack of wartime pressure, however, allowed Squibb time to exercise a wider nobility of purpose, likely related to his Quaker upbringing – improving the quality of all drugs. He became a member, in 1860, of the convention that revised the U.S. Pharmacopoeia every ten years. He helped to throw out useless preparations and raise standards for purity. Less successful was an attempt in the 1870s to have control of the Pharmacopoeia transferred to the AMA, provoking a revolt from the pharmaceutical community. He wrote pure food and drug acts for New York State and for New Jersey, paving the way for a national act later.

Inside vol.1 of An Ephemeris. From Internet Archive

     He fought to have an 1848 law to “prevent the importation of adulterated and spurious drugs and medicines” enforced, though to little avail.  As a further step he created his own publication, An Ephemeris of Materia Medica, Pharmacy, Therapeutics, and Collateral Information, the first issue appearing in January, 1882. In it he offered updates for physicians on medications, but more importantly he exposed useless patent medicines and gross adulterations, and advocated laws against these abuses.

     As he grew older Squibb spent less time in the shop. His two sons, having obtained their medical degrees, were filling in, and the firm was renamed E.R. Squibb and Sons. The scarring from his burns persisted, and in 1896 his left hand was amputated for a carcinoma that had developed. At the surgery he administered his own anesthesia until he lost consciousness. He died in 1900 of cardiac failure.

     Edward Squibb is remembered chiefly for his many pharmaceutical contributions, his drive for reform, and his irreproachable integrity.

Works consulted:

Blochman, Lawrence G: Doctor Squibb: The Life and Times of a Rugged Individualist. 1958

Navy Medicine 2005, v 96 (3,4): 24-27 in each. (Biography of Squibb)

Bost Med Surg J. 1899, v141: 312-14  Ether at Boston City Hosp

J Hist Med Allied Sci 1958. v13 (2): 382-94. The Squibb Lab in 1863.

Amer J Med Sci 1852, 23: 54-68. Mediterranean experience.

An Ephemeris of Materia Medica, Pharmacy, Therapeutics, and Collateral Information,     

       Scattered articles.

Am J Health-Syst Pharm 2000. v57: 475-89.Pharmacy in the Civil War.

     

THE LITTLE APPENDAGE

     Wait a minute – don’t take out that appendix!

     This sounds like heresy, but a recent article in JAMA (June 16, 2015) showing the near equivalency of antibiotics and surgery as treatment for appendicitis suggests a non-surgical approach as an alternative. Controversy over the appendix and appendicitis is hardly new, but how far back does it go?

    Berengario daCarpi, the famous anatomist and the first to describe anatomical structures based on his own human dissections, is credited with the first description of the appendix (1521). 
     Leonardo da Vinci included it in earlier anatomic drawings, but they were not published until the 18^th century. His translated comment on the structure is: "The auricle (appendix) n, of the colon, n m, is a part of the monoculus (caecum) and is capable of contracting and dilating so that excessive wind does not rupture the monoculus." (See right lower part of drawing.)

By Leonardo da Vinci, probably 1504-6. From Leonardo da Vinci on the Human Body by C.D. O'Malley and  J.B.de C.M. Saunders, 1952. Courtesy Hathi Trust.

From Vesalius' De Fabrica, Book 5. (Courtesy Biu Sante,Paris)

Vesalius showed the appendix clearly. He felt it should be called the caecum but the name appendix prevailed. 


     After experiments in removing the appendix (in animals) and noting its absence in certain animals it was later deemed to have no important function. Rare cases of perforated or gangrenous appendix were described at autopsy in the 18^th century, including one by John Hunter. More cases followed, and in 1827 Francois Mêlier described four fatal cases plus two from another surgeon, all showing at autopsy abdominal pus and a diseased appendix adjacent to an apparently healthy caecum. Mêlier was the first to suggest the possibility of surgery for the condition. 

Guillaume Dupuytren.  (From Wikipedia and Wellcome  Images)

     His opinion, however, was contradicted by Guillaume Dupuytren, the most prominent surgeon of the time, who felt that a diseased caecum was the culprit. Dupuytren’s exalted status and his abrupt personality apparently finished the argument, though it was largely academic since surgeons rarely ventured into the abdomen. Richard Bright and Thomas Addison, however, in their 1839 text (Elements of the Practice of Medicine) specifically mention “ulceration….of the vermiform process of the caecum” as a cause of acute peritonitis, as did occasional other writers. Names like “typhlitis” (cecal inflam-mation) and “paratyphlitis” (peri-cecal inflammation/pus) were given to the clinico-pathologic picture.        

Reginald Fitz. (From Nat. Library of Medicine)

     The issue was laid to rest by Reginald Fitz, professor of pathological anatomy at Harvard and a practicing surgeon. He had studied with Virchow (and others) in Europe and introduced the microscope into the Harvard medical school curriculum at the time of Charles Eliot’s presidency. His 1886 article in the American Journal of the Medical Sciences laid out the clinical and pathologic features of the disorder, using the word “appendicitis” for the first time, after which the vagaries of “typhlitis” and “paratyphlitis” died out. Most important, he recommended removal of the appendix as treatment. Other surgeons concurred, and contributed to raising appendectomy from a rare to a relatively common operation over the next decade. This was the age of anesthesia and “Listerism”, and a reduced fear of abdominal surgery.

     But the first surgeries had mixed results and controversies arose about when to operate, how to make the incision, how to predict perforation, and so on. William Osler pondered this problem. His extensive autopsy experience had taught him that appendicitis could heal by itself, or could resolve and recur. In the first edition of his text, 1892, he advised that "severe" cases have surgery. In mild cases it depended in part on the availability and skill of the surgeon, though he recognized that predicting perforation was chancy. On the other hand, he said, medical treatment could “be expressed in three words – rest, opium, and enemata”. Four years later, in the second edition, Osler was admitting cases directly to the surgical ward, warning that delays in surgery could be fatal, even though results from surgery were only fair at the time. Harvey Cushing's case (see below) illustrates the dilemma.  
     In Osler’s time the press had extensively publicized appendicitis, extolling the marvelous wonders of surgery, something Osler commented on in the 1896 edition: “There is a well-marked appendicular hypochondriasis (italics mine). Through the pernicious influence of the daily press, appendicitis has become a sort of fad, and the physician has often to deal with patients who have a sort of fixed idea that they have the disease. The worst cases of this class which I have seen have been in members of our profession…”
     Results improved over time and surgical treatment has prevailed until the present - now perhaps to be replaced by antibiotic therapy in early cases.

     

     A couple of interesting “appendicitis anecdotes”:

    1)  Harvey Cushing, as a resident at Hopkins, developed appendicitis and was operated on by William Halstead and two other surgeons (Finney and Bloodgood), with a slow recovery.

Harvey Cushing by Edmund Tarbell, from Wikipedia

Cushing wrote out his own history and examination (see insert). Fulton, his biographer, says, “The new operation had been performed several times at the Hopkins prior to his (Cushing’s) advent in Baltimore, but the results had not been particularly encouraging and Halstead was still reluctant to recommend it.” Halstead had little experience with it, in fact. Cushing knew this but pushed to operate, and left instructions with a friend on how to distribute his things in case of death.

     

{From Fulton's life of Cushing (Google Books)}

  2)  The coronation of King Edward VII, following the death of Queen Victoria, was scheduled for June 26, 1902. Fourteen days before, Edward developed abdominal pain and fever. He was seen by several physicians and improved with general measures. After a large pre-coronation banquet on the 25th Edward’s symptoms relapsed severely, and he was told by Sir Frederick Treves (and four other physicians in attendance) that he needed immediate surgery. When he protested that he had to attend his coronation, Treves told him, “Then, Sir, you will go as a corpse.” At surgery an abscess was opened and drained, and the appendix left in. He recovered. Treves was made a Baronet and accumulated a huge private practice, though his daughter, ironically, died of appendicitis.

Works consulted:

Smith, Dale: “Apendicitis, Appendectomy, and the Surgeon”. Bull Hist Med, 1996. v 70:414-441.

Melier, F: “Memoire et Observations sur Quelques Malades de l’Appendice coecale”. J Generale de Medecine, de Chirurgie, et de Pharmacie 1827, p 317.

Fitz, R. “Perforating Inflammation of the Vermiform Appendix”. Amer J Med Sci. 1886, 92:321-346.

Williams, G R. A History of Appendicitis. Ann of Surgery 1983. 197: 495-506.

Osler, William: Principles and Practice of Medicine, 1892 and 1896.

Fulton, J. Harvey Cushing: A Biography. 1946.

Bliss, Michael. Harvey Cushing: A Life in Surgery. 2005.

C D O'Malley, J B de C M Saunders: Leonardo da Vinci on the Human Body, 1952 (available at Hathi Trust web site)

     

PASTEUR and the ART WORLD

     What does Louis Pasteur have to do with the art world?

Quite a lot, it turns out.

    Thanks to the publications of the historian of medicine and science, Bert Hansen, and a former student and collaborator of his, Richard Weisberg, we have a window on an aspect of Pasteur’s life that has been neglected or overlooked. Pasteur displayed a keen interest in art, had artistic sensibility of his own, cultivated friendships with artists, and frequently helped them in their careers.

     As a teenager Pasteur studied art in his hometown of Arbois and then at Besancon, working mainly in pastels. Examples of his work, quite accomplished for his age and showing an appreciation for facial detail and expression, can be seen at http://orphea-linux.sis.pasteur.fr/index2.pgi. (click on Pasteur: oevre artistique)

     Pasteur went on to study physics and chemistry, obtain his degrees, marry, and fill various teaching and research positions until 1858 when he came to Paris permanently. In his travels for research he made a point of visiting art museums. He had an eye for sculpture as well as painting. In 1863, age 41, he began giving lectures at the École des Beaux-Arts, the leading art school in Paris, discussing physical and chemical properties of pigments, paints, and related materials. There he befriended a number of current and future artists.

     In those days most artists made their reputation by being accepted into the Paris Salon, a huge annual exhibition sponsored by the French Government. It was a juried show (with some established artists grandfathered in), opening May 1, lasting 6-8 weeks, and accepting between 2,000 and 5,000 works. Pasteur visited the Salon regularly, studied the press reviews, and knew some of the artists.

"Solitude" by Jean-Jacques Henner

      One of his close friends was the artist Jean-Jacques Henner. Henner, less well-known today, was a leading artist in Pasteur’s time, regularly exhibited in the Salon, a member of the Académie des Beaux Arts (which was limited to 40 seats, 14 of which were reserved for painting), and a winner of a number of awards. He is known for portraits and for scenes of women in somewhat spiritual settings. His work hangs today in the d’Orsay, National Gallery, Hermitage, and the Cantor Museum at Stanford (see insert). Pasteur entertained Henner in his home and on one occasion asked him to put in a good word for another artist at a Salon showing.

     Pasteur also took an interest in sculpture, which led to a warm relationship with the sculptor Jean-Joseph Perraud. Perraud too had won numerous awards, was in the Académie, and had been made a Chevalier of the Legion of Honor. He did a bust of Pasteur for which he refused payment, and when he was ill Pasteur helped secure medical care for him. Pasteur spoke at his funeral and later delivered a second eulogy at the unveiling of a bust of the artist in his hometown of Monay, done by a former student.

     The sculptor Paul Dubois and Pasteur knew each other well. They had both been guests of honor of the Emperor and Empress at a royal chateaux in 1865, and Dubois had won a number of honors and commissions.  A famous full-length work is his “Florentine Singer”(visible at: https://www.google.com/culturalinstitute/asset-viewer/a-fifteenth-century-florentine-singer/MQE_A8SRHMGNUw?hl=en). But  Dubois was most known for portrait busts, and executed one of Pasteur, commissioned by the Danish  brewer Jacob Christian Jacobsen. After the Franco-Prussian War of 1870 Pasteur, partly as an anti-German move, began studies to improve beer brewing. Beer spoiled easily, yeasts were hard to maintain, and so forth, and Pasteur cleared up many of these problems. The Danish brewer, Jacobsen (owner of Carlsberg Brewery, named after his son, Carl), was one of the first to utilize Pasteur’s research to upgrade his brewing techniques. He became hugely successful and established a laboratory for research on the science of brewing, now called the Carlsberg Laboratory. Results of all research were to be made public. To show his appreciation to Pasteur Jacobsen commissioned Dubois to sculpt a bust of the scientist. The original marble version was completed in 1879, shown at the Salon in 1880, and then placed in the new laboratory. A plaster copy went to Pasteur and a bronze copy was installed by Jacobsen’s son, Carl, on the exterior of his brewery (viewable at: https://www.flickr.com/photos/egdrossell/14671473537 ). Yet another copy, in bronze, was awarded to the Rockefeller Institute in 1909 by the Pasteur Institute in thanks for assistance in a meningitis outbreak in France. This was in fact a pandemic of meningococcal meningitis that began in New York in 1904-5 and then spread to Europe. Simon Flexner of the Rockefeller Institute had determined that anti-meningococcal serum prepared from immunized horses reduced the mortality rate considerably when injected intrathecally (the fluid space around the spinal cord), especially if given early. Large quantities were manufactured by the Rockefeller Institute and sent to a variety of countries, including France.

Pasteur in his Laboratory

     A few final words about another artist friend, Albert Edelfelt. Originally from Finland, he migrated to Paris, training at the École des Beaux Arts. Introduced by Pasteur’s son, he and Pasteur became close friends and Edelfelt over the years painted portraits of Pasteur and several members of his family. The portrait of Pasteur, painted in 1885 (insert), reveals him in his laboratory peering at a jar containing a drying rabbit spinal cord. While posing for the painting Pasteur was working actively on developing a rabies vaccine but the first case of preventing rabies in a human, that of Joseph Meister, was not until July of that year, just after the painting was finished. The work was entered in the Paris Salon in May of the next year, by which time Pasteur was an international hero, and it enhanced his fame even more. It was pioneering for its time in that the subject is not looking at the viewer nor is he in a chair or other posed setting. Rather he is concentrating on his work and the painting radiates this intensity of thought. A copy was made by the artist for Pasteur while the original was purchased by the French government and held at Versaille for many years until it was placed in the Museé d’Orsay, where it hangs now.

     I'll stop here, mentioning only that the cited articles tell of other artists in Pasteur's life. Pasteur enjoyed art, had an appreciation for it (though he appears not to have been interested in impressionism), welcomed artists as friends, and developed close relationships with several. A good balance to his intense scientific work.

Some works consulted:

  

Hansen and Weisberg: J Med Biography, May 29, 2015. (two articles)

Weisberg and Hansen: Bull Hist Medicine 2015. v89: 59-91 (on Edelfelt)

Hansen. Lecture before American Osler Society, 2014.

Debré, Patrice. Louis Pasteur. 1998 (Eng trans)

Flexner, S. J Exper. Med. 1913, v17: 553.

Pilgrim Haven to Hospital:

Ospedale Santa Maria della Scala
(Re-posted - somehow it got deleted)

     If you travel to Siena don’t miss a visit to the Ospedale Santa Maria della Scala. The latter part of the name derives from the steps of the cathedral next door.

     A feature of medieval and early Renaissance times was a pilgrimage to a holy site. In Europe the three principal destinations were Jerusalem, Santiago de Compostela (burial site of St. James), and Rome (burial site of St. Peter). The route to Jerusalem was closed after the Muslim takeover, but the other two routes remained open. Pilgrimages were popular, not only for religious reasons but because the journey earned a remission of sins and an easier entry into Heaven. The journey was fraught with hazards, including illness, injuries, and banditry.

     The principal north-south route, called the Via Francigena, ran, in its full extent, from Canterbury through Siena to Rome. The Archbishop of Canterbury documented his journey in the late tenth century, but it existed well before then. To accommodate weary, hungry, or ill pilgrims a large number of hostel/hospitals sprang up. A prominent one was Ospedale Santa Maria della Scala, which functioned as a hospital until 1990, over 1000 years. 

     Legend has it that the Ospedale was founded by a poor cobbler named Sorore, but the first documentation is dated 1090, labeling it as a “xenodochium et hospitalis” – a hostel and hospital. The term “xenodochium” goes back to early Byzantium when it referred to a hostel or shelter for the poor, while the “nosokomeian” (“hosptialis” here) functioned specifically to care for the sick. Later, on the pilgrim routes further west, the two functions appear to have been combined. Churches and monasteries were the main early providers of ospedales, but the clerical function of caring for the sick was gradually taken over by secular healers, and was officially ended in 1130 at the Council of Clermont. This corresponded with the rise of the secular medical school in Salerno and the rise of universities elsewhere. In 1193 a papal bull by Celestine III removed all Cathedral control over Santa Maria della Scala. The first lay rector was in 1200.

     Over time the Ospedale became a large concern, and self-sufficient. Through generous bequests and purchases it acquired or built numerous farms, granaries, and small ospedales in the surrounding countryside, eventually becoming one of the biggest landowners and economic entities of the State. The size concerned the State authorities, enough to insist in 1433 on being the ones to nominate the Rector, whom they could control.

     In addition to assisting pilgrims the Ospedale cared for the sick in general. Trying to cure patients rather than simply comforting them was an early goal. A physician, a surgeon, and an apothecary were kept as salaried employees. Surprisingly, for the times, there was only one patient per bed and the beds were covered with sheets, changed if dirty. In time student physicians and surgeons assisted in the work and more specific medicines were used, such as Peruvian bark. Nutritious diet (and wine) was provided, most from their own farms.

     Another function included the care of foundlings, a common problem. In 1298 there were over 300 under care, increasing to 1212 in 1618. The mortality rate of the infants was high. Identifying objects and records were kept in case the parents showed up later to reclaim the child. The infants were first handed over to wet nurses, then brought back in and educated in a trade (the boys) or sewing and weaving (the girls). Any earnings from their work were saved for the time of discharge at age 18, if they wanted to leave, and for girls money was granted as a dowry or to enter a convent.

     Finally, not losing sight of its religious origins, the Ospedale dispensed food to the poor three times a week, the Rector himself presiding on feast days.

Pellegrinaio (photo by author)

     This being Siena, art was not neglected. The front façade was originally covered with fresco, but the surface has been lost. In the interior, frescoes decorated various chapels, but to the medical historian the most fascinating are the frescoes of the “Pellegrinaio” – the Pilgrims’ Hall. The photo nearby shows the large hall, an open ward up until 1983, whose walls are covered with 15^th century murals, beautifully preserved. Most are painted by Domenico di Bartolo, the tutor of Piero della Francesca, and illustrate numerous details.

     You can zoom in on the pictures.

Caring for the Sick (photo by author)

   
     Look at “Caring for the Sick” (1440-1). In the center the Rector and some oblates of the hospital are next to a surgeon examining a man with a cut in his right thigh. To the left is a patient being eased onto a stretcher and two doctors examining a container of urine. On the right is a priest hearing confession and attendants are carrying a stretcher. The architectural details are said to be accurate.

Distribution of Alms (photo by author)

     Next, look at “The Distribution of Alms” (1441). In the center an almost nude man is being clothed, on the right bread is passed out (a woman with a baby already has her basket), and a cripple waits on the ground. On the left the Rector is taking off his hat in deference to a nobleman, probably an important benefactor. The background is a church within the Ospedale.

Payment to the Wet Nurses with Money (photo by author)

     “Payment of to the Wet Nurses with Money” was painted later, in the 16^th century, after an addition to the hall, by Metro d’Achille Crogi and Giovanni di Raffaele Navesi. Wet nurses were paid in grain or money, and the painting shows the monetary payment and the care of the foundlings. The purpose of the two large men is not clear to me.

     The Ospedale modernized with the times and functioned as a full hospital until 1990, when it was transferred to a large, modern building on the edge of the city. The old building is now a museum, still in the process of discovering all its ancient treasures, only a brief glimpse of which I have given.

     The Ospedale maintains a web site showing more details of the paintings and other treasures inside the building complex: http://www.santamariadellascala.com/w2d3/v3/view/sms2/storia--22/index_en.html

 Other reproductions are available at:

http://www.wga.hu/html_m/d/domenico/bartolo/pellegri/

Works consulted:

     Baron, JH: The Hospital of Santa Maria della Scala. BMJ 1990. v301, pp 1449-51

     Risse, GB: Mending Bodies, Saving Souls: A History of Hospitals. Oxf Univ Press,  

     1999.

     Museum-published book on the Ospedale.