History of Medicine

ADOLF KUSSMAUL

          Only a rare medical student is unfamiliar with the name Kussmaul. The Kussmaul breathing of the diabetic in severe acidosis and the Kussmaul, or paradoxical, pulse of the patient with constrictive pericarditis are part of medical jargon. Adolf Kussmaul’s life and other accomplishments, though, are less well known. His career is too full to cover here but his contributions to vasculitis and gastroenterology deserve mention.

Adolf Kussmaul (Wikipedia)

     Kussmaul, the son and grandson of doctors, was born in 1822 in Baden. He received his medical education at Heidelberg, following which he studied in Vienna under illustrious pioneers such as Hebra (dermatology), Rokitansky (pathology), Semmelweiss (obstetrics), and Skoda (internal medicine and chest disease), and in Prague under Johann von Oppolzer (internal medicine). After a stint in the Army, he settled into a country practice in Kandern, southwest Germany, the birthplace of John Sutter of California Gold Rush fame. 

     In the third year of a grueling practice that included house calls at night on horseback, Kussmaul suffered a frightening, though temporary, paralysis of his legs and bladder, possibly a case of polio. After months of recovery, he decided on an academic career. At the University of Würzburg, studying under Virchow, he received his MD degree, necessary for an academic career. He started at the University at Heidelberg, teaching materia medica and forensic medicine. There he showed that rigor mortis was due to chemical changes in dying muscle and not to nerve death, as was thought. Subsequent academic moves included professorships of medicine at the University of Erlangen (1859-63), the University of Freiburg (1863-77), the University of Strassburg (1878-88). Finally, as professor emeritus of medicine, he returned to the University of Heidelberg. 

     While at Freiburg, in May of 1865, he saw a 27-year-old man admitted with pallor, severe muscular weakness, rapid pulse, and abnormal urine. Peculiar small nodules appeared on the trunk as the patient became bedridden, demented, and finally expired. At autopsy, the nodules proved to be arteries showing,

microscopically, marked nodular inflammatory changes. A second case, less severe, was diagnosed through a muscle biopsy. Kussmaul and Rudolf Maier, professor of pathology, reported the cases as a new disease, periarteritis nodosa, a malady now widely recognized. Carl von Rokitansky had previously reported the disease but, not using a microscope, failed to recognize its nature.

     Kussmaul was also a pioneer in gastroenterology. He reported, in 1869, on patients with obstruction of the stomach outlet (pyloric obstruction), presenting with upper abdominal pain, persistent vomiting, and dilated stomachs. After passing a tube into the stomach and aspirating the contents he flushed frequently with Vichywater and bicarbonate solutions. If the obstruction was due to ulcers, a few treatments, followed by a soft diet with frequent milk feedings, led to good recovery, though with occasional relapses. Those with cancer had little relief. Nasogastric tubes had been used before, especially to treat poisonings, but Kussmaul recognized their value for pyloric obstruction and for the study of stomach physiology. He also suggested the possibility of surgery as a future therapy for obstruction. Twelve years later Theodore Billroth realized the suggestion by performing the first pyloric resection. 

     Kussmaul also mentioned that he had passed a scope to see the interior of the esophagus and stomach, about which he promised to report later. The report never came, but letters have come to light shedding light on Kussmaul’s contribution.

     The idea of peering into body cavities goes back to Philipp Bozzini, a German of Italian extraction. In 1806, using a candle for a light source and employing mirrors, he looked down a short tube to see into the urethra, bladder, and rectum. The apparatus did not catch on, however. In 1853 a French surgeon, Antoine J

Desormeaux's endoscope (from his book)

Desormeaux, developed an improved instrument, which he called an “endoscope”, the first use of the word. An alcohol lamp provided light that was reflected down the scope through a mirror with a central hole, again to visualize the urethra and bladder. 

     Kussmaul was familiar with Desormeaux’s work and was inspired to design a short, functional esophagoscope. In 1867 or 8, one of Kussmaul’s assistants, curious about the anatomy of a local sword swallower, brought him to the hospital to examine his larynx. While there, Kussmaul tried out his short scope but it failed to reach the stomach. A longer rigid tube was made that the sword swallower inserted, successfully. In Kussmaul’s own words, the sword swallower showed that “…a difficulty for gastroscopy, the bending of the

Sword swallowing (photo by Bill Golladay, Wikipedia)

esophagus at the cervical level, could be overcome with the proper positioning of the head and neck” (Neumann, Hellwig). Kussmaul could see down to the junction with the stomach, beyond which he saw only foam and darkness. The sword swallower agreed to visit clinics in Basel and Zurich, teaching doctors the technique. 

     Kussmaul’s endoscope helped diagnose cancers of the esophagus and cardia and proved useful in removing foreign bodies. But the interior of the stomach remained in darkness. Rigid gastroscopy proved tricky, as well, until supplanted by the semi-flexible scope of Rudolf Schindler, and later by the far superior flexible fiberoptic instruments. 

Crown Prince Friedrich W. (Wikipedia)

     Kussmaul’s reputation as a teacher and for his skill in combining clinical investigation with bedside medicine was widespread. His prestige was such that he was called to examine the lungs of the Crown Prince Friedrich Wilhelm, who suffered from laryngeal cancer. And Kussmaul’s use of the nasogastric tube for treatment of obstructing ulcers and his introduction of rigid gastroscopy paved the way for the specialty of gastroenterology. We owe a debt to that anonymous sword swallower.

SOURCES:

Kluge, F. Adolf Kussmaul 1822-1902. 2002; Rombach Verlag.

Matteson, E L and H R. polyarteritis Nodosa and Microscopic Polyangiitis. 1998; Mayo Foundation.(A translation of the original articles)

Neumann, H A and Hellwig. Vom Schwertschlucker zur Glasfiberoptik: Die Geschichte der Gastroskopie. 2001; Urban & Vogel.

Bast, T H and Miller, W S. The Life and Time of Adolf Kussmaul. 1926, Paul B Hoeber (Reprint)

Kluge, F and Seidler, E. “Zur Erstanwendung der Ösophago-und Gastroskopie: Briefe von Adolf Kussmaul und seinern Mitarbeitern.”. Medizinhistorisches Journal  1986; 21(3): 288-307.(contains excerpts of letters by Kussmaul and colleagues)

Matteson, E and Kluge, F. “Think Clearly, Be Sincere, Act Calmly: Adolf Kussmaul (February 22, 1822 – May 28, 1902) and his Relevance to Medicine in the 21^st Century.” Curr Opin Rheumatol 2003; 15: 29-34.

Desormeaux, A. De l”Endoscope et de ses Applications au Diagnostic et au Traitement des Affections de l’Urethre et de la Vessie: Lecons faites a l’Hopital Necker. 1894; J B Ballière.