America’s First Bronchoscopist

     Imagine a young girl, perhaps 7 or 8 years old, pale, weak, and emaciated. Her distraught mother explains that weeks earlier, her daughter had swallowed lye, thinking it was sugar. The resultant scars in her esophagus, contracting inexorably, now placed her near death from starvation or dehydration. During much of the 19^th century most homes kept lye for making soap, and the jars did not carry danger labels. Other home accidents included aspirated or swallowed bones, safety pins, or coins, that might obstruct or perforate the esophagus or bronchial tree. Short of chest surgery, risky at the time, there was little relief available.

     To the rescue came the inventive Dr. Chevalier Jackson. Born in 1863, Jackson grew up on a poor farm near Pittsburgh.

Chevalier Jackson (Wellcome Library)

Valuing education, he worked his way through Western Pennsylvania University (now Univ of Pittsburgh) and entered Jefferson Medical College. He took an interest in laryngology, influenced by professors at the recently founded nose and throat clinic. In the library of one professor, Jackson read through the works of Sir Morrell MacKenzie, the father of laryngology in England. Determined to study with MacKenzie, he booked the cheapest steerage passage to England, requiring him to bring his own mattress for the assigned double-decker bunk. He stayed with MacKenzie only briefly, however, disappointed in the design of his esophagoscope.

     On return, in 1886, he opened an office in Pittsburgh, a coal town that was so sooty that the lights were often kept on throughout the day. Jackson’s new specialty of laryngology, fortunately, was publicized by news bulletins about the crown prince of Germany, the son-in-law of Queen Victoria, who had cancer of the larynx and on whom MacKenzie had consulted (see blog of 2/11/17).

     Jackson was busy very soon. Enlarged, chronically infected tonsils interfered with sleeping and breathing in those days, and he removed them from many poor public-school children, rarely receiving any payment. He also was adept at passing a tube through the larynx or doing tracheotomies in children with diphtheria (where an anesthetic was contraindicated). His inventive genius, however, found its greatest application while dealing with foreign bodies and lye burns of the esophagus. Within four years of arrival he had devised a new esophagoscope, with which he removed a “tooth plate” from the esophagus of an adult and a coin from that of a child. He reported the cases to the local medical society, only to learn of tragic outcomes in similar instances treated by his untrained colleagues. He refused henceforth to allow the instruments to be used without proper instruction in anatomy and practice on anesthetized dogs.

     When Jackson found he could dilate constricted esophagi with his instruments, unexpected numbers of emaciated children crowded his office. The numbers were so large that he initiated a crusade to have labels placed on containers with poisonous substances. Industrial resistance to labeling was fierce, however, and no such law was passed until 1927 – the Federal Caustic Poison Law.

     Meanwhile in Austria, in 1897, Dr. Gustav Killian, the “father of bronchoscopy”, made history by removing a piece of bone

Gustav Killian (Wikipedia)

from the bronchus of a farmer, using a rigid tube. Killian’s reports stimulated Jackson to devise his own “bronchoscope”, and, in so doing, he introduced bronchoscopy to America. Lighting in the distal end was adapted from cystoscopy techniques. Jackson’s rigid scope was used almost exclusively for foreign body retrieval and biopsies.

     Jackson continued to revise and perfect new models of his scopes. He was rigorous about requiring training for their use, and many of those he

Swallowed trinket embedded in a candy, X-ray by C. Jackson (Wikipedia Commons)

trained went on to teaching positions elsewhere. As his reputation spread, he was asked to demonstrate at conferences in major cities, including Paris. He bypassed London, however; England’s severe antivivisection laws prohibited endoscopy on dogs, even anesthetized ones.

     In 1916, he accepted the Chair of Laryngology at Jefferson Medical College in Philadelphia, and eventually held faculty positions simultaneously at five medical schools in Philadelphia. This broke exclusivity rules at most of the institutions, but regulations were bent to keep him aboard. His one stumbling block was tuberculosis, each of three episodes putting him at bedrest for months at a time. He used the idle time to

Title page of Jackson's text (Hathi Trust)

write a popular text on endoscopy, a revised edition for use as a manual, other texts, and many articles, 238 of which were single-authored. He was an editor of the Archives of Otolaryngology, wrote an
autobiography, and was a founder of the American College of Surgeons. In his lifetime he extracted from patients over 2000 foreign bodies, all in the Mütter Museum in Philadelphia.

     Beneath this busy and inventive exterior lay a humane and charitable soul. Chevalier Jackson maintained that ninety percent of his work with patients was gratis. He never patented any of his instruments, considering it immoral to profit from medical inventions. He was a vegetarian and attributed his unusually steady hand in bronchoscopy to his abstinence from alcohol and tobacco. He was an accomplished artist and woodworker. He died at his farm, Sunrise Mill, near Philadelphia, at the age of 93.

Sunrise Mill, now a historic site (Wikipedia)

SOURCES:

Jackson, C. The Life of Chevalier Jackson: An Autobiography. 1938; Macmillan, 1938.

Marsh, B R. “Historic development of bronchoesophagology”. Otolaryngology-Head and Neck Surgery, 1996; 114: 689-716.

Boyd, A D. “Chevalier Jackson: The father of American bronchoesophagoscopy”. 1994; Ann Thoracic Surg 57: 502-5.

Coates, G M. “Chevalier Jackson” (obit.) 1959; AMA Arch Otolaryng 69(3): 372-4.

    

    

    

BERIBERI: AN INFECTION?

      Today we know that the cause of a disease of rice-eating countries, beriberi, is a deficiency of thiamine. During the latter part of the nineteenth century, however, the source of this mysterious disease that afflicted workers in Asian countries, bedeviled thousands in military services, and devastated prison inmates, was unknown. Numbness, muscular weakness, and cardiac insufficiency were its hallmarks, and the fatality rate was in the range of 30-35 percent. A British medical officer, William Anderson, an instructor in the Japanese Naval College (using British advisors) in Yedo, where the disease was known as kakké, reported on it in 1877. He considered factors such as overcrowding (common on ships), atmospheric conditions, geography, general hygienic conditions, and diet as possible causative factors. But he did not consider it an infectious or contagious disease.

Beriberi patient (National Library of Medicine)

     The year of that report, a young Japanese, Kanehiro Takaki, was in London studying medicine. Born into a samurai family, Takaki grew up learning Chinese, fencing, and riding. He read

medical books translated from Dutch  and served as a medic under the Prince of Satsuma in the civil wars following the fall of the shogunate. Disturbed by the poor treatment the wounded soldiers received, Takaki resolved to study medicine. He learned Dutch and English while studying under an English physician, William Willis, who encouraged further education in England. Takaki spent five years at St. Thomas School of Medicine in London, where he received several prizes and a gold medal.

     Returning to Japan, in 1880, as a medical officer in the

Kanehiro Takaki (National Library of Medicine)

Japanese Navy, he was confronted with a high prevalence of kakké among the sailors. Using techniques acquired in England, Takaki noticed that the nitrogen (a marker of protein) to carbon ratio was lower than an accepted value. Persuading the Navy brass to enrich the sailors’ diet for an upcoming cruise, identical to one on which kakké broke out, Takaki all but eliminated the scourge. He dismissed the idea that an infection caused the problem, noting the excellent state of hygiene on the ships. Later, barley or mungo beans added to the diet proved as effective as bread and meat. Barley had been discovered when prison authorities, to save money, partially substituted barley for rice, and watched beriberi disappear. The Navy was never troubled with kakké again.

     Japan’s medical schools, however, had invited German advisors, who focused on an infectious agent. Beriberi’s tendency to outbreaks and predilection for the summer season invited this speculation in an age of emerging germ theory. The Japanese Army doctors, also trained by Germans, also rejected the dietary hypothesis and concentrated on microbes.

     So did the Dutch. In 1886, the Dutch halted the suppression of a revolt in Sumatra due to alarming rates of beriberi among their troops. An investigating commission was formed whose leader, the pathologist Cornelis Pekelharing, was sent to study in Robert Koch’s laboratory before embarking. There he met

Christiaan Eijkman (Wikipedia)

Christiaan Eijkman, another Dutchman studying with Koch, and took him to Sumatra. Perhaps unsurprisingly, looking for an infecting agent, they isolated a micrococcus from patients but only with difficulty could they produce nerve changes. Pekelharing left after eight months and, probably for economy, Eijkman switched from mammals to chickens as an experimental animal. By chance, cooked rice left over from an Army kitchen was substituted for the usual chicken feed and the chickens developed the neuropathy characteristic of beriberi. Eijkman turned to dietary studies, eventually determining that the skin covering the rice grain, removed in the rice-polishing procedure, contained the necessary ingredient to prevent the disease in rice eaters.

      Japanese Army doctors pursued an infectious cause but in spite of exemplary hygienic measures, Beriberi devastated the Japanese soldiers during the 1904-5 Russo-Japanese War. Estimates of 80,000 to over 200,000 cases are available.    

     Beriberi also plagued the Philippines during the American occupation following the Spanish-American War of 1898. Soldiers, civilians, and prisoners were all affected. An American, Maximilian Herzog, was dispatched from Manila to the Japanese Army kakké hospital in Hiroshima to meet with Surgeon Major Kokubo, who, significantly, was a professor of infectious diseases in Tokyo. He also had isolated a coccus from patients. Herzog studied the coccus at the Army Research Center in Manila but could do nothing with it. Meanwhile, in 1905, General Terauchi, Japanese Minister of War, finally ordered barley added to Army rice rations, almost eliminating the disease in troops.

     In 1910, the Americans convened a conference in Manila, the First Congress of the Far Eastern Association for Tropical Disease. At the conference two British investigators, Henry Fraser and Thomas Stanton, presented convincing dietary studies carried out in Malaya, showing again that polished rice was the culprit.  Still, after much discussion the conference failed to pass a resolution stating that beriberi was due to a continuous diet of polished rice. The resolution slipped through later, though, at a final business meeting with fewer members present.

     Even so, the French Société de Pathologie Exotique, unconvinced, appointed yet another study commission. Only at the Second Congress, in 1912, was a firm resolution implicating polished-rice diets agreed upon. The notion of infection had finally expired.

Casimir Funk (Wikipedia)

     Takaki was appointed Navy Surgeon General in 1885 and was made a baron in 1905. Eijkman received the Nobel Prize in 1929 for his work. Casimir Funk coined the term “vitamine” in 1912 (later shortened to “vitamin”), and Robert R. Williams synthesized thiamine in 1935. In Japan, vials of liquid thiamine were sold as “Beriberol”, injected by civilians and military alike during WWII.

SOURCES:

Carpenter, Kenneth J. Beriberi, White Rice, and Vitamin B: A disease, a Cause, and a Cure. 2000; Univ of California Press.

Strong, R and Crowell, B. “The etiology of beriberi.” 1912; Philippine Journal of Science 7B: 271-411.

Heiser, V G. “Practical experience with beriberi and unpolished rice in the Philippines.” 1911;  JAMA 56: 1237-8.

Sugiyama, Y and Seita, A, “Kanehiro Takaki and the control of beriberi in the Japanese Navy.” J Royal Society of Medicine 106 (8): 332-4.

Hawk, B A, “The great disease enemy, kakké (beriberi) and the Imperial Japanese Army.” 2006; Military Medicine 171: 333-9.

Anonym, “The Far Eastern Association of Tropical Medicine.” BMJ April 23, 1910, pp 999-1000.

Fraser, H and Stanton, A T, “The etiology of beriberi.” Trans Royal Society Tropical Med and Hygiene 3(5): 235-67.

Herzog, M. “Beriberi in the Japanese Army during the late war: The kakké coccus of Okata-Kokubo.” 1906; Philipp J Science 1: 169.

Edit, “Baron Kanehiro Takaki.” 1906; Medicine 12: 241-3.

Bay, Alexander. Beriberi in Modern Japan: The Making of a National Disease. 2012; Univ of Rochester Press.

    

    

POLIO AND THE BIRTH OF RESPIRATORS

     Headlines during the Coronavirus epidemic have emphasized a critical shortage of respirators. The shortage is reminiscent of earlier epidemics associated with inqdequate respirator supplies: polio epidemics.

     Polio spreads fear partly because patients with upper body paralysis are unable to breathe, signaling a death sentence before the invention of respirators. The earliest devices to aid breathing were tilt tables, allowing the abdominal contents to push up against the diaphragm when tilted head-down and pull down when more erect. They had limited success. In 1928, Phillip Drinker, holder of a degree in chemical engineering and an instructor on ventilation and illumination at Harvard’s new School of Public Health, was consulted by Boston’s Children’s Hospital to help young polio victims, unable to breathe. Drinker had already developed a respirator for industrial cases of gas poisoning. With the help of Louis Agassiz Shaw, Drinker placed a cyanotic eight-year-old girl into the new device - an “iron lung” – a large metal tank, closed at the neck, that generated negative pressure to expand the lungs in a rhythmic fashion. The girl’s color pinked up quickly as the device took over her breathing. The “Drinker respirator” came into common use for polio patients. It was soon modified by John Emerson, a gifted man engaged in developing research apparatus for Boston-area medical schools. The Emerson respirator was more efficient, quieter, and cheaper, and was soon adopted as a standard. Drinker sued Emerson over patent rights, but eventually he lost both the suit and his patent rights. Tracheostomy as a way to control secretions while in the iron lung also was employed.

Polio Ward at Rancho Los Amigos National Rehabilitation Center, 1953. (Wikipedia)

     In 1952, polio’s devastation was unprecedented, the number of afflicted rising to almost 58,000 nationwide. Schools, churches, pools, and other public gathering spots were shut down and children kept indoors. In hospitals, Emerson respirators worked overtime, and thousands were in use. In far-away Denmark, the virus was equally relentless, with 5,722 cases throughout the country. In Copenhagen, one hospital, the Blegdams Hospital, with 500 beds, was assigned to handle polio patients. But the hospital, still suffering economically from the war, had only one “iron lung”, and six smaller, weaker versions, covering only the chest. Polio admissions ran as high as 30 to 50 a day, with 6 to 12 a day needing respiratory help. Doctors agonized over having to decide who got a respirator and who did not. An anesthetist, Björn Ibsen, was called to help, and help he did. 

     Ibsen, while a medical student in Copenhagen, had spent a rotation administering anesthesia at a provincial hospital in Jutland, using an ether mask. He had never intubated a patient and anesthesia was not a specialty in Denmark. To obtain further training he accepted a position at Massachusetts General Hospital as an anesthetist,

Henry Beecher (Wikipedia)

working under Henry K. Beecher. When he arrived in 1949, open drop ether was the method used and medical students had to induce at least 10 patients before graduating. A year later Ibsen was back in Copenhagen, working as a freelance anesthesiologist.

     When Ibsen arrived at the beleaguered Blegdams Hospital, the few tank respirators available functioned poorly. Twenty-seven out of thirty-one respirator cases died in spite of tracheostomies done to control secretions. Further, knowledge of blood gases was just emerging and not widespread among clinicians.  Having just read an article on the buildup of carbon dioxide in the body in such cases, Ibsen suspected this was part of the problem.

     A 12-year-old girl, turning blue and struggling to breathe, was Ibsen’s first patient. He showed quickly that CO2 narcosis developed at times of diminished breathing (by measuring the expired CO2), even with proper oxygenation. He relieved her distress

Björn Ibsen (Wikipedia)

with a tracheostomy and a bag respirator. Tracheostomy and artificial breathing with a bag respirator became routine as a supplement to tank respirators or as the sole breathing assistance. Medical students were called in to hand operate the respirator bags, working in 6-hour shifts around the clock. It was emotionally exhausting work, breathing for a child who was paralyzed and unable to speak. Standbys were also needed in case a student was sick or cancelled. (For an image of this see: https://www.nature.com/articles/d41586-020-01019-y?utm_source=Nature+Briefing&utm_campaign=64fb5afbff-briefing-dy-20200406&utm_medium=email&utm_term=0_c9dfd39373-64fb5afbff-44774997 ).

     Anxiety about contracting polio from the work and worry about finishing the medical curriculum led many students to drop out of the program after a few weeks. Dental students were next recruited. Eventually about 1,500 students put in 165,000 hours hand-ventilating. Bang & Olufsen designed and made mechanical respirators to relieve the strain, though the firm later concentrated on audio equipment.

     Many patients who were maintained on continuous bag respiration recovered to breathe on their own. Ibsen’s first polio patient, the 12-year-old girl, lived to the age of 31, when she died of pneumonia and diabetes.

     Ibsen also pioneered in the treatment of tetanus, using curare to paralyze the respiratory muscles while breathing for the patient, a treatment he had been advised against while in Boston. Later he was asked to consult on fluid replacement postoperatively in another hospital. He turned that hospital’s recovery room into the precursor of an ICU, said by some to be the world’s first, and later wrote a book on shock.

     It is an old truism that war spawns innovations in medical treatment. The same might be said of epidemics. The hand-operated respirators of the Blegdams Hospital, later mechanized, replaced iron lungs. And the successful Salk vaccine entered its first trials the year after the 1952 epidemic.

SOURCES:

Wackers, G L Constructivist Medicine. 1994; Thesis, University of Maastricht.

Lassen, H C A. “A Preliminary Report on the 1952 Epidemic of Poliomyelitis in Copenhagen.” 1953; Lancet Jan 3, pp 37-41.

West, J B. “The Physiologic Challenges of the 1952 Copenhagen Poliomyelitis Epidemic and a Renaissance in Clinical Respiratory Physiology.” 2005; J Appl Physiol 99(2): 424-32.

Shaw, L A and Drinker, P. “An Apparatus for the Prolonged Administration of Artificial Respiration: II. A Design for Small Children and Infants with an Appliance for the Administration of Oxygen and Carbon Dioxide.” 1929; J CVlin Invest 8(1): 33-46.

Phillip Drinker, obituary. 1973; Ann Occup. Hyg. 16: 93-4.

Berthelsen, P G and Cronqvist, M. “The First Intensive Care Unit in the World”.   2003; Acta Anaesthesiol Scand 47: 1190-5.

Senelar, L R. The Danish Anaesthesiologist Björn Ibsen: A Pioneer of Long-term Ventilation on the Upper Airways. 2009; Thesis, Johann Wolfgang Goethe University, Frankfurt am Main.

Lassen, Bjorneboe, Ibsen, and Neukirch. “Treatment of Tetanus with Curarisation, General Aneasthesia, and Intratracheal Positive-Pressure Ventilation.” 1954; Lancet Nov 20, pp 1040-4.

 Oshinsky, D. Polio, An American Story. 2005; Oxford Univ Press.

A HERO IN BURN THERAPY

     Some time ago, a friend referred me to a Medscape list of the “Fifty Most Influential Physicians in History”. Many names on the list are familiar to physicians and medical historians, but one unfamiliar name caught my attention: Dr. Zora Janzekovic. She was noted to be a plastic surgeon from Slovenia, elevated into this group of fifty for her major contributions to the therapy of burns. Her achievement is especially remarkable considering the demanding conditions under which she worked.

     Dr. Janzekovic was born in September, 1918, in Slovenska Bistrica, Slovenia. After receiving her MD degree at the Zagreb University Medical School, she obtained specialty training in plastic surgery in Belgrade, then underwent a rapid, six-month training course in burn management in Ljubljana, Slovenia. Enough scientific exchange with the West existed, however, to ensure good training. She was assigned to run a burn unit in the city of Maribor, the second-largest city in Slovenia, situated in the northeast, where burns, especially in children, were frequent.

     On arrival, Janzekovic was greeted with almost impossible conditions. Yugoslavia was still behind the Iron Curtain and the Cold War was on. In the Maribor hospital she found that no burn unit existed. Surgical equipment, food, dressings, and medications were all scarce or absent and there was limited access to pertinent literature. Nurses and physicians had not been trained to care for burn victims, and funds to remedy conditions were meager. Children with burns came frequently, and Dr. Janzekovic was pained to witness their emaciation and suffering.

Dr. Zora Janzekovic (Wikipedia)

    But she forged ahead. She managed to acquire three rooms in the dermatology department, gradually expanding to accommodate the approximately 350 burn patients seen per year, many of them serious, and most needing painstaking care. Dressings full of pus piled up after the daily changes, creating a repugnant stench, and medications were in short supply. The staff was buckling from overwork.

     Janzekovic commandeered yet more hospital space. Equally important, she realized that the infections under the dressings were coming from the patients’ own tissues, allowing her to cut down on isolation procedures, saving time and space. She trained the nurses and acquired another physician to help.

     The major breakthrough came next. At the time, the usual practice with deep burns was to protect the burn with dressings until the superficial dead tissue demarcated from the healthier tissues beneath, then apply skin grafts. This took time, and Janzekovic wondered if one could shorten the process by simply excising the upper, apparently dead, layers of tissue only a few days after the burn and then apply grafts immediately to the denuded area. Pushed by the sheer number of patients, she tried the new approach on a few smaller burns, with success. With more experience, she honed the technique and calibrated the best timing for excisions and dressing changes. Happily, the early grafts healed more rapidly and with a minimum of scarring. Gradually she tackled larger and larger burns, many large enough to require skin grafts from other donors. Overall the new procedure saved huge amounts of time, freed up needed beds, and reduced the infection rate dramatically, saving the use of scarce antibiotics.

     Soon her colleagues from the capital, Ljubljana, came to Maribor to see for themselves, and were impressed enough to invite others from abroad. In 1968 the Burns Society of Slovenia held the Third Congress of the Yugoslav Association for Plastic and Maxillofacial Surgery in Maribor. A number of burn specialists attended, among them Douglas Jackson, from England, who tried out the method in his home city of Birmingham. Dr. Jackson, named, in 1969, to give the first Everett Idris Evans Memorial Lecture (named after the surgeon who pioneered research on fluid dynamics in burns and on radiation burns), pronounced the method successful. His opinion brushed away a good deal of skepticism and the Janzekovic method spread.

     In 1975 Janzekovic published her experience with an astounding 2,615 patients who had undergone the excision and grafting procedure. Pain was reduced, patients discharged more promptly (average stay was 14 days), aesthetic appearance improved, and contractures from scarring were relatively infrequent.

     By this time Dr. Janzekovic was well known. Between 1968 and 1984 a total of 237 burn surgeons made a pilgrimage to her clinic, and she was invited to lecture at meetings “from Los Angeles to Shanghai,” as she put it. She was chosen, in 1975, to deliver the Evans Memorial Lecture, the same lecture at which Douglas Jackson had first publicized her technique. In 2007 a new award was created by the European Club for Pediatric Burns, the Zora Janzekovic Award: “The Golden Razor”. Dr. Janzekovic was, of course, the first recipient and she received many other honors.Today her technique is standard practice in burn therapy.

     In her later years Dr. Janzekovic did research on shock in burns, though, as she said, “it was far too great a challenge for our circumstances.” She did, however, think that overheated blood might produce toxins and speculated on the use of exchange transfusions to eliminate them.

     Zora Janzekovic, after many years of tireless work and healing thousands of children, retired in her native country. She had lived through WWII, worked throughout the Cold War in communist Yugoslavia, and, finally, made the transition to the European Union. At her 90^th birthday she was quoted as saying, “My life was worth having been lived.” She died in 2015 at age 96. It is fitting that she is ranked in Medscape’s 50 most influential physicians.

SOURCES:

Dr. Igor M Ravnik, in Ljubljana, kindly reviewed and helped with this essay.

Janzekovic, Z. “Once upon a time: How west discovered east”. 2008; J Plast Reconstr, Aesthet Surg 61: 240-44.

Burd, A. “Once upon a time and the timing of surgery in burns”. 2008; J Plast Reconstr Aesthet Surg 61: 237-9.

Janzekovic, Z. “A new concept in the early excision and immediate grafting of burns”. 1970; J Trauma 10: 1103-8.

Janzekovic, Z. “The burn wound from the surgical point of view”. 1975; J Trauma 15: 42-62.

Obituary. 2015; Burns 41:1374.

Barrow, R E and Herndon, D N. “History of treatments of burns”. Chapter in Herndon, D N, ed. Total Burn Care, 3^rd edit. 2007; pp 1-8.

Powers, J M and Feldman, M J. “Everett Evans, nuclear war, and the birth of the civilian burn center”. 2017; Amer Coll Surg Poster Competition.

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.    

A HISTORY OF CESAREAN SECTION

       The origin of the name "cesarean section" is unknown. Three principal explanations have been suggested.                                                                                            1)   Legend says that Julius Caesar was born in this manner, hence the name "Caesarean".  There are several reasons to doubt this.  First, the mother of Julius Caesar lived for many years after his birth and in 100 B.C. the survival rate for the procedure was

Birth of Julius Caesar, 1506 French woodblock (Wellcome Library)

essentially zero.  Second, the operation, whether performed on the living or the dead, is not mentioned by any medical writer before the Middle Ages.                                                 

 2)   It may have been derived from a Roman law, supposedly created by Numa Pompilius (eighth century B.C.), ordering that the procedure be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child.  This explanation then holds that the lex regia, as it was called at first, became the lex caesarea under the emperors, and the operation itself became known as the caesarean operation. The German term Kaiserschnitt reflects this derivation.                                                                                       3)   The word caesarean was possibly derived sometime in the Middle Ages from the Latin verb caedere, "to cut."  This explanation of the term caesarean seems most logical, but exactly when it was applied to the operation is uncertain. Since "section" is derived from the Latin word seco, which means "cut", the term Cesarean section seems redundant

     In reference to abdominal delivery in antiquity, it is pertinent that no such operation is mentioned by Hippocrates, Galen, Celsus, Paulus, Soranus, or any other classical medical writer. If cesarean

Soranus of Ephesus (Nat Library of Medicine)

section were employed at that time, it is surprising that Soranus, whose extensive work of the second century A.D. covers all aspects of obstetrics, does not mention cesarean

section.                                          

     Several references to abdominal delivery appear in the Talmud (Jewish civil and religious law writings) between the second and sixth centuries A.D., but whether they were used in a clinical setting is doubtful. Cesarean section on the dead appears to have been practiced, however, soon after the Catholic Church gained dominance, to enable baptism of the child. Locally, two records of postmortem sections are known, one at Mission Dolores in San

C Section on expired woman (Wikipedia)

Francisco in, 1805, and another at the Santa Clara Mission, in 1825. Neither infant survived.

     The earliest cesarean section done on a living woman was reported in 1500, performed by Jacob Nufer, a castrator of pigs at Sigerehausen, Switzerland. The patient (his wife) and the baby both survived, but since the mother subsequently delivered five more children vaginally there is doubt about the report's validity. Dr. Robert Harris reported on the first known cesarean operation in the U.S. A fourteen-year-old quadroon performed it on herself in a snowbank in Nassau, New York, using an L-shaped incision, dressed by her employer. Mother and baby survived.                                                                                                                        

         Credit for the first Cesarean section performed by an American physician goes to Dr. John Lambert Richmond. Growing up impoverished, he educated himself during childhood, eventually gaining entrance to the newly organized Medical College of Ohio. Under its founder, the formidable Daniel Drake (see blog of 9/16/2019), he received his M.D. degree in 1822. He also studied to become an ordained Baptist minister. Called to a house on the

Article by Richmond (Hathi Trust)

evening of April 22, 1827, Dr. Richmond found a primigravida exhausted from a thirty-hour labor, with no cervical dilation, and with seizures (probable eclampsia). He was seven miles from home, in a storm. In Richmond's own words, "…with only a case of common pocket instruments, about one o'clock at night I commenced the cesarean section. Here I must….relate the condition of the house, which was made of logs that were green and put together not more than a week before. The crevices were not chinked, there was no chimney, nor chamber floor. The night was stormy and windy, insomuch that the assistants had to hold blankets to keep the candles from being blown out." Under the precarious candlelight, Richmond made a vertical incision, removed the placenta, and delivered a large infant that did not survive. He found no opening between uterus and vagina. The uterus was not sutured closed (custom at the time), and the abdominal wall closed in two stages. The only complication to the mother was an infected hematoma, drained. She returned to work 24 days after the operation.

     Maternal mortality rates from cesarean section in the 19th century were 85 percent or higher, with the operation done as a last resort to save the life of the mother. Dr. Harris noted that as late as 1879, cesarean section was more successful when performed by the patient herself (or ripped open by a bull's horn). He compared nine such cases from the literature, with five recoveries, to twelve cesarean sections done in New York City during the same period with only one recovery.

     The turning point came in 1882 when Max Saenger, a 28-year-old assistant to Dr. Credé at the University Clinic in Leipzig,

Max Saenger (Wikipedia)

introduced suturing of the uterine wall, using silver wires. Eight out of seventeen mothers survived their sections, remarkable for the time. New surgical techniques, antibiotics, and blood transfusions have lowered the risk dramatically since then. In 1950, D'Espo reported 1000 consecutive cesarean deliveries without a single maternal death. The frequency of the operation rose, from 5 percent of births in 1970 to 23 percent in 1985. The CDC reports a rate of 31.9 percent of births for 2018.

     The present state of cesarean section surgery enables millions of women to avoid otherwise difficult childbirths with a safe and healthy outcome.

                                                                         Michael Shea MD

SOURCES:

Creasy, R K. and Resnik, R. Maternal Fetal Medicine Principles and Practice. 1984; W.B. Saunders Company.

Cunningham, F. G, MacDonald, Paul C. and Gant, Williams, J W. Williams Obstetrics. 1989; Appleton and Lange.

Eastman, N J and Helman, L M.  Obstetrics. 1961; Appleton-Century-Crofts Inc.

Harris, Henry. California's Medical Story. 1932; Carles C. Thomas.

Speert, Harold. Obstetrics and Gynecology in America: A History. 1980; Waverly Press.

King, A G. "America's First Cesarean Section". Obstetrics and Gynecology 1971; 37(5): 797-802.

Harris, R P. "A Study and Analysis of One Hundred Cesarean Operations Performed in the United States During the Present Century and Prior to the Year 1878". Am J Med Sci 1879; 77: 43-65.