DISCOVERING THE LYMPHATICS

 

         The widespread lymphatic vessels in the body are difficult to see and escaped proper study for centuries. These delicate, thin-walled vessels bring intestinally absorbed fat and tissue fluid from all parts of the body back to the general circulation, providing immunologic and antibacterial functions as they pass through numerous lymph nodes. The first to describe lymphatic vessels in some detail was Galen, the famous second-century Greek-Roman physician. During animal dissections he saw lymph nodes, that he considered “cushions” to protect organs, and described slender vessels running between abdominal lymph nodes and the intestines. In Galen’s concept of circulation, the liver manufactured blood that flowed in veins out to the intestines and other peripheral sites, nourishing them, while “spiritous” blood also flowed peripherally through arteries. The blood was absorbed in the periphery; it did not circulate back. 

         Andreas Vesalius, the great sixteenth century Belgian anatomist, still anchored to Galenic physiology, had a similar conception. Like Galen, he saw the tiny abdominal vessels without blood (lymphatics) leading to the liver, believing they connected to a portal vein that flowed bidirectionally, in part carrying chyle to the liver to aid in making blood. 

         By the early decades of the next century, experimentation to

Gaspare Aselli (Wikipedia)

establish knowledge, as opposed to genuflecting to ancient teachings, had come into vogue. In this vein, Gaspare Aselli, professor of anatomy and surgery at the University of Pavia, on July 23, 1622, dissected a dog for two colleagues who wanted to see the “recurrent nerves.” Pressing down on the intestines to view the diaphragm, he noticed in the mesentery “numberless fine white cords.” He thought they were nerves but on cutting one he saw a milky fluid emerge. When he opened another dog and could not find the vessels he remembered that the first

Woodblock print from Aselli's 1627
De lactibus, sive lacteis venis, quarto vasorum
mesaraicorum dissertatio (Wikipedia)
The slender white lines are lymph vessels passing
through the mesentery.

dog had eaten before the dissection. He soon proved that the tiny vessels indeed carried fat-laden fluid (chyle), absorbed after meals, through the mesentery toward the liver where he assumed they terminated, supplying nutrients for blood formation according to Galen’s scheme.

         Aselli died three years later, at age 44. Two of his colleagues, Alessandro Tadini and Senatore Settala, published his findings in 1627, one year before William Harvey’s publication on the circulation of the blood, a publication that shed doubt on Galen’s teaching of the liver as the source of blood.

Did these chylous vessels exist in humans? Nicolas-Claude Fabri de Peiresc, a wealthy senator in Provence and supporter of science, “caused a man which was condemned to be hanged to be fed lustily and securely before sentence was pronounced….and an hour and a half after he was turned off, he caused the Body to be brought into the Anatomical Theater.” (Gassendi). There de Peiresc found similar chylous vessels emerging from the intestines.

Jan de Wale (Wikipedia)

The picture of the lymphatic circulation was still incomplete. The Dutch anatomist, Jan de Wale (Johannes Walaeus) established, using ligatures of portal and lymphatic vessels, that the portal veins carrying blood from the intestines were distinct from the lymphatic vessels carrying chyle. He communicated these findings to Thomas Bartholin, who published them in 1641 and in enlarged form in 1645 in his anatomy text, Institutiones Anatomicae. Bartholin was one of Europe’s most

Thomas Bartholin (Wikipedia)

distinguished anatomists, based in Copenhagen. 

The liver remained the perceived endpoint of lymphatic flow, however, until animal dissections by the French physician Jean Pecquet found that chylous lymph from the intestines actually bypasses the liver, runs to a sac that gathers lymph (the cisterna chyli) and then rises through the thorax via the thoracic duct, a vessel that carries the lymph to the bloodstream. In short, the liver is not nourished by lymph.

Illustration from Picquet's Experimenta Nova Anatomica showing the chyli receptaculum
(cisterna chyli)  labeled "I" and thoracic ducts above. (Internet Archive) Click on image to enlarge.

Thomas Bartholin extended these observations and summarized the findings in 1653 under the title Vasa Lymphatica, Nuper Hafniae in Animantibus inventa, et Hepatis Exsequiae. The last two words translate as “obsequies of the liver,” a piece of humor by which he meant to convey the death of Galen’s teaching of the liver as the source of blood. 

Bartholin's Vasa Lymphatica
(Internet Archive)

Unbeknownst to Bartholin and Pecquet, a Swedish medical student, Olof Rudbeck, while dissecting a calf, had noticed “whey-like fluid” emanating from its upper thorax. He eventually traced out much of the lymphatic system, including, for the first time, the myriad vessels from the periphery, again showing that no lymph drained into the liver. In April 1652 he demonstrated his findings before Queen Christine and in May defended a thesis on the subject, published in 1653. He learned about Bartholin’s publications later that year and in 1654 a Leiden publisher produced a book containing publications of Pecquet, Bartholin, and Rudbeck. Rudbeck claimed that for this book Bartholin had backdated his work to 1652 (It is not certain this is true). 

Olof Rudbeck (Wikipedia)

A priority dispute arose between Rudbeck and Bartholin, fought out bitterly in various pamphlets and publications. Bartholin largely abstained from the quarrel as his supporters fanned the flames. One scholar who has studied the controversy, Charles Ambrose, credits Pecquet with discovering that abdominal lymph vessels bypass the liver to the thorax and the bloodstream, and Rudbeck with the discovery of the wider system of lymphatic drainage. In Rudbeck’s day, the public presentation of a scientific finding, such as before the Queen, was viewed as a date of communication. Rudbeck was a gifted scholar who taught several subjects and at age 31 was appointed rector of the University in Upsala. He used the name vasa glandularum serosa to describe the lymphatic system, but Bartholin’s vasa lymphatica is the name that survived in English as lymphatic vessels. 

The wonders of the lymphatic system are still unfolding, in particular its immunological functions.

 

SOURCES:

 

Suy, R, et al, “The Discovery of Lymphatic System in the Seventeenth Century: Part I: the Early History.” 2016; Acta Chirurgica Belgica 116 (4): 260-66 and "Part II," 116 (5): 325-331.

Park, J and Riva, M, “Gaspare Aselli (1581-1625) and Lacteis Venis: Four Centuries from the Discovery of Lymphatic System.” 2023; Amer Surgeon 89 (6): 2325-8.

Gassendus, Petrus, The Life of the Renowned Nicolaus Claudius Fabricius Lord of Peiresk, Senator of the Parliament at Aix. 1657, London.

Natale, G, et al, “Scholars and Scientists in the History of the Lymphatic System.” 2017; J Anatomy 231: 417-29.

Leeds, S, “Three Centuries of History of the Lymphatic System.” 1977; Surg Gyn Obs 144: 927-34.

Guerrini, A, “Experiments, Causation, and the Uses of Vivisection in the First Half of the Seventeenth Century.” 2013; J Hist Biology 46: 227-54.

Tonetti, L, “The Discovery of Lymphatic System as a Turning Point in Medical Knowledge: Aselli, Pecquet and the End of Hepatocentrism.” 2017; J Theoret Applied Vascular Research 2(2): 67-76.

Ambrose, C, “Immunology’s First Priority Dispute – An Account of the 17^th Century Rudbeck-Bartholin Feud.” 2006; Cellular Immunology 242: 1-8.

A full index of past essays is available at: 

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

 

 

 

 

 

 

         

COCAINE AND EYE SURGERY

         The time was early September, the year 1884, the place the famous Allgemeine Krankenhaus (General Hospital) in Vienna. Two house officers, Sigmund Freud and Carl Koller, who occupied rooms on the same floor, were discussing cocaine. Freud, interested in neurology and psychiatry, had found it to be a remedy for depression and had used it liberally on himself to lift his mood. Both were

Carl Koller (Wikipedia)

aware that, placed on the tongue, it had a numbing effect, an old discovery. Freud had suggested recently to a friend, Leopold Königstein, a young ophthalmologist, that he try it locally in cases of trachoma. Königstein tried it but used a dilute solution mixed with alcohol, failing to relieve any symptoms.

       Freud had just published an extensive review of cocaine and its uses (he mentioned the anesthetic effect on skin and mucous membranes but did not suggest any medical use in that regard), entitled “Über Coca.” He was also involved, with the help of Joseph Breuer, in the treatment of Dr. Ernst von Fleischl-Marxow, a physician addicted to morphine after suffering intense pain from neuromas complicating a thumb amputation. Based on reports from America of curing morphine addiction with cocaine, Freud and Breur attempted this therapy on Fleischl, though eventually with disastrous results. 

         Freud left Vienna in early September 1884, to visit his fiancée. Koller, intent on a career in ophthalmology, pondered the conversations on cocaine and suddenly decided to try its anesthetic

Sigmund Freud (Wikipedia)

effect on the eye. He went to the pathology laboratory, tried it on frog eyes, then on other animals, and finally on his own eyes and those of friends, finding in all cases complete anesthesia. Aware that the German Ophthalmologic Society was meeting soon in Heidelberg, and too poor to travel there on his own, Koller persuaded a friend, Josef Brettauer, to present his discovery. On September 15, 1884, Brettauer stunned the assembly as he exhibited a dog that remained indifferent while its cornea was pricked and rubbed by various instruments. 

Reports of this miracle flew around the globe. Henry D. Noyes, president of the American Ophthalmological Society, witnessed the event and reported it briefly in the Medical Record the following

Henry D. Noyes (Wikipedia)

month. Another attendee of the meeting was the rising American surgeon, William Halsted, who began investigating cocaine as a local anesthetic on himself, eventually succumbing to an addiction he could not shake. His colleague, Richard J. Hall, who had performed one of the first appendectomies, joined him in self-investigations. He also developed an addiction, giving up his position at the College of Physicians and Surgeons to practice surgery in Santa Barbara. He died there, ironically, of appendicitis. Halsted and Hall obtained their cocaine from Parke-Davis, the first pharmaceutical company to have a laboratory staffed by scientists. 

Herman Knapp, a German-born ophthalmologist in New York and founder of the Archives of Ophthalmology, not only praised cocaine’s use in eye surgery, he tried it in various other ways. He

William Halsted (Wikipedia)

injectied it into his urethra, after which he introduced silver nitrate (a treatment for gonorrhea) without pain. Ear, nose, throat specialists tried it successfully as a local anesthetic for their procedures. Ophthalmologists had used ether, of course, in surgery, but the after-effects, such as vomiting or restlessness, could endanger a recent eye operation. Globally, the price of cocaine shot up exponentially as patent medicine companies and tattoo parlors (to prevent pain) also made use of the drug.

Freud, on his return to Vienna, was chagrined that he had not thought one step further and tried it as a local anesthetic, either on the eye or elsewhere. Though Koller had made the breakthrough in Freud’s absence, Freud and Koller remained friends. Leopold Königstein, who had tried an inadequate cocaine preparation for trachoma, made a feeble attempt to claim credit, but Freud and the neuropathologist and psychiatrist Julius Wagner-Jauregg (who later received a Nobel Prize for treating neurosyphilis with malaria), persuaded him to retract his claim and credit Koller. Still later, Freud’s enthusiasm for cocaine turned to regret as its addictive qualities became more evident.

In spite of his instant fame, Koller’s future was insecure, for two reasons. He was Jewish and he had, in his daughter’s words, a difficult, tempestuous, personality. On top of that, a few months after his discovery, Carl had a fight with a colleague over the treatment of a hospital patient being admitted, for which he was challenged to a duel. Koller, though having no experience with foils, severely wounded his challenger. But he lost his chance at a university

Franz Donders (Wikipedia)

appointment since dueling was illegal. He managed to find a position in Utrecht, Holland, working with Franz C. Donders, creator of the tonometer and expert in the mechanism of accommodation, and Herman Snellen, creator of the Snellen eye charts used today (see essay of Aug 14, 2024). There he also befriended Willem Einthoven, father of the EKG. Two years later he was persuaded by Arthur Ewing, an American ophthalmologist whom he met in England, to move to America.

In New York, Koller established a thriving ophthalmology practice, married, and raised a family. According to his daughter, he regretted not having time for more research. His busy practice, an appointment to the Mount Sinai Hospital staff, and his duty as the first chief of ophthalmology at Montefiore Hospital occupied his time. Rewards came over the years, however, as he received numerous prizes for his discovery, including gold medals from the American Ophthalmological Society and the New York Academy of Medicine and the Kussmaul medal from the University of Heidelberg.

 

SOURCES:

 

Becker, H K (Koller’s daughter), “Carl Koller and Cocaine.” Psychoanalytic Quarterly 1963; 32 (3): 309-373.

 

Goldberg, M F, “Cocaine: The First Local Anesthetic and the ‘Third Scourge of Humanity.’” AMA Arch Ophthalmology 1984; 102: 1443-47.

 

Markel, H, An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine. 2011, Pantheon Books.

 

Spillane, J F, “Discovering Cocaine: An Historical Perspective on Drug Development and Regulation.” Drug Informat J 1995; 29: 1519S-1528S.

 

Hall, R J, “Hydrochlorate of Cocaine.” N Y Medical J 1884; 40: 643-4.

 

Lopez-Valverde et al, “The Surgeons Halsted and Hall, Cocaine and the discovery of Dental Anesthesia by Nerve Blocking.” Brit Dental J 2011; 211 (10): 487-87.

 

A full index of past essays is available at: 

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

 

 

 

 

         

 

         

 

 

 

 

 

   THE GUNFIGHTER’S SURGEON:

  GEORGE E. GOODFELLOW

 

“On the night of January 14, 1889, I was called to see Mr. R. A. Clark of… who had been shot in a fight a few minutes before. I reached him about half an hour after the reception of the injury and found him with a gunshot wound of the abdomen, evidently bleeding to death…

It was midnight in a little mountain mining town. I was alone entirely, having no skilled assistance of any sort, therefore was compelled to depend for aid upon the willing friends who were present — these consisting mostly of hard-handed miners just from their work on account of the fight.

Without delay he was put upon a table in the large dining room of a restaurant; the anaesthetic administered by a barber; lamps held, hot water brought, and other assistance rendered by others. There being no time to lose, the abdomen was opened in the mesial line, from the sternum to the umbilicus, by a single sweeping cut. An immense quantity of blood poured out through the incision.”

So begins a report in the Southern California Practitioner by Dr. George E. Goodfellow, a surgeon in Tombstone, Arizona. The report includes five cases of gunshot wounds to the abdomen, four of whom survived, a remarkable record at the time.

George Goodfellow (Wikipedia)

Goodfellow was one of several doctors providing medical service to a gun-toting population in the silver-mining town of Tombstone. 

Goodfellow, son of a mining engineer, was born in Downieville, California, in 1855. After a year at the University of California he enrolled at the U.S. Naval Academy but was expelled after a hazing incident. He read medicine briefly with a Pennsylvania doctor and received a medical diploma from the University of Wooster in Cleveland (now Wooster College) in 1877. After a brief stint practicing in Oakland, CA, and Prescott, Arizona, and possibly seeking more “action,” he moved to Tombstone, where he opened an office above the Crystal Palace Saloon in 1880. 

A silver strike three years earlier in vacant land had created a stampede for silver and by the time Goodfellow arrived about 2,000 people, primarily miners, supplemented by twelve “doctors” (only four had diplomas), populated the newly created town of Tombstone. Sharing space with the multiple saloons were three theaters, five churches, and a local scientific society. 

Tombstone in 1882 (Arizona Historical Society)

Men in Tombstone carried weapons, outlaws drifted in, and gunfights were especially frequent during 1881-3, a period Goodfellow called “our reign of terror.” Gunmen intending to kill generally aimed for the abdomen, where surgeons seldom dared to operate. Guns in the west were usually 44 to 45 caliber, larger than most guns in the east and more deadly. Goodfellow’s skills and reputation grew both from operating on multiple cases and from his own innovations. 

For abdominal wounds, Goodfellow sewed up tears in the intestinal wall, irrigated the abdomen generously with sterilized water, and followed the new “Lister method” of surgery, using sterilized instruments and carbolic acid spray in the operating area, a method to prevent infection that many surgeons resisted. Indeed, President Garfield, shot in 1881 while Goodfellow was in Tombstone, eventually died of infection after several “prominent” surgeons probed his wound with unwashed hands after dismounting from their horse. Goodfellow strongly advocated operating for abdominal gunshot wounds, advising that death was certain without surgery but might be avoided with it. He could not repair torn blood vessels and availability of transfusions and intravenous fluids was still in the future.

Goodfellow made another important observation. During a quarrel between two men, one shot the other in the chest with a 45 caliber Colt revolver at close range. The victim died quickly of a pierced heart and Goodfellow, who was also the town coroner, performed an autopsy. He wrote that from the wound “a silk handkerchief protruded, which I presumed had been stuffed in by some of his friends to prevent bleeding. I withdrew it and with it came the bullet. It was then seen that it had been carried in by the ball.” The bullet, he found, at six feet would pierce a four-inch plank of pine. He reported two further cases in which silk had not been pierced by a bullet. His discovery eventually led to the creation of bulletproof vests made from silk, worn by gangsters of the early 20^th century. Kevlar later replaced silk as a stronger material.

Reenactment of shootout at OK Corral (author's photograph)

Dr. Goodfellow had many adventures. As coroner, he autopsied the victims of the shoutout at the OK Corral, treated Wyatt Earp’s brother Virgil for multiple wounds and was present at the fatal shooting of Wyatt’s other brother, Morgan. He participated in the chase of Geronimo after his escape from a reservation and aided earthquake victims in nearby Mexico. Eventually, for a quieter life he moved to Tucson in 1891 as surgeon to a railroad.

Goodfellow performed a wide range of surgeries but perhaps most surprising is his interest in prostatic surgery. He was one of the first to develop a perineal approach to prostatectomy. He published on several cases and demonstrated his technique to Dr. Hugh Young at Johns Hopkins, one of the creators of the specialty of urology, who acknowledged its success.

During the Spanish-American War, Col. William Shafter brought him to Cuba as an aide, partly for his knowledge of Spanish. After the war he practiced in Los Angeles, then in San Francisco, and finally accepted a job as surgeon to the Southern Pacific Railroad in Mexico, where he died in 1910 of a progressive neuropathy.

         Donald Trunkey, a San Francisco trauma surgeon, has praised Dr. Goodfellow as the first civilian trauma surgeon. And urologists recognize him for popularizing a perineal approach to prostatectomy, though seldom practiced today.

 

 

SOURCES:

 

Goodfellow, G E, “Cases of Gunshot Wound of the Abdomen Treated by Operation” Southern Calif Practitioner 1889; 4 (5): 209-17.

 

Goodfellow, G E, “Note on the Impenetrability of Silk to Bullets” Southern Calif Practitioner 1887; 2: 95-8.

 

Goodfellow, G E “Perineal Prostatectomy” Occident Med Times 1901; 15 (11): 385-9.

 

Nation, E F, “George E. Goodfellow, M.D. (1855-1910): Gunfighter’s Surgeon and Urologist” Urology 1973; 11 (1): 85-92.

 

Trunkey, D D, “Doctor George Goodfellow, the First Civilian Trauma Surgeon” Surg Gyn Obst 1975; 141 (1): 97-104.

 

Quebbeman, F E, Medicine in Territorial Arizona. Thesis submitted 1966, Univ of Arizona.

 

Wesson, M B, “George E. Goodfellow, Frontier Surgeon and Soldier (1855-1910)” Ann Med Hist1933; 5(3): 236-245.

 

A full index of past essays is available at: 

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

 

 

 

TO REACH THE HEART:

CARDIAC CATHETERIZATION 

         

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

Werner Forstmann (Wikipedia)

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

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

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

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

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

Claude Bernard (Wikipedia)

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

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

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

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

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

André Cournand (Wikipedia)

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

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

Dickinson Richards (Wikipedia)

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

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

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

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

         

 

 SOURCES:

 

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

 

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

 

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

 

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

 

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

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

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

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

A full index of past essays is available at: 

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

 

 

 

 

 

 THE SOUNDS OF KOROTKOFF

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

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

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

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

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

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

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

Étienne-Jules Marey (Wikipedia)

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

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

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

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

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

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

Nicolai Korotkoff (Wikipedia)

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

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

Imperial Military Medical Academy, Saint
Petersburg (Wikipedia)

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

Joseph Erlanger 
(Wikipedia)

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

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

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

 

SOURCES:

 

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

 

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

 

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

 

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

 

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

 

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

  

A full index of past essays is available at: 

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