OBSTETRICS COMES TO THE COLONIES

 

         Obstetrics in American colonial times was practiced almost exclusively by midwives, whose medical knowledge and skills were generally low. Though the rare physician performed deliveries, the first American doctor to have formal training in obstetrics was William Shippen, Jr. He was also the first American professor of anatomy, a position he held at the newly opened College of Medicine of the University of Pennsylvania.

         After graduating from the College of New Jersey (later

William Shippen, Jr.  (Wikipedia)

Princeton University), young Schippen apprenticed for four years with his physician father in Philadelphia. For further study, he embarked, in 1758, to London. Possibly through family connections, he secured a position as student at St. Thomas’ Hospital, across the street from Guy’s Hospital and near London Bridge. There he made rounds with the surgical and medical staff, read widely, and often traveled to St. Bartholomew’s Hospital to watch Percival Pott operate. He seems to have decided early on a career in obstetrics and anatomy. He took midwifery instruction from a Dr. Colin Mackenzie, a former student of William Smellie, one of the first in England to practice obstetrics (or man-midwifery, as it was called). Mackenzie, less well known today, was highly regarded and a friend of William and John Hunter. Shippen's training with Mackenzie included valuable hands-on experience in his extensive practice.

For anatomy studies, Shippen enrolled in William Hunter’s

William Hunter  (Wikipedia)

 

 

private anatomy classes, considered the best in London. He moved into Hunter’s house in Covent Garden where the lectures and dissection took place. The students not only dissected, they practiced surgical operations on cadavers and injected waxy or oily solutions into vessels to demonstrate vascular patterns, a technique borrowed from the Dutch. It was these injections, done mainly by John Hunter, that first

John Hunter  (Wikipedia

demonstrated the separation of the maternal and fetal circulations of the pregnant mother. William Hunter also taught midwifery to Shippen, though his private practice and duties as Physician Extraordinary to Queen Charlotte limited his time. Shippen also benefitted from long conversations into the night with John Hunter, who found the young American an apt pupil.

 

Anatomy lecture at William Hunter's Anatomy School (Wellcome Library)

Shippen did not neglect pleasure in London. He frequented theatrical performances, from David Garrick’s Shakespearian dramas to low comedy, at the Drury Lane and Covent Garden theaters adjacent to the anatomy school. He attended the coronation of King George III. His easy personality helped him win invitations to dinners or weekend stays. He dined with Thomas Penn, proprietor of the colony, and Benjamin Franklin took him to the Royal Society and presented him at court. Shippen easily fell in with Franklin’s friend, Dr. John Fothergill, one of London’s most respected physicians.

John Fothergill (Wikipedia)

Fothergill, a Quaker, had an interest in Americans and in promoting medicine in America. He encouraged William to open a medical school in Pennsylvania.

William skipped study on the continent (the Seven Years War curtailed travel) and traveled to Edinburgh for a year, absorbing the lectures of William Cullen and the Monros. After receiving an MD degree in 1761, he married a woman from Virginia and sailed with her back to Philadelphia. He carried a letter from Dr. Fothergill recommending that the Pennsylvania Hospital start a medical school with Shippen as professor of anatomy. Fothergill had sent over copious anatomical drawings and skeletal parts as an inducement. The hospital demurred on the medical school but allowed Shippen to begin a private course in anatomy. It was well attended by the local doctors.

In 1765, Shippen began a course in midwifery, the first of its kind, open to men and women. He had initiated a small lying-in facility for poor people and used this for practical instruction in addition to giving lectures enhanced by models of female anatomy.

Shippen's lectures, taken by a student (Nat. Libr. Med)

Lectures also covered the circulation and nutrition of the fetus, labor, use of instruments (he was conservative), and diseases of women and children near birth. To maintain dignity in the profession, he urged a “grave deportment” during accouchements and warned against alcohol use.

That same year, another Pennsylvanian, John Morgan, returned from medical studies in Edinburgh, London, and the continent. He presented a second proposal to the Pennsylvania Hospital to open a

John Morgan (Wikipedia)

medical school. This time the trustees, now possessing a letter from Thomas Penn recommending the school, agreed and the first medical school in America opened later in the year. The Professorship of the Theory and Practice of Physick went to Morgan and Shippen was soon appointed Professor of Anatomy and Surgery. The first steps toward formal medical education in America had begun. Shippen continued with his midwifery school. The Pennsylvania Hospital did not acquire lying-in facilities and a separate department until 1803.

The American Revolution interrupted work at the school. Unfortunately, considerable hostility developed between Shippen and Morgan during the war. Both were appointed, at different times, to head the Army medical services, both were accused of incompetence or graft, and Shippen underwent a court-marshal, though he was exonerated. After the war, both remained on the faculty and Shippen continued his extensive obstetrical practice, imparting skills to the next generation of doctors and midwives. His open personality attracted such dignitaries as Washington, Hamilton, and John Adams, who all stayed at “Shippen House” in Philadelphia. He continued to teach, to dispel many myths about childbirth, and to promote the profession of man-midwifery. He did not write papers or books or carry out research, however, as many pioneers in their fields do. Only lecture notes and reminiscences remain to testify to his stature as the first professional obstetrician in America.

 

Note: No essay in May. I will be traveling. See you in June.

 

SOURCES:

Corner, Betsy C, William Shippen, Jr.: Pioneer inn American Medical Education. 1951; American Philosophical Society.

Thoms, H, “The Beginnings of Obstetrics in America.” Yale J Biol Med, 1932; 4: 665-75.

Scheffey, L C, “The Earlier History and the Transition Period of Obstetrics and Gynecology in Philadelphia.” Ann Med History, 1940; 2(3): 215-224.

 

 

 

 

 

 

 

 

 

 

                                   AIR IN THE BRAIN

 

 

         When looking for tumors, abscesses, and other lesions of the brain, physicians today turn to CT and MRI scans. That was not always the case. In the nineteenth century, a careful history and neurologic examination provided the only means available to diagnose and to localize such lesions. Since only the rare surgeon ventured into the cranial cavity without more concrete information, it was the autopsy, not surgery, that confirmed the clinical findings. 

         The discovery of X-rays in 1895 brought hopes of easier diagnosis, but the hopes foundered when tumors, brain tissue, and fluids all appeared gray, lacked contrast, and were indistinguishable. One surgeon lamented that the brain was still “a dark continent.” A possible solution was to introduce an agent that provided enough contrast on X-ray to demarcate a lesion. At Johns Hopkins Hospital, a rising neurosurgeon, Walter Dandy, tried several contrast agents that urologists used to visualize the bladder and ureters on X-ray, but in animal trials they were all too toxic to brain tissue. It was

Walter Dandy (Wikipedia)

common knowledge, though, that air appeared darker than soft tissue on X-rays. Why not introduce air into the ventricular system to provide the contrast?

         To accomplish this, a knowledge of the circulation of spinal fluid, the clear fluid that fills the ventricles and circulates over the entire brain, was necessary. Fortunately, Dandy had recently worked out the fluid dynamics in animal studies done in the Hunterian Laboratory at Hopkins. (The original name for the laboratory was the Magendie Laboratory but, after vociferous demonstrations by antivivisection activists, “Hunterian” replaced it.)  

Dandy began with children, primarily ones with hydrocephalus, injecting air directly into the ventricles through the still open space between fontanelles on top of the cranium. He needed to withdraw an equal amount of fluid to avoid changes in pressure, a tricky balancing act. His first paper on pneumoencephalography (PEG), as it came to be called, was in 1918. Soon after, he tried introducing air by lumbar puncture into the fluid-filled space around the spinal cord and published satisfactory results. This technique required rotating the patient in various ways, not all comfortable, to allow the air to move up the spine into the desired areas of the brain. He did not pursue the spinal approach, however.

Dandy's first X-rays using air to visualize the ventricles.
Here, the contrast is reversed, the air a lighter shade. (Hathi Trust)

         A year or two later, in Braunschweig, Germany, Adolf Bingel, chief of Internal Medicine at the Braunschweig Hospital, aware of work in Norway (and unaware of Dandy’s publications) using air
through the spinal route to see spinal tumors, adopted the lumbar approach. He noticed by chance that a patient, X-rayed the day after air was introduced spinally, showed air in the cranium. Trials on cadavers confirmed this route to the brain. Like Dandy, he showed that the air could outline the ventricles and provide contrast over the brain surface. His main concern about the spinal approach was that if the fluid pressure above grossly exceeded that from below, the stem of the brain could be squeezed, a life-threatening possibility. To avoid this, Bingel devised an apparatus to ensure that the spinal fluid pressure remained stable during the procedure, an important step (see illustration). He became aware of Dandy’s work with the lumbar approach only after his own first publication. Meanwhile, Dandy had returned to the ventricular approach, allegedly fearing potentially dangerous pressure differentials. Bingel, on the other hand, feared the direct ventricular injection approach, having lost two patients after using it. 

Frontal view of ventricles from paper by Bingel (Hathi Trust)

         Adolf Bingel appears to be an underappreciated innovator. Born in 1879 in Koblenz to a coal-and-wine-merchant father and the daughter of the famous guidebook publisher Karl Baedecker, he studied medicine at the University of Tübingen. He worked in academia in various places and was finally appointed chief of the medical service at the Braunschweig Hospital, a teaching hospital. He had already done research on blood pressure measurement and renin physiology and took up research on leukemia, syphilis therapy, pernicious anemia, neurologic problems, and more. He was a pioneer in needle biopsy of the liver as early as the 1920s. Over a period of 30 years, he conducted three blinded controlled trials of diphtheria antitoxin vs horse serum and found them equivalent, a controversial conclusion. It was at the Braunschweig Hospital, in the chaotic years after WWI, that Bingel began pneumoencephalography. He remained there through WWII, dying in 1953.

         In early days physicians removed most of the spinal fluid, replacing it with air. This produced severe headache and nausea, sometimes requiring anesthesia, and there were occasional fatalities. Understandably, pneumoencephalography was not widely accepted. In the 1930s the radiologist Cornelius Dyke and the neurosurgeon Leo Davidoff, at the Neurological Institute affiliated with Columbia-Presbyterian Hospital in New York, found that smaller amounts of air provided equally satisfactory imaging results. Fewer side effects and improved safety led more physicians to adopt the procedure, though it was still not risk-free.

To ease the distribution of air into the ventricles and over the brain surface, moveable chairs were devised that could move the patients into almost any position. They bore the interesting name of “somersault chairs,” and indeed, using a side arm, tilted the strapped-in patient into bizarre positions, maneuvers that made some radiologists nervous. Headache and vomiting were still common.

         The 1950s brought change with the introduction of angiography, followed by CT scanning in the 1970s, then MRI scanning. Compared to the new scanning techniques PEG seemed quite primitive and the difficult and potentially dangerous technique quickly passed into the realm of interesting historical curiosities and medical history blogs. 

 

SOURCES:

 

Marmaduke, M E, et al, Walter Dandy: The Personal Side of a Premier Neurosurgeon, 2002; Lippincott Williams & Wilkins.

 

Dandy, W E, “Ventriculography Following the Injection of Air into the Cerebral Ventricles.” Ann Surg 1918; 63 (1): 5-11.

 

Müller, J, et al, “Adolf Bingel, the Second Inventor of Lumbar Pneumoencephalography.” Amer J Neuroradiol 1995; 16: 487-90.

 

Kieffer, S A, “Cornelius G Dyke and the Neurological Institute of New York: The Foundations of American Neuroradiology.” Amer J Neuroradiol 1997; 18: 801-9.

 

Hoeffner, E G, et al, “Neuroradiology Back to the Future: Brain Imaging,” Amer J Neuroradiol2012; 33: 5-11. 

 

Trohler, U, “Adolf Bingel's Blinded, Controlled Comparison of Different Anti-diphtheritic Sera in 1918,” J Roy Soc Med 2011; 104 (7): 302-5.