Listening to the Body: Stethoscopes in 1900

Cinemax’s The Knick transports viewers to at a New York hospital at the turn of the twentieth century to listen in on the drama between colleagues and patients. Each episode shows the variety of early instruments, ranging from x-rays to thermometers, used by doctors in 1900 to diagnose disease and trauma. While these objects were able to speak to the body’s condition — the shape of a broken bone or the magnitude of a fever, it was the stethoscope that brought the actual sounds of the heart or lungs to the diagnostic listener. What stories did these devices hear, and do they have their own tales to tell?

From the Sharp & Sharp Catalog of Instruments, 1905, displaying the variety of Cammann Stethoscopes available.

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NYAM hosts Vesalius 500: Art and Anatomy

WebThis October, the New York Academy of Medicine will host Art, Anatomy, and the Body: Vesalius 500, Guest curated by artist and anatomist Riva Lehrer

On October 18, the NYAM’s second-annual Festival for Medical History and the Arts, “Art, Anatomy, and the Body: Vesalius 500″ will celebrate the 500th birthday of anatomist Andreas Vesalius. Our own Brandy Schillace, research associate and guest curator for the Dittrick, will be one of the hosted speakers! Click here for the full schedule–and see below for a short description.

Vesalius’ groundbreaking De humani corporis fabrica (The Fabric of the Human Body) of 1543 is a key Renaissance text, one that profoundly changed medical training, anatomical knowledge, and artistic representations of the body, an influence that has persisted over the centuries. The Festival is one of a global series of celebrations of his legacy, and a day-long event will explore the intersection of anatomy and the arts with a vibrant roster of performers and presenters, including Heidi Latsky’s “GIMP” Dance Project; the comics artists of Graphic Medicine; Sander Gilman on posture controlling the unruly body; Alice Dreger on inventing the medical photograph; Bill Hayes on researching hidden histories of medicine; Steven Assael, Ann Fox and Chun-shan (Sandie) Yi on anatomy in contemporary art; Chase Joynt’s Resisterectomy, a meditation on surgery and gender; Brandy Schillace on ambivalent depictions of female anatomy in the 18th century; Lisa Rosner on famous body snatchers Burke and Hare; the art of anatomical atlases with Michael Sappol; medical 3D printing demos by ProofX; anatomical painting directly on skin with Kriota Willberg; Daniel Garrison on translating Vesalius for modern audiences; Jeff Levine and Michael Nevins on revisiting The Fabrica Frontispiece; and many more!

To join this excellent event, register here or visit the NYAM blog!

Blood Rises – Tension and Truth in The Knick

“More suction, Bertie.” – Dr. Thackery

           “I’ve lost the pedal pulse.” – Nurse

“Blood rises, air becomes scarce. Which man can survive the longest? Care to wager, Bertie?” – Dr. Thackery

(Soderbergh, The Knick, ep. 4)

Cover of "Elecktromedizinische Apparate," 1898.

During the showdown between Dr. Edwards and Dr. Gallinger over an exsanguinating patient in Cinemax’s The Knick, it was clear who was not most likely to survive. In this scene, Dr. Edwards, a “colored” physician is not allowed to physically assist in a procedure using a galvanized wire to treat an aneurism, despite the fact that he was the coauthor of a paper describing its success. While verbally instructing Dr. Gallinger, a white physician who is unfamiliar with the procedure, Dr. Edwards becomes silent – daring Gallinger to either pass over the scalpel or let the patient die.

Is such a scene a work of modern fiction? As inspired by the New York Academy of Medicine’s amazing posts on the series, we ask: What was it like to perform such innovative procedures at the turn of the twentieth century? Let’s find out!

In 1899, Dr. Forest Willard at the University of Pennsylvania provided case reports on “aneurism of the thoracic aorta” and its “treatment by introduction of wire and electricity” (p 256). This paper, one year before the scene in the fictional Knickerbocker Hospital, reads with a similar dramatic style:

Galvanic Battery from "Elektro-Medizin Apparate," 1898.

Galvanic Battery from "Elektromedizinische Apparate," 1898.

As the conditions were growing worse, and rupture certainly approaching, the patient consented to accept the risks of the only operation that offered any chance of success, the introduction into the sac a certain quantity of wire as a framework or skeleton, each coil of which might form a nucleus for coagulation, producing eddies in the sac and final consolidation. (p. 256)

The basics of this procedure are as follows: A patient presents with an aneurism, a ballooning of a weakened blood vessel that may burst and lead to death. A physician makes a nick in the vessel and inserts a cannula that will shield the walls of the vessel from the electricity. A coil of wire, anywhere from 5 to 225 feet long, is inserted (quickly!) through the cannula into the sac of the aneurism, and the free end of the wire is connected to a galvanic battery. The wire becomes charged to begin coagulation of the blood. After a variable amount of time, the current is disconnected, the cannula is removed, but the wire coils are left behind to serve as a structure for the clot (Siddique et al., 2003).

From D.D. Stewart in 1901. This heart of an autopsied patient showing the coils within the hardened aneurysm.
From D.D. Stewart in 1901. This heart of an autopsied patient showing the coils within the hardened aneurysm.

One of the major differences between these historical and fictional accounts is the use of ether during such a procedure. Willard mentions that “aside from the first shock at the sight of spouting blood, the patient suffered no serious inconvenience…and he talked cheerfully throughout the operation” (p. 257). Instead, Dr. Gallinger’s patient lays unresponsive and unaware of the conversation above him. Imagine had he not been anesthetized and had witnessed the men play a game of chicken with his life!

Who would have needed this surgery? Based on the age of the patient in The Knick, the “etherized” male would have likely been syphilitic – as the tertiary stages of the disease lead to inflammation and aneurism. Five of Willard’s cases were patients with syphilis who were occasionally “of intemperate habits” or simply “drunkard[s]” (p. 259).

The hardened anuerysm would remain visible as a large lump on the patient’s chest (Stewart 1901) after the surgery. Unfortunately although “life [was] prolonged and made much more comfortable,” post-operative patients typically died only months later (Willard 1899, p. 261).

Stewart 1901. A patient a few months after surgery displaying a harden aneurysm.
From D.D. Stewart in 1901. Patient a few months after surgery with a harden aneurysm.

Will the young patient at The Knick survive? He may have served simply as a backdrop for the interpersonal tensions between the main characters. Historically, twentieth century doctors followed up on these cases for equally self-serving reasons. Autopsies allowed physicians to retrieve the remaining coil of wire, determine the success of their work, and to fine-tune their pioneering methods.

References:

Reiniger, Gebbert, & Schall. 1989. Elektromedizinische Apparate und Ihre Handhabung. Siebente Auflage. Erlangen.

Siddique, Khawar, Jorge Alvernia, Kenneth Fraser, and Guiseppe Lanzino. 2003. Treatment of aneurysms with wires and electricity: A historical overview. Journal of Neurosurgery  99:1102-1107.

Soderbergh, Steven. Sept. 5, 2014. Season 1, Episode 4 “Where’s the Dignity?” The Knick. Cinemax.

Stewart, D. D. 1901. “The galvanic current in the treatment of saccular aneurisms.” In An International System of Electro-Therapeutics for Students, General Practitioners, and Specialists. Horatio R. Bigelow and G. Betton Massey, eds. 2nd edition. Philadelphia, PA: F.A. Davis Company.

Willard, Forest. 1899. “Aneurysm of the thoracic aorta of traumatic origin; Treatment by introduction of wire and energy.” University of Pennsylvania Medical Bulletin XIV(7): 256-261.

Book Review: My Notorious Life by Kate Manning

NotoriousToday on the Fiction Reboot | Daily Dose, we present a review of My Notorious Life!  This work is based upon the true story of Anne Lohman, also known as Madame Restell, a prominent New York midwife enveloped in scandal, who died by suicide in 1879. The Dittrick Museum will host Kate Manning for a short talk and book signing on Sept 19th; RSVP to jks4@case.edu.

“Women’s Private Matters”: Thoughts on My Notorious Life by Kate Manning
Reviewed by–Anna Clutterbuck-Cook

Halfway through Kate Manning’s historical bildungs roman, My Notorious Life (Scribner, 2014) the young protagonist confronts her husband. Axie Ann (Muldoon) Jones has just performed her first abortion for Greta, childhood friend. Axie’s husband Charlie returns home and, upon learning of the abortion, turns angrily to his wife: “You want to tempt the devil on is, is that right? And the traps?” he accuses, “Is that what you’re doing there, then, [in your office] on Chatham Street?”

 –None of your business, I said. –It’s women’s private matters.

He stared at me like I was a stranger. Like he imagined in grim pictures what I done with Mrs. Evans [her teacher]. What I done for my friend. I feared what he thought of me, and how I would disgust him, and that he would leave me. –What else would you have me do? I cried. –Leave Greta on the road? (231).

 This exchange brings into stark relief the key tension around which My Notorious Life turns. Axie’s angry outburst — it’s women’s private matters! — is both a vicious indictment and and a powerful act of protection. By keeping her work in the shadows, particularly away from the scandalized and ill-informed eyes of men, Axie is able to care for her patients. Yet that same distance, the willful unknowingness of men regarding the experiences of women, isolates Axie personally and professionally — ultimately endangering not only her livelihood but her very life.

Loosely based on the real-life case of Madame Restell, a self-trained female physician who ran afoul of moral crusader Anthony Comstock and New York’s sensationalist press in the late nineteenth-century, Notorious is the fictional autobiography. Irish-American orphan Axie narrates her own life with a compelling voice that is by turns prickly, desperate, angry, generous — a complicated child grown into a complicated woman. We meet Axie as a child, separated from her ailing immigrant mother and sent West on an orphan train with her younger brother and sister — siblings who weave in and out of the narrative as actual and imagined characters, haunting Axie’s life long after they are separated and placed with different families. Resistant to relocation, Axie is returned to New York and ends up an unpaid housemaid-apprentice to a midwife, Mrs. Evans, who also “fixes” women who come to hear with unwanted pregnancies.

Our contemporary reproductive health landscape has its roots in the nineteenth-century world vividly fictionalized in the pages of My Notorious Life. As historians have ably documented — see, for example, Leslie Reagan’s seminal history When Abortion Was a Crime: Women, Medicine, and the Law in the United States, 1867-1973 (University of California Press, 1997) — midwifery and abortion occupied an uncertain space in the constellation of nineteenth-century health care. The reproductive lives of women had long been attended to by other women. However, as the modern medical profession evolved, the relationship between midwives and female physicians (denied access to medical schools) and the male medical establishment became contentious. Abortion — technically outlawed after “quickening” but largely ignored until the mid-1800s — became a cause du jour for reformers, ostensibly concerned for women’s safety, and medical men interested in the potentially lucrative business of women’s health services. These nineteenth-century battles lay the groundwork for a politicization of reproductive health care that remains in place to this day — as anti-abortion protests and lawsuits over birth control make clear.

It’s women’s private matters. The story of Axie’s life is overwhelmingly a story of women.* Men appear as charity workers, religious and political leaders, physicians, and occasionally lovers. Yet even Charlie, Axie’s husband, never completely emerges from the shadows despite his continual presence on the page. His motivations and emotional landscape remain shrouded. His courtship of Axie is perfunctory, their early marriage rocky, his understanding of her profession limited to its ability to stabilize family finances.

Instead, it is relationships between women that form the emotional core of My Notorious Life: Axie’s narrative is woven together by the threads of her connection to her mother, her sister, the midwife-physician to whom she is apprenticed, her friend Greta, her daughter, the women who seek out her services. Axie’s is a fully realized female world of love and ritual, moral complexity, anger, violence and loss. Against this rich tapestry of female relationships, characters like Charlie appear as distant players. In the end, My Notorious Life is a sweeping, melodramatic narrative worthy of its nineteenth-century protagonist — one which takes women’s private matters and makes them of more public concern.

*I’ve used binary terms throughout because those reflect the language used in the novel, the apparent identities of the characters, and the social framework of their world.

ABOUT THE REVIEWER
Anna Clutterbuck-Cook is a historian, librarian, and writer who serves as reference librarian at the Massachusetts Historical Society and is currently researching mid twentieth-century Christian understandings of human sexual diversity. She lives in Jamaica Plain, Massachusetts with her wife, two cats, and over one thousand books. You can find her online at thefeministlibrarian.com.

The Microscope: A Crucial “Lens” of History

gentlemanPicture for a moment the toxicologist, bending over his microscope to isolate and identify toxins–the biologist seeking new species in creek water–the geneticist parsing the double helix. Think of the physician, the scientist, even the micro-engineers. Now imagine those same specialists without one crucial piece of equipment: the microscope. Where would we be without this so-important “lens”?

The first “light microscope” owes its invention to Zacharias Jansen in the 1590’s, but interest in magnification began much earlier. The Romans explored the properties of glass and how, depending on curve and angle, it could make small objects appear larger. Later developments gave us the magnifying glass and even eye glasses (first made in the 13th century by Salvino D’Armate of Italy). The leap forward began with Jansen and his father, however, two Dutch eye-glass makers. Jansen’s device, which might remind us more of a telescope than a microscope, consisted of 3 sliding tubes fitted on either end with a glass lens. It magnifies 3x when the tubes were compressed, and 9x when fully extended to 18 inches. [1]

Isaac Beeckman provided the earliest known representation of a microscope (in print) in 1631, and members of the Accademia dei Lincei in Rome called it the “microscopium” as early as 1625. [2] Early models were not powerful enough to provide science with any considerable advantage. Anton van Leeuwenhoek (1632-1723), a Dutch cloth-merchant, made his own lenses, and his new lens tube had magnifying power of 270x. He later developed an instrument with a glass phial so that he could view blood circulation in the tail of a fish! [2]

L0043503 Robert Hooke, Micrographia, fleaNothing is so constant as change, and the microscope evolved from simple to compound; Robert Hooke’s Micrographia (1665) popularized their use. Hooke devised a side-pillar microscope on a solid base for use at a table, and John Marshall provided a stage plate in 1700. [2] Hooke looked at all sorts of objects, and what he saw opened new worlds of possibility. Snow crystals, the thin edge of a razor, or–and more dramatically–the flea. For the first time, a common household pest revealed itself an enormous creature with body hairs–all of which were rendered in detail at 18 inches across. He also pictures a louse, rendering it nearly two feet across when the image is unfolded. Imagine the impact of such a discovery–there were monsters in the house! [1]

Hooke described the flea as “adorn’d with a curiously polish’d suite of sable Armour, neatly jointed. . .” [3] But not everyone was impressed; some ridiculed Hooke for paying attention to “trifling” pursuits: “a Sot, that has spent 2000 £ in Microscopes, to find out the nature of Eels in Vinegar, Mites in Cheese, and the Blue of Plums which he has subtly found out to be living creatures.” [3] And yet, the book was a best seller in it’s day–and remains a curious volume even to the modern eye. Additional improvements, such as stabilizing distortion and aberration, made using the microscope possible Museum_dittrick-howardnot only for the specialist but for the lay-person; by the 19th century, microscopes were used by science, medicine, and an interested public.

Today, the microscope continues to fascinate. What child hasn’t looked on in wonder at salt crystals? Or seen something as inconsequential as dust or a droplet of water come to stunning new life? Here at the Dittrick, the microscope appears center stage in hospital medicine and in forensics, and a history of the microscope (through its evolution) may be explored in the Millikin Room on the 2nd floor. Come see medical and scientific history through its most crucial lens!

 

REFERENCES

[1] “Who invented the microscope?” A Complete History of the Microscope. <http://www.history-of-the-microscope.org/history-of-the-microscope-who-invented-the-microscope.php&gt;

[2] “Microscope, Optical (Early).” Instruments of Science, An Historical Encyclopedia. Eds. Robert Bud, Deborah Jean Warner. London: The Science Museum and SMAH, Smithsonian, Garland Publishing, 1998.

[3] “Robert Hooke.” History. University of California Museum of Paleontology, Berkely, CA. <http://www.ucmp.berkeley.edu/history/hooke.html&gt;

OUTBREAK! Rising Above in the Time of Cholera

L0040131 Blue stage of the spasmodic Cholera

Cholera Victim, “blue stage”: Wellcome Library, London

The recent outbreak of Ebola in parts of Africa–and the frightened posts and live-tweets that accompanied two infected health workers as they returned to the US–give us a glimpse not only of an epidemic’s power but of our private terrors. Self-preservation, fear of the unknown, and a desire to protect the boundaries of nations, persons, bodies and cells brings out the best and worst in us. History provides both sides; the uninfected locked up with the infected in 14th century plague houses, left to starve and suffer in the dark–or doctors like Cleveland’s Horace Ackley, who personally combated and contained an outbreak of Asiatic cholera in Sandusky in 1849. In the middle of the contest, we find the patient, caught between doctors and systems and, in our modern world as much as the historical one, political machinations.

L0073461 Illustration depicting cramped and squalid housing conditions

Squalid living conditions: Wellcome Library, London

The US cholera epidemic of 1832 began with an immigrant ship. After landing at Quebec with cases of Asiatic cholera, panic (and disease) swept the entire Great Lakes region. The epidemic killed thousands of people in Europe and North America resulting in wide spread panic. When it hit NY, 100,000 people fled, almost half those living there![1] The poor and immigrants were frequently blamed–why? The disease spread through infected water supplies, but many assumed squalor itself was the culprit. To make matters worse, people made an incorrect correlation between poverty and morals, so that filthy living conditions equated to a kind of loose living. The poor died–what was that to people of “good clean living?” But of course, cholera was no respecter of persons.

Since no one understood the disease, treatment basically consisted in waiting out the symptoms–which included violent vomiting; the loss of fluids put patients into shock. Prof Horace Ackley of Cleveland advocated the use of calomel, a mercury compound used as a purgative–it also killed bacteria. During the Sandusky outbreak of 1849, he gave patients five grains every five minutes in a tablespoonful of ice cold water. [2] But the significance of Ackley’s treatment consisted not so much in the medicine but the method. While people were fleeing the disease epicenter, Ackley was on the move within an hour, driving 60 miles without a stop except to water the horses. He took charge of the town, helped the sick, procured supplied, and buried the dead. He worked for two weeks to stop the progress of the disease, and in all that time “did not remove his clothes, except to change his linen, nor sleep in a bed.” [3] As a medical professional, he risked his own health to serve others.

Similarly, the Ebola infected health workers recently flown back to the Emory facility in Atlanta risked their lives to treat those in outbreak locations in Africa. Ebola has no known cure at present, just as cholera had no sure in the mid 1800s. The fear that drove people to blame the poor or to isolate and avoid them returns, this time along national lines. Despite assurances that they represent no threat, and despite the high tech treatment facility in Atlanta, many still railed against their return. CNN carried an article earlier this week, citing twitter hashtags that read “The road to hell was paved with good intentions.” [4]  Many feel the aid workers should be left in Africa–they might be citizens, but, through disease, they have been “othered,” and even blames. Dr. Bruce Ribner, who heads the center at Emory, countered that sentiment by reminding us that the doctors risked first–treating the ill with humanity and integrity.

L0044151 Portable Cholera Laboratory

Portable Cholera Lab, 1893: Wellcome Library, London

In the modern age, we frequently forget how precariously health is balanced, or how quickly the smallest of enemies can invade our borders. History teaches us the terror of outbreak, but we should endeavor to remember the humanity as well. Today’s outbreak of Ebola has been confined to West Africa, and the calamity, says Dr. Margaret Chan, head of the World Health Organization, can be stopped if the rest of the world steps up to provide resources. [4] We have more to learn from those who engage–like Ackley, but also like John Snow, who discovered cholera’s water-born nature, Spanish physician Jaime Ferrán who cultivated bacteria and vaccinated  50,000 people during a cholera epidemic in Valencia, or Robert Koch, who successfully isolated the cholera bacillus in pure culture and spread his discovery abroad. Let’s hope to see this latest outbreak among those we’ve successfully fought before.

  1. Cholera Epidemic, 1832
  2. Columbus Medical Journal: A Magazine of Medicine and Surgery, Volume 3
  3. Waite, Frederick Clayton. Western Reserve University Centennial History of the School of Medicine Cleveland; Western Reserve University Press, 1946.
  4. Greg Botelho, Ben Brumfield and Chelsea J. Carter. “2 Americans infected with Ebola in Liberia coming to Atlanta hospital” CNN, August 2, 2014

Brandy Schillace, PhD, is research associate and guest blogger for the Dittrick Medical History Center.

The Spring-Lancet, A “Bloodstain’d Faithful Friend!”

The origins of blood-letting date back to Hippocrates in ancient Greece when the practice was recommended to both prevent as well as remedy illness. Galen also supported therapeutic bleeding because it fit with his humoral theory. According to humoral theory, illness is caused by an imbalance of the body’s four humors: blood, yellow bile, black bile, and phlegm [1]. Thus, maintaining a balance of humors by the removal of excess blood was thought to preserve health.

The spring-lancet was predated by the thumb lancet (15th century) and fleams (17th and 18th centuries) [2]. Both these devices required the user to apply pressure manually on the blades against the patient in order make an incision.

ThumbLancetAndFleamBased on the earliest records, the first spring-lancet likely originated in Austria during the 18th century. To use the lancet, the practitioner would pull back a lever, coiling the interior spring. When the lever was released and the spring recoiled, the silver blade would drive into the patient [3]. Proponents of the spring-lancet claimed it provided greater precision in nicking a vein so blood could flow steadily from the incision. These devices served two purposes: the general removal of blood from the body (usually in the spring, as humoral theory proposed that the volume of blood was highest during that season) and the localized draining of blood from an inflamed area. Thus the former prevented illness, while the latter treated it.

SpringLancet

One of the benefits (?) of this design is that it allowed “untutored” bleeders the ability to make an incision over superficial veins. Thus, individuals without precise knowledge of the circulatory system could be fairly confident that they could remove blood without harming other vessels [4]. However, the French still preferred thumb lancets as they were less complicated and easier to use for physician/surgeons who were not ignorant of anatomy.

In the United States, the spring-lancet was much more economical than using other methods. One practitioner writing in 1813 stated “one spring-lancet, with an occasional new blade, will serve [a physician] all his life” [5, p. 281]. These devices were frequently very ornate and decorated with symbols that had a personal meaning to the owner. Unfortunately, spring-lancets were not indestructible. The spring could corrode due to trapped moisture acquired during use and cleaning [2]. Additionally, the mechanical complexity of the device made thorough cleaning difficult – making the transmittance of disease (not then a contemporary concern) much more likely. Despite these flaws, through at least the 1830s, every physician “without a single exception, carried a spring-lancet in his pocket, and daily used it” [6, p. 4].

In 1841, J.E. Snodgrass of Baltimore celebrated his apparatus in a poem entitled “To My Spring-Lancet.” The following stanzas allude to the frequent usage (and infrequent cleaning) of the spring-lancet for an American physician.

I love thee, bloodstain’d, faithful friend!
As warrior loves his sword or shield;
For how on thee did I depend
When foes of Life were in the field!  

Those blood spots on thy visage, tell
That thou, thro horrid scenes, hast past.
O, thou hast served me long and well;
And I shall love thee to the Last! [7]  

The conviction of Dr. Snodgrass’s ode may have been in response to the growing research and criticism against the efficacy of bloodletting. In the 1840s and 1850s, debate about the practice reached a peak when Dr. Hughes Bennett noted that rates of mortality from pneumonia decreased in a direct proportion to the decline in bloodletting [8]. Despite this, many physicians continued to use the spring-lancet to therapeutically bleed their patients. For example, Dr. A.P. Dutcher, at one time the President of the Cleveland Academy of Medicine, considered bloodletting to be “the most prompt and effective of all the known agencies that we possess to subdue inflammation” [9, p. 543].

Although the benefit of bloodletting as disease treatment was convincingly challenged in the mid-19th century, some physicians continued the practice for the next one hundred years. Fortunately, the growing acceptance of germ theory, as well as improved knowledge of the immune response, ushered in new aseptic surgical techniques. The reusable spring-lancet was no longer carried in every physician’s pocket, but instead “only found on the shelves of the medical curio cabinet” [10, p. 90].

N0029189 Pinprick device used in blood tests

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