Mary Cappello

by Swallow: Foreign Bodies

  Who was that man, Chevalier Jackson? What are these things? How does someone swallow that? No matter our differences, these are the questions everyone seems to ask in the pauses between craning to catch a look inside the drawers of what just might be the most popular exhibit in the museum of pathological specimens in Philadelphia: Jackson’s swallowed objects.

  The questions are as simple as the human swallow is complex.

  I would like to risk some answers.

  Remembering Forward: The Idea of a Legacy

  The mass of knowledge we know as medical science is built of the activities of forgotten men. The structure is parallel in a figurative sense to the coral island that is built of the carcasses of obliterated lives. . . . What difference will it make to the next generation whether it was Jackson, Johnson, Smith, or Jones who discovered bronchially lodged peanuts as potentially fatal to children? The important thing is for the disciples to expound the gospel of education of mothers as to the dangers of peanuts and nut candies to the baby without molars.

  —The Life of Chevalier Jackson: An Autobiography

  The tissues of the air passages are quite tolerant of vulcanite.

  —CHEVALIER JACKSON, Diseases of the Air and Food Passages of Foreign-Body Origin

  Each of us has our identity themes, motifs that we return to as we attempt to give shape and color to our lives, receding docks of departure to which we return when we want to feel moored. Our commitments might change, our passions may wax and wane, our focus might shift either by will or accident to such an extent that we no longer recognize ourselves, but our identity themes remain steadfast, us to them and them to us, like a regressive assignment and an agreeable consignment.

  Two images perpetually surface in Chevalier Jackson’s life’s work; two distillations of an idea of a self recur: Jackson as housepainter and Jackson as lighthouse keeper. According to the first, he’s working his way through the rooms of a house or applying pigment to an exterior facade, “hurrying to get through before his paint should give out”; according to the second, he’d like nothing so much as to be a “lighthouse tender where the supply boat came only every three months,” affording him “enough uninterrupted time to get something done” (LCJ, 4).

  The president of the Section of Laryngology of the Royal Society of Medicine, Frank A. Rose, tapped a fork against a glass before ascending the podium at a dinner in 1930 to honor Chevalier Jackson. As master of ceremonies, Rose speculated about what Jackson would be remembered for by future generations—not his success in operating on the larynx for carcinoma or for his dexterity in removing foreign bodies. No. Rose imagined Jackson’s legacy to be comparable to the act that made Elias Howe famous for the sewing machine. The British Medical Journal recorded part of his speech:

  Howe showed the world that the eye of a needle ought to be at its point; similarly Chevalier Jackson would perhaps be remembered longest as the man who taught the world to place the light of a bronchoscope at its tip. It might be that when the memory of his other achievements had grown dim, as they merged into the ever-growing stream of medical knowledge, Chevalier Jackson would for all time be known by his bronchoscope.

  In an interview for Energine Newsreel that Jackson gave in 1936, he described the ingenious device of the bronchoscope as “a thin-walled, brass tube with a tiny electric light, smaller than a grain of rice, at the far end, about the size of a canary seed. This tube is inserted, through the mouth, into the bronchi; looking through the tube we can see the interior of the bronchi brilliantly lighted up; and through it under guidance of the eye, we can insert the many other accessory instruments, such as slender forceps, hooks, safety pin closers, or whatever is needed for the solution of the particular problem” (see figure 6). Jackson’s incorporation of the distal light was a major advance in the perfecting of the instrument that he also designed, but he got the idea for the placement of the light, the idea of entering the body with a light inserted into the tube rather than trying to light the interior of the body from without (“proximal illumination”), from Max Einhorn, who, Jackson writes, in 1902 “made the excellent suggestion that a light carrier, then recently patented by a soulless mechanic for use on a cystoscope, be used on an esophagoscope” (LCJ, 106). Clerf concurs that Einhorn “introduced the idea of the auxiliary tube in the wall of the esophagoscope as the light carrier,” thus marking the “first employment of a distally illuminated tube.” Some historians would no doubt beg to differ with both Jackson and Clerf by naming the urologist whom Jackson dismisses as “soulless”—Maximilian Nitze—as well as surgeon Johann von Mikulicz and instrument maker Josef Leiter as the first to use the distally placed light. In a 1934 essay on the history of the stomach tube, Ralph Major puts the problem of attribution succinctly, at the same time that he understates the case: “Questions of priority are always vexing and troublesome, difficult to decide with full justice to those concerned and always certain to provoke bitter controversy and even more bitter recriminations.” Perhaps what Rose meant to say was that Jackson would be remembered for making direct observation of regions of the upper torso possible, thus making direct-vision diagnosis of otherwise hidden parts of the breathing and alimentary canals indispensable to doctors the world over. He will come down to us as one of the earliest explorers of—and one of the first to set eyes upon—the living body’s otherwise dark interior: its speech center, its esophageal folds, its breathing tree.

  Fig. 6. Part of an “action exhibit” mounted at Philadelphia’s Franklin Institute in 1938 that featured a breathing mannequin complete with inserted bronchoscope through which museumgoers could view and grasp (with forceps) an inspirited nail. Top to bottom: distal light, bronchoscope, forceps, fbdies. The Historical and Interpretive Collections of The Franklin Institute, Inc., Philadelphia, Pennsylvania.

  I could remember otherwise: I could say Chevalier Jackson will be remembered to this day as the person who dared to specialize in diseases of the throat—laryngology—in an era when specialization of any sort within the medical profession was affiliated with quackery. That his reputation for performing emergency tracheotomies using a technique that almost entirely prevented complications from diphtheria is what will endure. Or that he made his peers what one of his assistants called “foreign body conscious.”

  His construction of the bronchoscope in 1899 (it was not the first, but it came to be considered one of the best) was a major advance, as was his development of techniques for its safe passing and his proof of its harmlessness, if carefully applied, to living tissue. But prior to designing his bronchoscope, in 1890, Jackson conceived of, built, and brought into his practice an esophagoscope. After graduating from Jefferson Medical College in 1886, he raised enough money to travel abroad and visit clinics in Vienna, Berlin, Paris, and finally London, where he met and learned from Sir Morell Mackenzie, whose lack of a practical device for examining the esophagus inspired Jackson to develop one. The very first foreign bodies to constitute Jackson’s collection were a tooth plate that he had removed from the esophagus of an adult and a coin he removed from the esophagus of a child. Before Jackson’s instruments and techniques, only two patients out of one hundred might successfully cough up, regurgitate, or excrete a foreign body, and surgery resulted in death in 98 percent of all cases. In the course of his career, Jackson developed over five thousand instruments and saved as many lives; his students went on to save half a million more.

  Here’s a remembered chronology: he began working with wood and sharp tools at the age of four and was never without a workshop thereafter; he established his first medical practice in what had originally been a tailor’s shop in Pittsburgh at twenty-two; by the time he was thirty-five years old, in an era when medical professorships were reserved for practitioners at the end of their careers, he held the chair of laryngology at Western Pennsylvania University (now the University of Pittsburgh) and had been elected to staff positions at fourteen different hospitals. By then, he was considered an authority on the larynx. In
1916, when he was fifty-three years old, he and his family—wife, Alice; sister-in-law, Jo; and son, Chevalier L.—moved to Philadelphia so that Jackson could accept the professorship of laryngology at Jefferson Medical College. The position carried no stipend, was not endowed, and was, practically speaking, without precedent, but Jackson saw in it the opportunity to train more students, establish more clinics, and bring to full flower the medical specialty whose technical method he had recently devised.

  In 1911, 1913, and 1917, Jackson suffered three separate bouts of pulmonary tuberculosis. He spent a great deal of his recuperative time writing in bed from dawn to dusk or painting “endoscopic views.” Two years after moving to Philadelphia, Alice found the perfect place for them to live: a miller’s house and accompanying grist and sawmill that they restored; in the old water mill, Jackson rigged a machine shop that he called his “experimental laboratory,” a place for designing and producing instrument prototypes. The machine works were struck from various woods that Jackson recognized: hickory cog wheels, oaken gear shifts, and pine shafts. The home he came to call Old Sunrise Mills wasn’t convenient to the clinics where he worked or the classrooms in which he taught, but he experienced home as a recuperative sanctuary and didn’t seem to mind the seventy-eight-mile round-trip drive in his motorcar from Schwenksville to Philadelphia and back.

  By the age of ninety-three, this prodigious writer had produced 238 single-authored articles, 473 co-authored articles, 12 textbooks, and 6 monographs. Trained as a visual artist, he was known during his lifetime as much for his “chalk talks”—lively lectures accompanied by the visual aid of colorful illustrative sketches that he would make on the spot—as for fbdy removal. Copies of the sketches became coveted collectors’ items among his students. In 1938, at age seventy-three, he composed an autobiography that was an instant bestseller, The Life of Chevalier Jackson. His textbook Bronchoscopy and Esophagoscopy (1922) was considered the bronchoscopist’s bible. His first book, Peroral Endoscopy (1915), inaugurated the age of diagnosis by direct inspection of the upper torso.

  Vision and visual apparati were the new order of the day, and Jackson played a major role in their ascendancy in the medical domain—yet he still relied just as heavily on his ears and even more so on his touch. He might listen for the “asthmatoid wheeze” but then challenge acoustical protocol by instructing that “all that wheezes is not asthma” (an axiom so often repeated by Jackson, it is to this day an adage common among pulmonologists). He listened for “whiskey throat” and “grog blossom”—qualities of voice that signaled dilation of the capillaries of the mucous membrane that lined the larynx, which was indicative of too much drink. He tipped an ear or sometimes brought a stethoscope bell to an open mouth as though listening in on a concert played with broken musical instruments as he tried to sense “percussion notes,” “audible slap,” “tympany,” “cracked-pot note,” or “Wintrich’s change of tone.” He applied his palpating fingers like a tuning fork and, with an incomparably gentle and exacting touch, he felt his way with instruments that were extensions of his hands inside a network of seemingly impassable and blind passageways, inside a ligature and webbing so delicate that one wrong move could prove fatal, as it did in the ghastly record of gruesome acts that preceded Jackson’s refinement of the field: cases in which the patient was left not only with a foreign body impacted but with crudely designed instruments—metallic hooks, curved forceps, or pieces of wire—tightly wedged alongside or atop the Thing inside an orifice. The patient would in this attitude spend the last days of his life before succumbing.

  By his own account, Jackson never was a “medicine-giving doctor,” but one who had the utmost faith in his eyes and fingers (LCJ, 203). He worked a form of healing that was a particular (and literal) kind of laying on of hands and eyes. Essentially, he was a craftsman, a mechanic, an engineer who enjoyed an education of his senses—especially touch—from a very young age, and whose training at a lathe and “aching void for making things” out of wood or metal became almost an aesthetic in his medical practice, an attitude toward the body that was tantamount to an artistic style (LCJ, 197). He loved the odor of wood and could tell the type of tree by its fragrance in the woodshop. He could identify a tree by sight “even when leafless,” recognizing it by the “grain, and feel, and color” of its wood (LCJ, 196). We could remember him this way: as the doctor whose wood crafting made him highly attuned at the level of skin on skin.

  If Jackson could tell us how he wished to be remembered, I’m certain he would do so by assemblage, or meaningful collage, the way he had pieced together a gavel for the otolaryngology section of the College of Physicians: its head was derived from a scrap of dogwood from his home in Idlewood, Pennsylvania, that he had kept since he was a boy; the handle he crafted from the hickory handle of a hammer he’d used in his shop for years; the box he made from a Rambo apple tree planted by his maternal grandfather, Jean Morange, in 1828 on his country place near Pittsburgh. Morange was, in Jackson’s words, “a harbinger of the present mechanical age,” and the figure from whom he imagined having inherited his own mechanical gifts (LCJ, 196).

  Wizard. Magician. Miracle man. Stilts-walker. Humanitarian—Jackson’s treatment of Pittsburgh’s urban poor in the late nineteenth and early twentieth century, his lifelong tendency to prioritize the care of others over remuneration for his work, his refusal to patent the instruments in his armamentarium, and his seminal role in the creation and passage of the Federal Caustic Act of 1927 mandating that poisonous substances like household lye be labeled as such earned him this distinction. But what drove Jackson’s bronchoscopic quest—the pioneering work he did that would forever influence diagnostic and treatment methods of diseases of the upper torso—was not initially or implicitly an interest in saving lives. What drove his work was a capacious curiosity, an appetite for the unknown, the courting of impossibility—and a love of color. Saving lives was a happy by-product of his odd-because-uncommon preoccupations, his imaginative drift.

  “How did you come to undertake this strange study of bronchoscopy?” a radio interviewer asked Jackson in 1938. And he replied:

  It is a pleasure, sir, to answer that question as to myself, but this does not imply that I was alone in the development of bronchoscopy. The mystery of the unknown was attractive to me. Many times I had looked at the larynx with the ordinary throat mirror. Beyond the range of vision, in the mirror, lay a great, unknown, unexplored field. It was parallel to an explorer at the edge of a jungle that had never been seen by human eye. Then came the intrigue of the impossible. It had always been regarded as impossible to explore the air passages. All my life, the most fascinating problems have been those that were deemed impossible of solution. Another factor was the never-ending, awe-inspiring sights, in the depths of the bronchi; one seems to be in the midst of life’s machinery. Still another fascination was the play of colors, so beautiful to paint for illustrations and so interesting to draw with chalk for demonstration to the students.

  In one of his earliest essays on gastroscopy, he encouraged his peers in the profession by arguing that the misgivings and challenges of inserting a rigid tube into a human esophagus would be repaid by the visual display it afforded the operator: “Thorough and systematic search of the explorable area by introducing the tube into one fold after another, missing none, demands something of experience and more of patience, but these will very readily be yielded by the enthusiasm of one who has for the first time perceived a beautiful picture of the living membrane as obtained at the first introduction of the tube.” In his autobiography, he reserved a special place for color as pure perceptual pleasure: “the colors of mucous membranes, especially of the bronchi as seen through the bronchoscope, in health and disease, have always been interesting to me, entirely apart from their medical significance” (LCJ, 199).

  If I could piece together a telling of the color of his days, three hues would dominate: the gray black of Pittsburgh’s nineteenth-century skies; the cold green of
his operating room; and the blue-brown waters of the mill pond alongside his house outside of Philadelphia where he sat in a boat to write.

  At first the sun is absent: he was born in Pittsburgh on a “dark, dreary November day” in 1865, the year that ended the Civil War (LCJ, 1). He remembered the sun always receding before he had a chance to play. At the age of nine, following a major financial reversal for his father, he moved with his family to Idlewood, a few miles west of Pittsburgh, where they perched precariously on the edge of bituminous coal districts and not far from oil-producing territory. In the 1880s, his “white-marble-step college days in the then anthracite-burning Philadelphia” impressed him with a before-and-after, black-and-white contrast that stuck (LCJ, 96). When he returned to Pittsburgh to establish his practice, he experienced the lack of light there as nightmarish: on the four days in winter when the sun was visible through the layers of soot and grime that filled the air, it appeared like a full moon, white against black. When he came to make his sketches of the interior of the human body, he always worked from a striking black background, as though remembering Pittsburgh’s colorless skies.