For every attitude, disposition, presentation, type, and fbdy scenario, Chevalier Jackson seems to have designed a special instrument. He generally worked inductively rather than deductively, letting the fbdy dictate the choice of instrument rather than force an already existing instrument to fit the particular fbdy. Thus, a special bronchoscope was created with an oval end to accommodate both points of a swallowed staple (of which there were many in his clinics). For the rare but still occasional instance of a fbdy lodged in an upper bronchus, he designed a forceps that could reach around a corner; if the fbdy is hollow, a forceps that can fit inside the fbdy and then expand before making traction is required. The instruments must be well made—a well-made forceps, for example, hugs a fbdy, whereas a faulty forceps precariously balances upon it. All of these instruments are rendered useless if not properly cared for—and the degrees of mastery involved in Jackson’s practice multiply.
How exactly does Jackson free the points of a jackstone or remove a collar button without exacting harm? (See figures 34 and 35.) What made him so capable of retrieving safety pins? In dealing endoscopically with an open safety pin, lodged point upward, you don’t move forward until first determining seven essential things:
1. The size of the pin.
2. The greatest spread from the point to the keeper.
3. The exact plane of this greatest spread.
4. The direction of the point.
5. The precise location of the point, the keeper, and the spring.
6. The degree to which each of the two branches of the pin deviates from the vertical axis of the patient’s thorax.
7. Bends, breaks, kinks, or other imperfections of the pin. (NMP, 68)
The problem of the safety pin is often solved by using the forceps first to seize and then to rotate the pointed branch of the pin. Then this branch must be enclosed inside the instrument’s tube. The keeper remains outside the tube, and the entire ensemble slides harmlessly out through the windpipe or esophagus.
Fig. 34. The problem of the jackstone explained in Chevalier Jackson’s “New Mechanical Problems in the Bronchoscopic Extraction of Foreign Bodies from the Lungs and Esophagus,” Transactions of the American Laryngological, Rhinological, and Otolaryngological Society 27 (1921). Courtesy of Thomas Jefferson University, Archives and Special Collections.
Fig. 35. Solving the mechanical problems associated with retrieval of collar buttons in the upper torso as it appears in Chevalier Jackson’s “New Mechanical Problems in the Bronchoscopic Extraction of Foreign Bodies from the Lungs and Esophagus,” Transactions of the American Laryngological, Rhinological, and Otolaryngological Society 27 (1921). Courtesy of Thomas Jefferson University, Archives and Special Collections.
All that we cannot anticipate or imagine is literally within Chevalier Jackson’s grasp in his solution to these Gordian knots, and it’s neither miraculous, nor stupendous, nor transcendent: it’s the effect of the application of a quality of mind—“unbefogged by alcohol,” he’d be quick to add—reliant on a fundamental life-defining paradox: that nothing in the world is reliable (there are no safety nets, you’re sure to fall through the rabbit hole, other people can’t be trusted) and that every fbdy problem can be solved.
A splayed hairpin points upward in the esophagus. The bent part of the hairpin—its “dart”—lies lodged in the direction of the stomach while its two ends, like crinkled wings, threaten to pierce the esophageal wall on either side. Simply to grasp the dart with the forceps and attempt to pull the hairpin out could cause fatal trauma; it had done so in the past. Jackson’s carefully worked-out solution shows him disengaging each point one at a time or, more literally, lifting each pin out of its crevice by placing the forceps behind the pin and then rotating each point inward using a side-curved forceps in order finally to draw both ends into the tube.
Jackson might at first resemble a watchmaker, but on further consideration, it’s clear that he is a time-bomb detonator, a defuser of explosives, because his solutions depend on his figuring out a way to disengage and manipulate the fbdy against its intention to do the most harm. “It is sometimes desired to make traction on an irregularly shaped foreign body, and yet to allow the object to turn into the line of least resistance while traction is being made,” he wrote in his 1922 guide to bronchoscopy and esophagoscopy. Fbdy removal begins to sound like a method from which a system of thought, a set of spiritual principles, or a philosophy could be born. Call it the chi of bronchoscopy because the operator has to be sensitive to the simultaneity of yin and yang. He must be able to activate or instigate two opposed tendencies at once. Better yet, he must allow for a slackening, give himself over to it, and exert force at the same time. Giving himself over to accidents and mistakes, admitting that forces militate against such an arsenal of skill and foresight, and accepting that error could be occasioned by the instrumentarium itself was harder, and it is especially painful to encounter, in spite of Jackson’s unimaginable application and devotion and ingenuity, freak accidents to which he was not immune and (albeit rare) missteps.
In his 1908 report on some of the earliest cases in his tracheo-bronchoscopic practice, Jackson documents a fiendishly unpredictable series of events by which, working in reverse, a fbdy trapped the bronchoscope inside the patient’s body, the effect of the slits in the sides of the bronchoscope being placed too near its lower end. The patient coughed as the scope was inserted, and the pin that Jackson was attempting to remove made its way into one opening in the side of the scope and out the other, so that it was lodged like a crossbar inside the instrument, trapping it inside a bronchial wall. The pin, in effect, spiked the scope into position, rigidly fixing it in place and making it impossible for the instrument to be withdrawn. Jackson was forced to break the fbdy into three pieces, two of which were withdrawn and one of which was lost. It must have been a particularly bad day, because Jackson also explains that his protective glasses had broken, and the patient had coughed cocaine (used as a local anesthetic) into his naked eye, thus leaving it to Dr. Edith Waldie to make a careful, though unsuccessful, search for the remaining bit of pin. Jackson confidently concluded that the small remaining point was lost in the secretions withdrawn with the tube and noted the child’s perfect recovery, but we are left to wonder.
Jackson was an instruments man, no question. People who visited him at Old Sunrise Mills commented on the rich instrumentarium he laid out before a turkey he aimed to carve. He was both an instruments man and a doctor, and the combination of two in one (or three or four or five) helped distinguish him. Jackson was an instrument designer and a practitioner who made prototypes of his instruments on the metal lathe in his mill, and he enjoyed a lifelong relationship with the Philadelphia-based Pilling Company, which manufactured instruments for him en masse. James Edmonson concludes his short history of gastroscopy’s instrumentarium by remarking upon “the central importance of the vital, creative alliance of physician and instrument maker.” The two roles did not always exist so peacefully: in the mid-nineteenth century Dr. Maximilian Nitze and Josef Leiter, a leading instrument maker in Vienna, collaborated to make improvements upon the cystoscope but parted ways when “each claimed personal credit” for its design and success. Johann von Mikulicz and Josef Leiter proved a more successful team, even though their efforts were initially hampered by something Jackson criticized: they tried to use an instrument meant for one part of the body—the urethra and urinary bladder—on the very different conditions found inside the stomach. In the person of Chevalier Jackson, the physician and the instrument maker came together.
Chevalier Jackson was an artisan. A skilled laborer. An artist whose instruments are practical devices and works of art. The instruments might be part of a matrix of forces and formulae, working at the crossroads of a physician-body and a patient-body that define the practice of endoscopy, but they are also (especially when they are encountered in an archive) aesthetically charged; even more than beautiful, they are gorgeous Things.
A black tray and white gloves against instruments silvery, pristine, and absolutely clean—nothing mars them—lain against a backdrop of velvety green cloth. Down, down, down inside the Mütter Museum’s basement, inside the drawers inside the moving cases inside the vaults, lay seven light carriers that seem as though they could be plucked, so truly do they resemble violin strings. If you didn’t know that these were instruments of medicine, you’d suspect the tubes were musical instruments because of what resembles a mouthpiece, a spout that arcs out of the top, and the delicate holes at the bottom—surely, this is a cross between a clarinet and flute. Not really, though, because the spout is actually a hose attachment for supplying oxygen, the distal slits are drainage holes, and the tiniest hole at the top is the diminutive manhole cover that a person clings to for dear life, clings to from the underside, entire biological systems plus a soul tethered to an opening the size of a dot.
The scopes are of different diameters: one the size of a drinking straw, the other the size of a pipe, and all absolutely rigid. At the top of each is a part like a thumb or a wing that you use to hold the instrument when it is inserted. What “part” is the aperture the operator looks through? I look down through it and experience an eye within an eye, an iris within an iris. Two scopes show the same view, and a third an utterly different view. One has a wide opening at the top and two spigots fanning out like tulip heads, while the grasper is shaped like a knob, a pawn. At the base of one, a valve. Consider how tiny the circumference of the hole at the base is, and then what Jackson saw there, and what he depicted there. Now place your hand atop the cast made from his hand—the flat thumb, the knuckly, swollen joints, the slightly crooked little finger—after all this time spent imagining the fingers to be delicate and long (see figure 36). This hand, cut out, cut off, mounted, seems to perch on a bit of imaginary beach, drifting; tentacles detached from mind feel for disappearing things—the waxing and waning of inspiration, of expiration.
A seven-year-old girl stares wistfully at a glass of water. She hasn’t been able to swallow even a drop of water for a week. It’s amazing that she is still alive. When she tries to swallow, the water comes back through her nose and her mouth. The girl had been found on the floor of a coal miner’s shanty, where her three-year-old brother was attempting to feed her water with a tin cup from a tin pail. But the water fell out of her mouth and onto her clothes, soaking her, because she could not swallow it. One of countless children who were victims of lye (see figure 37), the girl was brought to Chevalier Jackson, who passed his esophagoscope down the girl’s throat and discovered a nearly closed esophagus, scars left by the lye that hadn’t entirely sealed the passage, and a cork-like plug of gray matter. He removed the plug with delicate forceps:
After removal of the instrument the child was given a glass of water. She took a small sip expecting it to choke her and come back up. It went slowly down; she took another sip, and it went down. Then she gently moved aside the glass of water in the nurse’s hand, took hold of my hand, and kissed it. She took more water and a glass of milk.
Fig. 36. Plaster cast of Chevalier Jackson’s hand. Collection of the Mütter Museum, The College of Physicians of Philadelphia.
Fig. 37. Children treated for ingestion of lye in the medical amphitheater of one of Jackson’s clinics. Chevalier Jackson Papers, 1890-1964, MS C 292, Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, Maryland.
At the end of two years, following dilation of the strictured esophagus with Jackson’s scope, the girl “could swallow any kind of food in a perfectly normal way; she grew well and strong” (LCJ, 107).
Astonished that she could swallow once again, and grateful for it, the girl pauses to choreograph a search: holding aside the liquid, without which none of us can live, she seeks the hand that saved her and brings it to her lips to kiss. There’s no utterance to speak of, but just this relay of lips and hands: to swallow, to kiss, to swallow again.
What are these Things? we might ask of Chevalier Jackson’s instruments. What are these Things but art objects and life-saving devices; on both counts, the product of his hands (see figure 38).
Modernist Portals and Secular Tabernacles: Chevalier Jackson Meets Joseph Cornell
On a brilliant spring day in 1930, members of the French Academy of Medicine sat in a darkened room. Changes were aloft in the Parisian fashion world—white dinner jackets, banjo sleeves, wide shoulder pads, and the color shocking pink had been introduced—but these French doctors stayed inside, clamoring for a place inside an amphitheater on whose screen was projected a compelling cartoon. The animated motion picture illustrated, in step-by-step fashion, a bronchoscopic method for treating abscesses of the lung that the film’s producer, Dr. Soulas, had learned from Chevalier Jackson.
Fig. 38 Chevalier Jackson’s signature with note. Chevalier Jackson Papers, 1890-1964, MS C 292, Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, Maryland.
Meanwhile, back in Philadelphia, Jackson’s audiences remained steadfast in their fascination with his demonstrative method, the never merely illustrative but embodied visual performances for which he was known. Those students who attended Jackson’s famous on-the-spot ambidextrous “chalk talks” went away dazzled and changed by the rare opportunity to bear witness, in a sense, to Jackson in repeated acts of first seeing and then remaking what he saw through his scopes in the forms of many-times-magnified chalk-pastel renderings. In this way, Jackson “worked up” the bodies that he treated, but not in the sense that medicine uses that phrase now. This was not a stats-gathering procedure, a collation, or a keeping of tabs. As if by magic, he brought the body’s insides to light, as light. Jackson’s hands were his imaging technology and they made for a unique pedagogical encounter irreducible to what we now think of as proplike visual “aids.” The Jacksonian chalk talks exerted a curiously hands-on seeing-feeling identification between student and teacher that was impossible to reproduce, for its emphasis was on medical practice not simply as away of seeing bodies or acting upon bodies, ill or well, but of making bodies.
“Dr. Jackson First Wooed Muse of Art: Bronchoscope Inventor Wields Brush.”
That was the headline for a 1928 Evening Public Ledger article in which Jackson said the only thing that kept him from pursuing art professionally was the fear of failure, starvation, and subsequent hunger. But Jackson’s art-making was not opposed to or exclusive of his medical practice. Jackson understood the manual dexterity required by painting to be in every way commensurate with the training of the hands and eyes called for by his endoscopic work. It was inextricable from and essential to his profession.
One of Jackson’s “how-to” illustrations might show a physician-reader the placement of the neck and head in what came to be known as the Boyce position (named for Dr. John W. Boyce); or it might resemble pictures in an instruction manual, diagrammed with arrows and marked with letters of the alphabet as pointers. (These sorts of pictures aren’t exactly suitable for framing, though one can imagine a collector of instruction manual art being intrigued by them.) Inside the same article or book, Jackson called upon a different order of art reserved for rendering the fbdy solo, unadorned by explication, there for the showy fact of it. Such illustrations don’t subordinate themselves to any text but stand on their own, rendered with the exactitude and flair of a natural historian. In place of an endangered species, a cockatoo, blue jay, or red-capped sparrow, in lieu of an unfurling fern or an arboreal taxonomy of leaves, we find a tack, nail, or button, voluble, nearly embossed, so true even in black and white that we feel as though we might be able to lift it from the page.
Chevalier Jackson’s offices were starkly utilitarian and fbdy-bedecked, but in the midst of that clinical coolness, one of Jackson’s ochre- or hay-colored oil paintings might appear, of his home on the Ohio River, where he recovered from his first bout of tuberculosis, or of sinewy old apple trees, the gold afterglow of Old S
unrise Mills, or Alice’s sewing basket. In his studio, poised before an easel of an afternoon, Jackson painted landscapes, “A Woodland Path” of “sycamores in fall foliage, Arroyo, Pasadena, morning effect.” Less often, he painted portraits—for example, of a girl named Yvonne in which the shadows from the forest make up the patches on the Sargent-like patterns of her robe (see figures 39 and 40). Are those morning glories or thin-as-paper roses of Sharon in various stages of opening in the undulating tapestry that is her dress? And her walnut-shaped eyes? Did they see into Chevalier Jackson’s heart? Did they glimpse his woodland brights and darks?
Mary Cappello Page 28
