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Dr. Mihran Kassabian

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Dr. Mihran K. Kassabian (1870-1910)
Dr. Mihran Kassabian, one of the most prominent radiologists of his day, was an Armenian by birth, which occurred in 1870 at Caesarea (Kaisarieh) in the ancient province of Cappadocia,in Asia Minor.

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Published Works

Biogrpaghy

Written by Percy Brown for American Journal of Radiology (1995)

Doctor Kassabian, one of the most prominent radiologists of his day, was an Armenian by birth, which occurred in 1870 at Caesanea (Kaisanieh) in the ancient province of Cappadocia,in Asia Minor. There he was educated at one of the excellent schools for boys and girls of the American Missionany Institute, after an early childhood fraught with almost constant danger of earthquake or massacre. Following his primary years as a pupil at the Mission, his continued aptitude and his growing seriousness of purpose won for him the post of an instructor there, as a stepping-stone toward the life of a medical missionary which it was his purpose to embrace. With this career in view, Kassabian journeyed to London in 1893, and the period of his life spent in that city marked the creation in him of a deeper interest in Medicine as a profession, and stimulated as well his strong inclination toward the practice of photography. His natural skill in this pursuit, already amply evinced, stood him in good stead almost immediately. While in London he embarked also upon the study of theology as a necessary qualification for serious medical missionary work, but as the months passed he found himself more and more enmeshed by the fascinations of medicine and of photography. The persistent dominance of his thoughts by these two interests now seems a subtle presage of his future, as one today reviews his remarkable career.


Young Kassabian had been already impressed, at the Mission of his early education, by American methods of teaching,and on completing the period of study in London that combined employment had made possible, he emigrated to Philadelphia. For this journey, his photography again came to his aid. The moment of R#{246}ntgen’s discovery found him matriculated at the Medico-Chirurgical College of Philadelphia.To be able to undertake so long a journey and to make so momentous a change in the course of his life entailed much sacrifice and hardship; a poor man as he had been always a poor boy, Kassabian was entirely self-supporting throughout his pursuit of a medical education, and here again his photographic talents served him, stimulating as well the growth of his interest in the new roentgen-rays. Well along his medical school course at the outbreak of the Spanish-Amenican War, he was quick to appreciate their importance as an aid to the surgery of warfare. In the spring of 1898, with his degree almost within his grasp and in urgent need of the livelihood that its possession might have made possible, Kassabian chose to heed a higher call for patriotic service to the country of his adoption. His naturalization having been obtained already, he immediately enlisted in the Hospital Corps of the regular army, wherein he worked faithfully and efficiently. In this manner he gained an experience in x-ray practice of great value to an incipient science, but of ineradicable harm to him. On his discharge from the Service at the end of the short war, Kassabian received his degree in medicine.


With due allowance for his qualities as a student and his capacity for thorough work, which must have been deciding factors, there is reason to believe that Kassabian’s continued skill as a photographer and his later-developed interest in the treatment of disease by electricity had much to do with his appointment soon after graduation as “Skiagrapher and Instructor in Electrotherapeutics” at the Medico-Chirurgical College and Hospital. At that early day, the title “skiagrapher” could hardly stand alone-indeed, its life was not a long one. It was practically synonymous with “photographer.” ‘The New Photography” continued to be the term spontaneously applied,in the general mind, to the process of producing “pictures” by the action of x-rays on a light-sensitized medium; thus the medical application of the roentgen-rays, as an institutional function, fell naturally to the lot of the hospital photographer. In this connection, Kassabian took a step which, measured in terms of its ultimate effect, may be called one of his major contnibutions toward the stabilization of roentgenology. At the Medico-Chirurgical Hospital he overcame an anomalous situation by combining closely his duties as “skiagrapher” with his responsibilities in the strictly clinical field of electrotherapeutics.In this way he gradually endowed his x-ray work with the dignified status of a clinical department, wherein teaching, in his opinion, was a function definitely to be stressed.


Kassabian’s tactful part in this process of adjustment gave him the opportunity to exalt, in turn, the position of electrotherapeutics.In itself a useful branch of therapeutics, practiced by a great number of upright and sincere men, it had become honeycombed and undermined by the dry rot of charlatanism. Kassabian’s serious interest in this work was the result of his steadfast confidence in its value when properly and appropriately applied. Although his was an ingenuous nature, with surprising acumen he realized the danger of a similar exploitation of the roentgen-rays, and he became a prominent member of the group that fought constantly this sinister tendency. Doctor Kassabian continued his work at the Medico-Chirurgical Hospital until 1903, when he was appointed Director of the Roentgen-Ray Laboratory at the Philadelphia Hospital.The moment the value of the roentgen-rays to medical science was demonstrated, and thereafter until 1 900, the use of the “fluoroscope” flourished. So widespread was its acceptance,especially by surgeons, that its routine use was demanded of the “skiagrapher” even to the exclusion of the radiograph. No doubt the influence of Mr. Edison, whose every pronouncement, naturally, made deep public impression,had much to do with the creation of this conviction. He had said in 1896 [1]: With the fluoroscope, as I have already said, a sungeon should be able to determine in a moment, in case a man has been shot, just where the bullet has lodged, and operate accordingly. There is no occasion to take photographs, shadowgraphs or radiographs. I stopped that long ago. You see for yourself,the fluoroscope does the work in a moment.

Such dogma as this, absorbed by contemporary surgical practitioners especially and reflected, through their urgent demands, into the atmosphere of the expanding x-ray laboratory, proved to be highly dangerous. As the demand of the surgeon was for fluoroscopic examination to effect a quick “diagnosis,” so was it the ambition of the roentgen-ray operaton to demonstrate by means of the skiagraph or radiograph, the medium to which the words of Edison ascribed such little importance. Apart from the fact that Kassabian, through his technical sense, attached but secondary importance to the use of the fluoroscope in that type of problem wherein it has not now been employed for years, he also realized his own danger in pursuing this practice, but unfortunately too late permanently to arrest the cumulative effect of his earliest exposures in his army work and during the years immediately following-the heyday of the unshielding fluoroscope. In after years he said in retrospection: “I would have stopped the [use of the] fluoroscope then, but they would not let me.” As if by the inspiration of the prophet, Doctor Kassabian made his first major contribution to the literature in October of 1900 on “X-ray as an Irritant” [2]. As a basis for his obsenvations, he recorded the fact that he had examined, in the course of two years’ work, more than three thousand medical and surgical cases and had made more than eight hundred “negatives” (radiographs) at the Medico-Chirurgical Hospital and also in the United States Government service in the late AJR:164, May 1995 AMERICAN MARTYRS TO RADIOLOGY 1287 war. These figures indicate cleanly the proportion between his fluoroscopic work and the cases in which radiographic records were made, but the balance on the side of the fluoroscopic screen is enormously increased if he pursued at that time a practice which he admits using later- that of making a preliminary screen examination in every case! In the same paper he describes the course of his own affliction as it had progressed up to that time: About five months ago, [April, 1900] the fingers, knuckles and dorsum of my left hand exhibited a general erythematous condition. This continued about a month; the itching became intense, the skin became tough, glossy, edematous and yellow. On my night hand it was less marked, occurring only on the fingers. This I attributed to the fact that I hold the fluoroscope with this hand. I also put my left over [in front of] the fluoroscope and expose it direct to the x-rays. (I used to show itto the patients before I began the application of the x-rays, as this tends to prevent the patient becoming emotional or excited.) First I thought this condition was due to the chemical action of the developer (metol), but it was not, evidently, because the discoloration appeared first on the left hand and along the wrist, [an area] which is most exposed to the x-rays and less to the developing process; if it had been due to the developer the right hand would have been affected first and most. And again, this is not possible because I have been wearing rubber gloves while developing the negatives. This leads me to believe that the changes taking place in the tissues afterexposure to the rays are due to their chemical (?)action on the tissues. The subject dealt with in this paper gave Kassabian the opportunity, in its closing paragraphs of argumentation, to deplore the prevalent and lax application of the term “burn” to the dermatitis produced by undue exposure to x-rays. The illeffect of this careless and indiscriminate usage he was quick to foresee, and he attacked it repeatedly until his death, often resorting to a description of his own case as a means of introducing the subject on appropriate occasions. His consistent position on this matter marks another of his contributions in support of the dignity of his specialty. It is believed that his antagonism to the use of the noun “burn” was not based on any misconception of its value in pathologic classification. He realized, as fully as does any pathologist, that burns of the skin may be produced not only by heat, but by cold, by sunlight, by direct electrical discharges and by chemical action. He did fear, however, that if “burns” came to be associated, in the popular mind, with the medical use of the roentgen-rays, the progress of a new science might be definitely inhibited at a crucial period in its development. During his earliest medical years, Doctor Kassabian probably shared with all contemporary investigators of x-radiation an uncertainty as to just what agency the skin reaction was due. His writings of that period indicate that for a time he leaned toward the theory that it was the result of a radiationproduced chemical action, but subsequent experience, in his case a bitter one, convinced him of the strength of the thesis of direct action, as held by Elihu Thomson and others. This uncertainty as to the causation of their acute afflictions having been dispelled, the pioneers could proceed to adopt the means of preventing repetitions of exposure, but what of their condition already sustained and perhaps established? What steps should be taken for relief and possible cure? Their efforts to attain this relief and cure are interwoven with the fabnc of their pathetic history-their comparison of notes in open discussion or by writings, their temporary victories over the unspeakable pain of the acute inflammation only to be assailed by the subtle advance of the sub-acute and chronic skin changes. Full five years after his initial symptoms, there is the faintest note of despair in Kassabian’s words as he discussed the situation with his colleagues of the American Roentgen Ray Society in 1903: Most of us have been “burned” by the x-rays when using the fluoroscope for indefinite periods, this being especially due to bringing the hand so near to the tube. Of course, today we are not making as many fluoroscopic examinations as formerly, so that. . .a smaller number of “burns” occur in this way.. . An irritant of electrical energy is constantly coming from the larger coils [Now recognized as secondary radiation. During his early career, Kassabian supported the theory that the skin changes were due to chemicalreaction, from either direct emanation or the static field. Also, he believed that personal idiosyncrasy has great influence in determining the severity of the lesions. The latter tenet has never been disproven.], which increases the severity of the “burns” with which we are already suffering.... In order to effect a cure of my hands, I have used every remedial agent mentioned in all the text-books on skin diseases and also every. . medicine that has come to me by mail and otherwise from time to time. I would use one for two or three days, then throw it away and try another, but nothing seemed to me any good. . . .1 would like to have some of you discuss the matter of treating “burns” of our hands, because it is very vital with us. I have been unfortunate in finding a remedy to cure my hands. I hope that we will soon be able to prevent these injuries and find a specific remedy, so beginners willnot have the same misfortune. Herein one can discern a prescience of irreparable physical damage as the price of his diligence in earlier years, but this intuition did not visibly affect his sustained enthusiasm in his work. To Kassabian, evidently, it was merely another barnier over which he must climb-another resistance in the course of a career already beset with handicaps! Doctor Kassabian’s second scientific paper [3] was perhaps the most valuable of any of his productions. This was read at the first meeting of the “Roentgen Society of the United States” held in the Grand Central Palace, New York City, in December of 1900. Before this society, which on that occasion became, by vote, the American Roentgen Ray Society, Kassabian exhibited a series of no less than one hundred and fifty “skiagrams.” His paper described in detail the ‘Technique of X1288 BROWN AJR:164, May 1995 ray Work,” with especial reference to its photography. As in a former paper by Weigel (vide p. 53), it gave its author the opportunity to make practical suggestions based on a wide experience. As such it was most welcome to a large group of early experimenters not deeply versed in the long-established methods of this important process. In the same paper, Kassabian discusses judicially the functions of the fluorescent screen and of the radiograph. It was “fluoroscope versus skiagram” at that day, and Kassabian experienced to his cost the temporary favor accorded to the fluoroscope. To those of long photographic experience, increasing ability to make short exposures denoted a distinct advancement of the art. Therefore the need of such short exposure in nadiography was quickly apparent to Weigel and to Kassabian. In his expositive writings in support of this need, and by way of contradistinction from the older order of radiographic technique, Kassabian consciously uses the term “instantaneous” in its figurative sense only, as it had been used by photographers for years; it suggested merely an exposure of very short dunation- shorten, perhaps, than any previously employed. The major controlling factor in the determination of Kassabian’s scale of “instantaneous” exposure [4] was the density of the anatomic part to be irradiated. In this scale, the criterion was the hand, to be exposed for one second! Read upward, it reached its maximum in the abdominal region, wherein an exposure of from fifty to ninety seconds was required. We may condescend to smile as we look down from the Olympian heights of our present-day practice, but we must remember that these recommendations punctuated an era in which x-ray exposures had been measured, of necessity, in minutes rather than seconds; so, by comparison, Kassabian’s exposures were indeed “instantaneous.” Especially was Doctor Kassabian prompt to appreciate the paramount value of this technical procedure in the radiography of the thorax. He devoted much study to its development and in consequence he was soon able to say: [5] . . .we are now in a position where the time of exposure has been lessened from one to four minutes to as many seconds, and even less, with a distinct improvement in the resulting picture. . .to overcome the defects in skiagnams due to movement during respiration, itis necessary to expose the part and plate to the action of the x-ray momentarily, and this at the end of the inspiration period. In the case of the heart, the exposure must obviously be instantaneous, or at least synchronous with the whole or a part of the cardiac cycle.... For this purpose Kassabian used a twenty-inch Ruhmkortf coil with an electrolytic interrupter. Great was the amount of manipulative skill required to nurse a gas-tube through a series of such exposures; for him the task was greater as he employed almost habitually at this period a tube notorious for its fickle behavior. ‘The degree of penetrability is best measured,” he observes, “by means of the fluorescent screen-hand method, but. . .1 do not recommend testing the tube with the fluoroscope. It is very injurious to the hand and this is the reason why so many of us are suffering from dermatitis.” Although Kassabian, in enumerating the modi operandi to effect exposures which at that day seemed so short, mentions the value of the intensifying-screen [Finely divided crystals of calcic tungstate fastened to a thin support and placed between the part to be radiographed and the sensitized surface receiving the image. Its use decreases matenially the length of exposure.], he recommends its use only where the patient’s safety demands the shortest possible exposure. This opinion reflected the adverse sentiment then prevailing relative to the use of intensifying-screens, as their structural imperfections impaired the quality of the finished “skiagram.” To Doctor Kassabian in 1 903 came an opportunity which he was prompt to embrace. With the advice and encouragement of many scientific men of Philadelphia, he entered upon the task of preparing a text-book dealing with the two branches of medicine to which his life had been dedicated [6]. For over three years he worked on this volume- a labor the more arduous because of his naturally imperfect knowledge of the English language. The result was a splendid book of nearly five hundred and fifty pages, the first edition of which appeared in 1907. One of the three outstanding American text-books of its time to deal comprehensively with the subject of radiology and yet such is the evanescence of human impressions that mention of it does not appear in a late (1933) analytical review of American radiologic literature. A meagre third of the work is devoted to electnotherapeutics; the remainder to x-ray diagnosis, to radiotherapy, to radium, to phototherapy and to an exposition of the value of the roentgen-nays in fonensic medicine. Kassabian’s selective inclination toward forensic roentgenology was revealed in his article [7] of 1 904 as well as by his thorough consideration of the subject in this volume. He acquired subsequently a sound reputation as an expert medical witness in causes relating to electrotherapy and radiology. The second edition of his book was published in 1910; its appearance was almost coincident with his death. Without question this elaborate text was the magnum opus of “a constant student, hard worker and thorough investigator.” [8] Not through these literary contributions alone, however, did Kassabian receive general recognition; his opinion had long since grown to be one of authority in matters connected with those branches of medicine in which the roentgen-rays are notably useful. He was honored by the Commonwealth of Pennsylvania by an appointment as X-ray Expert to its Tuberculosis Congress; frequently he served as a representative of the American Medical Association at international medical meetings abroad. It would seem that Kassabian’s search, which he had prosecuted for five years, for some form of palliative remedy to mitigate the discomfort of his chronically inflamed hands, had been successful in some measure, because by January of 1908 there was general improvement of the condition on the back ofthe right hand, with the exception of an extensive kenatosis at the base of the fourth finger. On the left hand, however, an area of ulceration had persisted for a long time on the middle finger and at the base of the first phalanx of the fourth AJR:164, May 1995 AMERICAN MARTYRS TO RADIOLOGY 1289 finger; within a few months these had become definitely malignant in character. In April these fingers were amputated in part and at the time of this operation no evidence of upward extension of the carcinomatous process was noted. In 1909, nevertheless, the axilla became metastatically involved quickly, apparently from a more recent area on the hand. The axillary glands were excised, but tissue repair did not take place. Funthen involvement of the glands of the chest-wall necessitated wider operative intervention. With characteristic fortitude, Doctor Kassabian continued his practice in spite of this tremendous handicap, yielding only when it became obvious even to him that he had no strength to continue. Again, it was characteristic of him that, during the entire eight years’ course of his affliction, he left no stone unturned to forestall public intimation of the extent of his condition or his suffering from it. He was fearful lest such information might in some way conduce to the discredit of the roentgen-rays. He was jealous of the good name of a great natural force in which he could see so cleanly a superlative benefit to mankind. Actuated by this sentiment, it is said that he even entered hospital for his first operation under an assumed name. Doctor Kassabian’s enthusiasm for his work never faded up to the moment of his end. One can still clearly visualize the sparkle of his dank eyes, the flush beneath his olive skin, the slight hesitation in the soft intonation of his English speech, as he expatiated on the beauties of an x-ray demonstration. To the portal of his death he brought this enthusiasm in his life’s endeavor and with high-headed pride he carried it beyond, leaving behind in the lap of Humanity the full-ripened fruits of his labors.

He is buried at Arlington Cemetery in Drexel Hill, Pennsylvania.

REFERENCES 1. Am J Photogr, 1896;27:160 2. Kassabian MK. X-ray as a irritant. Am X-ray J, 1900:7:784 3. Kassabian MK. Technique of x-ray work. Am X-ray J, 19018:867 4. Kassabian MK. Instantaneous skiagraphy. Am x-ray J, 1903;12:41 5. Kassabian MK. Instantaneous skiagraphy of the thoracic organs. Trans Am Roentgen Ray Society. 1903:95 6. Kassabian MK. Roentgen rays and electrotherapeutics (with chapters on radium and phototherapy). Philadelphia: Lippincott, 1907 7. Kassabian MK. The medico-legal value of the Roentgen rays. Am X-ray J, 1904;9:39 8. Manges WF. Mihran Krikor Kassabian-an appreciation. Am Q Roentgenol, 1910:2:280

Further Reading

His writing: William Saroyan Books

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