Adolf Kussmaul (1822-1902), one of the great men of German medicine in the 19th century, is remembered for his description of the characteristic acidotic breathing in diabetic ketoacidosis. His paper began, ‘Since I have seen three diabetics in the course of a year die, with remarkably similar symptoms in which there was a peculiar comatose condition preceded and accompanied by dyspnoea, I believe that it is not merely chance, but am of the opinion that it has to do with a form of death in diabetes which is rarely observed and bears the closest relationship to the disturbances in the metabolism in diabetes.’
Adolf KussmaulHis first patient was a well nourished multiparous 35 year old who in 1869 noted that her urine left white spots on her linen. During the winter of 1872 she was thirsty and became strikingly thin. Then on the night of the 18th/19th May 1873,
She slept well until two o'clock in the morning when she awakened with great shortness of breath, complained of severe pains in the hypogastrium and feeling very sick. Her condition rapidly became so disturbing that the family physician asked me to come to a consultation. I found her lying in bed but in the greatest uneasiness, throwing herself here and there and begging for help in the fear of death. She seemed very pale, face and body cool, extremities cold, pulse very small and fast, breathing loud, rapid and the respiratory movements strikingly large….she sank soon afterwards into a stuporous condition in which the great loud breathing continued and died at nine o'clock at night.
About this peculiar form of breathing, Kussmaul wrote:
There is nothing to betray that the air in its passage to and from the lungs has the slightest obstruction to overcome, the thorax expands perfectly in every direction, the complete inspirations are followed by just as complete expirations, there is no stasis of blood in the veins of the neck, no cyanosis. These great respirations were also as a rule accentuated. The contrast between the power of the respiratory movements and the general weakness is one of the most striking features of the picture.
Kussmaul was the oldest of 7 children. Both his father and grandfather were physicians. He completed his medical studies in Heidelberg in 1845 and then went to Prague and Vienna for postgraduate work. On his return to Germany he served as a military surgeon and then settled for four years in a small town in the Black Forest where he developed an extensive and profitable general practice. This stage of his life was ended by a paralytic illness which sounds like Guillain-Barré syndrome and took many months to recover.
Having recovered he made preparations for an academic career which had always been his real ambition. He always told his students that a good doctor should have had a serious illness so that they would understand what care, kindness and tenderness mean to a suffering patient. He insisted that his students should learn the particulars of nursing, making beds and preparing food.
Kussmaul,s contributions extended into many areas of medicine. His famous essay ‘Studies on the Psychology of the Newborn’ was delivered as an opening address before the medical faculty of the University of Erlangen where he became professor in 1859. His book on disturbances of speech was first published in 1877 and went through several editions in the next 30 years. He published pioneering work on rigor mortis, mercury poisoning, osteomyelitis, embolism of the mesenteric arteries, paradoxical pulse and polyarteritis nodosa. He is credited with performing one of the first gastroscopies. As he wrote in a letter,
I had acquired the Désormeaux endoscope introduced into practice in 1855 for clinical purposes and, with it, could successfully visualize a proximal esophageal carcinoma. You told me of the performance of a “sword swallower” who had passed a straight sword down into the stomach, which appeared to me to be of interest regarding the question of gastroscopy. You brought the sword swallower to the clinic . . . Long tubes were made, with which it was possible to pass through the cardia, the lighting . . . of the endoscope proved insufficient; we looked in vain at the darkness.