Recommended Dose

Teaching with the Visual Medical Archive: Deciphering the National Tuberculosis Sanatorium in Cuba

By Kelly Urban

As most history instructors do, when I design my courses, I include weekly primary sources. Research has established the pedagogical benefits of reading and discussing these artifacts: It provides students the opportunity to hone their critical thinking skills, promotes active learning, and “exposes them to the lived experience” of historical actors (Tobbell 2016, p. 127).

At the University of Pittsburgh, I recently designed a new course, “History of Medicine and Health Care: Latin America and the Caribbean.” Students from across disciplines and backgrounds enrolled, but only a handful of them had the ability to read in a language other than English. When designing past courses, such as “Modern Latin America,” I could draw on a host of primary source texts that had already been translated from Spanish, Portuguese, Quechua, or Nahuatl. For the history of medicine in the region, however, primary sources that were already translated and ready for student reading were incredibly difficult to track down.

Several other professors pointed me to the Virtual Archive of the History of Science in Latin America and the Caribbean, a superb collection of predominantly visual sources. For the second class meeting, I assigned selections depicting medical practices in the Florentine Codex, a 16th century manuscript filled with fascinating illustrations of the lifestyle and history of the peoples of the Aztec/Mexica Empire. While students found the images interesting, discussion of them proved strained and stunted, paling in comparison to what I had seen previous students do with textual sources.

Somewhat discouraged, I shifted to analyzing only secondary sources during the next few units. My students brought original thoughts and careful critique of the articles to these discussions, so I began to wonder if they had simply lacked the scaffolding to make sense of the images from the Florentine Codex. I searched out a pedagogical resource to help them, settling upon Elspeth H. Brown’s “Reading the Visual Record.” She writes in that essay, “While many students have learned strategies for analyzing textual documents, such as identifying the author’s use of metaphor or imagery, few history students have been trained in parallel methodologies for reading visual records” (p. 362).

Armed with the tools she suggested, I planned the following visual analysis exercise during the unit on state-building, citizenship, and health in twentieth-century Latin America.

Lesson Plan

By the end of the lesson, students should be able to:

  • Better analyze visual sources, applying their pre-existing knowledge of textual document analysis, while also learning new skills for studying visual documents
  • Understand how medical knowledge and the practice of health care shape and are shaped by social relations, political processes, economic structures, and culture (one of the central objectives of the course)
    • Apply this abstract knowledge to a specific historical context, identifying the positive and negative consequences of the anti-tuberculosis campaign in Cuba, and more specifically, its national sanatorium project

To assist their comprehension, before coming to class, students read briefly about the rise of populist movements in mid-twentieth-century Latin America and the resulting expansion of social rights and medical programs (as well as their limits). They also read Elspeth Brown’s article on visual analysis.


  • Marcos Cueto and Steven Palmer, Medicine and Public Health in Latin America: A History (New York: Cambridge University Press, 2015): 122–25, 135–39, 168–74.
  • Elspeth H. Brown, “Appendix A: ‘Reading the Visual Record’,” in Looking for America: The Visual Production of Nation and People, ed. Ardis Cameron (Malden, MA: Blackwell Publishing, 2005): 362–70.

Visual Analysis Activity

As students arrived in class, I projected an image of the front of a postcard on the screen at the front of the room (see Figure 1). The postcard is part of my own collection, so I wrapped it in a protective sleeve and passed it around the class (thus including both visual and kinesthetic learners). While I allowed students to reference the back side of the postcard (see Figure 2) in the final stages of discussion, for the purposes of the image analysis exercise, I directed them to focus solely on the front side.


Figure 1. Source: N.a., “Topes de Collantes (Collantes Hilltop), an immensely large edifice built as a hospital,” September 21, 1954, Postcard, 14 x 9 cm, From: Author’s Collection. A copy of the original photograph (without the stamp), titled “Topes de Collantes tuberculosis sanatorium, near Trinidad, Cuba,” can be found in the digital Cuban Photograph Collection (no. CHC0329) of the Cuban Heritage Collection at the University of Miami.



Figure 2. Source: “Topes de Collantes (Collantes Hilltop), an immensely large edifice built as a hospital,” September 21, 1954, Postcard, 14 x 9 cm, From: Author’s Collection.


I then had students pull out their (hopefully annotated) copies of Brown’s article (the instructional scaffolding for the day) and told them that we were going to go through each of her stages during our time together (Ambrose 2010.)

I. Stage 1 (15 minutes)

Brown’s first stage (and the hardest one for students to complete) is “description.” Here the focus is on only “seeing” the image, without “quickly process[ing] visual information into cultural meanings” (p. 362). I had students describe what they saw, continually urging them to “us[e] only the visual evidence present in the image” (p. 362). By this point, students had asked several times what they were looking at, but I refrained from giving answers, promising them that (most of) their questions would be answered by the end of class.

Brown suggests three steps during stage one: First, describe the physical and material aspects of the image (which is one reason why distributing the postcard is useful, although not necessary); second, discuss the content of the image; and, third, conduct a “formal analysis” of the image (e.g., direction and number of lines, foreground/background).

I had students free write answers on their own for each of these steps and then had several of them briefly (5 minutes) share their descriptions with the entire class. Having them repeat their answers out loud was useful for correcting them when they had made assumptions or jumped to analyzing the meaning of the image.

II. Stage 2 (20 minutes)

The second stage is deduction, in which students “consider the image in relationship to [their] own subjectivity” (p. 365).  The goal is to figure out what meaning(s) the image is trying to convey and how. Students have to perform a balancing act during this stage, considering their own reaction to the image (anchored in their contemporary world), while also keeping in mind the “specific moment in history when the image was in circulation” (p. 367).  I had students take a few minutes to reflect on these questions and then share in pairs.

Then, I asked students to place themselves in the world of the postcard’s image, what Brown describes as “engag[ing] with the image empathetically” (p. 366). My students needed some direction at this point, so you can lead them with more specific questions. Brown asks, for example, “What’s the weather like? Is there a breeze blowing? Would you be warm or cold, comfortable or disoriented if you were inhabiting the pictorial space? Crucially, why?” (p. 366). I then had students share some of their answers with the entire class. (In fact, using the “think/pair/share” strategy is useful at each step of this activity).

I reminded the class that these meanings were just hypotheses at this point, and we would return to accept, modify, or reject them after Stage 3.

III. Stage 3 (10–15 minutes)

We then moved to Brown’s final stage: speculation. At this point, students get to ask questions of the image – and students’ questions poured out at this point, as they had been holding them in from the moment the exercise started. The objective of this stage is to “develop theories and hypotheses about the social and cultural work performed by the image in the historical context of its production and circulation” (p. 367). I had students generate as many questions as they liked in their pair and then each group wrote 2–3 questions on the chalkboard. If they needed help generating ideas at this point, I directed them back to the Brown reading, as she provides a host of questions on pages 367–68.

IV. Contextualizing the Image: Lecture (20 minutes)

Brown’s final step is for students to develop a research agenda based on this exercise and to find primary and secondary sources to answer their research question. As I used this exercise during a time-crunched summer semester, I modified her approach, skipping this step and instead providing students with a lecture that spoke to the wider historical and social milieu of the postcard.

The postcard was distributed in September 1954 (and the photograph was likely taken in 1954 as well), in celebration of the May 1954 inauguration of the Topes de Collantes National Sanatorium, dedicated to the treatment of tuberculosis. The hospital was a prestige project of the central figure of Cuba’s republican period, Fulgencio Batista, who served as a military dictator in the 1930s, president from 1940–44, and then returned as dictator from 1952–58 (see Figure 3).


Figure 3. Batista, “the man who had the will to conceive and execute it,” stands in front of “the pride of Cuba and of America.” Source: “El gobierno constructivo del General Fulgencio Batista al servicio de Cuba,” El Crisol, March 19, 1954, n.p.


In the first decades of the twentieth century, Cuban public health officials and statesmen were predominantly concerned with yellow fever, a disease that attacked primarily white Spanish immigrants (see Stepan 1978 and Espinosa 2009 to understand the Cuban state’s prioritization of yellow fever). In contrast, tuberculosis killed large numbers of native-born Cubans every year, most of whom were poor and non-white. By the 1920s, amidst the backdrop of popular mobilization and surging nationalism, health activists, physicians, and ordinary citizens began to articulate the right to state health care and the necessity of greater state funding of tuberculosis treatment centers. The visibility and politicization of tuberculosis increased, and in 1936, in order to gain political legitimacy, Batista founded the National Tuberculosis Council (Consejo Nacional de Tuberculosis) to lead a state-directed anti-tuberculosis campaign.

As argued in my forthcoming article in the Bulletin of the History of Medicine, the intersection of disease and politics in Cuba in the mid-1930s pushed Batista to prioritize a disease that was often neglected by other national and colonial governments until the post-war period. Nonetheless, national politics also undermined efforts to control the disease in Cuba. Authoritarianism facilitated Batista’s considerable influence over tuberculosis policy, and he and his advisors pursued political objectives rather than following the technical advice offered by professional groups. As a result, the administration of the campaign was inefficient, nowhere more conspicuous than in the Topes de Collantes Sanatorium project.

The second half of the lecture recounts the saga of the national sanatorium project from 1937 to late 1954 (when the postcard and stamp had been circulating for several months), including how the project advanced and why it often stalled, as well as the benefits of the anti-tuberculosis campaign and its limitations. (I save the final argument of the article – that the criticisms of this disease control campaign and Topes de Collantes Sanatorium had political consequences, informing citizens’ growing dissatisfaction with the Batista regime during a period of political instability in the 1950s – for after the visual analysis exercise is completed, in order to let students draw their own conclusions from the narrative itself.)

V. Final Discussion

 a. Deciding on Meaning(s) (25 minutes)

With this contextual information fresh in their minds, I had them return to the meanings that they previously hypothesized. I asked them to again discuss (in pairs) Brown’s “speculation” questions, such as who the intended audience was and “what sorts of cultural work the image performed and for whom, at a specific historical moment, as well as (perhaps) how these meanings changed over time, and why” (p. 369).

If time permits, it is useful to also discuss the medium of the source (in this case, a postcard). This allows students to draw on questions that they are accustomed to asking of other (textual) primary sources, such as newspaper articles or diary entries. Pertinent questions might include:

  • What is the function of a postcard? Why broadcast the image in this medium rather than in some other format (e.g., a national newspaper, a poster, or a book)? Where do the audiences of these different mediums overlap and where do they differ?
  • Who is selling this postcard and why?
  • Who is buying the postcard? Who can afford it? Why are they buying it? And, if someone has made a choice to purchase and use this postcard, is it still propaganda? (The same questions can also be asked of the stamp.)
  • What are the probable contexts of consumption? Where, when, how, why, and who might have seen this image?

Once they were done discussing all of these questions, each pair summed up in one short paragraph (2–3 sentences) what they believed the message of the image to be.

Then, we had another large group discussion, with students sharing their mini-paragraphs and reaching consensus as a group as to the main messages of the image. For this postcard, they decided on three major “meanings”: that the hospital was constructed (in both the material and discursive senses) to communicate Fulgencio Batista’s beneficence; that it served as an exemplar of (medical) modernity on the island; and that it was meant to secure Batista’s political rule.

When students offered possible meanings, I pressed them to provide evidence (from the image, not lecture) to back up their opinion. For example, one student argued that the image primarily conveyed Cuba’s modernity. She pointed to the cutting-edge Art Deco architecture, the size of the hospital, and its juxtaposition with primitive nature. Another student said the image and the hospital itself were used as tools to strengthen Batista’s legitimacy, noting that Batista’s name was in several places on the postcard, including twice on the stamp  (see Figure 4).


Figure 4. The stamp on the front of the postcard. Source: N.a., “Topes de Collantes (Collantes Hilltop), an immensely large edifice built as a hospital,” 1954, Postcard, 14 x 9 cm, From: Author’s Collection.


b. Estimating Reception (10–20 minutes)

Students were then asked: did you find the message(s) of the image convincing? Why/why not? If students tend to be overly critical or overly susceptible to the image, it helps spur discussion to ask what in particular was convincing and what specifically was not convincing. (Many students are skeptical of the message in images, and the former question helps students consider what advances the hospital might represent, especially in comparison to other places in the world, where rural hospitals and TB were not being adequately addressed by the state.)

One interesting question to push students into deeper reflection is to ask them about what Brown calls “blind spots” in the image. For example, what is missing? What did you expect to see but don’t? What does this image not show us? I selected one meaning of the image – the sanatorium as commitment to the health of the Cuban people – and asked what other images could more convincingly prove this message.

One of my students pointed out, for example, that no humans were depicted in this image. The only (implicit) individual is Batista, whose name is on the stamp (and the back of the postcard). I followed up on this astute point by asking which humans might have been included and how that would have changed the message. Another student mentioned the lack of patients, and said he would have been more convinced about the success of the project if he could get a sense of how many people were served by the hospital.

At this point in the exercise, I suggest allowing students to make their own observations and pursue what may seem to be tangents, rather than directing them towards a specific lesson you want to get across. The sophistication and creativity of my students’ answers surprised me, and I was glad to serve as a facilitator of the discussion, rather than the instructor.

Reflections on the Exercise

Even though students resisted the somewhat tedious work of deconstructing the image in Stages 1 and 2, by Stage 3 they were more interested in participating (and had done the hard work of garnering the evidence to create a complex discussion in the final half of class.) Due to the success of the activity, in the future I plan to have students complete this exercise periodically throughout the course, using images from my own research and from the Virtual Archive of the History of Science in Latin America and the Caribbean.

Deconstructing the visual historical medical record using Brown’s stages forces students to deal with the material at hand, but also allows them to make observations and ask questions that are of interest to them. More broadly, using visual sources helps students better understand a culture, place, and time different from their own. This exercise immerses them in that world and peaks their interest in it. Furthermore, much of the learning in this exercise is self-generated, which has been proven to more successfully “effect attitude change,” (Huston 2009, p. 201).

Possible modifications and additions to this exercise:

  • We spent approximately an hour and a half on this exercise. I had ample time as I taught it during a three-hour summer semester session and had a group of approximately 15 students. If doing the entire exercise in one class meeting, give one or two 5-minute breaks throughout to ensure students’ attention stays focused.
    • The exercise could be modified for a shorter class meeting, with the lecture given in a previous meeting or context given in readings completed for the day. Alternatively (and preferably), students could also do the first two stages of description and deduction as homework for the meeting, turning in their responses at the beginning of class as proof of preparation and then briefly sharing their findings.
  • A possible addendum is to introduce role playing in the final part of the “estimating reception” section. Select 3–4 different subject positions from the historical world of the image and put them on notecards, creating multiples of each subject position so that each student can draw a card. For this exercise, I might select three positions: a Spanish immigrant in Havana, a poor slum dweller in Santiago de Cuba, and a cane cutter in rural Cuba. Students are then asked, would this historical actor find the image’s message convincing? Why/why not?
    • Students can ask you questions about their historical subject (e.g., how far does she live from the sanatorium? Did he support Batista? Does their family have health insurance?) to better understand their character.
    • Students will have just reflected on if they themselves find the image convincing. However, this exercise prompts students to more deeply consider whether this historical actor would find the image convincing, and why or why not.
  • Pair the visual exercise with a theoretical framework. In this case, after students have completed the exercise, one could introduce Foucault’s concept of “biopower,” and then ask students how the theory applies to the concrete historical instance that they are now well acquainted with.
  • Have students conduct their own research in a visual archive or other database.
    • For example, they could earn extra credit by (1) bringing in another visual example of the intersection of politics and health care, and (2) providing an oral or written analysis of this image.


Ambrose, Susan A., et al., How Learning Works: Seven Research-Based Principles for Smart Teaching (San Francisco: Jossey-Bass, 2010), 132–33.

Brown, Elspeth H.,“Appendix A: ‘Reading the Visual Record,’” in Looking for America: The Visual Production of Nation and People, ed. Ardis Cameron (Malden, MA: Blackwell Publishing, 2005).

Espinosa, Mariola, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: The University of Chicago Press, 2009).

Huston, Therese, Teaching What You Don’t Know (Cambridge, MA: Harvard University Press, 2009).

Stefan, Nancy, “The Interplay between Socio-Economic Factors and Medical Science: Yellow Fever Research, Cuba and the United States,” Social Studies of Science 8, no. 4 (Nov. 1978): 397–423.

Tobbell, Dominique A., “Teaching Medical History with Primary Sources: Introduction,” Bulletin of the History of Medicine 90, no. 1 (2016).

Finding a Cure for Venereal Disease in Early Modern London

By Olivia Weisser

For many of us, one of the most challenging aspects of writing a history paper is crafting a strong argument. How do you take an assortment of primary sources and actually say something arguable about them? I tell my students to look for patterns. Patterns can point toward exciting historical problems and attempts to explain those problems, in turn, can develop into arguments. Patterns, in other words, compel us to prove something rather than report what our sources say.


Country Journal or The Craftsman, April 27, 1734, British Library

I, too, try to find and explain patterns in my own work. My forthcoming research in the Bulletin of the History of Medicine, for example, tries to explain an intriguing pattern I found in healers’ writing about venereal disease from the early 1700s: medical cases tend to end with confessions of sexual secrets. Patients admitted to sleeping with prostitutes or having secret affairs with servant maids. Why would this be? I ultimately found that confessions enabled healers to highlight their expertise. Patients’ admissions of sexual dalliances validated healers’ diagnoses of disease.

This post looks at a lesson I developed to help students work through the key steps of moving from source to argument. It does so using some of the sources from my forthcoming article in the Bulletin.

This lesson is part of a longer unit on the history of venereal disease that I teach in a research methods class, “Sex and Society (1600-1800),” at the University of Massachusetts Boston. We begin by discussing a secondary source about our topic. I like to assign a fantastic article by historian Kevin Siena that shows how patient demand for privacy shaped venereal healers’ practices. We talk about the author’s sources–hundreds of advertisements for venereal cures–and how he uses them to support his argument. I bring in my own work, to show how two historians can interpret the same sources differently. Then we try it for ourselves.

Students read a packet of advertisements for venereal cures from the early 1700s. The images above and below offer examples of what some of these advertisements look like.


Advertisement by Dr. James Tilborgh, British Library

Using these sources as models, students inhabit the mindset of an early modern healer by creating their own advertisements, but with one key difference: their ads are set in the early modern “world” of our university. Instead of a shop located “by the Golden Ball on Fleet Street” as it might be in a London advertisement, students refer to the buildings and culture of our campus. One group last fall, for instance, advertised a “shop behind Quinn Café.” They instructed readers to “order a latte with extra cinnamon and it will arrive with a secret cure for the pox.”

Students present their advertisements to the class and together we generate a list of features they all share in common: how healers assert expertise, the secret locations of shops, the kinds of diseases they purportedly cure, and so on. By the end of the presentations, we have a long list of patterns found in the early modern advertisements, as well as students’ humorous versions of the ads. We discuss these patterns and highlight those that seem surprising, contradictory, or particularly interesting. That is, we locate the patterns in our primary sources that require explanation. Those explanations, students begin to see, are where arguments are born.

Better together: MOOCs and the ancient world


‘Behind closed doors’ about to film in the reconstructed barracks room at Caerleon.

Helen King

Interested in the ancient world? Stimulated by a TV programme or film you’ve watched? Want to find out more? Your obvious destination is a MOOC: free, fun and informative.

In 2012 The Open University started FutureLearn, a MOOC platform which now has over 5,000,000 learners. The platform currently has very few MOOCs on ancient topics, and approached me with a very specific brief: a 6-week course on health in the ancient world. The first stage was a Learning Design meeting in which eight people around a table quizzed me. They made me write profiles of my imaginary learners – as FutureLearn MOOCs are available worldwide, and many learners are not native English speakers, it’s important to think about how the material will play out with them. I had to show how I would engage learners rather than just talking at them, because FutureLearn never follows the model of the Expert Expounding Their Wisdom. Watching or listening to lectures risks offering entertainment only, making the learner into a passive recipient.


Helen King and Jessica Hughes in the recording studio.

I’ve described the FutureLearn model elsewhere, but, in brief, it uses the community of learners working together with the educators. Material is structured in short ‘steps’: 5 minutes of audio or video, or a text of c.750 words. Every single step – typically around 15-20 in one week, or three hours, of study – has a section for learners to talk among themselves, ask questions and share their discoveries. ‘Liking’ a comment flags it up so that we can respond to the points which interest the most learners.


I was clear from the start that I couldn’t write this on my own. I approached my two ideal collaborators: Patty Baker and Laurence Totelin. We sent ideas back and forth, and gradually mapped out the steps for each of the six weeks. We wanted to see objects, not just talking heads, and to think about the whole context of health rather than focusing on medical texts. We found film locations which would offer learners something special: a very friendly museum at Caerleon, and the Museum of London, where Rebecca Redfern could show us what osteoarcheology can reveal. We also visited Ralph Jackson at the British Museum to talk about eye surgery.


Thinking about the Roman army’s diet at Caerleon.

In a team, the people you work with shape what you do. Patty knows about the Roman army, and the perfect complement for Greece was my former student Owen Rees, who helped us think about how well soldiers were prepared for war, both physically and mentally. Laurence’s interests include recipes and milk, both topics which took us to real people and their practices. I wanted to produce something which would interest those coming to the MOOC from a health background, so I needed an ‘ancient and modern’ video to open each week. I was very lucky to find Mathijs Lucassen, whose background is in occupational therapy and mental health and who can chat about anything related to health; he studied Classics earlier in his life.


Laurence Totelin making Roman remedies in the basement at the Roman Legionary Museum in Caerleon.

Because this isn’t about videoing lectures, a lot depended on working with creative people within the OU and outside who could help us think about our materials and our questions. Laurence was happy to make some ancient remedies for the camera. Doing this in costume not only looked right but, she said, made her more relaxed. Even without video, a lot can be done with imaginative use of still images. So we made ‘enhanced audios’ on topics such as amulets and votives, the latter with my colleague Jessica Hughes. Does it all work? You can find out if you take the course!


Who Knows Anything? – Journalism, Caesarean Section, and the Production of Knowledge — How Did We Get Into This Mess?

The New York Times ran a story about an amazing c-section survival in 1337. But historians of medieval medicine don’t think it happened. By Monica H. GreenOn Wednesday, 23 November 2016—the day before the Thanksgiving holiday in the U.S.—the New York Times ran what it likely assumed to be a “fun fact” story, a minor historical…

via Who Knows Anything? – Journalism, Caesarean Section, and the Production of Knowledge — How Did We Get Into This Mess?

London’s Pulse: Life and Health in Modern London

Kathleen Crowther

This past semester in my history of medicine class (HSCI 3423 at the University of Oklahoma), I asked students to design and execute a research project based on the on-line resource London’s Pulse: Medical Officer of Health Reports 1848-1972, one of the digital collections of the Wellcome Library.  This was a group research project, the second of two group research projects in this class.  There were 6 groups, each with 8-9 students.  For the first research project they had to write a collaborative paper of 15 pages with footnotes and bibliography. For this project, I thought it would be more interesting to have them construct a class website with the results of their research, and they created the London’s Pulse Projects site.

L0003051 A cholera patient experimenting with remedies. Coloured

A cholera patient experimenting with remedies. (1832) Wellcome Images.

My goal was to get them to work with primary and secondary sources to construct a historical narrative. I say “narrative” rather than “argument” intentionally.  Some of them actually DID uncover things that were somewhat unexpected and could serve as the basis for more in depth and advanced research projects. In general, I don’t expect students at this level (many taking their first and only history of science or medicine class) to be able to know enough about the historical literature to judge whether or not they are making an original contribution to that literature. At least, I expect they need considerably more guidance to do this. I have another couple of assignments where I work with them on how to make a historical argument.  With this assignment I wanted to encourage students to dig around in an extensive set of primary sources and find things that struck them as interesting.  Further, because this was a website, not a formal research paper, I encouraged students to write in a somewhat more relaxed and informal style, more suited to a broad general audience. In terms of content, this assignment also fit with one of the major themes of the course which is health inequalities, and the importance of the social determinants of health.

The stages of the assignment were:

Explore the database (1 class day plus an on-line discussion). On the first class period of this assignment, I broke each group into 3 subgroups. I asked each subgroup to search the MOH reports for the following keywords: cholera, rats, and fog. I advised them that each of these terms would pull up hundred of records, and recommended that they see what happened if they limited to a certain year or set of years, or to a borough or set of boroughs. Each subgroup was to scan through the reports and note at least THREE trends or things that struck them as interesting or surprising. They were then asked to pick ONE MOH report with their search term and read it more carefully. They had to explain why they picked this particular report, write a brief description of what it said about the search term, and share it with the rest of your group. Once they had discussed the search terms in their groups, all the subgroups shared their findings with the entire class. In this way, they could see certain patterns emerging, but also anomalies and differences introduced by the use of different limiting search terms.

After the first in class discussion, I asked all students to read the “Health of London Timeline” on the London’s Pulse website and get familiar with the key events in the history of public health in modern London. In addition, each student picked one blog post about “London’s Pulse” from the Wellcome Library’s blog. These posts are by scholars explaining how they used the information in the MOH reports in their research. I thought this would give students some idea of the kinds of questions and problems that the historical data in London’s Pulse can answer. Each student read one of these posts and described it in about a paragraph on an on-line discussion with their group members. In addition to their original post, each student responded to at least two other students’ posts.

Choose a topic (1 class day). In the second class devoted to this project, each group had to come up with three keywords of their own to search.  If they found one of my key words particularly interesting, they could use it again, but they had to come up with two more. I gave them some suggestions, but urged them to get creative. My suggestions included: a disease (e.g. syphilis), a type of illness (e.g. diarrhea, infant mortality), an institution (e.g. workhouse, factory, hospital), a time period (e.g World War I), weather (e.g. fog, rain), a public health measure (e.g. immunizations). Once again, they broke into three subgroups and each searched the MOH reports for the keywords. At the end of this class they had to decide which of their keywords would make the most interesting topic for the group project. A few groups needed another day to figure this out, but most came up with a general topic by the end of the class period.

L0046484 Workhouse for 300 paupers - ground plan

Workhouse for 300 paupers – ground plan. From Annual report of the Poor Law Commissioners for England and Wales. (1835-1847). Wellcome Images.

I set up the website (using WordPress) with the six topics they close: child labor, workhouses, pollution, World War II, infant and child mortality, and cholera.

I set up front pages and associated pages for each topic.  I gave every student access to the site so they could edit the site. Students added content, both text and images, to each of the pages.

Find sources and make a work plan (1 class day plus an on-line discussion). I asked students to assemble a bibliography of primary and secondary sources, including MOH reports; and to divide the project into subtopics that one or two students could work on. Each person could contribute something separate, or small groups of 2-3 could collaborate.

Writing (about 3 class days were devoted to writing and editing pages). Each student was required to write 700-1000 words and to use 5 sources (ideally a mix of primary and secondary).

I read through drafts of the pages and made comments. The site remained private until I had graded everything. I corrected grammar and spelling as I read through the final version of each page. I removed images (and sometimes replaced them with others) if they were under copyright.

Things that worked:

  • Many students got really enthused by this project and wrote very thorough, well-researched pages. They wrote longer pages and used more sources than were required.
  • All groups devised interesting projects and did a great job dividing up the work equally.  The fact that each of them was responsible for an individual page alleviated concerns that stronger students were expected to “carry” weaker students (a perennial problem with group work), but the fact that they were working as groups meant that their project was larger and more in depth than an individual research project. They were also able to share sources.
  • Some students made really interesting connections that I didn’t expect. For example, Danya Majeed juxtaposed William Cadogan’s advice on child rearing with the regimen for children in workhouses. While Cadogan’s text was meant for wealthy families, his advice about not “coddling” children and the need to “toughen them up” arguably informed the draconian regimes in workhouses and other places where children were institutionalized. Tracy Turner’s discussion of infant nutrition in the project on Infant and Child Mortality shows how Medical Officers of Health felt they had to educate poor mothers in the proper care and feeding of their children.  There is some acknowledgment of the constraints these women faced in bringing up their children, but considerably more blame placed on them than sympathy. Jenna McGrath draws trenchant parallels between sweatshop labor in Victorian Britain and today.
V0010880 A man covering his mouth with a handkerchief, walking throug

A man covering his mouth with a handkerchief, walking through a smoggy London street. Wellcome Images.

Things that didn’t go so well:

  • Some pages are quite superficial.  I made clear that this website would be public, and that other members of the class would read it, so I assumed since people would not want to display shoddy work publicly, but I was mistaken.
  • Many students did not make as much use of the MOH reports as I would have liked. (They bring in one or two in to illustrate a point they found in the secondary literature. They don’t bring in secondary literature to understand what they read in the MOH reports.)
  • Despite what I thought were pretty extensive discussions in class on how to find scholarly secondary sources in databases like the “History of Science, Technology and Medicine” and “Historical Abstracts,” some students relied heavily on sources they found through Google.
  • I needed to give students more instruction than I did in using WordPress. It’s not that difficult, but there were a few hiccups (e.g. one student inadvertently deleted another student’s work). I don’t feel like I really gave them the skills to blog independently, and I’d like to do that next time.


The Sphygmomanometer and its Impact on Clinical Practice

The following post is a paper written by Haylie Helms (@HaylieHelms), a junior majoring in Biology, Society, and Environment at the University of Minnesota, in the spring semester of 2015 for Dominique Tobbell’s class HMED 3075.  In a recently published pair of articles in the Bulletin of the History of Medicine, Dominique Tobbell and Lois Hendrickson described  their use of historical artifacts (from the Wangensteen Historical Library) in their history of medicine courses.  Ms. Helm’s paper is the third of three papers offered as examples of the work students have done in their classes.


Blood, and its circulation throughout the body, has been studied for thousands of years. The earliest recorded writings about the circulatory system can be found in the Ebers Papyrus, an ancient Egyptian manuscript, dating back to 1500 BCE.[1] The Egyptians acknowledged the presence of mtw, which can be roughly translated to vessels that transport blood and nutrients throughout the body.[2] The understanding of how the blood circulated remained a highly debated topic throughout much of the 17th century. Although William Harvey, an English physician, is credited with the discovery of blood circulation in 1628, most physicians of the time believed that the lungs were responsible for moving the blood.[3] Once the connection between heart rate and pulse was discovered, it was then possible to determine blood volume and blood pressure.[4] Blood pressure was measured for the first time by Stephen Hales in 1733.[5] Hales placed a brass tube into the crural artery of a mare and connected to it a glass tube that was nine feet long.[6] By calculating how high the blood rose, Hales was able to calculate the blood pressure. It was not until nearly a century later that blood pressure was accurately studied. Early methods of studying blood pressure in humans followed the same technique.  The first noninvasive blood pressure measurement tool, called a sphygmomanometer, was invented in 1881 by Samuel Siegfried Karl Ritter Von Basch.[7]

I will examine the introduction of the sphygmomanometer into medical practice using Roger’s sphygmomanometer from the Wangensteen Historical Library of Medicine. In particular, upon the invention of the sphygmomanometer, how were the physicians’ understanding of heart health altered? In what ways did the invention of the sphygmomanometer impact clinical diagnoses? Lastly, how did the user of the sphygmomanometer change from when it was first introduced in practice in 1881 until the 1930s? It is hypothesized that the invention of the sphygmomanometer alone did not change the physician’s understanding of heart health. It was in unison with many other areas of research that the field of cardiology and pathology progressed. As a result of the progression of clinical diagnostics, the user shifted from the scientist to health promotion companies. No longer was it solely the physician who ordered for blood pressure to be measured; the general public was requesting it as well. Therefore, the invention of the sphygmomanometer set the stage for a deeper understanding of heart anatomy and disease for both physicians and the general public alike.

The Von Basch Sphygmomanometer

Early methods for measuring blood pressure required glass tubes filled with mercury to be inserted into the artery of the patient. The invasiveness of the procedure limited the feasibility of these devices to be used as a diagnostic tool. Von Basch’s 1881 noninvasive sphygmomanometer, however, used a rubber ball that was placed over the radial artery to suppress the pulse.[8] The rubber ball was filled with water and connected to a mercury tube.[9] When the pulse was no longer felt, the reading on the mercury tube indicated the systolic blood pressure.[10][11]

M0017687 Samuel Siegfried von Basch: Sphygmomanometer

Figure 1: Samuel Siegfried von Basch: Sphygmomanometer. Wood engraving Down’s surgical instrument catalogue Published: 1906. Welcome Library.


Von Basch went on to measure 100,000 patients’ blood pressure over the span of ten years using his sphygmomanometer.[12]  He concluded that the normal blood pressure was between 135 and 165 mmHg.[13] He also noted instances when patient’s blood pressures were abnormal and their current symptoms or diagnosis. Through his work, Von Basch identified the equivalent of today’s hypertension, which he called latent atherosclerosis, and cardiac hypertrophy.[14]

Although the Von Basch sphygmomanometer was safe for patients and provided accurate clinical data, it was not widely used by physicians.[15] Dr. Scipione Riva-Rocci stated, “It is not surprising that despite the many persistent attempts to introduce sphygmomanometry into medical practice, this has remained nothing more than a luxury measurement or an unusual investigation.”[16] Most physicians of the time preferred old techniques such as using the pressure from their hands to restrict flow.[17] The British Medical Journal published their view that sphygmomanometers “pauperizes the senses and weakens clinical acuity.”[18]  It was not just the sphygmomanometer that was under scrutiny; many physicians and scientists of the time were opposed to many new technologies at the turn of the century. Upon the introduction of the x-ray machine into clinical practice in 1895, physicians preferred to use their hands to make diagnosis.[19]

The Introduction of the Modern Blood Pressure

In 1896 Dr. Scipione Riva-Rocci published his method of measuring blood pressure.[23] Riva-Rocci’s method placed a 5 cm band around the patient’s arm and inflated it using a bulb filled with air.[24] The cuff was inflated until the pulse was no longer detected; like the Von Basch sphygmomanometer, the value recorded was the systolic pressure.


Figure 2: Riva-Rocci-type sphygmomanometer, originally developed in 1896.[25] Wangensteen Historical Library of Medicine.

In 1901 Von Recklinghausen found a crucial flaw in Riva-Rocci’s system; the band was too narrow.[26] This resulted in an acute angle that would form between the cuff and the skin. Coincidentally, it caused local areas of high pressure buildup, which skewed the pressure reading.[27] Von Recklinghausen fixed the problem by simply widened the band to 12 cm.[28] The sphygmomanometer with the wider band provided accurate and safe blood pressure readings that could be used for clinical diagnostics and research. However, this method only allowed for the measurement of the systolic blood pressure and not the diastolic pressure.

In order to measure both the systolic and diastolic pressure, the oscillometric technique, which was created in 1876, was paired with the sphygmomanometer.[29] Under the oscillatory blood pressure method, the user would use the Riva-Rocci method while watching the oscillations transmitted to the mercury in a manometer.[30] When the cuff pressure was equal to the arterial pressure the compressed artery would throb causing small fluctuations in the cuff pressure.[31] The fluctuations would transition from small to large oscillations identifying the diastolic pressure.[32]

The Riva-Rocci method plus the oscillatory method would be modified once more to acquire the basic method of blood pressure measurement seen today. In 1905 Russian surgeon Dr. Nikolai Korotkoff identified the difference in sound between the systolic and diastolic pressures.[33] Using a stethoscope, Dr. Korotkoff was able to hear tapping sounds, which he explained as the blood flowing back into the artery.[34] Known as the Korotkoff sound, the slight difference in the way blood pressure was recorded changed the way physicians viewed the device. Initially, many physicians were opposed to sphygmomanometers because they believed it took away their reliance on their senses and weakened clinical acuity. By requiring the physicians to listen for the sound, it brought back the prestige of the method since only those trained could properly acquire and interpret data. The Korotkoff sound set the stage for future cardiologists to uncover the underlying pathology.[35]

The Impact of the Sphygmomanometer

Physicians in the late 1890s understood the effects of the vessels and heart on blood pressure: blood pressure is controlled by the constriction and dilation of blood vessels and the frequency and stroke volume of the heart.[36]  Riva-Riccoi warned physicians of the usefulness of the sphygmomanometer during clinical diagnosis.

Therefore, if all aspects of the problem were like this [multiple factors affecting the blood pressure], and only like this, sphygmomanometry would not have any clinical applications. The data it supplied would only give us abstract information of purely academic interest, but nothing that could be used on patients or for learning the course of a morbid process.[37]

Many researchers studied the usefulness of blood pressure readings over the next decades in order to uncover its usefulness. Common studies included finding trends associated with patient size, temperature, position (sitting, standing, and laying), age, occupation, diet, sleep, time of day, alcohol and tobacco, mental state, exercise, external temperature, atmospheric pressure, and menstruation.[38] Despite all of the research conducted, the data sphygmomanometers collected was still not very useful in clinical diagnostics for pathological diseases.

Like all current knowledge of symptoms and disease, discoveries were made based on repeated exposure and documentation. When patients had abnormal blood pressures that could not be explained, physicians documented their symptoms and the course of their illness. For example, arterio-sclerosis was diagnosed with the aid of the sphygmomanometer and the observation of thickening of superficial arteries, signs of enlarged left ventricle, and the “ringing aortic second sound.”[39]

As time went on, and more correlations were found between symptoms, vitals, and diagnoses, physicians began to uncover the usefulness of the sphygmomanometer in clinical practice. In 1910 Dr. Janeway argued that the sphygmomanometer was most valued in diagnosing hypertension.[40] Physicians understood the effects and dangers of hypertension. Dr. Janeway wrote,

Hypertension is not merely a symptom of diagnostic and prognostic value, nor is it to be considered only as an effect of causes acting on the heart and vessels. It is of itself a source of altered function throughout the circulatory system, which leads to further secondary changes. These cannot in all cases be clearly separated from the primary changes producing the high pressure, but they may frequently be distinguished anatomically as well as theoretically.[41]

As compared to an x-ray machine that can be used as the sole diagnostic tool when determining if a bone is broken, the sphygmomanometer alone cannot be used to diagnose a patient. Mental state, temperature, diet, exercise, and sleep all must be considered as physicians understood the effect they can have on blood pressure.[42] As displayed in Dr. Janeway’s writings, upon the introduction of the sphygmomanometer into clinical practice, the physician’s understanding of heart pathology was further developed. The device itself did not change the physicians understanding of heart health; it set the foundation for further medical discoveries.

The Evolution of the User

The sphygmomanometer is a technology closely related to the thermometer’s history of invention, development of knowledge, introduction to practice, and evolution of the user.[43] The sphygmomanometer was initially sold to the physician or clinical researchers with the mindset that the sphygmomanometer could only be operated by someone with extensive training in the sciences.[44] It was believed that only those with a scientific background could properly acquire precise data and interpret the results. The device itself was not hard to use, however. As one physician wrote, “after all, no mysterious nor difficult [technique] is involved in sphygmomanometry, as the study of blood pressure may be correctly termed.”[45] Nonetheless, the prestige associated with the user upon the invention of the sphygmomanometer made it acceptable for only those who were trained extensively in the sciences, such as physicians or researchers, to operate it.

As physicians became more aware of the associations between blood pressure and heart pathology, there was an increase in demand for the sphygmomanometer. Blood pressure, measured by the sphygmomanometer, became a standard vital taken on patients by the 1910s.[46] Dr. Satterthwaite wrote, “No physical examination is complete without a record of the blood pressure. It is also very helpful in the diagnosis and management of cardiovascular and renal diseases and toxemias.”[47] In addition, heart health became a topic of discussion in local newspapers. Columns written by doctors explained what blood pressure is, how it is measured, and the importance of monitoring it.[48] Ads urged patients to be more aware of their heart health and to actively monitor their blood pressure. “Your high blood pressure can be measured. The sphygmomanometer registers it with absolute accuracy.”[49] Other ads in the newspaper used fear to urge patients to be more aware of their blood pressure: “He closed the door behind him and walked down the stairs in a kind of a daze, the doctor’s words ringing in his ears: ‘High blood pressure.’  ‘You may die any time – you can’t live over three years.’”[50]  “Arterio-sclerosis. Recent knowledge of the disease from which Paul Morton died.”[51]

As the demand for the sphygmomanometer increased at a rapid rate, physicians were inundated with blood pressure requests. Like the thermometer, physicians began to realize that measuring blood pressure was tedious and repetitive.[52] To ease the strain on physicians, nurses were needed to use the sphygmomanometer; the modern hospital depended on the invention of the ‘thinking nurse.’[53] As Margarete Sandelowski outlined, the ‘thinking nurse’ was necessary for quantification of clinical signs and symptoms.[54] Nurses were needed to carry out physicians’ orders and have knowledge to record, interpret, and report information vital to diagnosis and treatment.[55]

The user evolved once more; after the nurse was qualified to operate the sphygmomanometer, health promotions companies began utilizing the sphygmomanometer. Health insurance companies utilized the sphygmomanometer to promote healthy living and screen future customers for life threatening diseases. Some companies required a blood pressure evaluation prior to granting insurance coverage.[56] Other companies used the sphygmomanometer to attract customers: “For your own sake and for the sake of those you love and who are dependent on you, you should investigate the Witter Water Treatment.”[57] “When the sphygmomanometer, before your eyes, shows that your pressure has been reduced, there is no chance of error. We get, in the majority of cases, a marked reduction in pressure after one treatment.”[58] Although treatments such as the Witter Water Treatment were not scientifically proven, and likely ineffective, they brought the sphygmomanometer to the attention of the public. Patients were now approaching their physician for blood pressure measurements. These actions by patients, and outside organizations, aided in the shift of medicine at the turn of the century to a scientific, evidenced based, system.[59]


The invention of the sphygmomanometer alone did not change the physician’s understanding of heart health. It was in unison with many other areas of research that the field of cardiology and pathology progressed. The work of many scientists, including but not limited to Von Basch, Riva-Rocci, and Korotkoff, laid the foundation for future cardiologists and pathologists. Symptoms were recorded in addition to blood pressure readings to properly diagnose patients. Initially the blood pressure readings could only be obtained by the physicians as there was a belief that the physician was the only one scientifically inclined enough to record and interpret the data. However, as blood pressure became a standard of practice, and patients began to request blood pressure readings, the physicians were inundated with the tedious task of testing the blood pressure. To alleviate the strain on the physicians, nurses were trained to take the blood pressure. The ‘thinking nurse’ led to the increased efficiency in the hospital and a more scientific based approach in diagnostics. In addition, the routine use of the sphygmomanometer led to a shift in knowledge surrounding heart anatomy and disease from physician to public. Newspapers ran advertisements to inform the public of the importance of getting regular blood pressure readings. Other organizations, such as insurance companies, understood the dangers of high blood pressure and required customers to receive a blood pressure test before they could receive insurance. Prior to the invention of the sphygmomanometer routine tests in the clinical setting were not possible due to the invasiveness of the procedure. Therefore, the invention of the sphygmomanometer set the stage for a deeper understanding of heart anatomy and disease for both physicians and the general public alike while aiding in the shift of the hospital to a greater scientific approach in the turn of the century.


“Display Ad 11.” Los Angeles Times, August 4, 1923.

“Display Ad 451.” Los Angeles Times, February 4, 1923.

American Diagnostic Organization. “History of the Sphygmomanometer.” Accessed November 11, 2015.

Barr, Justin. “Vascular Medicine and Surgery in Ancient Egypt.” Journal of Vascular Surgery 60, no. 1 (2014): 260-263.

Booth, Jeremy A. “A Short History of Blood Pressure Measurement.” Proceedings of the Royal Society of Medicine 70, no. 11 (1977): 793-799.

Detroit Pharmaceutical Co., Catalogue of Physician’s Supplies: Including drugs and chemicals, dispensing supplies, pharmaceuticals, surgical instruments, electric apparatus, trusses and appliances Michigan: Aldine Printing Works, 1894.

Evans, Dr. W.A. “How to Keep Well: Blood Pressure.” Chicago Daily Tribune, June 28, 1914.

Faught, F.A. Blood-Pressure Prime. Philadelphia: .P. Philling & Son, 1914.

Howell, Joel. Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century. Baltimore: Johns Hopkins University Press, 1995.

Janeway M.D., Theodore Caldwell. The Clinical Study of Blood Pressure. New York: D. Appleton and Company, 1910.

Kotchen, Theodore A. “Historical Trends and Milestone in Hypertension Research: A Model of the Process of Translational Research.” Journal of Hypertension 58 (2011): 522-538.

Middleton, Dr. William S. “Blood Pressure Determination: A Nursing Procedure.” The American Journal of Nursing 30, no. 10 (1930): 1219-1225.

Noyes, Bradford. “The History of the Thermometer and the Sphygmomanometer.” Bulletin of the Medical Library Association 24, no. 3 (1936): 155-165.

Ogedegbe, Gbenga. “Principles and Techniques of Blood Pressure Measurement,” Cardiology Clinics 28, no 4. (2010): 571–586.

Riva-Rocci, Dr. Scipione. “A New Sphygmomanometer.” Gazzetta Medica di Torino 47, no. 50 (1896): 981-996.

Sandelowski, Margarete Devices and Desires: Gender, Technology, and American Nursing. Chapel Hill: The University of North Carolina Press, 2000. 21-43

Satterthwait, Dr. Thomas E. Cardio-vascular Diseases: Recent advances in their physiology, diagnosis, and treatment. New York City: Lemcke and Buechner, 1913.

Science Museum Brought to Life, Exploring the History of Medicine. “Bloch Type Sphygmomanometer, Paris, France, 1881-1913.” Accessed December 7, 2015.

Soto-Perez-de-Celis, Enrique. “Karl Samuel Ritter Von Basch: the Sphygmomanometer and the Empire.” Journal of Hypertension 25, no. 7 (2007): 1507-1509.

Tracy, Dr. S.G. “Arterio-Sclerosis: Recent Knowledge of the Disease from which Paul Morton Died.” The Washington Post, January 25, 1911.


[1] Justin Barr “Vascular Medicine and Surgery in Ancient Egypt.” Journal of Vascular Surgery 60, no. 1 (2014): 260.

[2] Barr, “Vascular Medicine and Surgery in Ancient Egypt,” 261.

[3] Jeremy A Booth “A Short History of Blood Pressure Measurement.” Proceedings of the Royal Society of Medicine 70, no. 11 (1977): 793.

[4] American Diagnostic Organization. “History of the Sphygmomanometer.” (accessed November 11, 2015).

[5] Booth, “A Short History,” 794.

[6] Booth, “A Short History,” 794.

[7] Enrique Soto-Perez-de-Celis.”Karl Samuel Ritter Von Basch: the Sphygmomanometer and the Empire.” Journal of Hypertension 25, no. 7 (2007): 1507.

[8] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1507.

[9] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[10] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[11] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[12] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[13] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[14] Soto-Perez-De-Celis, “Karl Samuel Ritter Von Basch,” 1508.

[15] Theodore A. Kotchen, “Historical Trends and Milestone in Hypertension Research: A Model of the Process of Translational Research.” Journal of Hypertension 58 (2011): 522.

[16] Dr. Scipione Riva-Rocci, “A New Sphygmomanometer.” Gazzetta Medica di Torino 47, no. 50 (1896): 985.

[17] Science Museum Brought to Life, Exploring the History of Medicine. “Bloch Type Sphygmomanometer, Paris, France, 1881-1913.” (accessed December 7, 2015).

[18] Kotchen, “Historical Trends and Milestone in Hypertension Research,” 522.

[19] Joel Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century, (Baltimore: Johns Hopkins University Press, 1995), 103-132.

[20] Riva-Rocci, “A New Sphygmomanometer,” 984.

[21] Riva-Rocci, “A New Sphygmomanometer,” 983-984.

[22] Riva-Rocci, “A New Sphygmomanometer,” 989.

[23] Booth, “A Short History,” 797.

[24] Riva-Rocci, “A New Sphygmomanometer,” 985.

[25] Riva-Rocci, “A New Sphygmomanometer,” 985.

[26] Booth, “A Short History,” 797-798.

[27] Booth, “A Short History,” 797-798.

[28] Booth, “A Short History,” 798.

[29] Gbenga Ogedegbe, “Principles and Techniques of Blood Pressure Measurement,” Cardiology Clinics 28, no 4. (2010): 572.

[30] Booth, “A Short History,” 798.

[31] Booth, “A Short History,” 798.

[32] Booth, “A Short History,” 798.

[33] Booth, “A Short History,” 798

[34] Booth, “A Short History,” 798

[35] Booth, “A Short History,” 798.

[36] Riva-Rocci, “A New Sphygmomanometer,” 989.

[37] Riva-Rocci, “A New Sphygmomanometer,” 989.

[38] Theodore Caldwell Janeway M.D., The Clinical Study of Blood Pressure. (New York: D. Appleton and Company, 1910), 108-127.

[39] Janeway, The Clinical Study of Blood Pressure, 143.

[40] Janeway, The Clinical Study of Blood Pressure, 137.

[41] Janeway, The Clinical Study of Blood Pressure, 148.

[42] Janeway, The Clinical Study of Blood Pressure, 108-127.

[43] Bradford Noyes, “The History of the Thermometer and the Sphygmomanometer.” Bulletin of the Medical Library Association 24, no. 3 (1936): 155-165.

[44] Detroit Pharmaceutical Co., Catalogue of Physician’s Supplies: Including drugs and chemicals, dispensing supplies, pharmaceuticals, surgical instruments, electric apparatus, trusses and appliances (Michigan: Aldine Printing Works, 1894).

[45] Dr. William S. Middleton, “Blood Pressure Determination: A Nursing Procedure.” The American Journal of Nursing 30, no. 10 (1930): 1219.

[46] Dr. Thomas E. Satterthwait. Cardio-vascular Diseases: Recent advances in their physiology, diagnosis, and treatment. (New York City: Lemcke and Buechner, 1913), 40.

[47] Satterthwait, Cardio-vascular Disease, 40.

[48] Dr. W.A. Evans, “How to Keep Well: Blood Pressure.” Chicago Daily Tribune, June 28, 1914, A4.

[49] “Display Ad 11.” Los Angeles Times, August 4, 1923, 7.

[50] “Display Ad 451.” Los Angeles Times, February 4, 1923, X123.

[51] Dr. S.G. Tracy. “Arterio-Sclerosis: Recent Knowledge of the Disease from which Paul Morton Died.” The Washington Post, January 25, 1911, 6.

[52] Noyes, “The History of the Thermometer and Sphygmomanometer,” 155-165.

[53] Margarete Sandelowski, Devices and Desires: Gender, Technology, and American Nursing (Chapel Hill: The University of North Carolina Press, 2000), 21-43.

[54] Sandelowski, Devices and Desires, 21-43.

[55] Sandelowski, Devices and Desires, 21-43.

[56] F.A. Faught, Blood-Pressure Prime. (Philadelphia: G.P. Philling & Son. 1914).

[57] “Display Ad 451,” X123.

[58] “Display Ad 11,” 7.

[59] Howell, Technology in Modern America, 30-68.

A Beautiful Technology: The Lost Art of Triangular Bandaging

The following post is a paper written by Maria Null, a junior majoring in Biology, Society, and Environment at the University of Minnesota, in the spring semester of 2015 for Dominique Tobbell’s class HMED 3075.  In a recently published pair of articles in the Bulletin of the History of Medicine, Dominique Tobbell and Lois Hendrickson described  their use of historical artifacts (from the Wangensteen Historical Library) in their history of medicine courses.  Ms. Null’s paper is the second of three papers offered as examples of the work students have done in their classes.

Bandages have demonstrated power as a medical technology in their many varieties, applications, and restorative health qualities throughout the history of humanity. Bandaging as a ‘practice’ has been characterized as an ‘art’ in the literature of medicine, nursing, and mortuary sciences cross-culturally.  Notably referred to as a “dying art,” early bandaging has been evidenced by the Egyptian practices of mummification, biblical texts, and popular fictional literature.[1] The prevalence of injuries warranting bandaging in war, medicine, and civilian life are interrelated and their treatments informed by the dissemination of knowledge by those who have studied, practiced, and mastered the “art of bandaging.”

This paper will argue that the improvement of the materials of the triangular bandage, its notable efficacy in sustaining life after being wounded, and the dissemination of its associated knowledge for application during the First World War (1914-1918) contributed to its decline in status as a medical technology through reforms in nursing and ‘first-aid’ education.

“Bandage,” is derived from the French term “bande” meaning an article used to secure an injury and to bind it.[2] It is important, for the purposes of this essay to distinguish between two terms most commonly used interchangeably for one another- “dressing” and “bandage.” In this text, “dressings” will be shortly examined only as they are relevant to the application of a “bandage” to bind the dressing to a portion of the human body.  “Bandage” will refer to an apparatus used to either bind a dressing, support a portion of the body, or directly cover a portion of the body during an emergency situation- and in this way, acting as what the reader may mistakenly conceive to be a “dressing.”

The rise of the modern bandage, in its many forms, was coupled by increased knowledge of human anatomy and physiology, which enabled physicians and nurses to designate specific bandages for unique applications to certain portions of the human body. Four unique bandage types have been popularly employed in nursing since the early nineteenth century: the roller bandage, the four-tailed bandage, the scultetus, and the triangular bandage.[3]  Each bandage was used for a specific purpose, however each was credited with the capacity to retain dressings or splints.[4]  Amongst the four popular bandage types, the late 1800s saw the rise of what became known as the ‘triangular bandage.’  In 1831, Swiss surgeon Mathias Mayor was first credited for acknowledging the utility of what he called the ‘handkerchief bandage.’[5]  But the ‘handkerchief bandage’ remained unpopular in medicine until nearly forty years later, when it was used in the field of battle by German surgeon, Professor Johannes Friedrich von Esmarch.[6]  In texts and according to manufacturers, Esmarch’s “discovery” defined the triangular bandage throughout the First World War.  Indeed, he was the first to suggest printing the illustrations for use, which would come to uniquely characterize the triangular bandage.[7]  However, his accomplishment has been contested by medical doctors throughout history due to the leniency with which the triangular bandage may be defined as a technology. [8]

Figure 1. Professor Esmarch’s Bandage with Printed Graphic Illustrating Use


Esmarch’s Bandage: The triangular bandage is depicted with elaborate illustration to inform the user of its many applications.[9] Image captured at the Wangensteen Library.

The triangular bandage as a technology is defined by its existence as a physical object, its versatile functions, and the knowledge needed to apply it.[10]  Early nursing texts and supplementary readings suggest the bandage was amorphously fabricated by clothing, linen, pillowcases, handkerchiefs, and bed sheets in dire emergencies. [11] Additional texts inform the physical fabrication and measurements of the technology when bandages were produced to act as a medical technology. Bleached or unbleached muslin or calico, linen, silk, or gauze was utilized in instruction and treatment of injury.[12]  The physical measurements of triangular bandages varied and were determined by user selection and eventually by the manufacturer.  Texts suggest an appropriate median measurement for the triangular bandage of the 1910s was approximately one square yard.[13] The bandage only serviced its many functions upon folding, which was illustrated in numerous nursing texts and additional ‘first-aid’ handbooks.[14]

Figure 2. A Manual of Instruction in Folding the Triangular Bandage


Standard illustration with instructional text in aid book.  Figure 59 depicts starting materials, figure 60 the triangular bandage. Figures 61 through 65 depict conversion of the triangular bandage into a compact for storage or transport. Figures 66 and 67 illustrate the folds of the triangular bandage into a ‘cravat’, and subsequent rolling into its ‘cord’ form.[15]

Among its many functions, arresting hemorrhaging was of particular importance in the field of battle- a function requiring extensive knowledge of the many utilities of the triangular bandage for the proper treatment to be achieved. After its introduction to ambulance work in the field by Esmarch in the late 1800s, physicians began producing texts characterized by elaborate illustration and in-depth instruction on triangular bandaging.[16] Understanding texts from the late 1800s through the mid-1920s required knowledge of medical terminology and anatomy, as well as the motivation to learn and practice countless variations on the bandaging techniques.  Knowledge of the most useful materials and the speed, neatness, and proper tension required of the application were integral to the success of the treatment, and often the survival of the patient.  As the U.S. entered into the First World War, few collective groups in America possessed the same drive and commitment to establishing the agency of the triangular bandage overseas as the United States Army Nursing Corps.

Nurses, patients, first responders, and surgeons observed and experienced the impact of the triangular bandage in medical practice. As a bandage with the primary purpose of serving in emergency situations, first responders were typical users. First responders in the field of battle were soldiers of the U.S. army who were equipped with the bandage in early ‘first-aid kits.’ A ‘first-aider’ as defined by Major Charles Lynch of the Medical Corps of the U.S. Army, was any individual intervening during a medical emergency prior to the summoning or arrival of a physician. [17] Field hospitals stocked with nurses were frontlines of ‘first-aid.’  Triage and dressing stations saw casualties, and upon assessment, nurses donned soldiers with more elaborate triangular bandages. Bandages in field hospitals were not themselves any more complex in fabrication than their field ‘first-aid’ counterparts but they were, however, embodied with greater power to treat injury by the nurses with the knowledge and experience of manipulating them.  By 1917 the national curriculum for nursing education had outlined coursework for instruction in the use of the triangular bandage.  Elementary bandaging was instructed throughout five classes over a time span of ten hours.  Instructors or “competent” head-nurses in association with surgery, orthopedics, and first-aid taught classes.  The emphasis on critical manipulation, practice, and demonstration of bandaging skills required speed, efficiency and dexterity of nurses.  Likely, two or fewer hours were spent on instruction of the triangular bandage- which was acknowledged as a first aid utility requiring additional education and training.[18] An additional ten hours of instruction on elementary nursing and first aid focused on preparing nurses to adapt readily to emergency situations, much like those in the army.  The outline of curriculum emphasized the additional training of nurses required of them upon entry into the Army Nursing Corps.[19]

The evolution of the triangular bandage, in its fabrication and dimensions, contributed to its increasingly widespread use, manufacturing, and distribution to civilians.  While the bandage was readily available to any user with the knowledge of textiles, which could be manipulated for bandaging purposes, it was not until the mass production of the ‘Esmarch bandage’ by American consumer healthcare company Johnson & Johnson that civilians saw standard triangular bandages in their very own ‘First-Aid Kits.’  By 1917, Johnson & Johnson was regularly producing a triangular bandage for civilian ‘First-Aid Kits.’[20] The 36 inch squared ‘Esmarch Bandage,’ was a staple of Kits, originally supplied to soldiers as early as the Spanish American war in the late 1800s, when the company had first entered into war-time production efforts.[21] In notes on manufacturing for the American Red Cross, Johnson & Johnson included an “explanation of numbers shown on figures in illustration of the Esmarch Bandage.”[22] The graphic illustration attempted to recreate the iconic print characteristic of Professor Esmarch’s original fabrications.  The widespread development and distribution of the bandage extended the user base and established a market for American consumers of first-aid products.

Figure 3. Johnson & Johnson’s Manufactured “Esmarch Bandage”


Johnson & Johnson’s triangular bandage named for Professor Esmarch of Kiel. The bandage mimiced Esmarch’s original design with graphic illustration for the dissemination of knowledge of the bandage’s utilities.[23]

Bandages for purchase were fabricated from surgical gauze or muslin and were available at drug stores.  Not only were they staples of the ‘First-Aid Kit,’ but they were also included in the ‘Johnson’s First Aid Cabinet,’ and the popular packet known as ‘Johnson’s First Aid for Wounds.’[24]  Both were features of aid in the railroad industry, manufacturing establishments, and schools.  The importance of ‘first-aid,’ and responsibility of citizens to learn about it and administer it was demonstrated in Johnson’s First Aid Manual.  The manual depicted improved bandaging materials and denounced the improvisation of triangular bandages; in effect suggesting that efficacy of treatment required the newer and standardized ‘first-aid’ materials supplied by the manufacturer.[25]

Indeed, Johnson & Johnson boasted the efficacy of the triangular bandage suggesting, “It is probable no other system of wound dressing can accomplish so much, and in such a reliable manner, in rendering first aid, as the use of the triangular bandage.[26]  Improved function with the use of the triangular bandage coupled its improved materials.  As the bandage was developed, altered in size to be more compact, and its materials made to be more durable, ‘first-aid’ was rendered more successfully by soldiers, nurses, and civilians. This was demonstrated in part by curriculum change in nursing from 1917 to 1933, which incorporated the new text published by Instructor of Surgery at the University of Pennsylvania, A.D. Whiting: Bandaging.  In his text Whiting outlined the effect of the elimination of gauze from use as a fabric for the triangular bandage. While gauze had been a central fabric to earlier triangular bandages, Whiting proclaimed the improved treatment of injury achieved by bandages made of different fabric.  Whiting suggested that gauze was not sturdy enough to exercise the utilities of the bandage, and rather bleached or unbleached muslin had been proven materials for increasing proper bandaging and sustaining life in emergency situations.[27]  Whiting’s text became the standard for bandaging in nursing curriculum following the First World War and represented the transforming identity of the bandage in several key ways.

While the medical terminology in Whiting’s text maintained the integrity of the triangular bandage as a medical technology within the surgical and nursing professions (including the ‘Occipitofrontal Triangle,’ the ‘Iliofemoral Triangle,’ and the ‘Mentovertico-occipital Cravat), American citizens in the 1910s and 20s were increasingly exposed to new language in popularized ‘first-aid’ education.[28]  Johnson & Johnson not only served as a manufacturer contributing to the physical evolution of the triangular bandage, but they also served as a primary source of education on the procedures of ‘first-aid’ as given with their products.  Johnson’s First Aid Manual, in its many additions, used language contradictory to that of Whiting’s and other medical texts in the early 1910s.  A 1917 edition of Johnson’s explicitly stated, “no instructions are given in this Manual in respect to anatomy or physiology. A knowledge of these subjects is not deemed essential either to the intelligent use of the manual or the application of first aid.”[29]  The certainty with which the Manual discerned  “non-essential” features of medicine in ‘first-aid’ contributed to a shifting paradigm in U.S. ‘first-aid’ culture.  With the improvement of the bandage nearing the end of the First World War, manufacturers, educators, and the American Red Cross began to simplify and consolidate aid education to promote the identity of the ‘first-aider.’

In early texts, the complexity of the triangular bandage as a technology is evident. While the triangular bandage was free in form, it was manipulated by adhering to the principles of geometry. Rudimentary knowledge of the subject was required of users who were instructed to fold the triangular bandage relative to its features: bases, sides, apexes, squares, quadrilaterals, triangles within larger triangles, extremities and ends, and angles of the triangle.[30] ‘Broad’ and ‘narrow’ folds of the bandage and its shape as a ‘cravat’ and ‘cord’ classified its many configurations.[31] Efficacy of the treatment and preservation of life required knowledge of each of these features.  Additionally, knowledge of how and where to apply a bandage, and with certain pressure, was essential. A majority of texts alluded to the error, which would result from applying a triangular bandage ineffectively, resulting in the continuity of hemorrhaging or arresting of circulation. While it was often assumed that any attempt at immediate aid (erroneous or informed) would increase chances of survival, texts and aid books asserted that an improperly applied bandage could just as likely harm a patient as hurt them.[32] Extensive study, and practice manipulating the triangular bandage was required of nurses to master the ‘art of bandaging.’ While acknowledging the excessive skill possessed by nurses who “perfected” the “art” of application of the triangular bandage in ‘first-aid,’ virtually no texts awarded them with prestige.  This reflects the position of the status in the historical context- nurses characterized by tasks of manual dexterity requiring little subjective analysis of procedures.[33] The bandage itself, in contrast, had reached a new status as an efficacious medical technology as its ‘first-aid’ properties were realized by American civilians following the First World War.

The distribution of knowledge of the bandage to civilians was characterized by a change in the language of texts, illustrations and photographs and demonstrations, and conceptualization of the status of the bandage as a technology.  From descriptions of nearly twenty specialized triangular bandages in medical texts such as Whiting’s, to only eight in First Aid in Emergencies, the triangular bandage experienced a reduction in its versatility once adopted by the civilian ‘first-aider.’[34] Fewer varieties of the triangular bandage were included in texts intended for civilian education in aid. Texts, which once required understanding of medical terminology, anatomy, and geometry, were modified for the American consumer.  While highly descriptive texts instructed bandaging in the late 1800s, the 1910s saw the efficient integration of photographs with fewer lengthy text inserts.  Willing civilians could learn by following step-by-step depictions of bandaging, featured in numerous publications at the time. In her Illustrations of Bandaging and First-Aid, registered nurse Lois Oakes produced knowledge for the public eye- once reserved for the production and consumption by surgeons and nurses.  Oakes’ publication thoroughly depicted the many functions of the triangular bandage, attempting to preserve its status as a complex technology. The illustrations and review by the American Journal of Nursing, however, reflected the declining status of the bandage and the popular assumption that any willing individual could become skilled in administering aid.[35]  The journal’s review proclaimed Oakes illustrated the use of the bandage “so plainly that even an inexperienced person could study them with advantage.”[36] While not declaring the civilian’s capacity to supersede the skills of a trained nurse, the journal was suggesting that the civilian could acquire the skills once reserved for nurses. Additionally, demonstrations and lectures on first-aid, known as “ambulance” work, became popularized with the public through the American Red Cross several years into the First World War.  A 1917 article in the Washington Post reflected varieties of newspaper clips from the time period: lectures on first aid and bandaging for the public.[37] These changes reflected the American attitude toward ‘first-aid’ by the end of the war- that the civilian had the agency and responsibility to become a competent first-aid responder.

Through evident changes in nursing education and ‘first-aid’ curriculum adoption, it is possible to examine the affects the evolution of the triangular bandage ultimately had on its own declining status as a medical technology.  While the bandage was increasingly manufactured to meet consumer demand in a new age of civilian ‘first-aid,’ a job that had once formally belonged to a nurse, underwent scrutiny.  Updates to the national curriculum in nursing by 1933 reflected a subtle but important decline in time dedicated to bandaging training.  Course time in elementary bandaging had been decreased from 10 to eight hours of instruction.[38]  In contrast, however, there was a five-hour increase in emergency nursing and first aid.  This increase in instructional training (following increased demand following the First World War) might have reflected increased emphasis on emergency bandaging techniques, had the triangular bandage maintained its status as a medical technology.  Rather, the opposite occurred.  Coursework objectives outlined Army and Red Cross nursing equipment training, training on wounds, fractures, and strains, with no explicit mention of bandaging.[39]  Red Cross texts listed as supplementary materials suggest a shift in American aid culture as the U.S. affiliate of the International Federation of the Red Cross and Red Crescent Societies was officially integrated into American nursing education.  The motivation of the American Red Cross in aid education was continuously transformed as America adopted ‘first-aid’ culture after the triangular bandage was made accessible.  Educating citizens was not only a public health measure, but also a market move in conjunction with consumer healthcare company Johnson & Johnson.  The triangular bandage and its manual in the ‘First-Aid Kit’ of the home, the factory, and the school empowered citizens and subsequently lowered its status as a medical technology in the hands of the educated, practiced, and masterfully skilled artists of bandaging: America’s nurses.

Gradually, references to the Esmarch bandage began to disappear from texts by the 1940s. Due in part to the emergence of newer technologies (some developed by Esmarch himself, including a rubber bandage), but largely determined by declining status as a medical technology, the complexity of the triangular bandage fell out of favor with clinical and civilian texts.  Many outside actors had established the importance of first-aid, namely, manufacturer Johnson & Johnson backed by the American Red Cross.  The ‘art of bandaging’ so masterfully executed by trained nurses was simplified and condensed to teach the civilian to adopt the new identity of the American ‘first-aider’: an obligated responder in emergency situations.  The relegation of the triangular bandage largely contributed to its disappearance as a prominent feature of nursing curriculum.  However, the change was successful in establishing a solid foundation of ‘first-aid’ for American citizens.  From a soldier’s pocket to the nurse’s field hospital to the hands of the American adolescent in ‘first-aid’ class, the triangular bandage was one of the most versatile medical technologies to ever reach the hands of the American citizen.

[1] Herrmann, E.K. “The Dying Art of Bandaging,” Western Journal of Nursing Research Vol. 14, No.6 (1992): 791.

[2] Ambulance Work and Nursing (Chicago: W. T. Keener & Co., 1899), 67.

[3] Committee on Education of the National League of Nursing Education, Standard Curriculum for Schools of Nursing. (Baltimore: Waverly Press,1917), 86.

[4] Albert S. Marrow, The Immediate Care of the Injured (Philadelphia and London: W.B. Saunders Company, 1906), 108.

[5] Little, Vincent J. “The Fabric of First Aid: A History of the Triangular Bandage.” Pharmacy History Australia: The Newsletter of the Australian Academy for the History of Pharmacy no.9 (1999): 10.

[6] Ibid

[7] Ambulance Work, 67.

[8] J.M. Grant M.D. “Professor Esmarch’s Triangular Bandage,” The Lancet (1874): 746.

[9] Johannes Friedreich von Esmarch, Samariterbriefe (Kiel: Verlag von Lipsius & Tischer, 1886), 29.

[10] Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the

Early Twentieth Century (Baltimore: Johns Hopkins University Press, 1995), 8.

[11] Major Charles Lynch, American Red Cross Abridged Text-Book on First Aid: Women’s Addition; a Manual of Instruction (Philadelphia: P. Blakiston’s Son & Co., 1913), 10; Alvah H. Doty, M.D., A Manual of Instruction in Principles of Prompt Aid to the Injured: Designed for Military and Civil Use (New York: D. Appleton and Company, 1890), 77.

[12] Henry R. Wharton, M.D., Minor Surgery and Bandaging (Philadelphia and New York: Lea Brothers & Co., 1902), 17.

[13] Albert S. Marrow, The Immediate Care of the Injured, 134.

[14] Ambulance Work, 68.

[15] Ibid

[16] Henry C. Leonard, A Manual of Bandaging: Adapted for Self-Instruction. (Detroit: Daily Post Book Printing Establishment, 1876).

[17] Lynch, Charles, American Red Cross Abridged, 2.

[18] Committee on Education. Standard Curriculum for Schools of Nursing, 85.

[19] Committee on Education. Standard Curriculum for Schools of Nursing, 117.

[20] W.G. Stimpson. Prevention of Disease and Care of the Sick, (Washington: Government Printing Office, 1917), 224.

[21] Ibid;General Index to Red Cross Notes, (New Brunswick: Johnson & Johnson, 1900), 18.

[22] General Index to Red Cross Notes, 104.

[23] A.D. Whiting, Bandaging, (Philadelphia and London: W. B. Saunders Company, 1915), 131.

[24] Johnson’s First Aid Manual, (Baltimore: Johnson & Johnson, 1917), 59.

[25] Johnson’s First Aid Manual, 69-75.

[26] Johnson’s First Aid Manual, 69.

[27] A.D. Whiting, Preface to Bandaging, 7.

[28] A.D. Whiting, Bandaging, 132-143.

[29] Johnson’s First Aid Manual, 3.

[30] Ambulence Work, 68.

[31] Ambulence Work, 69.

[32] Charles Lynch, American Red Cross Abridged, 1.

[33] Dominique Tobbell, “Nursing In the Early 20th Century.” (Lecture presented, Minneapolis, Minnesota, October 05, 2015).

[34] A.D. Whiting, Bandaging, 10; Eldridge L. Eliason, in Contents of First Aid in Emergencies, (Philadelphia and London: J.B. Lincott Company, 1915), v.

[35] Lois Oakes. Illustrations of Bandaging and First-Aid (Baltimore: The Williams and Wilkins Company, 1942).

[36] “Book Reviews” American Journal of Nursing. Vol 41, No. 1 (1941): 130.

[37] “First Aid Advice in Red Cross Lecture,” Washington Post, March 22nd, 1917, 4.

[38] Committee on Education of the National League of Nursing Education, A Curriculum for Schools of Nursing, (New York: National League of Nursing Education, 1932), 108.

[39] Committee on Education , A Curriculum, 155.



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