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Dangerous medicine

Until the middle of the 19th century, surgeries were a dangerous and painful procedure for patients. But two surgeons who appeared at that time changed this ancient art of pensions with the help of science. Excerpt from a book published by Scientific American.

Agnew's Clinic, an 1889 painting by Thomas Eakins, depicts an American operating theater after the advent of general anesthesia. Source: Thomas Eakins.
Agnew's Clinic, an 1889 painting by Thomas Eakins, depicts an American operating theater after the advent of general anesthesia. source: Wikimedia.

By Lindsey Fitzharris, the article is published with the approval of Scientific American Israel and the Ort Israel Network 09.11.2017

  • Until the middle of the 19th century, surgery almost certainly caused suffering to patients.
  • With the adoption of ether as a general anesthetic, more surgical procedures were performed, but the rate of infections and complications also increased.
  • After witnessing the trauma of painless surgery as a young medical student, Joseph Lister began his quest to find a way to operate without endangering the patients after surgery.

The veteran surgeon Robert Liston stood before the assembled in the operating theater of University College London, a few days before Christmas 1846. He held in his hands a jar of site Liquid, transparent, which might have exempted him from the need to hurry during the operation. If the American promises are fulfilled, the nature of surgery may change forever. And yet, Liston couldn't help but wonder if Ether was another act of fraud that would have little, if any, impact on the field of surgery.

The tension was great. Just 15 minutes before Liston entered the hall, his colleague William Squire turned to the large audience and asked for a volunteer to train him. A nervous hum filled the room. Squire held a device that looked like an Arab hookah made of glass to which a rubber tube and a bell-like mask were attached. The device was designed by Peter, Squire's uncle who was an apothecary in London, and had been used by dentist James Robinson to extract a tooth just two days before. The facility was not known to the public and no one dared to volunteer.

In his desperation, Squire finally ordered the hall keeper, whom he named Drake, to volunteer himself for the experiment. He was not a good choice because, as retired surgeon Harold Ellis wrote, he was "fat, bloated, and with a liver that was no doubt used to strong alcohol." Squire gently placed the device on the doorman's fleshy face. After a few deep breaths of ether, the porter jumped off the table, it is said, and ran out of the room, cursing the surgeons and the audience at the top of his lungs.

No more preliminary tests will be conducted. The decisive moment has arrived.

The end of suffering

Twenty-five minutes after two in the afternoon, Frederick Churchill, a 36-year-old servant from Hurley Street, was brought into the hall on a stretcher. The young man suffered from chronic inflammation of the tibia, which was caused by a bacterial infection and caused his right knee to swell and bend sharply. In his first operation, conducted three years before, the inflamed area was opened and, as described in a 1915 article in the American Journal of Surgery, they removed from the knee "several layered bodies of indeterminate shape" the size of a pea to a bean. On November 23, 1846, Churchill was hospitalized again. A few days later, Liston made an incision and inserted a test device into the knee. With unwashed hands, Liston felt and felt the bone to make sure it was stable. He ordered to wash the opening with warm water, bandage it and allow the patient to rest. But in the days that followed Churchill's condition deteriorated. Soon he began to feel a sharp pain that radiated from his hip to his toes. The pain recurred three weeks later. Liston decided that the leg should be amputated.

Churchill was brought into the operating theater on a stretcher and placed on the wooden table. Two assistants stood nearby in case the ether failed and they had to restrain the terrified patient while Liston removed the limb. Liston gave the signal and Squire stepped forward and pressed the mask over Churchill's mouth. Within minutes the patient was unconscious. Squire placed an ether-soaked handkerchief over Churchill's face to make sure he wouldn't wake up during the operation. He nodded to Liston and said, "I think he fits, sir."

Liston opened a long suitcase and took out an amputation knife straight from his invention. An onlooker in the crowd that afternoon noted that the tool must have been a favorite of Liston's because the upright had small notches marking the number of times he had used the knife in the past. Liston ran his thumb nail over the blade to test its sharpness. After he was convinced that the knife was suitable for the task, he ordered his assistant, William Cadge to "take the artery," then turned towards the crowd.

"Now, gentlemen, measure the time!" he shouted. A wave of clicking went through the hall as the pocket watches were pulled out of their jackets and opened.

Liston returned to the patient and tightened his left hand around the man's thigh. In one sharp movement he made a deep cut above the right knee. One of his assistants immediately tightened the tourniquet around the leg to stop the flow of blood, while Liston pushed his fingers up under the skin flap to pull it back. The surgeon made another series of quick movements with his knife, exposing the femur. Then he stopped.

Many surgeons, as soon as they stand in front of an exposed bone, are frightened by the need to saw through it. Earlier in the 19th century, Charles Bell warned medical students to saw slowly and steadily. Even those skilled in making cuts were sometimes afraid when it was necessary to amputate a limb. In 1823, Thomas Alcock declared that humanity "trembles at the thought that men unskilled in the use of any implements, except the daily use of fork and knife, should, with sinful hands, pretend to dissect their suffering brethren." He recalled a chilling story about a surgeon whose saw got stuck so hard in bone that it could not be removed. One of his colleagues, William Gibson, advised that novice surgeons practice on a piece of wood to avoid such gruesome scenarios.

Liston gave the knife to one of the medics, who handed him a saw instead. That assistant flexed the muscles, which would then be used to create a suitable stump for the amputee. The great surgeon made half a dozen movements before the limb fell, straight into the waiting hands of another assistant, who immediately tossed it into a box full of sawdust that stood beside the operating table.

Meanwhile, the first assistant momentarily loosened the tourniquet to reveal severed arteries and veins that needed to be tied and blocked. In hip amputations there are usually 11 such blood vessels that must be tied. Liston closed the main artery with a square knot and then turned his attention to the smaller blood vessels, pulling them one by one with sharp hooked forceps called forceps. The assistant released the tourniquet again while Liston sutured the remaining flesh.

It took Liston only 28 seconds to amputate Churchill's right leg, during which time the patient did not move or scream. When the man awoke a few minutes later, he reportedly asked when the surgery would begin and received an answer in the form of his raised stump, to the delight of onlookers who gazed in amazement at the spectacle they witnessed. Liston, face flushed with excitement, declared: "This Yankee trick beats hypnosis with two hands tied behind the back!"

The age of suffering is coming to an end.

Two days later, the surgeon called James Miller Liston's hastily written letter to his medical students in Edinburgh, "in which he enthusiastically announced a new light that had been thrown on surgery." During the first months of 1847 both surgeons and curious celebrities alike frequented the operating theaters to witness the wonders of the ether. Everyone, message Charles Napier, governor of a colony that is now a province in Pakistan, and the prince's council Jerome Bonaparte, the younger brother of Napoleon I, came to witness with their own eyes the effect of the ether.

The term "anesthesia with ether" was coined, and newspapers across the country praised the use of ether in surgeries as a miracle. News of his power spread. "In the history of medicine there is no precedent for the perfect success of the use of ether," the paper declared Exeter Plaining Post. Also ePeople's Journal The Londoner announced Liston's success: "What happiness to every heart with feelings...the announcement of this noble discovery of the power to quiet the sense of pain, and to mask the eye and memory from all the horrors of surgery...we have defeated the pain."

invisible enemy

An event of parallel importance to that of Liston's victory with the ether was the presence, that day, of a young man named Joseph Lister, who was sitting quietly at the back of the operating room. Fascinated and captivated by the dramatic spectacle he had just witnessed, the promising medical student realized, as he strode out of the hall onto Gower Street, that the nature of his future profession had changed forever. No longer would he and his classmates have to witness "such a terrible and disturbing sight" as the one witnessed by William Wilde, a surgical student who was reluctantly present at the removal of a patient's eye without anesthesia. Nor will they feel the need to flee, as surgeon John Flint did whenever the screams of those being butchered by their surgeons became unbearable.

And yet, as Lister made his way through the crowd of men shaking hands and congratulating themselves on their choice of profession and noble victory, he was acutely aware that pain was only one obstacle to a successful operation.

He knew that for thousands of years the constant threat of infection had limited the achievements of surgeons. Entering the abdominal cavity, for example, was almost always fatal because of this. The chest was also out of bounds. For the most part, while doctors treated internal conditions, hence the term "internal medicine" is still valid today, surgeons treated peripheral problems: cuts, fractures, skin ulcers, burns. Only when amputations were performed did the surgeon's knife go deep into the body. Surviving the surgery was one thing. But to fully recover from it without complications was another thing entirely.

As it turned out, during the twenty years immediately after ether anesthesia took root, the results of the surgeries actually worsened. With the new confidence to operate without causing pain, surgeons showed a greater willingness to swing the knife, and the rate of post-operative infections and shock increased. At Massachusetts General Hospital, for example, the amputation death rate rose from 19% before the ether era to 23% after it. The operating theaters became dirtier than ever as the number of surgeries increased. Surgeons still did not understand the cause of the infections and operated on a large number of patients one after another using the same unwashed instruments. As the crowd in the hall grew, so did the likelihood that even the simplest sanitary precautions would be taken. And among those operated on who went under the knife, many died or did not make a full recovery and then spent their lives disabled. It was a worldwide problem. The fear of patients around the world increased in front of the word "hospital", and even the most skilled surgeons doubted their own abilities.

When Liston witnessed Liston's ethereal victory, he witnessed the removal of only one of the two obstacles that stood in the way of successful surgery - pain. Inspired by what he saw that afternoon on December 21st, but aware of the dangers that still hindered his colleagues, Joseph Lister dek the diagnostician devoted the rest of his life to deciphering the causes and nature of postoperative infections and finding solutions to them. In the shadow of one of the profession's last great butchers, another surgical revolution was about to take shape.

The article was adapted from the book "The Art of Pensions: Joseph Lister's Journey to Overturn the Grim World of Victorian Medicine”, by Lindsey Fitzharris, under agreement with Scientific American/Farrer, Strauss and Giro. All rights reserved to Lindsey Fitzharris.

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