The history of modern surgery is the history of the last 100 years. It began on 16 October 1846 with the discovery of anaesthesia, which made it possible to operate without pain. All that preceded it was one night of ignorance, torment and fruitless groping in the dark. Even before that date, the surgeon did not know whether his patient would die on the operating table from the terrible pain. The story of surgery took on new dimensions on 10 December 1844 in Hartford, Connecticut, when laughing gas, or laughing gas as it was called, was introduced to the public in a lecture theatre.
The lecturers invited all the townspeople who dared to inhale the gas to come and jump on stage, laugh and talk nonsense. Among those who dared to try it was young Horace Wells, already a respected citizen and a good dentist. He inhaled the laughing gas, and when he awoke from his stupor and, along with the other townsfolk, danced around the stage, singing and laughing, he knew in an instant that the gas would be fatal to him. When the stupor had completely worn off, he noticed his fellow-townsman Cooley, still dancing on the stage, hitting the sharp edge of the bench with the whistle with all his might.
Wells knew he must have been in terrible pain, but Cooley didn’t flinch, even though a stream of blood was running down his leg. He asked him if he knew that he had hit the edge of the bench, but he replied that he knew nothing about it. Then it dawned on Wells that he could have knocked out a man’s tooth or amputated his leg without pain if he had inhaled laughing gas beforehand.
But immediately, questions came to his mind to which he did not yet have answers. Will the one who is heavily intoxicated surely wake up from his stupor? Where is the line beyond which death may lurk? There was only one way to find out – by testing the matter for himself. Wells still had his wisdom tooth, which, although it did not hurt, he now decided to have it extracted by his assistant. Only after he had inhaled the laughing gas, of course. If he felt no pain, he would be on the right track.
The next morning, he inhaled gas, his face turned bluish, his eyes glazed over, and finally his head rested on his chest. The assistant took a pair of pliers and started pulling the tooth. Wells did not flinch in pain, he was completely silent, and when he regained consciousness, he said he felt no pain. “This is the most beautiful discovery of our time,” he said.
In a few weeks, he used laughing gas to extract teeth in his dental practice on 15 patients, and in only two cases was it completely unsuccessful. Since that day, he has lived only for his invention. He moved into his own laboratory, made laughing gas and experimented on himself every day.
But Hartford was a small town and he knew he had to succeed in nearby Boston, home to the famous Harvard Medical School and the country’s most eminent surgeon, John Warren. How he got in touch with him is unknown, but it is known that he was able to present his experiment to the students in January 1845.
Before he took the test, he met his former pupil William Morton, who was working in Boston. He told him what he had discovered and what he planned to do. Morton listened indifferently and wished him every success.
Wells then gassed a man with a toothache to sleep in front of students in a lecture theatre, took a pair of pliers and tried to extract the tooth. The patient started screaming and the students in the room started heckling. Wells, ashamed, picked up his belongings and disappeared, pale. His confidence was shaken.
But on 16 October 1846, the experiment was repeated on a patient who had to have a lump excised that had invaded the jaw gland and part of the tongue. The old operating theatre was again packed with students, doctors and guests. It was, in fact, a normal operating day. In the waiting room, patients were waiting for various operations, all of them pale with fear of the coming pain. Surgeon Warren turned to the audience and said, “During this operation, we are going to try Mr Morton’s new remedy, which claims that those who inhale it feel no pain.”
Wells did not dare to appear in front of an audience this time, because it was here that he suffered his greatest public failure. So, after a 15-minute delay, Morton appeared on the scene, turned to his patient Gilbert Abbott and asked him if he was afraid of the operation. When the answer was no, he waved a glass bowl in front of his face and said, “Please put your mouth over this opening and breathe. Know that the coughing will pass very soon. Breathe deeply.”
Abbot obeyed him. His lips slowly parted, releasing the glass tube, his lip hung limply and his head lolled on his chest. Morton nodded to Dr Warren and told him to begin, who rolled up his sleeves, grasped the knife and slashed with lightning speed. The patient didn’t even flinch. Dr. Warren cut deeper and deeper and popped the lump. The room was deathly silent.
Dr Warren cut the last ligaments of the tissue and pressed the usual sponges to stop the bleeding and wiped the sweat from his forehead. He then ordered Abbott to be taken away and another patient brought in who had a spinal condition which was then being treated – unsuccessfully – by making deep scars along the spine with a pounded iron to relieve the pressure on the spine.
During this procedure, the patient was certainly in terrible pain, but the Morton remedy worked and not a sigh was heard. Pain, the most formidable obstacle that has hindered the development of surgery, was apparently overcome. Only later did it come to light that Morton’s remedy was sulphuric ether.
First operation under anaesthesia
News from America travelled by boat to Europe at the time, and within a few weeks several letters arrived in London describing a pain-free operation. Most of them were read, shrugged their shoulders and forgotten about, but Dr Robert Liston, the most comical of all the surgeons in Britain, did not forget this letter. He decided to repeat the American experiment. If he succeeded, it would add to his fame.
On 21 December 1846, doctors and students crowded into University College Hospital in London, despite the cold. Two men brought into the operating theatre a glass container with a tube attached to the end with an inhaler attached. They were Liston’s assistants and they began to prepare the instruments, the saw, the vein cutters and the thread and sutures on the chair.
The servers brought the patient in and placed him on the operating table. He was pale, frightened and exhausted from the heat. He had injured his tibia in a fall and had grown a post-operative lump, which Dr Liston had already removed. However, as his hands were not disinfected and the instruments were also infected, the wound became infected, as was almost the norm at the time, and only amputation of the leg could save the patient.
Revez, who was crying with fear, quickly had the mouthpiece pushed into his mouth and a pinch put on his nose. The patient gasped, coughed and tried to get out of the mouthpiece, then fell silent and started breathing steadily. The students and doctors took out watches from their pockets, apparently to measure how long the operation would take.
Dr Liston quickly cut with a knife, removed the tissue down to the bone and demanded a saw. There was a scraping sound and in a few strokes the leg stump was in Dr Liston’s hands. He placed it in a container filled with sawdust. “Twenty-eight seconds,” the spectators measured.
The patient woke up after the stitching and bandaging and asked, “When are you going to start the anaesthetic?” The assistant showed him his amputated leg. The first anaesthetic operation in Europe was a success and the news spread like lightning. Within a few months, all European countries with a surgical tradition were operating using the new method.
Pain-free childbirth
Then the following news appeared in a British newspaper: ‘On 19 January 1847, Dr James Simpson, a well-known professor of obstetrics in Edinburgh, assisted a lady of the town to give birth without pain.’
The idea of using ether in childbirth has been with doctors since the beginning. The only problem was that at the time, no one could say whether ether only banishes labour pains or also stops the contraction of the muscle that is actually the driving force of labour. So Dr Simpson chose a case that was hopeless enough that it almost did not matter what happened.
The patient had given birth once before, but the delivery was very difficult and the baby was stillborn. Now the baby’s rather large head was blocking the birth path and a natural birth was out of the question. In the evening, Dr Simpson intervened by ether and the howling of the parturient ceased. The baby was hastily turned in the womb, but had already suffered so much that as soon as he came into the world, he gasped.
When the patient woke up, she stated that she felt no pain. However, Dr Simpsom felt that the ether did have some faults. It had to be taken in large quantities, it forced coughing and irritated the lungs, which was not good. He knew that there were other substances with similar effects.
He started researching and in November 1847 discovered that chloroform was also a good pain reliever. For almost a year, he tried out various vapours and gases at home at the dinner table with his family. In the morning, friends would come to see if they were all still alive or had been killed by one of his gases. Simpson had also heard of chloroform and bought some, but then forgot about it.
One evening, remembering that he hadn’t tried it yet, he looked it up and gave each family member a tablespoon of the chloroform solution in a glass. Soon they were all collapsing under the table. “That’s it,” Dr Simpson was convinced, “it’s much stronger than ether.” Soon he was using it on a parturient. He poured half a teaspoon of chloroform on a handkerchief and put it on her mouth and nose. Half an hour later, she gave birth to a baby girl without pain. She said she slept wonderfully.
But the Church was very resistant to chloroform, citing the biblical phrase from Genesis III:16: “In pain you will bear children…” But even the chloroform advocates turned to Genesis II, 27, which says: “And God put Adam into a deep sleep, and he slept, and took one of his ribs …”
In 1853, news spread through London that Queen Victoria had given birth to her fourth son, Leopold, at Buchingham Palace. This was followed by a note that she had been assisted in childbirth by Dr Snow, a well-known anaesthetist, using chloroform anaesthesia. Victoria also gave birth to her next child, Princess Beatrice, with the help of anaesthesia. Many of London’s high society patients now give birth only with the aid of anaesthesia. But no one suspected that both of the Queen’s children, born under chloroform anaesthesia, already had a blood disease. If they had known this then, chloroform would surely have disappeared from medical practice.
Just as Dr Simpson was beginning to discover the properties of chloroform, news arrived from New York that no one had paid much attention to. Horace Wells, frustrated by the failure of his life, committed suicide in a hotel. He inhaled a large quantity of ether and, just before falling asleep, cut himself with a knife. What drove him to such an extreme measure? He had to fight his way through a thicket of lies, deception, self-deception and deceit from others, because he had been set up by his former colleague Morton, who was not a warrior for ideals, nor a man of theory.
Morton wanted to make money and enjoy life. After Wells failed in his experiment in front of the students, Morton visited him and Wells told him about his discovery. He told him everything and Morton remembered it all. Morton was convinced that Wells’ discovery was worth a lot. He knew that people would willingly sacrifice all their money just to get out of pain. He began to work out his own anaesthetic procedure. Since he could not get laughing gas anywhere, someone recommended that he take sulphuric ether, a liquid that turns into ether vapour when it touches air, which acts like laughing gas.
It was clear to Morton that ether was known and instantly recognisable to all chemical technicians and that he would not be able to demonstrate its use as a novelty. Even the doctors were surprised that Morton refused to say what his painkiller consisted of. So he mixed various other harmless compounds into the ether and claimed that these were the most important in pain management. He had already applied for a patent and had authorised some agents to sell his remedy.
Meanwhile, Wells struggled to get his discovery recognised. He was savagely attacked, slandered and ridiculed by Morton, who surrounded him with a mob of lawyers. This struggle left Wells physically and mentally exhausted. Morton was also exhausted, as his patent was revoked and licensing sales stalled. When he tried to enforce his exclusive right to use ether narcosis by suing a New York eye clinic, he was burned. He contracted leprosy, was admitted to hospital and died there aged 48.
Death from purulent wounds
But overcoming pain was only one of the problems of the time. Dying from the consequences of war was no less painful, and everyone wanted the Crimean War to be over soon. Increasingly, the British press reported on the disastrous conditions in the large British rear-guard hospital in the former Turkish barracks at Skutari on the European side of Istanbul. “They’re all dying in the same shit”, one visitor was told.
The smell of rotting from the military infirmary was sickeningly sweet. This smell also spread from the ships carrying hundreds of wounded from Sevastopol to Istanbul. The Turkish porters simply threw the wounded like logs from the ships into boats and then onto trolleys. When they reached land, the wounded were thrown on the bare ground covered with excrement. Those who could still crawl crawled alone from there to a large door leading to the inside of the infirmary, where drunken whores were already waiting to do their business in the gloomy and vaulted cellars of the hospital.
There was no operating theatre in the infirmary, so they operated among the wounded. The wounded, ready for surgery, were simply laid on boards nailed to wooden goats. The operated wounded lay right next to the operated wounded. All that could be seen were the purulent and stinking bandages, the pale yellowish faces, the drooping eyes and protruding cheekbones, the rapid and labored breathing. Incidentally, because of cholera, the doctors had been absent from the infirmary for several days.
The wounded were lying on the ground, some still alive, others already dead, others dying. Only in one room was it possible to see a woman in the middle of this hell. She was dressed in a shapeless grey robe, with a white aura on her head. It was one of Florence Nightingale’s maids, who was distributing tea and said apologetically, “They haven’t had food or water for days.”
The Minister of the Army asked Florence Nightingale, who was known for her efforts to improve the care of the sick, to form a team of nursing maids and travel to the infirmary in Scutari to take over the care of the wounded. The Minister did not realise that this was an impossible thing to do, as there were too many wounded and too few attendants, and Florence Nightingale had practically no special powers. In any case, she was received with reluctance in the infirmary. She was regarded as an intruder who disturbed the established order and was given a room in which a dead Russian general had been lying for several days.
Living with just one kidney
Jobert de Lamballe, Dr Simon, Margaretha Kleb – three names that are forgotten today. The first died in a hospital in Passy, paralysed and delirious with syphilitic paralysis. The whole of Paris attended his funeral. The second, Dr Simon, suffocated in Heidelberg from a vascular aneurysm, and a large crowd of people followed him to his funeral. The third died alone in a poor bed in a workhouse and was mourned by no one except her children.
Yet all three had something in common: they were closely involved in solving prismatic pain. When Gustav Simon, Professor of Surgery, successfully removed a human kidney for the first time in August 1869 from a patient who was doomed to die, his act was bordering on murder. Jobert de Lamballe stood at the beginning of his journey from army doctor to university professor, and showed him the way to the great adventure of kidney surgery.
He told him that there was no sadder sight than the sight of women suffering from blistering. “She is disgusted with herself, she is disgusted with her husband, she is disgusted with her children.” Lamballe, who had many years of experience in the field, said, “I operated on one woman eighteen times and still did not cure her.”
Dr Simon followed Jobert’s example as a muck operator and even set up a small hospital of his own. One day, a woman came to him with a large lump on her ovary. A doctor had operated on her some time before, opened her abdomen and saw that the lump was already fused to the uterus, and the growths had extended to the left ureter. He also removed a large part of her ureter with a bulla. This destroyed the natural urinary tract and the left kidney emptied into the lower abdominal cavity. The wound had also not yet closed and the secretions found their way through the caecum.
Dr Simon tried to close the abdominal wall three times. The unfortunate woman was in terrible pain. The very thought of removing the left kidney and perhaps having the right kidney take over the work of both seemed adventurous to the doctor. Any injury to the kidneys was considered fatal. Dr Simon knew only a little about a certain kidney operation. In 1474, an archer who had suffered for years from kidney stones was sentenced to death for some misdemeanours. The Faculty of Medicine asked King Charles VIII of France to pardon him if he was willing to have his kidney opened in a living body. Apparently the operation was successful and the archer survived.
Margaretha Kleb was certainly in excruciating pain and had a high fever, which was indicative of urine poisoning. Dr Simon took an unusual step before the operation. He lectured his colleagues on why he was going to undertake the operation and what procedure he would use so that if the outcome was unfortunate, no one could accuse him of being foolhardy.
On 2 August 1869, he began operating. He cut through the skin, the fat pad and the leaf of the diaphragm, and began to peel the kidney with his hands, exposing its trunk. He then separated the kidney from its trunk. The wound was bleeding profusely, but they managed to clean and stitch it. When the patient woke up from the anaesthetic, she was very restless and kept vomiting. Dr Simon examined her urine, but there was no trace of blood. This partly reassured him.
The wound was still oozing pus, but the abdominal walls showed no signs of distension, which would indicate an inflamed diaphragm. The remaining kidney had therefore successfully taken over the work of the excised kidney. After a month, the patient was almost pain-free and started to walk. When the German-French war broke out, she was employed as a servant for the wounded. In November 1870, she left the clinic and returned home a healthy person.
Caesarean section
San Matteo in Pavia was a typical hospital from the era of the pus fevers. Unclean corridors and halls, dirty walls and a suffocating stench of rot and manure. But it was also the setting for the story of a young Italian woman, Giulia Covallini, and a surgeon, Edoardo Porro. In April 1876, Giulia arrived at the hospital, her body pouring in streams, her thin legs no longer able to carry the heavy load. Her old and shriveled dress strained over her mother’s mighty belly.
Edoardo Porra was 33 years old at the time, a garibaldine fighter and professor of obstetrics in Padua. He walked up to Giulia and said to her, “Rest. The child is alive, but sometimes children are not in a hurry. You must wait.” He said quietly to his assistants, “A very deformed uterus. Oblique narrowing. The opening of the pelvis is not large enough to allow at least the baby to be cut open with a rake, and it will not survive a caesarean section. Of course, we will at least do a caesarean section and maybe save the baby.”
Caesarean sections were the terror of obstetricians at the time, with mothers dying of internal bleeding and catarrh. The “Caesarean birth” has been a testimony to the tribulations of childbirth throughout time and in all the surviving writings of the millennia – from the Rigveda, the Jewish Talmud, through the testimonies of the Greeks and Romans and Arabs. According to an admittedly highly dubious legend, Julius Caesar was also cut out of his mother’s womb, and his name Caesar was later interpreted as “Caesus”, which was supposed to mean as much as the one cut out.
However, it was known that the ancient world knew how to cut children out of dead mothers until the peak of the Middle Ages. This was required by the Catholic Church, as everything had to be done to baptise the child. During the Renaissance, in 1581, a textbook was published in Paris, written by Francois Rousset, a chamberlain to the Duke of Savoy, describing the Caesarean section. It recommended that the surgeon should cut the uterus and lift the baby and the placenta with his hands, but that it was not a good idea to suture the incision.
For several centuries, this textbook was the only one obstetricians could rely on, even though Rousset himself had never performed a caesarean section and had never seen one. There were many other theories on how to perform a Caesarean section, but all of them were unsuccessful. Dr Porro thought. Wasn’t Rousset wrong when he argued that the unsewn uterus should be recessed into the abdominal cavity after the removal of the baby and only the abdominal wall sewn up? Do not rotting creatures also invade the abdominal cavity and kill the mother?
On the morning of 21 May 1876, the nurse told her that Julia had begun her first miscarriages. Soon Julia was under deep anaesthesia and Dr Porro had a scalpel in his hand. He cut into the womb, grasped the baby and cut the umbilical cord. The baby was breathing, but the wound was bleeding. How to proceed, should he follow the instructions in the textbook and push the womb back into the abdominal opening, or should he cross the threshold of what he had known up to that point and do it his way?
He made a quick decision. With a few cuts, he separated the uterus from the stalk. The decisive step was now irrevocably taken. He then stitched the wound. On the first day, Julia complained of abdominal pain and vomited frequently. Was this due to the anaesthesia or were these signs of an inflamed diaphragm? The patient was restless and pale.
The child was alive and well. Julia was also finally fever-free after a month. Dr Porro published a report on his caesarean section and received an overwhelming response. His method of radical removal of the uterus was introduced almost overnight in many hospitals. He proved that the uterus is not life-saving and that it can be removed to avoid inflammation of the diaphragm.
Chlorine water barrel
The man who identified the causes and understood their fatality, and was the first to see a way out of the maze of fevers and purulent deaths, was Ignaz Semmelweis. In 1846, he became an assistant at the First Maternity Clinic in Vienna. The maternity ward was then a hotbed of puerperal fever. The month Semmelweis took up his post, 36 out of 208 women in labour died. The women who came to the clinic were usually mothers “without the blessing of the Church”, women who counted for something always gave birth at home.
Klein, the director of the clinic, was already numb to the problems and said, “This is the way it is and there is nothing we can do about it.” He could only watch the agony of the mothers and the despair of the widowed husbands and the cries of the orphans. The maternity ward of the Vienna Maternity Hospital was then divided into two parts. The first, where Semmelweis worked, was used by students, but the second was not used by students, who were trained as midwives.
In the first ward, about ten percent of the parturients died, and in the second ward barely one percent, which puzzled Semmelweis. When he opened the corpses of mothers in the morgue, he saw the same things; pus and inflammation all over the body, not only in the uterus, but also in the liver, spleen, lymph nodes, kidneys, meninges and diaphragm.
The resemblance to surgical suppurative diseases was striking. The work in the ward where Semmelweis worked was always the same. First, they performed dissections on dead mothers. Immediately after the dissection, the doctors would go into the next room and there, with the students, examine the women who had already given birth or were still waiting to give birth. The reputation of the first ward of the maternity hospital was so bad that women resisted being placed there.
Semmelweis often discussed the mortality problem with his Czech colleague Kolletschek and despaired. Disappointed, he went on holiday to Venice and when he returned three weeks later, Kolletschek was nowhere to be found. “Don’t you know, Doctor, that Kolletschka has died,” the butler explained. Kolletschka had been accidentally wounded with a knife by a student during a dissection. The next evening he was feverish and shivering and died a few days later in feverish delirium.
The report listed suppuration and inflammation of the lymph nodes, veins, ribs, cataract, pericardium and meninges. It was as if he had been reading one of the hundreds of reports of mothers who had died of puerperal fever, Semmelweis thought. He suspected that he was at that moment experiencing one of those moments of genius in which he had discovered the secret of nature. If the results of the dissection are the same, are not the causes of Kolletschko’s death and the deaths of the women in labour the same? Did he and his students not carry some dangerous thing with their hands as they went straight from the work in the dissecting room to the women in labour?
This question haunted him day and night. So a few days later, he put a notice on the door of the clinic saying, “From today, everyone who comes out of the clinic must wash their hands honestly with chlorine water from the barrel placed outside the entrance.” Semmelweis knew nothing about the bacteria that caused puerperal fever, and nothing about surgical purulent wounds. Soap, a nailbrush and chlorine lime were now always available in his ward, although the students laughed at this desire for cleanliness. In the following months, the maternal mortality rate dropped to just three per cent.
Semmelweis thought he was on the verge of success when he was hit by a blow he thought he would not survive. One morning, when he walked into the delivery room, he saw that all twelve of the women in the room were suffering from puerperal fever. Nine of them died a few days later. It soon became clear to him what had happened. In the first bed was a woman in labour who had uterine carcinoma. Semmelweis and the students washed their hands before entering the delivery room and examined first this patient and then all the others, without washing their hands after each examination.
It was brought to his attention that doctors transmit infectious substances not only from the dead to the living, but also from patients with purulent processes to the healthy. He ordered the strictest washing of hands and instruments before every examination or use. He ordered sick parturients with inflammation to be transferred to an isolation room, sparking a wave of resistance among the staff. But for the first time, the number of deaths of parturients slipped to just one per cent.
The revolutionary year of 1848 came and Semmelweis, a native Hungarian, sided with the revolutionaries. This backfired on him, as the Vienna hospital no longer renewed his work contract. He took refuge in Budapest, worked there for a while as a general practitioner, and then took over the management of the maternity ward, which had only five rooms in a dilapidated building. It stank everywhere and the maids had no idea about cleanliness.
Here he discovered that infectious things can also be transmitted through bed linen. On the sheets of the freshly made beds, there were still traces of the deceased patient’s pus secretions. His opponents considered him a madman obsessed with cleanliness. These criticisms drove him to despair, and he spent hours pacing the room, talking to himself. He would stop pedestrians in the streets and tell them to wash their hands with chlorine water.
The worried wife asked friends in Vienna for help. On the pretext that he would meet them, he was lured to Vienna, where he was immediately sent to a mental hospital and put in a straitjacket. He died in August 1865, just like his friend Kolletschka. During an autopsy in Budapest, he slightly wounded his finger, and through this wound the illness he had fought against all his life had entered. He fought sepsis and died of it.
Festering wounds that kill
The tragedy of Semmelweis was that in the year he died, a man who was already working in London, who had been given the task of solving the problem of purulent wound diseases, and who was famous for it, was already working in London. This was Professor Joseph Lister of Glasgow. There have been as many proposals for overcoming purulent wound disease as there have been failures. The most critical was the situation in America. There, the Civil War had claimed 67 000 casualties on the Union side alone, and just as many of the wounded had subsequently succumbed to their wounds in hospitals.
There were several suggestions to solve the problem of purulent wounds. Some tried to block atmospheric air from reaching the wounds by placing rubber and gilded foil over them. Others tied rubber caps with suction cups to the amputation stumps and pumped out the air, while others tried cotton pillows that simply lay on the wounds for days.
But all this did not help. The hospitals smelled of sugary manure, the mattresses on which the wounded lay were filthy and bloody, the air suffocating. Dung sores on wounds were everywhere, although to varying degrees. At Glasgow University, where Dr Lister was working at the time and which was in a poor quarter of Irish settlers, it was different. The wounded rooms were airy and had plenty of windows, the beds were not close together, and there was no smell of manure or decay in the rooms. Many of the patients who were lying here were being treated for open fractures.
At that time, an open fracture was considered almost mandatory amputation of a limb, as the festered fracture would cause chills within three days at the latest. It was necessary to cut if it was not already too late. But with Dr Lister, open fractures healed and amputations were a rarity. For many years, Dr Lister had been working on wound healing and inflammation. At that time, it was still thought that gases hovered over hospitals and were then released into wounds, causing them to rot.
Then one day, Lister read an article by an unknown chemist, Louis Pasteur, in a French magazine. Pasteur had also been working on the processes of inflammation and putrefaction in 1863, and during a microscopic examination of the rotting matter, he discovered unidentified living creatures in the decaying matter, which increased exponentially in number as putrefaction progressed. He believed that these creatures must be the cause of the inflammation and putrefaction. His argument met with fierce resistance, as his opponents argued that these living beings were the result, not the cause, of putrefaction.
Dr Lister was increasingly convinced that the same or similar microbes that Pasteur had found were invading open wounds and poisoning first the inside of the wound and then the whole body. Then he learned that in the rice paddies, the rotting smell of drains was eliminated by a chemical called carbolic acid. So if you cover a wound with something that is soaked in a carbolic acid solution, it could prevent microbes from getting to the wound. Of all the cases he treated in this way, he lost only one patient.
After initial successes with open fractures treated with carbolic, Lister wanted to test his system on the most dangerous surgical condition of all; purulent hip abcesses. Filled with a particularly severe pus, these abcesses were certain to lead to a slow death if they waited until they opened on their own. If they were opened with a knife, the patient met a quick death.
Like all innovations, Lister’s theory has been met with prejudice. One has to think of the prejudice that the discovery of narcosis itself encountered. But the removal of pain was a clear and demonstrable thing for everyone. But the germs that invade the surgical wound and are supposed to cause chills from suppuration, the germs that carbolic is supposed to prevent from infecting wounds? Where are they, can Lister point them out and hold them in his hands? Who has ever heard of Pasteur, who is not even a doctor, but only a chemist?
These questions were put to Lister at a meeting of the Medical Association in Dublin in August 1867, and he had only twenty minutes to answer. At the end of his speech, there was a round of applause, modest, but a sign that some doctors merely recognised the importance of his discovery. This did not stop the attacks on him. Someone even accused him of plagiarism, saying that a French pharmacist, Gustave Lemaire, had discovered by accident long ago that carbolic acid destroys small living things if it comes into contact with them.
But Lister did not give up. He went beyond the carbolic commitments. He started washing his hands and soaking his instruments in a carbolic acid solution, knowing that germs from the air would also settle on them. In the operating theatres, he installed nebulizers to create a thick mist of carbolic acid. He started washing the patients’ skin with carbolic acid solution in the operating theatre. But he was still alone in England with his successes.
Then his system was first taken over by Dr Thierscxh from Leipzig, desperate because of the rampant purulent diseases in his hospital. He was soon followed by the director of the Charité Hospital in Berlin and then by all the important German surgeons. Lister travelled to Germany and America lecturing on his method. In October 1877, he became Surgeon General of King’s College London and gave a demonstration lecture to the students. He lectured them on putrefaction, living microbes and inflammation.
The students got bored and slowly left the lecture room. Even the catering staff made a fool of his “frenzied cleanliness system”. But then, in the small German town of Wollstein, a completely unknown country doctor logically proved for the first time what Pasteur had only suspected and Lister had incorporated into his method: the existence of those microbes that cause putrefaction and fever. The country doctor’s name was Robert Koch, and if one had seen him one would never have believed that he was the one who would change the face of medicine.
He was bent over a microscope almost all day, looking at the spherical bacteria called cocci, which he discovered caused in the patients the kind of scurvy whose stench poisoned most of the world’s hospitals. As a district doctor, he examined sheep in his official capacity, and they died in large numbers on the pastures in those years because of an unknown disease. All they knew was that their spleens turned black during the disease, so they called it anthrax.
Koch had to steal time from his work as a rural doctor to do research. Under the microscope, he noticed unidentified rods in the blood of sheep, which mixed with other living things and appeared lifeless and dead to him. He decided to isolate them, bring them back to life and see how they reproduced. If he then passed them on to healthy animals and they died, he would prove that these rods were carriers of disease.
He found a suitable medium for these rods – the fluid from healthy ox eyes – and created the right temperature to stimulate them to life. And indeed they began to multiply at an incredible rate. Within a short time, they were no longer to be counted. Then he did experiments on mice and all the mice he transferred the rods to died immediately.
Based on his discoveries, he began to look for the various germs responsible for various hospital diseases; scourge, shingles and tetanus. He discovered that scurvy was caused by germs which Lister had taken as the basis of his wound treatment without being able to prove it.
Rubber gloves
Lister did not see the bacteria, he only suspected their existence, but Koch made the bacteria visible and it was clear from the accuracy of the Germans that they would continue their work until all the bacteria that cause wound diseases were visible.
This was the thinking of Dr Halsted, who studied in America and then trained in Europe, and who later became a pioneer of the new scientific surgery in America. For many surgeons in America, the Lister procedure was too difficult and time-consuming. And even in the air, no germs could be detected that would cause wounds to become diseased. On the contrary, millions of germs swarmed on the floor, in dust, in a single drop of pus oozing from a purulent wound, or on a surgical instrument that had not been cleaned. Obviously, the bacteria did not come from the air, but entered the wound through direct contact with debris, instruments or hands.
Dipping the hands in carbolic acid also had a limited effect, as it did not reach the bacteria hiding in the sweat glands and corners of the hands. Better results were obtained by brushing the hands, rubbing with sterile towels and using alcohol swabs. But complete elimination of the germs could not be achieved.
In the summer of 1890, a saving change arrived from Baltimore. It was then still a dreamy country town, very different from New York. Dr. Halsted, who worked there, thought otherwise. He was quite special. He was the only one who wore a tall silk hat, his suits were made by the best London tailors, his shoes were made to measure from special leathers, and his shirts were sent to Paris to be washed and ironed, even if it took a few weeks. He was still single, but he had an attractive chief operating nurse, Miss Caroline Hampton.
The story of Halsted’s discovery is undoubtedly a fascinating passage that traces the development of surgery. In the winter of 1890, Caroline’s skin showed some changes, probably caused by the sublimate used in the operating theatre to disinfect her hands. Eczema developed and spread steadily, affecting her elbows. At that time, no one had any idea of Dr Halsted’s feelings for Caroline.
He tried countless things to get rid of his eczema, but it was all in vain. Caroline was in danger of having to leave Baltimore and look for work elsewhere. But a few days later, Dr Halsted handed her a pair of extremely thin rubber gloves made by Goodyear. They protected her hands but did not interfere with her work. No one had ever used gloves like these before.
The rubber gloves used occasionally by anatomists were made of crude, cumbersome material and could not be used in operating theatres. From that day on, Caroline always wore them and they were sterilised in a steam room. When she left the post of chief operating room nurse, the gloves stayed on. When Halsted’s assistant later put them on, he unromantically declared: “What goes down well with the bird will go down well with the cock.”
Soon, rubber surgical gloves conquered the world, closing an important gap in the asepsis system.
