By the end of the nineteenth century, many surgeons had joined micro- biologists in using improved methods of sterilization and were full participants in the debates concerning the relative merits of heat versus chemical sterilization, and antiseptic versus aseptic methods. The goal of antisepsis is to kill the germs in and around a wound by means of ger- micidal agents. The goal of asepsis is to prevent the introduction of germs into the surgical site. Because almost all wounds contain some
microbial contaminants, the concept of aseptic wounds is essentially an oxymoronic microbiological myth. On the other hand, antiseptics alone cannot guarantee uncomplicated healing; the immunological status of the patient and the pathogenic burden are important factors. Lister gen- erally preferred his own antiseptic methods and, despite his admiration for Louis Pasteur, insisted on keeping his instruments in carbolic acid, even after Pasteur and his colleague Charles Chamberland (1851–1908) demonstrated that heat sterilization was superior to chemical disinfection of surgical instruments. Chamberland’s autoclave, a device for sterilization by moist heat under pressure, was in general use in bacteriology laboratories in the 1880s.
The relationship between Listerian antisepsis and the acceptance of
asepsis by nineteenth-century surgeons involves a complex web of motives, prejudices, loyalties, and theories. What has been called the
‘‘full aseptic ritual’’ never became part of Lister’s routine. Lister himself
had little enthusiasm for some of the later additions to the surgical ritual, such as white gowns, masks, and gloves. After adopting the asep- tic ritual, some of Lister’s disciples recalled that Lister, operating in his old coat under a cloud of carbolic acid spray, had had just as much suc- cess with much less fuss. As surgeons adopted asepsis and antisepsis with increasing rigor, operations that had once been the miraculous achievements of truly gifted or unusually lucky performers became a matter of routine. The conversion of surgeons to the gospel of antisepsis and asepsis was, however, not rapid or universal, nor were all hospitals capable of providing a supportive staff and environment. Even at the turn of the century, indifference toward antiseptic procedures was not uncommon. Advocates of asepsis adopted the habit of answering the question ‘‘What is new in surgery?’’ with the declaration: ‘‘Today we wash our hands before operations!’’
Surprisingly, the last of the critical factors considered in the battle
against infection was the surgeon’s hand. William Stewart Halsted (1852–1922), a pioneer of local anesthesia, was also a leader in the battle for aseptic surgery. The great French chemist Louis Pasteur said that if he had been a surgeon, he would not only use perfectly clean instruments and heat-sterilized water and bandages, he would willingly submit his hands to a rapid ﬂaming after washing them with the greatest care. It is difﬁcult to imagine surgeons agreeing to a routine ‘‘ﬂaming’’ of their hands, but the antiseptic solutions used for scrubbing were almost as unpleasant. When Halsted came to terms with the fact that the human hand could not be sterilized, he decided that it should be covered by ﬂex- ible gloves, resistant to harsh disinfectants. Initially, Halsted asked the Goodyear Rubber Company to make rubber gloves for Miss Caroline Hampton, head nurse in the surgical division, because she was very sensitive to disinfectants. The experiment was successful, except for the fact that Johns Hopkins lost an efﬁcient nurse when
Miss Hampton married Halsted. In the 1890s, the use of rubber gloves was added to the surgical ritual at Johns Hopkins. Doctors had pre- viously used gloves to protect themselves from patients, especially those who might be syphilitic, but surgical rubber gloves were an innovation designed to protect the patient from the surgeon.
Halsted attempted to instill in his associates an understanding of
antiseptic and aseptic principles and an operating style that minimized injury and insult to the tissues. In treating patient with breast cancer, however, Halsted insisted that his radical mastectomy was needed to save lives and cure the disease. Halsted paid little attention to the patient’s future ‘‘quality of life’’ and the disﬁguring and crippling effect of radical surgery since he thought that was not very important in such cases. A famous portrait of the surgeon D. Hayes Agnew, painted by Thomas Eakins (1844–1916), depicts the conditions under which mas- tectomy was conducted in 1889. Like Leonardo da Vinci, Eakins was intensely interested in science and medicine. He often attended medical lectures and surgical demonstrations and taught anatomy at the Pennsylvania Academy of the Fine Arts. Nineteenth-century audiences were shocked by his highly realistic portraits of surgeons at work, but today ‘‘The Gross Clinic’’ (1876) and ‘‘The Agnew Clinic’’ (1889) are regarded as masterpieces. ‘‘The Gross Clinic’’ shows Dr. Samuel Gross in a blood-stained frock coat operating on a patient’s leg. The portrait of Agnew depicts surgeons in clean, white gowns conducting a mastec- tomy on an anesthetized woman. The mortality rate for this operation was very high and surgeons acknowledged that few patients actually beneﬁted from the procedure. Surgery did not cure the disease and, in many cases, it probably shortened the patient’s life.
Recalling the surgical technique taught at Johns Hopkins in the
1890s, Halsted’s students described it as ‘‘rigorous and even painful to the staff if not to the patient.’’ For the sake of asepsis, some surgeons even trimmed their magniﬁcent beards and mustaches and refrained from talking to observers and yelling at their assistants during opera- tions. Eventually, the full aseptic ritual included special surgical gowns, caps, masks, and the banishment of spectators from the operating room. Some hospitals installed special mirrors or glass domes so that observers could watch without contaminating the operating room. When properly applied, antisepsis, asepsis, and anesthesia transformed the operating room from the doorway to death into an arena of quiet routine.
To explore the achievements of the many famous surgeons of the
post-Listerian period would be an impossible task, and rather like com- piling a catalog of all the parts of the body. It is more important to recognize the fact that the surgical revolution involved much more than the obvious technical triumphs of anesthesia and antisepsis. More subtle, but fundamental factors involved changes in the status and train- ing of the surgeon, which made it possible for practitioners of a once
lowly craft to integrate advances in pathological anatomy, medical instrumentation, and the life sciences into the science and art of surgery.
Since the late nineteenth century, progress in controlling the three
major obstacles to successful surgery—pain, infection, and bleeding— has been remarkable. Understanding of the immunological basis of blood-group substances and practical methods for the storage and transfusion of blood and blood products have made it possible for the patient to survive even when accidents or surgical errors cause catas- trophic blood loss. Knowledge of the most hidden parts of the body has grown via the classical pathway of anatomical study and through the introduction of new instruments and techniques for visualizing, exploring, and sampling body parts and products. The surgeon is no longer engaged in single-handed combat, but is part of a team of special- ists in anesthesia, pathology, radiology, bacteriology, immunology, and so forth. Surgical triumphs had become so routine by the 1960s that gaining an international reputation, or at least a cover story in Time magazine, required nothing less than a return to the stuff of myth: the transplantation of human hearts.
Not all of the factors that determine the success of surgery are,
strictly speaking, a part of medical science. Some of the major postoper- ative threats to the patient are so humble that it would have been an insult to the dignity of the medical profession to take notice of them. For example, hospital bandages were generally made of rags that had gone through a laundry process that scarcely inconvenienced their microbial passengers. Rags were a major item of international trade and a good vehicle for the exchange of disease. No matter how skillful the surgeon, no matter how clean the operating room might be, if the patient was later bandaged with contaminated dressings, and put into soiled bedding, infection and death could claim another victim.