12 May

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.

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