University College Hospital, London,May 1842
The operating theatre was positioned at the centre of the hospital, next to the mortuary. It was separated from the public areas by thick walls and a long corridor. This arrangement had two significant advantages: it helped shield passers-by from the screams; and its proximity to the mortuary meant that surgeons could move easily from operation to post-mortem, often with the same patient.
As it was, most people did their best to avoid the precincts of the hospital on operating days, and the staff did their utmost to distract anyone within screaming distance. It was not good for morale, particularly for those in the surgical wards who would soon go under the knife.
The steeply raked semicircular wooden galleries of the operating theatre had been swept that morning. The dust hung in the air, dancing in the few shafts of sunlight that managed to penetrate the grime of the high windows. A smoky coal fire burnt in a grate in the corner. At the centre of the room, where the surgeon would be performing, the gas lights hung from the ceiling on a chain above the operating table.
The table was made of deal – a cheap pine timber – and resembled a crude workbench. High and narrow, with a wedge-shaped block for the patient's head, it was bolted to the floor with thick iron brackets. The grain of the wood was marked with deep grooves and stained brown by the coagulated blood and soiled blankets of previous patients. Beneath the table was a box of sawdust, fresh that morning, although some still remained from previous operations, stuck to the side of the box like hardened brown putty.
One of the assistant surgeons, known in the hospital as a 'dresser', laid a thick woollen blanket on the operating table while his colleague carried in a case of surgical instruments. Both the men were nearing the end of their training and had already assisted in dozens of operations, although neither of them could say they had got used to it. The dresser carefully took the instruments from the deep velvet padding of the case. He laid them out in strict order on a tray placed on a small cabinet near by. He knew if he got the order wrong he would be in terrible trouble. He checked his notebook to make doubly sure.
· Two straight knives made of hardened steel, twelve inches long, with an embossed ebony handle and the sharpest of pointed blades
· A saw, short and polished, with fine sharp teeth and a good strong grip
· One pair of forceps
· Assorted sponges
· Threaded needles to tie blood vessels
· Short pliers or nippers to trim any jagged remnants of bone
The dresser covered the instruments with a cloth. There was also a bowl of water so that the surgeon could rinse the blood off his hands between operations.
Everything was ready. The first operation was scheduled to begin at noon.
In the male surgical ward the patient, rested and well fed, was as prepared as he would ever be. His bowels had been emptied that morning by means of an enema syringe, the resulting discharge being reported as 'copious and of bad quality at first' (the patient, the case notes recorded, was well rid of it). Two porters arrived to take the man to the operating theatre.
As they prepared to lift the patient from his bed on to a canvas stretcher, they could see that he was in a bad way. The poor man's lower leg had begun to suppurate: a thick fluid trickled from the open wound – a mixture of blood and pus seeping between the jagged ends of broken bone that protruded through the skin of his calf. The porters tried not to get too close. The smell of decay, like that of rotting meat, was almost more than they could bear. Without an operation the patient would die, that much was a certainty. The only cure for such a compound fracture was amputation, but with the infection creeping up the man's leg so fast that you could almost see it, the decision had been taken to remove his leg at the thigh.
The patient had sustained the injury on the Great Northern Railway when he had slipped between the platform and a moving train. Fortunately, the company's terminus at King's Cross was only a few hundred yards from University College Hospital. This meant he would be operated on by Britain's finest surgeon, Robert Liston. Liston had recently been appointed as the hospital's most senior surgeon, and professor of clinical surgery at the university. Author of the latest surgical textbook, he was the foremost surgeon of the age. And he knew it.
The room goes quiet as Liston strides through the door. 'Sharp features, sharp temper' is how his colleagues describe him. Most of his students (and many of his staff) are scared of Liston, but he is good at what he does and his operations are always well attended. True, there are those who have to attend them, such as the surgery undergraduates, but there are usually also rival surgeons and even visiting dignitaries in the audience. This is, after all, the very latest surgical practice, the best the British Empire has to offer.
Liston – six feet two inches tall, domineering and self-assured – hangs up his frock coat, takes an apron from the peg and rolls up his sleeves. 'Good afternoon, gentlemen,' he says to the now packed theatre. 'Today I shall be performing an amputation of the thigh in the usual manner.'
The two porters take this as their cue to carry in the patient. They lift him as gently as possible on to the operating table. The patient winces. This, he thinks, must be how condemned prisoners feel as they are led to the scaffold. His eyes dart around the room, his heart pounds, his utter terror mitigated only by the excruciating pain from his leg whenever he moves – a pain overlaid by a duller, steady, nauseating ache. He wants to vomit but can only gag.
Liston had made surgery his life's work and knew it had the power to save lives, but even he – described by his enemies as arrogant and aloof – operated only as a last resort. He also made every effort to instil in his students some sense of the feelings and fears of the patient. 'These operations must be set about with determination and completed rapidly, in order that dangerous effusion of blood may be prevented,' he told them. 'They are not to be undertaken without great consideration.' In short, it was all about speed.
The porters shut the doors and stand guard, arms folded, defying anyone to pass them. It has been known for patients to try to make a run for it, but this one only groans and mumbles indistinctly. It is probably a prayer. Most patients pray – it's amazing how many people find religion in the operating theatre. Many also beg or plead to be taken back to the ward even though they know that without surgery they will die. Others lie on the table calmly, as if possessed by some inner strength. Women, Liston finds, are often the most composed.
A dresser slips the strap of 'Petit's improved tourniquet' around the patient's upper thigh and pulls it through a small clamp. A wedge-shaped ridge on the strap is placed against the artery but not yet tightened, its purpose being to prevent blood loss during the operation. Without the tourniquet the patient's entire body would bleed dry in less than five minutes. Applying it properly was a matter of some skill. Tighten it too early and the upper leg would swell with blood. Too late and the patient could bleed to death.
Liston has himself witnessed the disastrous effects of a poorly applied tourniquet and is fond of telling the story in his lectures. 'A scene of indescribable and, under other circumstances, most laughable confusion ensued,' he says. 'Two assistant surgeons got on the table and pressed with all their might and main on the groin to stop the bleeding.' Liston is, in this instance, good enough not to reveal the surgeon responsible, but the story serves to remind people of his intolerance of error. The fate of the patient is not recorded.
With Liston in charge, there will be no such mistake today. One of the dressers takes a handkerchief from his pocket and ties the patient's good leg to the table to keep it as far away as possible from the knife. Two other assistants firmly hold the patient's shoulders and arms to stop him struggling. They try to keep their hands away from his mouth. He can squirm but cannot move; scream but not bite. The patient glances at the instruments, then at the ceiling. Finally at the audience – witnesses to his fate.
Liston motions for a young student to come forward from the gallery to support the limb that is going to be removed. The nervous pupil knows that if his grip slips or the leg bends, causing the bone to snap rather than be sawn through cleanly, he will suffer Liston's anger and abuse. He also hopes that Liston himself keeps a steady hand.
The surgeon clamps his left hand across the patient's thigh. His right hand reaches for his favourite knife, marked with a series of notches – one for each operation. The knife glitters in the flickering gaslight. Liston turns to the galleries; everyone is leaning over the railings to witness the action. 'Time me gentlemen!' Those familiar with a Liston operation already have their pocket watches ready.
In one rapid movement, he slices into the flesh, and a dresser immediately screws down the tourniquet to stem the rhythmically spurting fountain of blood. Drawing the blade under the skin with the grain of the muscles, Liston pulls it towards the hip, down to the bone, then sweeps it around the leg and back towards the knee to leave two U-shaped incisions on the top and bottom of the thigh. There is nothing theatrical about the patient's cry. It is a chilling, horrible scream of terror. He is weeping now, struggling, mewling, whimpering.
Liston flings the knife into a tray and grabs the saw. His assistant puts his hand into the cut, fingers reaching right the way down to the bone. He pulls back the mass of skin, muscle, nerves and fat towards the hip to expose as much bone as possible. Liston places his left hand on the exposed bone and, with his right, begins to saw through it with rapid but precise strokes.
The student supporting the leg is concentrating so much that he barely realizes when he's holding its full weight. He looks down with a shudder, kicks the box of sawdust towards him and drops in the severed limb. It lands with a thud, sending up a small cloud of bloody sawdust.
The saw falls to the floor and, with his assistant still holding back the flesh of the stump, Liston bends close to tease out the main artery in the thigh – the femoral artery on the underside of the leg. The stump begins to ooze as Liston's bloodied hands reach for the needle and thread. He ties off the blood vessel with a reef knot. A 'good, honest, devilish tight and hard knot,' as he will later tell his students. He notices other, smaller, blood vessels and knots the ends together, holding the thread in his mouth at one point to make sure it is really tight.
Liston shouts at a dresser to loosen the tourniquet. A gently flowing stream of blood meanders between the ridges of the blanket to drip into a pool on the floor. But the pool is small, not large enough to be life threatening. The assistant allows the flesh he has pulled aside to spring back so that the bone is once again covered and protected by soft tissue. The two U-shaped flaps of skin are pulled together over the stump. A thin line of coagulating blood seeps between them.
The operation is over. From first cut to final stitch, the whole procedure has taken only thirty seconds. Thirty seconds of remarkable dexterity, flashing blades, rapid movements and brilliant showmanship. Thirty seconds of such pain that few patients are ever able to put it adequately into words. The memory of those thirty seconds will haunt them for the rest of their lives. If they live.
Fortunately, the mortality rate from Robert Liston's operations was remarkably good. Between 1835 and 1840 he conducted sixty-six amputations. Ten of his patients died – a death rate of around one in six. About a mile away at St Bartholomew's Hospital, surgeons were sending one in four patients to the mortuary, or 'dead house', where the all too frequent post-mortems took place.
Given that many surgeons were appointed through patronage or, more usually, nepotism, there was a large degree of surgical incompetence even in the most renowned hospitals. Surgeon William Lucas at Guy's Hospital in south London was generally kept away from the operating theatre for everyone's safety. In one thigh amputation he cut the U-shaped flaps of skin the wrong way round leaving a raw stump and a dismembered limb with two excess flaps of skin. His botched operations (the word 'botched' became synonymous with failed surgery) were notorious. They were thought to be the main reason that a young dresser at Guy's, John Keats, abandoned the surgical profession to become a poet.
In rural areas the local physician was expected to carry out his own operations. The medical literature of the day is littered with accounts of attempted surgical procedures and their consequences. Martin A. Evans, a physician in Galway, recorded a typical example from his casebook in the Lancet medical journal of 1834. His patient was forty-five-year-old Martin Conolly, whose leg was crushed by falling timber. Having persuaded the man that amputation offered the only chance of survival, Evans conducted the surgery, but his account gives little detail about the procedure itself, except that it was 'done by circular incision without assistance'. It is unlikely to have been as quick and efficient as Liston's operation, but was performed 'in the usual manner'.
As soon as the limb was removed Conolly reported feeling better and stronger, but in a few moments became faint and gradually weaker. 'He died,' reported Dr Evans, 'without having lost four ounces of blood during the entire process.' Evans attributes this not to any surgical failure resulting in massive internal bleeding, but to the patient. 'He had been a strong man, but was fearful of consequences, the only cause to which I can attribute his sudden dissolution.'
Patients had every reason to be fearful. Liston usually operated on reasonably fit young men or women with strong constitutions, and considered long operations cruel. That his were speedy affairs helped minimize blood loss and reduced the risk of disease. Liston also believed in keeping wounds clean. After the skin had been stitched together – with stitches known as 'sutures' (from the Latin word meaning 'to sew') – he advocated dressing the wound with sheets of lint dipped in cold water. These were to be frequently changed as the wound suppurated, with warm poultices applied to reduce the swelling and 'encourage discharge'.
Not for Liston the filthy bandages and straps of some of his rivals. These, as he was fond of saying, only encouraged 'putrefaction, fermentation, stench and filth'. It wasn't unusual for surgeons to reuse bandages and dressings already stiff with blood. For convenience, one surgeon proudly kept a drawer of 'plasters' passed from patient to patient over the years. Well, he and others reasoned, why waste them?
Liston would also wash his hands before operating and always wore a clean apron. Or at least it started off clean at the beginning of the day. Other surgeons took pride in conducting operations in the same frock coats they had used for years. The blood and pus that had built up into a hardened crust of material were regarded with respect. Surgeons were, after all, respected members of society; they had almost the same standing as doctors.
Liston and most of his contemporaries could, with some justification, claim to save lives. They had a firm grasp of anatomy, knowing with some certainty the name and position of every bone, muscle and organ in the body. They also knew broadly what each organ did, even if they had only a limited understanding of the underlying mechanisms. Crucially for Liston's generation of surgeons, they had also developed the skills and dexterity to stop their patients from bleeding to death on the operating table.
The decision to operate was determined by the pain the patient could withstand. In some quarters pain was seen as a prerequisite for a successful operation – a stimulant to the body's natural powers of recuperation. Perhaps the Galway patient had not been in enough pain? Many operations took far longer than the few seconds required for a basic amputation. Liston considered some of these too cruel. A mastectomy, for example, would take several minutes, the breast being slowly dissected 'with all due caution and deliberation'.
Neither was there any understanding of infection – what it was or how it was spread or prevented. Although Liston chose to operate in a clean apron with relatively clean hands, instruments and dressings, these practices owed everything to his sense of cleanliness and common sense rather than any theory of disease or how it was controlled.
The speed with which he conducted his operations, which included the removal of tumours and growths, and even reconstructive surgery (see page 217), was a hallmark of his work. Sometimes, though, his arrogance would get the better of him. (Indeed, the arrogance of surgeons is a theme throughout the history of surgery.)
Jealous rivals would whisper that Liston was so quick that he once accidentally amputated the penis of an amputee. On another occasion he was asked to look at a young boy with a swelling on his neck. A junior surgeon was convinced that the tumour was connected to the main artery in the neck – the carotid. 'Pooh!' said Liston as he drove a knife into the tumour. Unfortunately, the junior surgeon was right. The boy died within minutes.
However, the most worrying incident for his students occurred during an amputation when Liston accidentally amputated an assistant's fingers. The outcome of this operation was horrific: the patient died of infection, as did the assistant, and an observer died of shock. It was the only operation in surgical history with a 300 per cent mortality rate.
Liston's operations were messy, bloody and traumatic but, despite the occasional setback, he was one of the best surgeons of the day. His patients suffered terribly, but a fair proportion of them came out of hospital alive. This eminent surgeon owed his relative success to two thousand years of surgical development. A tortuous history involving dismembered criminals, wounded soldiers and Roman celebrities.
INSIDE THE BODY
Pergamum, Roman province of Asia Minor (Western Turkey), AD157
The gladiatorial display was the zenith of Roman entertainment, a glamorous spectacle of skill, excitement and bloodshed. The day of the contest was one of celebration, and the amphitheatre was packed with expectant crowds ready to be entertained.
The day started with a display of exotic creatures gathered from the far reaches of the empire – leopards, wild horses and an angry bear. The animals were goaded in mock hunting demonstrations. A few were killed, but others were saved and employed as executioners to tear apart local criminals who were tied to stakes in front of the baying crowd. As the gladiators entered the ring, they waved to acknowledge the screams of the spectators, who idolized them as celebrities, their beautifully toned bodies admired by men and adored by women.
The gladiators fought in pairs – a warrior in heavy armour pitched against a nimble opponent with a net and trident; a fighter with swords against one with spears and daggers. Although the event was staged, the brutality of the fighting was terrifyingly – and thrillingly – real. The men fought to injure, to wound, to win. They were taught to aim for the arteries of the neck, and behind the knee. It was a fight to the death, but they shouldn't kill. The choice of whether a gladiator would live or die was the prerogative of the sponsor. He alone could decide whether the victor should deliver a final, fatal blow. The sponsor could not afford to allow too many gladiators to die – it would be like killing half the cast of actors after each performance of a play – as he would have to buy replacements.
Within the hierarchy of Roman society, gladiators were near the bottom of the heap. They were slaves and members of what was considered a disreputable profession. This was a standing they shared with prostitutes and, of course, actors. But despite their lack of freedom and their apparently low status, gladiators were rightly treated as the elite sportsmen they were. Their rigorous training was complemented by a high-energy diet and the very best medical treatment. The post of physician to the gladiators in Pergamum, or any major city of the empire, was a prestigious one. Celebrity gladiators required their own celebrity surgeon. This was the perfect position for a showman such as the ambitious Claudius Galen.*
* No one seems to know for sure what Galen's first name was. 'Claudius' is used in many references, but some historians suggest it was more likely to be Aelius or Julius.
Galen was a servant of the healing god Asclepius and had studied alongside distinguished physicians. This did not necessarily make him a surgeon, but he did know how to impress. When he was interviewed for the post of physician to the gladiators, Galen took along a monkey. He then proceeded to slice open its stomach and sew it back together again. 'Can anyone else do that?' he asked. He got the job and, as an added bonus, the monkey survived.
In his new role Galen would learn to deal with everything from minor sports injuries, such as muscle strains, to serious battle wounds. When the survivors of the contests left the arena Galen would be waiting to set bones or amputate limbs. He became an expert at stemming blood flow and restoring the fighters to health. As one of the first trauma surgeons, he was perfectly placed to study the inner workings of the human body. The exposed guts of a defeated gladiator, spilling out from a stomach wound, enabled him to examine the digestive system. An amputation revealed the bones, muscles and structure of the tendons, the bands of tissue that connect bone and muscle. He noticed how blood vessels pulsed and that some blood was brightly coloured. Galen later claimed that no gladiator under his medical care had died, but, even given their superior fitness, this is hard to believe. The physician, though, had a legend to build and a reputation to maintain.
As Galen's career advanced, he extended his studies of anatomy to animals – dead or, quite often, alive. He held public lectures and demonstrations where an animal was publicly dissected. Pigs seemed to bear the brunt of Galen's experiments as he considered them to be most similar to humans. His favourite demonstration involved severing the nerves in the neck of a live pig. As he cut them away, the wriggling animal became increasingly paralysed. First unable to move its hind legs, its front legs would then become still. With the final slice, Galen could stop the pig squealing.
In the manner of a true celebrity surgeon, Galen eventually became a personal physician to the emperor Marcus Aurelius. His ultimate ambition, though, was to become as famous as the Greek 'father of medicine' himself, Hippocrates. Galen hoped to be immortalized by the medical profession as someone who understood how the human body functioned. However, his only direct knowledge of human anatomy came from his work as a surgeon. Dissection of dead bodies was rare, and many considered it unclean and blasphemous. As a respected member of Roman society, Galen could not risk even suggesting such a thing, so instead he based most of his descriptions of human anatomy on what he had learnt by dissecting animals. The rest he surmised from consultations with his patients, or simply made up.
Much of what he deduced was right. Stopping a pig's squeals by severing its nerves made him realize that the brain controlled the voice. Aristotle had previously suggested that the brain was some sort of cooling system for the body. Galen concluded that arteries contained blood (rather than air) and that each organ had a particular function. He also advised that the strength, frequency and rhythm of the pulse could be used to diagnose disease. Indeed, he developed elaborate and complex theories on the differences between the various types of pulse that eventually stretched to sixteen books.
Some of his theories, however, were completely wrong. He taught that the blood was produced in the liver and distributed in veins. He saw the heart as some sort of furnace containing two chambers with tiny pores or micro-holes between them that allowed the blood to seep from one side to the other. There was no sense that the blood circulated around the body or was pumped from the heart. The pulsating movement of the arteries he attributed to their muscular structure, which he supposed contracted and expanded 'naturally'. And although he realized that urine was produced in the kidneys rather than the bladder, he got the position of the kidneys wrong.
Galen's crowning achievement was 'perfecting' the philosophical medical theories developed by the ancient Greeks: the four humours. Each humour corresponded to a different temperament and element: yellow bile was associated with fire; black bile with earth; phlegm with water; and blood with air. Illness occurred when the humours were out of balance. To rebalance the humours, the doctor could remove blood, induce vomiting or purge the body with an enema. A fever, for example, might be attributed to an excess of blood, so Galen advocated bloodletting to cool the body. A general feeling of melancholy suggested too much black bile, requiring the gut to be purged.
Galen believed he was a brilliant scientist and philosopher. Considering that most of his anatomical experience was based on animals, he did not do such a bad job. Many of his conclusions were based on real experimental evidence and would have made ideal foundations for later natural philosophers and doctors to refine and so improve our understanding of anatomy. The problem was that until the sixteenth century no one bothered.
The Roman Empire fell, Islam rose, Europe embarked on the Crusades, Columbus 'discovered' America, Magna Carta was signed and the printing press invented. Yet still, after one and a half thousand years, our knowledge of medicine, surgery and anatomy was based on the writings of Galen, a boastful Roman surgeon. That Galen was wrong about so much was hardly his fault, nevertheless it took more than one thousand years before doctors and surgeons began to question his teachings.
DEAD MEN'S SECRETS
Louvain, Flanders, 1536
It was nearing dusk. The city gates were about to be shut for the night. Outside the walls of Louvain, swinging on a gibbet in the gentle evening breeze, was the macabre silhouette of one of the city's criminals. The body was still more or less intact, but you could see through the ribcage. Ligaments connected many of the bones, but the skull was snapped unnaturally to one side – evidence that the hanged man had at least died quickly from a broken neck rather than from slow strangulation. Some parts of the body had fallen to the ground, the result of scavenging dogs jumping up and tearing them off. The kneecaps had gone, as had one of the feet. Birds too had feasted on the decomposing flesh, their activities betrayed by the guano on the man's shoulder blades.
The authorities were particularly worried about undesirables arriving in Flanders from France. A decomposing corpse stationed outside the city gates sent a clear message that criminal activity would be severely punished. There was little evidence that the display worked, but it certainly unnerved most of the God-fearing citizens passing by.
This evening the road is deserted and a precocious medical student, Andreas Vesalius, is on his way home. He needs to be back in the city by the evening curfew, otherwise he will have to spend the night locked outside the city walls. He sees the gibbet at the roadside and goes across to take a closer look. The dangling corpse is exactly what he has been looking for – an ideal subject for study. Getting hold of bodies is difficult, and if he does not take this opportunity he thinks it likely that another medical student will.
The chain supporting the skeleton hangs some nine feet off the ground, and the corpse itself is considerably bigger than Vesalius. Even if he manages to get it down, he realizes he has little chance of carrying it home in one piece. With time against him, the obvious solution is to take one bit at a time, so Vesalius jumps up and grabs one of the legs. Tugging hard – it's surprising how strongly the femur is attached to the bones of the pelvis – he pulls it towards him until the ligaments rip with a hollow tearing sound and the joint pops out of its socket. He hauls it clear as the skeleton lurches to one side, dancing crazily on the end of its chain.
Vesalius then pulls off the second leg, twisting it out of its socket. The bones pile up at his feet. Next he decides to take the arms, but has to be careful not to damage the ligaments holding together the fragile bones of the hands. He also has to reach them. Fortunately, the wooden scaffold is rough and he can climb up, grabbing the swaying chain to pull the stinking corpse closer. Using one hand to steady himself, he grabs an arm with the other, gives it a sharp twist to pop it out of the joint and drops it to the ground. He then yanks the chain to spin the body round and reaches across for the second arm.
Jumping to the ground, he bundles up the bones in his cloak, like firewood, and hastens towards the city, keeping to the shadows as he makes his way home. Once there, he dumps the pile of bones on his kitchen table and, pausing only to pick up a hammer, heads back to the gibbet. He is determined to remove the rest of the body.
The head and trunk are all that remain, but the chain is attached to the top of the backbone and takes some hefty blows from the hammer before it comes free. Although he tries to catch them, these final body parts – the ribcage, pelvis and skull – fall to the ground, so he jumps down and wraps them in his cloak.
The gibbet casts a long shadow in the moonlight as Vesalius scrabbles around in the dirt to gather any stray pieces of cartilage and stuff them into his pockets.
The final challenge is to get back into the city. Night has fallen and the curfew is in place. Returning through the main gate would be foolish. Even an educated man such as Vesalius would have a hard job explaining his mission to the watch-keepers. He heads instead for another gate – one where he can slip past the guards unnoticed or, at worst, bribe them to get in.
Stealing a corpse from a gibbet might seem enough work for one night, but Vesalius is a man possessed. Safely back home, he now has a substantial collection of bones on his kitchen table – but they are starting to smell. There is more flesh on the bones than he thought. In the warmth of the kitchen, even the smoky fire can't disguise the sickly stench. Not only is this unpleasant, but the neighbours will notice. This could only lead to difficult questions. So, undeterred, Vesalius sets about stripping the corpse down to its bare bones.
After placing a large pan of water to heat on the fire, Vesalius gets a knife and scrapes away any last shreds of muscle, tendons and skin. He reaches his fingers into joints to separate out the cartilage and places this carefully to one side. When the water has boiled, he drops in the bones. He tries to keep the bones of some parts – such as the hands and feet – together as much as possible.
After a few minutes, he drains away the fat, straining the liquid to avoid losing any odd pieces of cartilage or fragments of bone. By daybreak the task is complete, the rotten flesh is discarded outside in the gutter and the bones and cartilage are gathered in an enormous pile on his kitchen table. Now all Vesalius has to do is put the skeleton back together again.
Although technically illegal, bodysnatching wasn't a wholly unusual pastime for a medical student. Few people were likely to complain if the remains of a criminal or pauper went missing. Frankly, it was doing everyone a favour. Neither was this the first time Vesalius had been involved in stealing a body. Desperate for some hands-on experience of anatomy, he had already joined with other young physicians to take bodies from the cemeteries of Paris when he was at medical school. But dead human bodies were difficult to come by, and Vesalius had a plan for his boiled-up bones.
In sixteenth-century Europe, Galenic medicine was as healthy as ever (unlike many of the patients who received treatment). Galen's 'scientific' writings had been recently rediscovered, translated and adapted; his theories re-examined and absorbed into the Christian doctrine for the modern European age. Medical treatment involved a thorough examination of the patient. The pulse would be read and therapy prescribed, depending on the imbalance of the humours. Just as in Galen's day if you went to the doctor with a fever there was a good chance he would get out the bleeding bowl or reach for the purgative and funnel to clear out your bowels.
But whereas the study of medicine was a respected, even noble, profession, surgeons were, as Vesalius would bemoan, considered little better than servants. There was, however, a growing fascination with anatomy. This was led, to a large extent, by artists. Renaissance artists were enthralled by the human body, its form, bone structure and musculature. And in the same way that doctors looked to Galen for insights, artists took inspiration from the beautiful statues of ancient Greek and Roman culture. A few years earlier, Leonardo da Vinci had become intrigued by the mechanics of the body. He produced intricately detailed drawings of human anatomy, of the brain, blood vessels and nervous system. Unfortunately, they remained unpublished during his lifetime.
Human dissection, almost always of criminals, was rare but gaining in popularity as part of medical training. Students were expected to attend lectures on human anatomy. At these, a professor would stand in a pulpit to read from Galen's text, while an assistant opened up the body. But these events could become awkward affairs when it became apparent that what Galen had described bore little relation to the anatomical reality of the human body. People were beginning to realize that, for all his genius, Galen had probably cut open animals rather than people. Some in the medical profession – particularly precocious medical students – were starting to question his wisdom. For surgery to develop, someone had to get a proper grip on where everything was and how it worked.
Vesalius set himself the task of reaching a fuller understanding of human anatomy. Back in his kitchen he began to sort out the bones and cartilage of the skeleton. He painstakingly identified each bone and laid it out in the correct position until his human jigsaw gradually came together. The parts that were missing, the foot and kneecaps, he 'obtained' from another corpse. There are 206 different bones in the human body, and Vesalius eventually laid out every one before carefully wiring them together into a skeleton that could be hung from a hook – not unlike the gibbet it was originally taken from.
The reconstructed skeleton was only the start. Over the next six years Vesalius dissected as many bodies as he could lay his hands on. Many were those of executed criminals; others he acquired from cemeteries. The contributions these dead people made to medicine were considerable. With their help, Vesalius was soon able to map every single organ, muscle and ligament in the human body.
Within the next few years Vesalius popularized dissection and started holding public anatomy demonstrations. These were attended by hundreds of spectators – not just medical students. Dissection became such a popular entertainment that the supply of bodies started to run out. This created a lucrative source of employment for less desirable elements of society. Working in gangs, bodysnatchers (or resurrectionists, as they would later be known in Victorian London) could make a comfortable income. However, the profession wasn't without its occupational hazards. Even if the authorities turned a blind eye, bodysnatching was still illegal. There was also the risk of picking up diseases. A small infected cut and you could soon be joining the other bodies destined for the dissecting table.
Vesalius published his work in De Humani Corporis Fabrica (The Construction of the Human Body). The invention of printing, using movable type and woodcuts, allowed him to include technically accurate and lavish illustrations. These pictures accurately identify the locations of all the major organs, nerves and muscles in the human body. The woodcuts show corpses posed in various unlikely situations, as if they are still alive. A picture revealing human muscles has the figure posed on a hillside in front of a town. There is a corpse dangling from a pulley and a skeleton resting against a tomb as if contemplating the meaning of life (or death).
The book was widely distributed and read by medical practitioners across Europe. In it Vesalius corrected more than two hundred of Galen's mistakes. These ranged from the structure of bones to the shape of the liver. In the second edition of his book, Vesalius also ruled out a connection (through Galen's micro-holes) between the two sides of the heart. However, even though he had worked out the structure of the heart, he still believed arteries originated in the heart and agreed with Galen that veins started in the liver. It was another eighty years before William Harvey concluded that the blood circulated around the body (see Chapter 2).
After 1300 years of stagnation, anatomy was finally on a firm scientific footing. Physicians and surgeons at last knew how the human body fitted together. Vesalius had broken the first barrier to the development of modern surgery. However, there were still three more barriers to go.
BLOOD ON THE BATTLEFIELD
A field near Turin, Italy, 1537
This is what happens when a musket shot hits a human body.
The bullet punctures the skin. As it does so, it drags fragments of clothing and gunpowder with it. The shot rips through the flesh, burning the tissue and splaying slivers of skin outwards. It gouges its way through the muscle, tearing apart the muscle fibres and severing tendons, veins and arteries.
As an artery wall is ruptured, blood starts to spray from the wound – pulsing at high pressure into the cavity the bullet has drilled. The bullet slows as it reaches the bone. The bone splinters, scattering sharp fragments. The two ends of the broken bone smash outwards through the skin. By now, the bullet has lost momentum and becomes lodged in the wound, mixing with the congealing bloody broth of muscle, bone, cloth and skin.
Injuries from musket bullets were far worse than anything that had been seen with daggers, swords or arrows. When a blade or arrow enters the body it inflicts a 'clean' wound and, with any luck, comes straight out again. But with the invention of the musket, and the larger guns that went with it, the battlefield was transformed. The few battlefield surgeons available had to cope with overwhelming casualties on a daily basis. When the guns opened fire and the men fell, the smoke mingled with a flume of fine red mist – blood spraying upwards from the injured and dying men.
Ambroise Paré had never seen such horror. The twenty-seven-year-old had been appointed as a battlefield surgeon to the French infantry commander at the siege of Turin. The army had been sent into northern Italy by the king, François I, in a long-running dispute over territory with the Holy Roman emperor, Charles V. By the time Paré arrived, the carnage was already horrific. To get close to the battlefield he had to ride across the bodies of dead and fatally wounded soldiers. Picking his way between them as best he could, he was forced to ignore their dying moans and pleas for help.
As Vesalius had noted, in sixteenth-century European medicine even experienced surgeons held little standing in society. The people who practised surgery were usually barbers. They had received no formal medical training and spent most of their time trimming beards or lopping off the odd wart. They might sometimes be employed to assist doctors with bloodletting. As for Paré, he was neither qualified nor registered as a surgeon. He had been working as a barber-surgeon at the largest hospital in Paris, he had no academic qualifications and no experience of anything other than the most basic surgical procedures. Everything he learnt about the profession (if it could even be described as such a thing) came from hands-on experience. He was familiar with basic anatomy and the theories of more advanced surgical techniques, such as amputation, but had not had the opportunity to put his knowledge into practice. He was going to have to learn fast.
Although the technology of war had advanced considerably over the last few centuries, battlefield surgery had changed very little. Surgeons had few options at their disposal. Any substantial wounds or compound fractures of a leg or arm usually meant the limb had to be removed. If a bullet entered a soldier's abdomen, surgeons might attempt to remove it with their fingers, or try to drain the wound of blood (and later pus as infection developed), but could do little else. For any seriously wounded soldier, the odds of survival were poor. However, surgery might give them a chance of life.
Every day Paré would saw off limbs. To stop the bleeding he used a hot cauterizing iron. As the leg or arm was removed, he placed the iron against the flesh – searing the muscle, blood vessels and skin together. Bullet wounds received the same treatment. With larger wounds, boiling oil was applied instead. Poured into the hole left by the bullet, the oil would burn everything it touched, destroying tissue but defeating blood flow. There was a belief at the time that gunpowder was poisonous, so cauterizing with an iron or pouring in hot oil had the secondary effect of destroying any poison. Or so the theory went. When bullets had failed to kill the soldiers, the shock of having boiling oil poured into their wounds often finished the job.
Cauterizing was not only brutal, it was also ineffective. By the time the surgeons had amputated a limb, a tremendous amount of blood had already been lost. Many soldiers bled to death before the arteries could be sealed shut. Even if they didn't die immediately, they would often lose so much blood that their chances of recovery became even slimmer.*
* Paré also had to deal with increasing numbers of casualties suffering severe burns. Lines of gunpowder would be laid by the enemy to create explosive walls of flame, cannons could misfire, and there were regular accidents with powder flasks and kegs. The salves available for burnt skin caused horrible blistering, and wounds often became infected as a result. Paré developed new treatments for burns and revised traditional ones. In one instance he used thejuice of onions mixed with salt, which he applied to the wound with a cloth. He reported it as being a remarkable treatment.
Paré started desperately looking for better and more humanitarian ways of treating battle wounds. His priority was to work out a more effective method of stemming the flow of blood. What little spare time he had was devoted to studying anatomy texts. When the guns went silent, he spent the evenings drawing diagrams and making reams of notes. His aim was to seal the arteries themselves – rather than the entire wound – block them off to prevent the worst of the blood loss.
His solutions were simple. His first invention he called a 'crow's beak'. The beak consisted of a set of curved forceps that could be clamped across the artery to block the flow of blood. Although other, smaller blood vessels would still be open, this device stopped the worst of the bleeding and bought him time during operations.
Next Paré devised a way of tying off blood vessels during amputations. This was not a completely new idea, but there is no evidence that it had been tried in practice before. Once the artery was clamped off using the crow's beak, he would tie off the vessel downstream of the forceps using silk thread. This 'ligature' would permanently block the artery. Starved of blood, the portion below the ligature would eventually die and drop off.
Paré published his first book, Treatise on Gunshot Wounds, in 1545. In it he detailed his experiences in combat and the lessons he had learnt. His practice of not using a cauterizing iron or boiling oil was widely adopted by those who read his work. The book revolutionized trauma surgery, or at least it did in many parts of mainland Europe. Unfortunately, because the book was written in French and not translated into Latin or English, other surgeons – particularly in Britain – continued to use cauterizing as a 'treatment'.
From a young, inexperienced, barely qualified surgeon, Paré went on to become one of France's most celebrated medical practitioners. His treatise was finally translated into English in 1617 as The Method of Curing Wounds Made by Gun Shot (Also by arrows and darts). The book is gloriously illustrated with a gruesome woodcut of a 'man of wounds'. The man has an axe through his head, a bullet through his leg and a dagger in his side, in addition to wounds from swords, arrows, spears and darts. Seventeen wounds in total. Even an accomplished surgeon like Paré would be hard pushed to treat him successfully.
Paré's crow's beak and ligature, although brilliant innovations, were less effective in practice. To stem the flow of blood completely following a thigh amputation, for example, more than fifty ligatures are required – although around ten would probably suffice to stop the worst of the bleeding. But in the dirt, smoke and poor light of a makeshift field hospital, even applying ten ligatures would prove completely impractical.
Likewise, trying to apply the crow's beak to a slippery artery that was spurting out blood at high pressure, while struggling to hold down a screaming patient, was an appalling challenge. It wasn't until the invention of an effective tourniquet (such as the 'Petit' type used by Liston) that ligatures really came into their own. But Ambroise Paré's contributions to modern surgery are nevertheless considerable. Above all, his efforts to reduce his patients' suffering shines through as a fine example to future generations of surgeons.
Thanks to Vesalius, Galen's mistakes had been corrected and surgeons now knew how the body fitted together. Paré had worked out how to tie off blood vessels and prevent patients from bleeding to death. What both men had in common was the courage to question the status quo; to challenge incorrect medical dogma. These were surgeons who trusted what they saw with their own eyes and learnt from their own experiences. Two major barriers to successful surgery had been broken. It would be more than three hundred years before the next major obstacle – pain – was overcome.
University College Hospital, London, 1846
Frederick Churchill of 37 Upper Harley Street was admitted to hospital on 23 November. Unmarried, and employed in service all his life, he had started as a footman and for the past sixteen years had worked as a butler.
A clerk noted down everything as the dresser asked a series of questions. The case notes would later run to some ten pages.
Aged thirty-six, Churchill was five feet eight inches tall with a fair complexion. His state of mind was cheerful and his sleep was generally sound. His habitual state of health was good, although not as strong as it had been eight or nine years ago. He was, the dresser noted, rather thin. Churchill's medical history included an attack of gonorrhoea eighteen years previously, and another attack around ten years after that.
In the year 1840 the patient had experienced a swelling in his right knee that became very painful. Severe pain was also experienced following a later fall in which the same knee was violently bent. In 1842 'considerably more' swelling and a 'discoloration of the leg ensued' following an injury to the left limb.
There had, the dresser recorded, been some outpatient treatment ordered by a medical man, but this had been discontinued. Then, in 1843, the swelling had been opened up – cut into with a knife – and 'a number of irregularly shaped bodies' were pressed out. These bodies appeared to have a fibrous, granular structure and varied in size from a pea to a large bean. They were preserved in alcohol and examined under a microscope. There were sufficient of these bodies to fill a two-ounce bottle.
'It is Professor Liston's opinion,' the dresser concluded, 'that these bodies are the remains of extravasated [forced out] blood.' Churchill's appearance was described as like that of someone in 'good but not robust health'. The right knee was much swollen and a probe could be passed through the cavity in the joint. Following this, Churchill was ordered to remain in bed. 'A thin serous discharge is given out. Pulse 80. Ordered to have a full diet and milk 1 pint.'
On 25 November Professor Liston examined the patient himself. He passed a probe into the knee and made an incision. Probing with his finger he could feel bare bone and the head of the tibia, one of the lower bones of the leg. He pulled on the bone to see if it was loose but this did not appear to be the case. Liston ordered that clean warm-water dressings should be applied and Churchill should undergo complete rest.
Churchill's condition began to deteriorate. He lost his appetite and the dressers noted that his tongue had become furred. More substantial food was ordered – a chop daily, a pint of beef tea and a pint of porter. On 27 November he experienced a terrible attack of pain extending from the hip to the toes. The swelling in the knee had increased and he suffered shivering, sickness and headache. Hot fomentations (poultices) were applied, which helped to relieve the pain.
On 17 December the dresser recorded that the patient 'had a kind of hysterical attack and was much excited', but by 20 December his appearance had improved and he appeared to be 'more healthy'. The next day he would go to the operating theatre to have the limb removed. Frederick Churchill had yet to be told that he would be part of a groundbreaking experiment.
At twenty-five minutes past two on the afternoon of 21 December, the porters carry Churchill into the operating theatre. As usual the galleries are filled with undergraduates nervously anticipating what was usually a dramatic, and often horrific, event.
Churchill is utterly terrified. He had known when he was admitted to hospital that it would probably come to this. At least with Professor Liston the ordeal would be over in a matter of seconds. Could he bear the pain? Could he appear strong in front of all these men?
Liston enters. The room goes quiet. 'We are going to try a Yankee dodge today, gentlemen, for making men insensible.' For the first time in the United Kingdom an amputation is about to be attempted using an anaesthetic. There had already been some trials at the hospital using hypnotism, or 'mesmerism', but the results had been mixed. Fundamentally, it was difficult to prove the scientific rationale for mesmerism, and among men of science it was considered superstitious nonsense.
The 'Yankee' Liston spoke of was the American inventor of the ether anaesthetic, William Morton, a Boston dentist. Morton had been trying a gas called ether – a pungent mixture of alcohol and sulphuric acid – on his patients during the extraction of teeth. (Given the generally poor state of dental health, there was no shortage of subjects.) Morton's process of 'insensibility' reached the attention of surgeons at the Massachusetts General Hospital in Boston, who were keen to use ether during operations. In a submission to the American Academy of Arts and Sciences, a surgeon at the hospital, Henry Bigelow, described the effects of ether both for dentistry and more serious operations. He reported a tooth extraction on a 'stout' boy of twelve. Upon wakening, the boy declared it was 'the best fun he ever saw'. The boy insisted on having another tooth extracted. In early November 1846 ether was tried on a young girl having her leg amputated above the knee. She lasted the whole operation without feeling a thing.
But Churchill doesn't know any of this. He lies on the operating table. A rubber tube is held to his mouth and he is told to breath through it for two to three minutes. The tube is connected to a flask containing ether gas. As Liston stands ready with his knife, the only sound in the room is Churchill's deep anxious breaths. Eventually the man becomes still.
After the rubber tube is removed from Churchill's mouth, a handkerchief laced with some drops of ether is laid over his face. Liston looks up at the galleries. The students are more excitable than usual – this would truly be one for the history books.
'Now gentlemen, time me!'
Liston slices his knife into Churchill's thigh. The tourniquet is tightened, Liston's swift movements cut the familiar U-shaped incisions, sweeping around the leg, pulling aside the flesh to expose the bone, to and fro with the saw, the ligature ready and the stitches in, the severed limb lying in a pool of congealing blood in the sawdust.
'How long, gentlemen?'
'No, I made it thirty!'
'Thirty?' exclaims Liston.
This last figure has the time recorded in the case notes for the operation. Churchill has remained insensible throughout, not a sound came from his lips, not a groan, not even the slightest grimace.
'When are you going to begin?' exclaims the patient a few moments later.
This is greeted with peals of laughter from the gallery. There was rarely laughter after an operation. Churchill looks terrified. 'Take me back, I can't have it done!' Only when his amputated leg is held up for him to see does he believe that the operation has already taken place. He looks down to see his gently weeping stump. Later Churchill recalled feeling only a sense of great coldness and the memory of 'something like a wheel going round his leg'. The porters come forward with the stretcher to take him back to the ward. 'This Yankee dodge, gentlemen, beats mesmerism hollow!' declares Liston.
Later in the day another patient is given ether inhalation during an operation for an ingrowing toenail – previously an unbearably painful procedure. Flushed with success, Liston rushes off a quick letter to the Lancet, writing of the 'most perfect and satisfactory results'.
It is some minutes after Churchill is laid back in bed that he starts to feel any pain. By seven in the evening it has become excruciating. A dresser ties off more ligatures, making a total of ten altogether. Later, the two U-shaped flaps of skin are tied together with a series of sutures. Considering the agony, Churchill is remarkably cheerful, and as the evening progresses the pain begins to subside.
The patient is to remain in hospital for another seven weeks. On 31 December the dressers report that he is improving daily, the stump is healthy and 'discharging a small quantity of good pus'. A bandage is applied. By the end of January he is walking around on crutches. Frederick Churchill's case notes record that he was 'discharged, cured' on 11 February.
Soon, thanks to the pioneering efforts of a Boston dentist and Liston's reputation in Britain, almost every surgeon wanted to try ether. This Yankee dodge was surely the future of surgery. Some still felt that pain was an essential part of the healing process, but given the choice, what patient would want to go to them for an operation? During the Crimean War (1853–6), for instance, by which time anaesthetics were commonplace, surgeon John Hall was reported as saying, 'I like my patients to feel the smart of the knife.'
Liston took to holding parties at which ether was passed around the assembled guests. These social events usually included a cross-section of the capital's best-known artists and sportsmen, as well as surgeons, doctors and other gentlemen and their wives. Much hilarity ensued when the gas was tried out by some of Liston's assistants and they were seen to lapse into insensibility.
The relatively small doses of ether applied before operations meant that patients were 'under' for only a few minutes at most, yet the possibilities the successful relief of pain offered were endless. Operations no longer had to be so fast. Surgeons could take their time; they could attempt more complicated procedures. Robert Liston would not live to see the full potential of anaesthetics realized. He died in a sailing accident less than a year later. But by then his era of lightning-quick surgery was over.
THE MEDICAL STATE OF THE ART
While surgeons were saving lives with new techniques, medical science was struggling to catch up. The work of doctors had barely advanced since the Middle Ages, and if surgery was an inexact science, then Western medicine was more akin to a faith, a bit like astrology – scientific method built on foundations of sand. Treatments had changed little over the proceeding centuries and were limited in their scope. There were few cures available to doctors, and fewer genuinely effective drugs. Apothecaries boiled up all sorts of weird mixtures with varying results. A typical example from Guy's Hospital includes 'bath of herbs and sheep heads' prescribed to a woman suffering from an 'unknown illness'. How marinating the poor lady in offal was going to cure her was anyone's guess. Still, she probably paid handsomely for the privilege.
At best, all doctors could hope to do was to assist the natural process of healing. This might work for influenza, but would be completely ineffective against tuberculosis, syphilis or a heart condition. Even in the 1840s, the work of the physician was still firmly rooted in superstition. When you called on a doctor to attend you – and they did not come cheap – you might reasonably expect some sort of treatment. But the physician's options were limited. Medical practice was still based on the theory of the four humours developed by Galen. It was the job of the doctor to balance the bodily fluids of yellow bile, black bile, phlegm and blood.
As the understanding of anatomy had advanced over the centuries, most Victorian doctors knew this view of physiology no longer made sense. Yet the treatments available remained largely unchanged. Doctors could prescribe drugs. Some were effective for pain relief but others, such as mercury, were downright dangerous. Physicians would induce vomiting or diarrhoea in the patient to purge the body. They could also drain away excess blood. All these treatments made sense if you accepted the idea of the humours. They made no sense at all if you looked at the growing scientific evidence against them.
Bloodletting was as important to early Victorian medicine as it had been for almost two thousand years. Draining blood allowed doctors to remove 'morbid' matter from the bloodstream. This, the logic went, would be replaced by new healthy blood. Doctors carried scalpels or lancets (hence the name of the medical journal) to cut the skin and allow the blood to drain into shallow bowls. Others employed 'cupping' techniques, where small glass bowls were heated and placed over the lanced area of skin. The bowls cooled, forming a vacuum which helped to suck blood from the body.*
* Cupping also proved effective for pain relief, and was in common use in hospitals until the 1950s.
Some doctors preferred using leeches rather than cups. When leeches are attached to the skin they secrete a chemical that prevents the blood from clotting. This anticoagulant is so effective that even when the leech is removed, the wound will continue to bleed for another three to four hours. Leeches were particularly useful for bleeding sensitive areas of the body, such as the gums or around the eyes. American leeches were said to have a less irritating bite than British ones. The received wisdom was that leeches should be kept in a tub of river water with some peat or turf. It was best to rinse them before application.
For the modern physician who wanted to keep up with cutting-edge medical advances, scarifiers were the answer. These vicious contraptions resembled the mechanism of a clock and were marketed as the 'mechanical leech'. This 'new and modern' device contained a row of blades. When it was placed against the skin and a button was depressed, the blades sprang out to puncture the surface and induce bleeding.
The cases where bloodletting appeared to be effective were probably attributable to the placebo effect – the patient's belief in the treatment.* At least with bloodletting, patients were getting something for their money. However, by the 1860s evidence was mounting that the procedure was not only useless, but was probably doing more harm than good, particularly when advances in human physiology showed that bloodletting reduced the concentration of red blood cells. These contain haemoglobin, the protein complex that carries oxygen.
* There have been several studies over the years that show the placebo effect is actually quite an effective treatment. If patients believe a drug is doing them good, they tend to recover more quickly.
Nevertheless, and despite the scientific evidence, doctors were reluctant to abandon bloodletting altogether. At the turn of the twentieth century it remained a recommended treatment for high blood pressure (based on the 'common sense' argument that less blood meant less pressure). Even as late as the First World War, the technique of bloodletting was applied to the victims of gas attacks in the trenches.
Aside from blood, there were plenty of other bodily secretions to worry about. Urine in particular was seen as a valuable diagnostic tool. Not its chemical composition – its protein or sugar concentration – but its colour. Much, it was said, could be read into the colour of urine. Some specialists made their diagnosis on urine alone. Flasks of urine would be sent to them by other doctors for a specialist opinion. Often, somewhat inevitably, the prescribed treatment for the patient's ailment would be bloodletting. And so it went on. Doctors seemed to be struggling to keep up with scientific developments. Surgeons, on the other hand, were as eager as ever to try something new.
MR SIMPSON CONDUCTS SOME INTERESTING
Ether was gaining in popularity, but the anaesthetic did have its drawbacks. It was a noxious gas to breathe, irritating the mouth and lungs. It had a tendency to induce vomiting in patients. The flask and tubes involved in administering it were awkward, and its effectiveness proved inconsistent. But the biggest problem was ether's high flammability.
Ether was being used only inches from the naked flames of the gas lights hanging over the operating table. The slightest upset and the gas was likely to explode in a ball of flame. There was also no way of telling how the prolonged use of ether would affect the patient. Would it leave them permanently unconscious or even brain damaged? Surgeons were used to their patients dying, but this seemed an especially unnatural way to go. There was also the question of its pedigree: it had been invented by a maverick 'Yankee' dentist. This was deeply unsettling to British, scientifically trained surgeons.
The only way the medical questions were going to be answered was to experiment on patients. Surgeons, of course, usually had no problem with this. Some, however, felt the drawbacks of ether were too great and started to look for an alternative.
James Simpson was a young professor of midwifery at Edinburgh University. As a student under Robert Liston, Simpson had attended his first operation aged just sixteen (he qualified in medicine at eighteen). The horror of the experience had lived with him ever since. Now head of obstetrics, he realized that every day he was witnessing more pain than ever.
Simpson was the son of a village baker, so to have risen to such a high position within the Scottish medical establishment was a remarkable achievement. He appears to have won the post through a combination of political persuasion (money may or may not have changed hands), public campaigning and, above all, an overwhelming sense of confidence and self-belief. It helped that he was also an excellent surgeon.
During a visit to London, shortly after the first ether operation, he had the opportunity to talk to Liston and confirm what was involved in the procedure. Perhaps he could apply pain relief during childbirth to relieve the terrible suffering some women had to endure? But questions about ether's safety become even more important when childbirth is involved. The gas would not only have to be used over a long period – hours possibly – but there was no knowing what effect it could have on the foetus. Might the child be killed or born an idiot? Simpson would also have to contend with religious and moral objections to the use of pain relief. Surely the pain of childbirth was a natural process? Didn't Genesis state that woman should bring forth her children in sorrow?
But Simpson was a driven man. He spent that summer trying out every chemical he could lay his hands on. He mixed a whole variety of substances together, drank and sniffed a cocktail of compounds. Every chemical that might prove a suitable candidate was inhaled or ingested. Then one day Simpson tried a new chemical that had been suggested by a Liverpool chemist. He woke up on the floor.
The last substance Simpson had tried before he passed out was known as chloroform. A colourless liquid composed of alcohol and chlorinated lime, chloroform had been invented some fifteen years earlier and marketed both as a treatment for asthma and a stimulant. That it had quite the opposite effect was an early cautionary lesson to not always believe what the pharmaceutical industry puts on the bottle. After trying the chemical a few more times, Simpson decided that chloroform needed rigorous testing before he used it on patients. So a few days later he took the opportunity to experiment on friends and family.
After dinner one night he served up tumblers of chloroform to some of the assembled guests. On breathing in its sweet, fruity aroma, they slipped into a magical state of relaxation. They laughed, they joked, the room started to spin, the conversation became distant and faint. The guests tumbled off their chairs or lay themselves down on the floor. Then everything went blank. 'This is better than ether!' exclaimed Simpson as he picked himself up off the rug some minutes later. 'A most pleasurable experience.' So pleasurable, in fact, that all the other guests were keen to try the thrill of chloroform for themselves. Simpson's niece had a sniff and presently declared herself an angel before passing out on the settee.
His scientific trial now complete, Simpson concluded that chloroform was a great success, and was in no doubt that it would bring untold benefits to his patients.
Four days later, Jane Carstairs is in the final stages of labour. Her screams following each contraction can be heard far beyond the delivery room. Bathed in a blanket of sweat, she is starting to become exhausted. Simpson knows he will have to intervene. He will probably have to use forceps, slipping the instrument – like a pair of long, wooden-handled serving spoons – either side of the infant's head. Then he will pull and it will hurt even more.
Simpson sprinkles a few drops of chloroform on to a handkerchief and lays it across Mrs Carstairs' mouth and nose. 'Keep breathing deeply,' he tells her. Within a minute she is asleep. When she awakes she is handed a little baby girl. The first success for this marvellous chemical.
This was the final proof Simpson needed that chloroform would transform nineteenth-century medicine. The charismatic surgeon saw it as his mission to spread the word. 'It was my duty,' he said, 'to teach all these people that they were wrong and I was right.' While taking every opportunity to try the drug out in his own practice (within a week he had used the new anaesthetic in an astonishing fifty cases), Simpson planned a marketing campaign to make sure as many people as possible knew about chloroform. Rather than publish his findings in a journal, couched in cautious scientific terms and possibly written in Latin, he took his results directly to the public. He drew up pamphlets that he sent out to other doctors. He gave talks and held demonstrations. He even took out an advert in the Scotsman newspaper, proclaiming this new miracle pain relief.
Not only was chloroform a more effective anaesthetic than ether, it was also a Scottish invention, and soon became a source of national pride. Simpson's confidence was infectious, and surgeons across Europe began to adopt his technique. Others sought to refine it, looking at new ways of administering the drug. One of Simpson's friends, a certain Dr Smith, tried to administer the drug rectally. Filling a syringe with chloroform, he injected it into his back passage. He woke up some hours later in a pool of diarrhoea with the syringe still in place, and suffered severe anal burns.
Apart from Dr Smith's misfortune, chloroform seemed to have few disadvantages. Patients were comfortable taking chloroform; it was easy to use and, unlike ether, involved no cumbersome equipment. As Simpson put it, 'No special kind of inhaler or instrument is necessary for its exhibition. A little of the liquid, diffused upon the interior of a hollow-shaped sponge, or a piece of linen or paper, and held over the mouth and nostrils, so as to be fully inhaled, generally suffices, in about a minute or two, to produce the desired effect.'
For the first few months everything seemed to be going well. Then, on 28 January 1848, fifteen-year-old Hannah Greener of Winlaton, near Newcastle upon Tyne, went to see surgeon Thomas Meggison for the removal of a toenail. She had undergone a similar procedure a few months earlier under the influence of ether, so was less fearful than she might otherwise have been. Nervous nevertheless, she was reassured by her uncle that everything would be fine. Mr Meggison would be using this new anaesthetic, chloroform. She would not feel a thing.
Hannah is seated in a chair. Meggison drips a teaspoon of chloroform on to a cloth and holds it to the girl's nose. She takes two deep breaths and pulls Meggison's hand away. He asks her to try again, this time breathing naturally. Half a minute later the muscles of Hannah's arm become rigid and her breath a little shorter. Meggison puts his hand on her pulse. It seems somewhat weaker but has not altered in frequency.
Meggison asks his assistant, Mr Lloyd, to begin the operation. Using a knife, Lloyd makes a semicircular incision and carefully prises off the toenail. Hannah starts to struggle and jerks forward. Meggison believes this is because the chloroform has not had sufficient effect, but he does not administer any more. Hannah's eyes are closed, but when the surgeon reaches forward to open them, they remain open. He starts to become concerned. Her mouth is also open, and her lips and face are suddenly pale.
Meggison calls for water and throws some in the girl's face. She does not move. He tries to give her some brandy. He holds it to her lips and, he later claims, she swallows – albeit with difficulty. Increasingly desperate, he lays her on the floor, cuts her arm with a lancet and tries to bleed her. When only a few drops come out, he tries bleeding her from the jugular vein in the neck, but manages to get only a spoonful of blood. Three minutes after Meggison administered the chloroform, Hannah Greener is dead.
An inquest before a jury was opened four days later and Meggison gave his account of Hannah's final minutes. The inquest heard from the doctors who conducted the post-mortem examination. They reported that the girl's lungs were in a 'very high state of congestion'. The coroner, J.M. Flavell, also included in the record an account of a chloroform experiment on mice. The mice had also died from congestion of the lungs. The jury concluded that Hannah 'died of congestion of the lung produced by chloroform'.
Simpson rejected the findings of the inquest, claiming that the death was more likely caused by the water and brandy. Subsequent studies have found it very unlikely that chloroform had a direct effect on Hannah's lungs. But it seems certain that it was at least partly to blame for the girl's death. And although she was the first to die under the influence of chloroform, she would not be the last. As surgeons started to use the drug for everything from ingrown toenails to major amputations, more and more people were dying. The deaths were sudden and dramatic as if, one surgeon reported, 'the patient had been shot'.
Curiously, the people who died were generally young and fit. Chloroform also seemed to kill a higher proportion of those who were more afraid of the procedure. Perhaps inevitably, deaths were higher in Scotland, where chloroform was the anaesthetic of choice, than in England, where ether was still preferred. Not that Simpson was experiencing any problems himself. All except one of his patients survived chloroform anaesthesia, but as the woman was quite frail anyway he was able to dismiss (in his own mind at least) any link to the chemical. A substance that had started out as a party trick, and was being used successfully on a daily basis, was also turning out to be a killer.
What the chloroform anaesthetic lacked up until now was any science. No proper studies had been done into what effect the chemical had on the body, or the doses that should be used. Simpson's advice to use 'a little of the liquid diffused upon a pocket handkerchief' was beginning to reveal its shortcomings. Should less be used for a young girl than an old man? How long should the handkerchief be held over the patient's face? These were fundamental scientific questions that no one had bothered to ask. Fortunately, someone else was already working on the problem.
In London Dr John Snow had been following the development of anaesthesia with great interest. He had already devised a number of improvements to administer ether, including a new type of vapour inhaler, and had drawn up tables to help surgeons calculate the correct (and safe) concentration of gas required.
Snow was the complete opposite of Simpson. He was a quiet, calm, diligent man given to careful scientific study. In 1848, as well as trying to save lives by improving anaesthetics, he was studying the outbreaks of cholera that were killing tens of thousands of people in the capital.*
* Snow worked out that cholera was spread through contaminated water rather than being carried in the air. Unfortunately, thousands more Londoners would die before his findings were accepted by the city authorities.
In his publications on anaesthetics, Snow was very careful not to criticize Simpson 'in conferring on us the benefit of chloroform'. However, Snow was convinced that surgeons and doctors were using too much of it. He studied the effects of different concentrations of chloroform and divided them into 'degrees of narcotism'. In the first degree the patient was fully conscious, aware perhaps of the agreeable feelings felt when inhaling the chemical. The second to fourth degrees referred to various stages of insensibility or unconsciousness. Experiments with frogs suggested that a patient in the fifth degree of narcotism might stop breathing or suffer complete heart failure.
Snow concluded that chloroform had an effect on both respiration and the heart, and that there was a terribly fine line between insensibility and death. A third of a teaspoon of chloroform was enough to knock a patient out, but half a teaspoon could kill them. He reasoned that different people needed different doses. Young, fit patients might need more chloroform to render them unconscious, but this pushed them closer to a fatal dose. As for those who were 'fearful', it was probably because they were holding their breath for as long as possible. When they finally took a breath, they inhaled enough chloroform to stop their heart.
After applying his study to different classes and sensibilities, Snow took his conclusions further:
Those persons whose mental faculties are most cultivated appear usually to retain their consciousness longest whilst inhaling chloroform and, on the other hand, certain navigators and other labourers, whom one occasionally meets with in the hospital, having the smallest possible amount of intelligence, often lose their consciousness, and get into a riotous drunken condition, almost as soon as they have begun to inhale. There is a widely different class of persons who also yield up their consciousness very readily, and get very soon into a dreaming condition when inhaling chloroform. I allude to hysterical females.
On Chloroform and Other Anaesthetics: Their Action and Administration (1858)
Of course, the effect of chloroform had nothing to do with intelligence, educational attainment or class, but there was clearly some sense in controlling and regulating the dose. For those, such as 'hysterical females' who 'yield up their consciousness very readily', Snow advised using lower doses of chloroform. Whatever the subject's susceptibility to the drug, it was obvious to Snow that splashing a few drops on a handkerchief was downright dangerous. Just as he had devised better means of delivering ether to patients, he now set about designing an inhaler for chloroform.
A measured amount of liquid chloroform was added to a flask. This was attached to a tube, and a mask was placed over the patient's face. When the doctor cupped his hands around the flask this warmed the liquid, vaporizing some of the chloroform to a gas that the patient could comfortably breathe in. Even hysterical females. Snow's method was safe, easy to use and reliable. He administered chloroform to more than four thousand people. Only one of them died, and that was probably from other complications.
By 1853 Snow had become one of the physicians to Queen Victoria. During the birth of her eighth child, Prince Leopold, Snow administered chloroform. There were no complications with the birth and it is likely that he used only a small dose for pain relief. However, when the medical establishment found out, the Lancet published a furious editorial chastising Snow (although not by name) for putting Her Majesty's life at risk. The editorial spoke of the 'deplorable catastrophes' that were referable to the 'poisonous action' of chloroform, and the 'awful responsibility' of advising the administration of the drug to the queen.
Not that this controversy deterred Snow; after all, he had a genuinely fine track record. He employed chloroform again during the birth of Princess Beatrice four years later. Had Simpson been overseeing the birth, there might have been more cause for concern. That Snow, rather than Simpson, bore the brunt of criticism from the Lancet for risking lives with anaesthesia seems hardly fair. But then Snow was never to receive the recognition he deserved for any of his medical or public health achievements.
James Simpson died, aged fifty-nine, in 1870, a Scottish hero. He was the first man to be knighted for services to medicine. A huge state funeral was held in Edinburgh, the largest in Scottish history. Flags were flown at half-mast and thirty thousand mourners lined the streets. Statues and memorials were built. Hospitals were named after him.
John Snow, the man who had made Simpson's discovery safe, had died ten years previously. His great work on anaesthetics was published after his death. Snow's small grave was paid for by friends and colleagues. He also has a pub named after him.
Chloroform would continue to be used as a popular anaesthetic well into the twentieth century. In the end, Simpson's method of putting a few drops of chloroform on a piece of cloth became the most popular method of application. However, thanks to Snow's efforts surgeons used a lint mask and measured the chloroform using charts and a specially designed 'drop bottle'. Now (relatively) safe, chloroform could be used in the most difficult of circumstances and was the favoured anaesthetic in battlefield hospitals. Still, not everyone was convinced: some older surgeons were still suspicious of pain relief, preferring to hear the 'lusty screams' of soldiers as they went under the knife, a sure sign that the men were fighting for survival.
The invention of anaesthesia meant that surgeons had now conquered the third barrier to successful surgery. This, allied with a full understanding of anatomy and the ability to stem blood flow, meant they could now attempt new and more daring operations. People would seek treatment earlier. Women in particular might see a surgeon to have a small lump removed from their breast before the cancer took hold.
In theory, more lives than ever should have been saved. In practice, more and more people were dying. One out of five patients would probably end up in the dead house. In some hospitals, half of those operated on would be expected to die. Disease would ravage entire hospital wards. The disease even had a name: 'hospitalism'. Admittance to some hospitals amounted to a death sentence, and many people decided they would rather take their chances at home. Despite all the advances in science and medicine, no one could figure out why so many patients were dying.
NOW WASH YOUR HANDS
Childbed or puerperal fever was a terrible disease. Within days of giving birth, the mother would start to experience discomfort, soreness and a rising temperature. Abscesses and sores developed and spread across the body, accompanied by a swelling of the abdomen. As the infection spread, it devoured tissues and attacked the vital organs. Meningitis – a swelling in the lining of the brain – might be accompanied by fits and periods of unconsciousness. Few women recovered. And while this was bad enough, in many cases their newborn babies died too.
In one clinic in the maternity wing at Vienna General Hospital, puerperal fever was killing hundreds of mothers each year. In January 1846, out of 336 births, there were 45 deaths. In February of the same year, 53 out of 293 women died. This was a death rate of 18 per cent – one in five patients.
There were two clinics at the hospital. In the First Clinic the patients were seen by doctors – mostly medical students. The Second Clinic was run entirely by midwives. When the authorities divided the maternity unit into the two clinics, they expected to see a rise in mortality rates in the ward where the midwives were in charge. It was, they argued, only common sense: midwives received less training, were less scientific in their approach and, of course, less rigorous in their intellect (there were no women doctors).
But the opposite was happening. In the clinic run by midwives there were far fewer deaths. In 1846 a total of 459 women (11.4 per cent) died in the doctor's clinic compared with 105 (2.7 per cent) in the midwives' care. It was a striking difference – and one that soon became well known throughout the city.
The two clinics admitted patients on alternate days. The changeover between the clinics was at four o'clock in the afternoon. Women in the advanced stages of labour would delay admission as long as possible so that they would be admitted to the midwives' rather than the doctors' clinic. As a result, women were giving birth in the street or in carriages. Others would run screaming from the hospital or had to be dragged through the corridors when they discovered they'd been put in the First Clinic.
Something needed to be done. A commission was set up to investigate the disparity. Its conclusions were desperate. Male student doctors, 'particularly foreigners', were blamed for being too rough in their examinations. Most foreign students were removed. When this failed to reduce the death rate the 'atmospheric-cosmicterrestrial conditions of Vienna' were blamed for spreading disease – a 'miasma' was pervading the wards. The authorities struggled, though, to explain why, if there was something in the air, more women died in the First Clinic than the Second.
The patients themselves were blamed. These women were often the poorest in society; the wealthy would usually give birth at home (where the mortality rate was less than 1 per cent). Perhaps it was to do with the mothers' temperament or their slack morals? Many of them were fallen women. In an eventual admission of defeat, the authorities changed the days of admission, so women no longer knew which clinic they would end up in. It became, in effect, a lottery as to how likely they were to die.
There was one major difference between the clinics that the commission had failed to spot or perhaps considered unimportant. In order to refine their skills, the doctors had access to the bodies of the recently deceased. The midwives were forbidden by law to practise on cadavers, and had to make do with wax mannequins and porcelain models. As a result, the doctors and medical students spent much of their time in the mortuary. When needed, they returned to the wards to attend to their patients, the sweet smell of cadavers still on their hands. Some students even claimed that the scent was attractive to women.
In 1847 a twenty-nine-year-old Hungarian physician called Ignaz Semmelweis was appointed as first assistant to the professor of obstetrics at the hospital. He had responsibility for the First Clinic and saw for himself the horrible ravages of childbed fever. An intense yet kind young doctor, Semmelweis became obsessed with solving the mystery of all these deaths. Driven by the knowledge that for every ten patients he treated, two would die, he set out to find a solution.
As well as conducting autopsies on his deceased patients, Semmelweis pursued every theory he could think of. He suggested the disease was something to do with the position of the women when they were giving birth. Childbed fever seemed to affect firsttime mothers more than others – perhaps this was something to do with their labour being more prolonged. Could it be fear of the doctors that was causing the deaths? Being examined for the instruction of male students was surely offending their modesty. If the women were already predisposed to puerperal fever, maybe their fear of being examined led to the onset of the disease? Of course, their modesty could be offended in many ways, so this theory was quickly dismissed.
Semmelweis observed that a priest was passing among the women – usually to administer the last rites. Maybe the disease was something to do with a man of the cloth spreading the fear of death? Certainly the priest had more cause to visit the First Clinic than the Second. He was very understanding when asked not to ring the little bell he carried around with him. But even if fear was a factor in the women's deaths, this would not explain the deaths of the infants.
Nothing seemed to work. Every theory Semmelweis came up with failed to answer the fundamental question: why were more women dying in the First Clinic than in the Second? Obsession turned to frustration and anger as he failed to solve the mystery. His superiors noted that he was behaving oddly, making lots of bizarre changes to little effect. Semmelweis needed a holiday – for everyone's sake.
In March 1847 he and two colleagues set off for Venice. The Italian city was part of the Austrian Empire and had, once again, become a popular tourist destination. This was in part because it was much easier to get to than it had been previously, thanks to the new railway line speeding through the Austrian countryside – a wonder of the age. It was hoped that seeing the art treasures of Venice would revive Semmelweis's spirits, and it did seem to have the desired effect. He headed back to Vienna reinvigorated, ready to resume the challenge of tackling childbed fever.
He returned to find that, in his absence, one of his best friends had died. Professor Jakob Kolletschka, a pioneer of forensic medicine, had become fascinated by finding out how people died, and conducted regular autopsies. It was during an autopsy that he met his fate. He had been dissecting a body with some students. The hand of one of them slipped while making an incision and accidentally pricked Kolletschka's finger. The professor thought nothing of it – the cut was small, these sorts of things happened all the time. For anyone involved in surgery or medicine, cutting yourself with a scalpel was an occupational hazard.
Within a few hours there was some redness around the wound, but nothing to worry about. The redness started to spread up Kolletschka's arm, he became feverish and sores began to develop. Soon he was covered in multiple abscesses and had a swollen abdomen. The post-mortem found that his organs were infected and he experienced pneumonia and meningitis. Kolletschka eventually became delirious and slipped into a coma. Only a few days after becoming infected, he was dead. Semmelweis was distraught.
Kolletschka was not only a close friend – the two men had often worked together, and Kolletschka had supported Semmelweis throughout his obsession with childbed fever. But Kolletschka was to help Semmelweis one last time.
Reading through the post-mortem protocol, it did not take long for Semmelweis to realize that his friend's symptoms were identical to those of the women who died of childbed fever. His mourning would have to wait. Now he knew what was killing the women. 'The exciting cause of Professor Kolletschka's death was known,' he proclaimed. 'It was the wound by the autopsy knife that had been contaminated by cadaverous particles. Not the wound, but the contamination of the wound by the cadaverous particles caused his death.'
Semmelweis had realized that if his friend had been killed by particles from a dead body, then the same particles were killing the women. Doctors were conducting autopsies and then administering to their patients. At best they might wash their hands with soap before conducting vaginal examinations, but this still left the lingering smell of the cadavers. The doctors were spreading the disease. They had been carrying death on their hands. Semmelweis had been killing the very patients he was trying to help. The conclusion was shocking. 'I have examined corpses to an extent equalled by few other obstetricians,' he wrote. 'Only God knows the number of women who descended prematurely into the grave because of me. None of us knew that we were causing the numerous deaths.'
Semmelweis decided that something more than a quick wash with soap and water was needed to stop the spread of material from cadavers to patients. In the middle of May 1847 he introduced a strict new regime in the clinic. Before examinations all doctors had to wash their hands in chloride of lime, a caustic chemical much like bleach. He posted notices to this effect:
All students and doctors who enter the wards for the purpose of making an examination must wash and scrub their fingers and hands thoroughly in the solution of chlorinated lime placed in basins at the entrance to the wards. One disinfection is sufficient for one visit, but between the examination of each patient the hands must be washed with soap and water.
The results were better than Semmelweis could have hoped for.
In April 1847 there had been 57 deaths, the worst monthly mortality rate yet at 18.27 per cent. In May the figure came down to 36 deaths, or 12.24 per cent. The June figure was remarkable: there were only six deaths – a rate of 2.38 per cent, better even than the midwives' clinic. The following months were better still: in March and August 1848 not one patient died. Statistically, it was now safer for women to give birth in the hospital than at home. Thanks to Semmelweis, the hospital was now doing its job – saving lives.
The findings could not be clearer: childbed fever was caused by cadaverous particles transferred from the bodies of the dead. It was nothing to do with the atmospheric-cosmic-terrestrial conditions of Vienna, fear or foreigners. Semmelweis drew up tables to prove his point. 'Unchallengeable proof,' he said, 'for my opinion that childbed fever originates with the spread of animal-organic matter.'
He should have been a hero. Perhaps his manner did not help, or the fact that he himself was a foreigner. Some colleagues mocked him. They found the new regime of washing in chloride of lime inconvenient. It irritated their skin. And although everyone accepted that the number of deaths on the wards had dropped dramatically, where was the scientific explanation for Semmelweis's findings? What was this 'animal-organic matter' he talked of? How could the lingering smell of this material – this decaying flesh – possibly be enough to kill any healthy young woman?
His 'unchallengeable proof' was challenged by the head of the clinics – an ineffectual man drifting towards retirement. He did not want any controversy in his final months at the hospital, and this assistant was becoming increasingly troublesome. The doctors were complaining about this confounded new procedure. Semmelweis was sowing discontent and didn't know his place.
Semmelweis himself might also have been partly to blame for failing to get proper recognition for his work. He became entrenched in his views, would quarrel with anyone who disagreed with him and flew into rages. Except for those within the hospital and a small number of visiting doctors from elsewhere in Europe, few people knew of Semmelweis's discovery. Eventually his findings were published, but not by him. Some other hospitals adopted his procedures, but many did not.
The upshot was that hardly anyone outside the hospital and Semmelweis's immediate circle of friends knew anything of what he had achieved. His superiors eventually had enough of him and it came as little surprise when his contract was not renewed. In 1850 he returned to Hungary and took up the post of professor of obstetrics at St Rokus Hospital in Pest (later Budapest).
Here, if anything, conditions were even worse than they had been in Vienna. The Vienna General Hospital was at least a modern establishment, but of the eight beds in the obstetric unit at Rokus, one contained the dead body of a woman who had passed away the night before of childbed fever; the next bed contained a woman who was nearing the end of her life. The other six women were in the final stages of labour, but as they were also suffering from childbed fever it was extremely unlikely they would leave the hospital alive. The surgeon in charge carried out post-mortem examinations every morning before doing his rounds of the wards.
Semmelweis was quick to instigate a programme of cleanliness. He introduced chloride of lime and rigorous procedures for washing hands and instruments. By 1856 the mortality from childbed fever at the hospital was to drop to less than 1 per cent – lower than he had achieved in Vienna.
After much political wrangling (he was not the first choice for the job), Semmelweis was appointed head of obstetrics at the University of Pest medical school. The position sounded better than it was. The wards were filthy. The facilities consisted of a few cramped and poorly ventilated rooms in a tenement block. Of those women who were admitted – and even the poorest women made every effort to avoid this – a third would die of childbed fever. Again, Semmelweis introduced his reforms, but this time the mortality rate remained obstinately high. Then he examined the bedlinen.
In a cost-saving measure, the hospital had taken on a surprisingly cheap laundry firm. It soon became clear why the price was so surprising, when Semmelweis realized they were not actually washing the linen. They seemed merely to collect the stinking and stained sheets one day and return them in a similar condition the next. This time disease was being spread not by doctors but by 'matter' on the sheets. The laundry firm was sacked; the mortality rate dropped.
In 1857, now in his late thirties, Semmelweis married the nineteen-year-old daughter of a friend. His young wife gave birth to five children, the first died shortly after birth, the second from an infection – neither, at least, from childbed fever. Despite these tragedies, which were not an unusual occurrence in the nineteenth century, Semmelweis appeared settled and even declined a job offer from abroad. He decided it was time to write up his life's work.
When it was published in 1860 The Etiology, Concept and Prophylaxis of Childbed Fever was greeted with overwhelming apathy. Those responses it did receive were generally unfavourable; Semmelweis' theories were discounted. Prominent surgeons, including Scotland's James Simpson, lined up to criticize him. Many surgeons had theories of their own about the causes of childbed fever, including a suggestion that it was related to swelling of the Fallopian tubes. The Vienna General Hospital had already abandoned his 'crackpot' ideas as unworkable. 'We believe that this chlorine washing theory has long outlived its usefulness,' one doctor wrote in the Viennese Medical Journal. 'It is time we are no longer to be deceived by this theory.'
Unfortunately, even the most objective person reading the book would be inclined to treat Semmelweis with a degree of scepticism. Only a relatively small part of The Etiology, Concept and Prophylaxis of Childbed Fever is taken up with his experiments in Vienna and his defeat of disease. The rest reads as a bitter polemic on the way he was treated, underlined throughout by a sense of frustration that so few people would take him seriously. The epilogue reads as a morbid and futile cry for help, albeit tinged with some hope for the future.
When, with my current convictions, I look into the past, I can endure the miseries to which I have been subjected only by looking at the same time into the future?If I am not allowed to see this fortunate time with my own eyes, therefore, my death will nevertheless be brightened by the conviction that sooner or later this time will inevitably arrive.
The rambling and sometimes vitriolic nature of the book revealed Semmelweis's declining mental health. He had become even more irritable, absent-minded and depressed. He wrote to doctors accusing them of murder for failing to listen to him. He went to the hospital chapel to pray for forgiveness for the deaths he had caused. He took to heavy drinking and visited prostitutes. His wife was being driven to despair. His own doctors suggested he take a holiday.
The Semmelweis family took a train to Vienna, where they were met by an old friend, Professor Hebra. The professor seemed keen to show Semmelweis his new hospital. Leaving his wife and children behind, he accompanied the professor to see the facilities. The hospital turned out to be the Lower-Austrian Mental Home. Semmelweis was held, tied into a straitjacket and confined to the ward for maniacs.
When his wife came to visit him the next day she was forbidden from seeing him. It seemed Semmelweis had tried to escape and had been restrained by six attendants. He was being held in a secure cell for his own protection. Accounts are confused about what happened next. Some believe that in being restrained he had in effect been beaten up; others say that he cut his finger (this could also have happened when he was restrained). Within days Semmelweis had become seriously ill: he was feverish, his body swollen, covered in abscesses and sores. Two weeks after entering the asylum, Ignaz Semmelweis was dead. He died from the same disease that had killed his friend Jakob Kolletschka and all those thousands of women.
At the time, few mourned his passing. They had always thought he was a madman, and the nature of his death only confirmed this belief. Anyway, as soon as he had entered the doors of the asylum Semmelweis was effectively dead, and his ideas with him. It was many years before his research was re-examined and his discovery – that cleanliness can prevent the spread of infection – fully appreciated.*But by that time, someone else had got the credit.
* Decades after his death Semmelweis finally got the recognition he deserved. He now has a university named after him in Budapest, and is known by many as 'the saviour of mothers'.
OPERATION SUCCESSFUL: PATIENT DIED
Joseph Lister was walking his ward. The professor of surgery stopped at each bed in turn to talk to the patients. He would ask the nurse to remove the sheets so that he could have a look at their wounds. It could be a depressing experience. The sweet, sickly smell of putrefying flesh pervaded the room. Patients would arrive at the hospital in good spirits, confident of recovery. Two weeks later they would be dead. Despite all the advances in surgery, patients all too often succumbed to gangrene, fevers and blood poisoning. Any exposed wound was likely to become diseased. Even the most minor procedures, such as the removal of a small growth or wart, could end in a lingering death.
It saddened Lister how many amputations he had to carry out. A young child would come in with a fractured leg, having fallen awkwardly while playing or been knocked over by a cart or tram (there were increasing numbers of traffic accidents). If the child's skin was broken, Lister knew that within days infection would set in, the flesh would begin to rot and the limb would have to be amputated. Too many limbs were being lost because surgeons could not control disease.
Then there were the new operations that surgeons were trying to develop. They should be able to do more than hack off limbs or growths. With anaesthetics, they could take their time during surgery and try new techniques. Surgeons ought to be able to open up the body and operate on the organs. But, like any sensible surgeon, Lister would not operate unless absolutely necessary. He would not cut into the flesh unless he had to, and certainly not into the abdomen. Any wound was a potential source of disease and death.
The cause of this disease, or any disease, was still a mystery. Perhaps it was spread by bad air – some sort of miasma. But this was a new hospital. The wards had high ceilings, the beds were well spaced, there were large windows down the sides. With hard wooden floors and whitewashed walls, the wards were light and airy. Admittedly, the air was full of the smoke and smog of industrial Glasgow, but could that really be causing all this disease? Some of the more superstitious patients blamed it on the position of the hospital: it was built over the graves of cholera victims. Maybe they were right? Lister was prepared to consider anything.
Lister was a good but not particularly exceptional surgeon. He had risen gradually through the ranks to reach his position at Glasgow. Ever since he had been a medical student at University College London under Robert Liston, his overwhelming desire had been to save lives. Lister had witnessed Professor Liston's first use of anaesthetics and had closely followed advances in surgical techniques, as pain relief enabled surgeons to take more time with their operations. But the mortality rates from the amputations Lister carried out were still typical of the period. Around half the patients he operated on would die.
The development of surgery had ground to a halt. Surgeons knew how the body worked and they could control blood loss. They could even put their patients safely to sleep while they operated. Despite all this, far too many people who were admitted to hospital were dying. Until the problems of infection were solved, surgery could go no further. And opening up the abdomen to remove an appendix or operate on the organs was completely out of the question.
In his spare time Lister was also a scientist. There were few full-time scientists as such, apart from those in the chemical industry. For a gentleman, studying science wasn't really a vocation, more of a hobby. Science ran in the family. Lister's father, a wine merchant, was a respected microscopist and had devised significant refinements to microscopic technique. The younger Lister started his own experiments on frogs. He used a microscope to observe what happened when wounds became inflamed. He found that gangrene was a process of rotting – the flesh was decomposing. What he could not understand was why a simple fracture – a bone broken beneath the skin – healed, whereas a compound fracture – where the bone penetrated the skin and was exposed to the air – became infected.
One of the greatest tragedies in the history of medicine is how long it took the medical profession to realize that disease and infection were caused by micro-organisms. The invention of the microscope in the seventeenth century had revealed these 'germs' for the first time, but the work was never pursued and the connections never made between these 'microscopic' creatures and disease.
For all his achievements, not even Semmelweis had worked it out. He died believing that disease was spread by dead matter itself, rather than anything on the dead matter. Furthermore, few surgeons made the connection between dirty conditions and rates of infection. Florence Nightingale had shown how sanitary hospital conditions reduced death rates significantly, and even old-school surgeon Robert Liston had probably lost fewer patients than his rivals thanks to his attention to cleanliness. The fact that Liston operated so quickly also probably kept the death rate down. With anaesthetics, most operations were often taking longer, so wounds were exposed for a greater amount of time, increasing the opportunity for infection.
Doubtless more surgical patients survived in Victorian Britain than elsewhere, thanks to the obsession with order and cleanli- ness. But while most surgeons might be smartly turned out when they arrived at the hospital, when they came to operate they would don their old frock coat, encrusted with blood and pus – the result of years of messy surgery – and would pick up the same instruments they had used on the previous patient, wiped down to stop them rusting.
A professor of chemistry at the university, Thomas Anderson, told Lister about some experiments that had been conducted in France by Louis Pasteur. Lister found Pasteur's work simple but compelling. In one of his experiments, Pasteur sterilized a flask of broth by boiling it. He plugged the top of the glass vessel with cotton wool to allow the passage of air but nothing else. He left the flask for a few days and found the broth remained sterile. When the cotton wool was removed, the broth became putrid. Pasteur had proved that it was something in the air, not the air itself, that caused a substance to rot. The something, he surmised, was germs – micro-organisms in the air.
Pasteur's most famous refinement of this experiment was conducted using a swan-necked flask – a specially made glass container with a long, curved glass stem protruding from the top. Air could pass freely through the stem, but any dust or microscopic organisms in the air would become trapped. He filled the flask with broth and?it remained sterile.*
* Pasteur's research was published in a series of papers between 1857 and 1860. Semmelweis was still working on his book during this period, but there is no evidence that he knew of Pasteur's work or that he ever made the connection between hospital infection and micro-organisms. Given that Semmelweis's achievements were published in only a very limited way, it is assumed by historians that Pasteur never came across his research.
Reading through Pasteur's published research was heavy going, but Lister's efforts were rewarded. He started to piece together the evidence and began to realize what was happening to his patients: they were being killed by germs. So, he surmised, if he could kill the microscopic organisms or prevent them getting into wounds, there would be no infection. But Pasteur had sterilized his experiments using heat (a process that would later become known as pasteurization). How on earth could Lister sterilize a wound on a living person?
Lister tried a few experiments with various chemicals and compounds but with little success. The answer was to come from sewage. A hundred miles south, on the other side of the Scottish border, the authorities in Carlisle were trying out a new type of sewage treatment on the drains and cesspools of the city. The chemical they were using – carbolic acid – removed the terrible smell. Made from coal tar, carbolic acid had been shown in studies to kill germs. Lister reasoned that a chemical used to destroy micro-organisms in sewage might also be used to destroy micro-organisms in wounds and prevent infection. After all, the septic smell of rotting flesh pervading the surgical ward was not unlike that of untreated sewage. In the best traditions of surgery, Lister decided to try out his new 'antiseptic' principle on a patient.
On 12 August 1865, eleven-year-old James Greenlees was run over by a cart. He was admitted to the Glasgow Royal Infirmary later that day with a compound fracture of the left leg. The wheel of the cart had broken his tibia (the main bone of the lower leg) in two. The broken bone had punctured the skin, leaving a wound some one and a half inches long and three-quarters of an inch wide. When Lister examined the boy, he passed a metal probe into the wound to feel the broken bone. He observed that there was surprisingly little blood.
Under normal circumstances, the wound would have been covered and the boy rested. Splints would have been applied in the hope that the injury would heal, but Lister knew that eventually he would have little choice but to amputate. The boy would be left a cripple, his chances in life appallingly diminished.
Instead, Lister orders his house surgeon, Mr Macfee, to dress the wound using lint dipped in undiluted carbolic acid. The lint is laid across the wound and then covered with a sheet of tinfoil. The foil will prevent the carbolic acid from evaporating. Two wooden splints are then strapped on either side of James's broken leg.
Four days later, James says the wound is feeling sore, so Lister decides to take off the dressings to see what is happening. Urging the boy to keep still, he carefully removes the splints and peels back the dressings. Lister has never got used to this moment. Normally he would be forced to step backwards as his nostrils were hit by the smell of rotting flesh and putrefaction. This would normally be the time he would have to sit down and calmly tell the patient that amputation is the only option.
The final piece of lint is removed. He has never seen anything like it. There are no signs at all of suppuration; the wound is completely clean. The only smell is from the carbolic. The worst that could be said about the wound is that the edges are red – probably burnt, he thinks, by the acid. The soreness the boy has been complaining of is from the dressing, not, thank God, from disease.
Lister reapplies the lint, this time diluting the carbolic with clean water. Five days later he looks at the wound again – there is no pus or other sign of infection. However, the carbolic is still burning the skin, so Lister tries a mixture of carbolic and olive oil. After another few days he replaces this with a dressing of lint soaked in water. Six weeks later the wound is completely healed, the splints are removed and James walks home. It is, says Lister, 'a most encouraging result'.
By 16 March 1867, when the first results of Lister's work were published in the Lancet, he had treated a total of eleven patients using his new antiseptic method. Of those, only one had died, and that was through a complication that was nothing to do with Lister's wound-dressing technique.
Now, for the first time, patients with compound fractures were likely to leave the hospital with all their limbs intact. The next stage was to apply the technique to surgery. Operating theatres had changed little since Liston's day. The stained wooden operating table was usually surrounded by a raked gallery. When surgeons were operating the spectators would often gather close around the table, their outside boots grinding the dirt of the street into the timber floor. Light was provided by gas lamps or even candles. Devising an antiseptic operating technique under such conditions was quite a challenge, so Lister decided to rely on carbolic.
Before the operation he washes everything in a solution of carbolic. Hands, instruments, sponges and dressings are all dipped in the diluted acid. The patient's skin is brushed with carbolic, and towels soaked in carbolic are placed around the wound. To keep the air free of germs Lister employs a special contraption heated by a spirit lamp to send a spray of high-pressure carbolic steam over the operating table. The spray has to be adjusted to ensure the droplets are small because large ones could burn the eyes.
Once the patient has been put to sleep with chloroform, Lister rolls up his sleeves and the operation begins. The procedure takes place in a cloud of carbolic. Everything quickly becomes soaked. A fog covers the table and those surrounding it. Lister turns up the collar of his coat to avoid the acid reaching the skin of his neck. It is like operating in a rainstorm. When the time comes to close the wound, Lister uses sutures of catgut (made from the intestines of sheep) that have been soaked in carbolic. In the days of suppurating wounds it had been easy enough to pull out silk threads through the slush of decaying tissue. Now, as there is no infection, removing such sutures or ligatures could prove difficult. Not only is catgut sterile, but because the threads are organic, they are reabsorbed by the body and will not have to be removed later.
Operating under these conditions was deeply unpleasant, but the results spoke for themselves. Before antiseptic operations were introduced at the hospital, there were sixteen deaths in thirty-five surgical cases. Almost one in every two patients died. After antiseptic surgery was introduced in the summer of 1865, there were only six deaths in forty cases. The mortality rate had dropped from almost 50 per cent to around 15 per cent. It was a remarkable achievement.
Not everyone was so easily impressed. 'Listerism' was dismissed by some as nonsense. Despite the evidence, surgeons failed to accept the very idea of infection being caused by germs. They dismissed these 'little beasts' as a figment of Lister's imagination. Even those surgeons who understood the scientific basis for germs were not convinced by Lister's techniques. Operating under a spray of carbolic was inconvenient and unpleasant. New York surgeon William Halsted was even forced to operate in a tent because Bellevue Hospital staff hated the fumes from carbolic so much. Other surgeons had been getting good results of their own simply by keeping their operating theatres clean and washing their hands properly. Lister rinsed his hands in carbolic but was still operating in his old, bloodstained coat.
Lister eventually abandoned the carbolic spray, realizing that there was a greater risk of infection from his hands or his instruments than from any germs in the air. It took more than ten years, but gradually Lister's ideas started to be adopted and operating theatres began to change. The rooms were scrubbed, the old wooden tables replaced by shiny metal, the floors sealed with linoleum. Surgeons hung their old operating coats up for the final time and started wearing clean linen shirts and operating gowns. They washed their hands and sterilized their instruments either by using heat or dousing them in carbolic. Wounds were covered with carbolic dressings. Some surgeons even started wearing rubber gloves. No one yet wore masks in the operating theatre, so a cough or a sneeze could still kill a patient, but death rates from operations continued to fall.
Listerism was here to stay and Joseph Lister became a national hero. He was the first surgeon to be awarded a peerage, and a public monument was erected in his honour. He even had a bacterium, Listeria, named after him, and thousands of people honour his memory every day when they gargle with Listerine mouthwash.
When Robert Liston, one of the world's finest surgeons, operated on patients in 1842 they had a one in six chance of coming out of hospital alive. If they had a compound fracture, an operation was their only chance of survival. For that they would have to endure the horrific torture of being held down on a hard wooden table, without anaesthetic, while their leg was sawn off. Ten years later they would have still have lost their leg, but at least there was pain relief and, assuming the chloroform did not kill them, a similar chance of survival.
Finally, by the end of the nineteenth century, surgery had become reasonably safe. The odds of survival had improved to better than one in ten (depending on the operation), and patients were much more likely to leave hospital with all their legs and arms intact. Despite many false starts, the four barriers to successful surgery had been overcome. Surgeons understood anatomy; they could stem blood loss and were able to control pain. Now they could even operate without causing infection. No part of the body was off limits. Surgery was becoming a science. Surgeons could do anything.