Five Patients - Crichton Michael. Страница 17

To make matters worse, when ether was finally used successfully in surgery by two men in 1842-Crawford W. Long in Georgia and Elijah Pope in New York-neither publicized his work widely, and their work had no impact on future events.

In 1844, Horace Wells, a Hartford dentist, painlessly extracted a tooth with nitrous oxide. He immediately communicated this news to a former dentist, then a Harvard medical student, William T. G. Morton. Morton in turn obtained permission for Wells to come to Boston and demonstrate anesthesia before the class of Dr. John C. Warren at the MGH. Wells did this soon after, but apparently did not obtain sufficiently deep anesthesia with nitrous oxide (which is, in any case, not a powerful anesthetic). At the crucial moment, the patient screamed; the students hissed; Wells slunk off in disgrace.

The idea of painless operation was abandoned as hopeless fantasy by all except Morton, who later met a chemist named Charles T. Jackson. Jackson suggested the use of ether instead of nitrous oxide; Morton found that it worked and himself approached Warren for a chance to demonstrate the method publicly. It is to Warren's credit that, despite a resounding failure only a short time before, he agreed to a second trial under his auspices. This occurred on October 16, 1846, in the hospital amphitheater under the Bulfinch Dome.

It must have been a strange scene. Morton arrived late, permitting some jokes about a last minute failure of nerve. The patient, a man with a tumor under the jaw, sat in a straight-backed chair, facing Warren and the assembled students, all wearing frock coats. Also in the room were articles then considered fit decoration for an operating theater: a skeleton, a large marble statue of Apollo, and a mummy from Thebes. A photographer was also present, but according to a newspaper account, "the sight of blood so unnerved him that he was obliged to retire."

Apparently the photographer was the only person to experience pain that day, for the patient underwent deep anesthesia, made no sound during surgery, and when he awoke, reported that he had felt nothing. Dr. Warren, then sixty-eight years old, turned with tears in his eyes to the audience and said, "Gentlemen, this is no humbug." [Morton, who anesthetized Warren's patient, attempted to exploit his discovery for financial gain. He labeled the ether "letheon" and tried to disguise its characteristic smell with various aromatic oils, hoping no one would discover it was only ether. The ploy failed and even the name was dropped when Oliver Wendell Holmes suggested that "anesthetic" would be a better word.]

News of the operation spread with extraordinary rapidity. The first English ether operation was done some ten weeks later; it was performed by the noted surgeon Robert Liston, who first announced skeptically, "We are going to try a Yankee dodge to make men insensible." Although the anesthetic worked, Liston operated with his customary speed, single-handedly amputating the leg at the thigh in exactly twenty-eight seconds.

The first important effect of anesthesia was to increase the number of operations performed. The Undaunted, Morton then petitioned Congress for an award for his discovery. The sum of one hundred thousand dollars was suggested, but he never received it; almost immediately a Southern senator put forward a claim in the name of Crawford Long, and Charles Jackson, the Boston chemist, entered one of his own. Debate raged until the outbreak of the Civil War turned the attention of Congress to other matters.

The aftermath of all this is depressing. Horace Wells, the Hartford dentist, went insane, was jailed for throwing acid at two girls, and committed suicide while in prison. Charles Jackson also went insane and died in an asylum. William Morton died a forgotten pauper on a park bench at the age of forty-nine. second was to lengthen the time of operation: the split-second showmanship of Liston and many others became obsolete overnight, and new standards of meticulous skill sprang up.

But problems were far from ended. Difficulty with infection remained for many years afterward, until Joseph Lister in Scotland formulated his antiseptic methods.

Within the hospital, cross-infection was commonplace for all patients. But surgical patients, in the absence of sterile operating techniques, were particularly prone to infection, and one effect of increasing the duration of operations was to increase the opportunity for bacterial contamination of the wound. Thus, in the decades after the introduction of anesthesia, the chief cause of surgical mortality was infection. [The great majority of surgical incisions became infected afterward and surgeons spoke favorably of "laudable pus" in the wound. But as Edward D. Churchill has said, 'To intimate that surgeons before Lister expected all wounds to suppurate and pour forth 'laudable pus' is to underestimate the intelligence of generations of shrewd observers over the course of centuries… Hippocrates taught that dead flesh in a wound must turn to pus, but Theodoric as well as Mondeville [two medieval surgeons] expected incised wounds, in which dead tissue is customarily minimal, to heal without suppuration as a matter of course. In Lister's own century, at the Battle of Waterloo, it was generally agreed among English surgeons that if the edges of clean-cut saber wounds were drawn together by adhesive straps, healing would be accomplished without suppuration. Listerism could not, nor did it pretend to, eliminate suppuration arising in contaminated dead tissue… The principle of excision of dead tissue (debridement) as the initial step in wound management finally emerged in the 1914-1918 war."]

There was confusion about infection caused by crosscontamination, from wound infection, and from decomposition of dead tissue within the wound. In the absence of clear understanding, hospital infections-termed "hospitalism"-were generally attributed to general environmental causes. The location of the hospital was deemed crucial.

The Massachusetts General was built on reclaimed land. It was noted that during the summer "the neighborhood was rendered offensive and unwholesome by emenations from the flats and newly made land." In 1875, the Board of Consultation recommended to hospital trustees that "no more buildings should be erected upon the land adjacent to the present wards because of improper (land) filling… At some future time, it will be for the best interest of the hospital if the buildings should be given up and a new site selected, one more fitted to the purposes of a hospital than the present one is now or ever can be."

The date of this comment, 1875, is significant, for Listerian antisepsis had been introduced six years before to the MGH by staff members who had visited the Scottish innovator's hospital in Edinburgh. Antisepsis was not widely accepted in this country, however, for nearly thirty years afterward. Instead, environmental arguments continued-despite the fact that Lister had halved infection rates in a hospital that was built on the site of a makeshift cemetery in which thousands of cholera victims had been shallowly buried only a decade previously.

It took less than three months for anesthesia to gain wide acceptance in medicine. It took more than thirty years for antisepsis to be accepted. Why? Both discoveries addressed themselves to equally important problems-if anything, infection was an even greater problem than pain. And both techniques, though primitive, certainly worked. What accounts for the difference in speed of acceptance?

Scientific understanding is not part of it. At the time the two innovations were proposed, neither could be explained. And though we now understand antisepsis, we still cannot explain why anesthetic gases kill pain.

Nor is diffusion of information a problem. News of antisepsis spread as quickly as news of anesthesia. Lister's techniques were widely and hotly debated in every Western country.

The answer seems to lie with medicine's capacity for dealing with individuals rather than groups. Anesthesia was dramatic, it produced a positive effect, and it could be seen working in the individual. On the other hand, antisepsis was passive, not dramatic, and negative in the sense that it tried to prevent an effect, not produce one. It was common in the early days of antisepsis for a skeptical surgeon to half-heartedly try the lengthy, exasperating techniques on one or two patients, find that the patients still became infected, and generalize from this experience to conclude the system was worthless. Nor can one really hold this against them, for a modern understanding of individual and group effects-the notion, for example, of a "controlled clinical trial" in all its statistical ramifications-is very recent indeed.

Nonetheless, antisepsis eventually became accepted in principle and thereafter followed a string of contributions to sterile operative technique. William S. Halstead, the Johns Hopkins surgeon, is credited with introducing rubber gloves for surgery in 1898. Special gowns to replace street clothes came at the turn of the century. Masks were not common until the late 1920's.

Ultimately, antibiotics provided the final powerful tool. Thus, in the space of a century, surgical mortality, which was generally 80 per cent at the time of the Civil War, was cut to 45 per cent by Listerian methods, and slowly cut even further in ensuing years, until it is now about 3 per cent in most hospitals.

Ways to reduce the percentage to zero are being explored. In recent years, the evolved ritual of timed scrubs, sterile gowns, rubber gloves, and masks has been criticized. Various studies have indicated that scrubbing does not clean the skin, but just loosens the bacteria on the hands, making them more mobile; that one quarter of all gloves have holes in them; that modern gowns are permeable to bacteria, especially if they become wet (as they often do in the course of operation); that doorways sealing off operating rooms do not prevent spread of bacteria but serve as collecting places for them. Such studies are too conflicting at present to see a clear trend, but it is likely that the ritual will be strongly modified in coming years.

Surgeons themselves tend to be almost complacent about the studies, largely because postoperative infection is no longer a major problem. In fact, the most common early, immediate, direct cause of death from surgery is not the operation but the anesthesia.

One wonders why this was not always so, especially in view of early methods for administering ether, by use of a cone-shaped sponge. J. C. Warren recalls that during the Civil War period:

These men, many of whom had become inured both to fighting and to a free use of alcohol, were not favorable subjects for the administration of ether, and I have still a vivid recollection of my efforts as a student and a house pupil at the hospital [1865-6] to etherize these patients. "Going under ether" in those days was no trifling ordeal and often was suggestive of the scrimmage of a football team rather than the quiet decorum which should surround the operating table. No preliminary treatment was thought necessary, except possibly to avoid the use of food for a certain time previous to the adminstration. Patients came practically as they were to the operating table and had to take their chances. They were usually etherized at the top of the staircase on a little chair outside the operating theater, as there was no room existing for this purpose at the time. In the struggle which ensued, I can recall often being forced against the bannisters with nothing but a thin rail to protect me from a fall down three flights. But however powerful the patient might be, the man behind the sponge came out victorious and the panting subject was carried triumphantly into the operating room by the house pupil and attendant.