Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (3 page)

A year later, on October 16, 1846, a dentist named William T. G. Morton administered a substance called ether while surgeon John Collins Warren painlessly removed a small tumor from the neck of a sleeping patient. With the memory of the prior failure still fresh, the audience of doctors and medical students at Morton’s demonstration were prepared for another discouraging failure.

Morton first impregnated gauze with the ethyl ether compound, then placed the gauze in a decanter-like blown-glass inhaler. The inhaler had an intake valve for air and a mouthpiece through which the ether fumes were delivered to the patient. Virtually nothing was known about dosage or the levels of anesthesia produced. Warren had taught his Harvard Medical School students that ether was far too dangerous a substance for use, but Morton, who had attended those lectures, was crafty enough not to identify the mysterious substance within the glass contraption. He had employed it in several extractions in the past, and had gained enough support among respected members of the medical community to convince Warren to take part in the demonstration.

Gilbert Abbott, the patient, was strapped tightly into the blood-colored, velvet operating chair, and attendants stood by to further restrain him if it became necessary. A bit agitated as he first inhaled the ether, Abbott thrashed around, then quickly fell off to sleep. The operation went on uninterrupted, with Abbott sleeping quietly. Upon waking, he reported no sensation of pain, nor any memory of the event. Warren, who was duly impressed, turned to the gallery, raised his arms, and said, “Gentlemen, this is no humbug.”

Numerous similar demonstrations of the technique were attempted for more extensive procedures with equal success, and
ether assumed its place in operating rooms around the world. Oliver Wendell Holmes, renowned physician, lawyer, poet, and father of the future Supreme Court justice, wrote in 1846, “The state of lack of sensation should, I think, be called ‘Anaesthesia’ … The adjective will be Anaesthetic. Thus we might say the state of Anaesthesia, or the anaesthetic state.”

The era of painless surgery had begun.

Chemical variations on ethyl ether came in and out of vogue, including trichloroethylene, or chloroform, which had the benefit of being considerably less flammable than ether. When Queen Victoria gave birth to Prince Leopold under chloroform anesthesia, it became all the rage. But chloroform proved more toxic than ether and soon fell from popularity. The word
ether
became interchangeable with
anesthesia
. It was used well beyond the first half of the 20th century, only to disappear from operating rooms when safer, and more controllable, anesthetics were introduced.
¹

In 1896, the 50th anniversary of the first operation under ether was being celebrated in Boston. At the same time, Hugh Young, the urologist on Halsted’s staff at Johns Hopkins, unveiled a series of letters and affidavits, as well as a paper in the
Southern Medical Journal
, which told a different story. The documents credited Dr. Crawford W. Long with having operated on patients under ether anesthesia in the town of Jefferson, Georgia, four and a half years before Morton’s demonstration. History seems to have been happy with the Massachusetts General version of events. If nothing else, it was well witnessed, quite dramatic, and gave the process a name.

PASSAGE INTO THE
anesthetic era relieved patients of unbearable pain. Surgeons could be more adventurous in approaching disease and trauma, and the entire profession benefited from a new image. Although speed was no longer necessary in order to spare the patient, surgeons did not easily change their ways. Surgery was still performed as quickly and brutally as before, with only the patient’s pain removed from the equation. Little thought was given to a more strategic, tissue-sparing approach.

While patients could now be less fearful of the pain of surgery, serious procedures still carried a mortality rate of nearly 50 percent. Compound fractures were a particular problem. Fractures can be simple breaks in which the ends of the bones have not moved from their normal position and need only immobilization to heal. Fractures can also be displaced from their normal position, requiring the ends to be returned to the normal position, or set. These procedures could now be performed under anesthesia, properly and painlessly, and with vastly improved results. More serious fractures in which the bones are fragmented, or comminuted, require setting and immobilization as well, but they remain contained within the unbroken skin and without risk of infection. Compound fractures are those injuries in which the broken bone pierces the skin. This represents potential catastrophe. In this pre-antiseptic, pre-antibiotic era, these injuries would nearly always result in devastating and life-threatening infection, and were often treated by immediate amputation. The actual amputation could now be performed in a more measured and respectful fashion with the patient blissfully anesthetized, but, asleep or not, the injury meant losing the limb.

Doctors still believed disease, infection, and suppuration, or “laudable pus,” arose from an imbalance of humors, or just materialized spontaneously, and there was nothing one could do about it. The same magical thinking had been applied to putrefaction and spoilage of
food. The first step in the climb from this deep well of ignorance was taken long ago by Francesco Redi. In 1668, Redi conducted a series of experiments in which he disproved the concept of spontaneous generation of flies and maggots in meat. He placed fresh meat or fish in jars that were either uncovered or covered with fine gauze. Meat in the uncovered jars soon became riddled with maggots and swarming with flies. Meat in gauze-covered jars remained free of maggots in the flesh and flies on the surface, though flies could be found outside the gauze screen circling the prey.

This had great implications for the sanitary preservation of food, but the concept did not carry over to medicine, where infective materials were believed to materialize spontaneously from the wounds themselves. Little thought was given to the possibility of introduction of infection from the outside, or protection from it. Suppuration was thought to be a natural consequence of wounds and a step on the road to resolution. This could mean resolution of the infection or, at the other extreme, death.

The American Civil War provided two horrific examples of the inability to understand and control these events. The two most devastating wounds a soldier could sustain were being “gut shot” or stricken with hospital gangrene. In the first instance, being shot in the abdomen meant spillage of the bowel’s fecal contents into the abdominal cavity, resulting in peritonitis, and a painful death within two or three days. In the second instance, a small non–life-threatening wound would become infected in the unsanitary conditions of the hospital, tent, or whatever rudimentary facility was available to house the wounded. The wound would turn black, enlarge, and burrow under the skin, raising a horrible stench from the rotting tissue. Black spot, or hospital gangrene, typically resulted in amputation or death. In both cases, events were predictable, unpreventable, and untreatable.

This changed in 1861, when Louis Pasteur, a chemist in Paris, showed that the souring of milk was caused by bacteria and could
be prevented by heat sterilization. His work not only lay to rest the idea of spontaneous generation but also placed the blame squarely on bacteria, and offered a solution, Pasteurization.

In 1878, Pasteur delivered a paper outlining the steps he would take, were he a surgeon, to prevent wound infection. Particularly prescient were his suggestions for the heat sterilization of instruments, gauze, bandages, and water used in surgery.

While Pasteur moved on and achieved worldwide fame for developing the rabies vaccine, a German physician and scientist named Robert Koch was able to cultivate the long, rod-shaped anthrax bacillus. In 1877, Koch demonstrated its life cycle, including the dormant spore form in which it was able to maintain viability for long periods until conditions were proper for conversion into the infective bacillus. His findings were celebrated, but were not universally accepted until Pasteur arrived at the same conclusions while working on an anthrax vaccine five years later.

Koch continued his work identifying organisms and correlating them with various diseases. In 1882, he arrived at what have become known as Koch’s postulates, the equivalent of the Commandments of medical bacteriology. They provide the basis for proving the relationship between an organism and the disease it causes:

1. The organism can be discovered in every instance of the disease.
   

2. When recovered from the body, the bacteria can be repeatedly produced in pure culture.
   

3. The initially isolated pure culture, or its successive generations, when introduced into experimental animals can reproduce the disease.
   

4. The organism can be recovered from the animal and re-cultured.
   

Koch’s clear and concise rules for identifying the cause of various infections forced even the hard-core nonscientists among physicians to take note.

In 1882, Koch identified the tubercle bacillus as the cause of tuberculosis, creating an uproar heard in scientific circles around the world. The following year he added greatly to his exalted reputation by clearly identifying another bacillus, this time the one that had caused cholera epidemics in Egypt and India, and indicted contaminated drinking water as the vehicle through which the dreaded disease was spread.

While Pasteur and Koch were inventing bacteriology, the man who would bring these concepts to life in surgery, Joseph Lister, was at work in Edinburgh and Glasgow, Scotland. Born in 1827 into a wealthy family in Upton, a Quaker community in the suburbs of London, Lister spent his youth within the insular sect in what amounted to something a bit less confining than a ghetto. Members were part of the economic fabric of the city, but they tended to intermarry and live close to their roots. Educated in London, Lister was ineligible to attend either Cambridge or Oxford since he was not a member of the Church of England. He practiced surgery in Edinburgh and Glasgow for the most productive periods of his career, and later, after achieving fame and adopting his wife’s Anglican faith, he was offered the chair in surgery at King’s College Hospital, London, which he accepted. He went on to become a talented and imaginative surgeon, but nothing he did as surgeon or teacher would equal the impact of introducing antisepsis to surgery.

Aware of Pasteur’s work, Lister began thinking of ways to destroy germs in surgical wounds. The revolutionary idea had occurred to others, and some, including Oliver Wendell Holmes in Boston (the same Holmes who coined the term
anaesthesia)
, had spoken out on the theoretical value of antiseptics, but didn’t act. Only Lister saw the future and dedicated his career to it.

Since human tissue could not be heated to kill bacteria as Pasteur
had done in the process that came to be called Pasteurization, Lister searched for a chemical agent to do the job. He settled on carbolic acid. Carbolic acid killed bacteria in experiments, and in dilute solution was fairly well tolerated by human tissues.

In 1865, Lister began a series of surgical experiments to test his theory. He began treating compound fractures, the devastating injury in which broken bone penetrates the skin, with carbolic preparations prior to operating, during surgery, and after surgery as well. Theories varied as to whether the inevitable bone infection was caused by humors in the ambient air or was introduced by the environment of the injury, manure being a common cause. However, no thought was given to introduction of infection from the surgeon’s hands or tools as a source of contamination.

Lister’s first two attempts resulted in failure. The third compound fracture, in the leg of an 11-year-old boy, was a resounding success. Carbolic acid was used to cleanse the skin and the wound and to soak the dressings. The wound healed slowly, but cleanly and completely.

From that point on, success followed success, and in 1867 Lister published his series of cases in
The Lancet
, the leading British scientific journal. Though experienced surgeons were impressed with Lister’s results, there was no groundswell, no rush to adopt his techniques. Even in Glasgow and Edinburgh, where he was professor and held in the highest regard, the theory and practice of antiseptic surgery was not readily adopted. In London, both the author and his technique were met with indifference, if not open hostility.

Lister continued to believe that bacteria were in the environment as well as in the wound, and that it was imperative to infiltrate the air with antiseptic. He soon developed a carbolic spray device, which he called the carbolizer. This was placed in the operating room, near the surgical field, covering surgeon, patient, and assistants in a fine carbolic acid mist. Unpleasant as this aerosol irritant made the work environment, the number of surgical infections decreased.