Blood and Guts

by Richard Hollingham

  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

  Glasgow, 1865

  * * *

  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 hu
ndred 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 i
mproved 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.

  CHAPTER 2

  AFFAIRS OF

  THE HEART

  DOOR TO THE HEART

  Montgomery, Alabama, 15 September 1902

  * * *

  It was only a few minutes after midnight and the small, dusty back roads of the city were pitch dark. The horse kicked up the dirt as it cantered along, the buggy jarring violently on unseen rocks and hidden potholes. Physicians of Dr Luther Leonidas Hill's reputation rarely came to this part of town; even during the day, it was easy to get lost. This was the negro area, where few could afford proper medical treatment; doctors usually called here only out of charity. But despite Hill's discomfort and the late hour, this house call was worth it. He might be able to save a life, if he was not too late.