Welcome back to the Daily Dose and MedHum Monday! Today we present an essay by Sydney Tenaglia, a student at Case Western Reserve University. Sydney spent time in the Dittrick Museum examining artifacts and discovering that it’s not just the knife, it’s how you use it! History provides us with a useful lens for examining medicine and the implications of tools for doctors and for patients.
The Applications of the Surgeon’s Operating Case
Throughout the nineteenth century, operating was oftentimes the only solution for most major injuries and chronic illnesses. Before Alexander Flemming’s discovery of penicillin and the widespread use of antibiotics during the twentieth century, removal of the infected portions of the body was the only cure. Serious injuries such as shattered bones or head trauma also provoked operative treatment. Thus, “a cased set of amputation and surgical instruments constituted the most prized possession of the nineteenth century physician and surgeon” (Dittrick Medical Museum). These cases typically included saws, knives, and tourniquets for use in amputations; equipment for trephining; a myriad forceps, probes, and needles; and catheters (Dittrick Medical Museum). A well-stocked operating case could mean the difference between life and death, usually from infection of an untreatable wound.
While it gave many patients suffering from catastrophic injuries, infections, and general chronic maladies an opportunity to evade what was, for the most part, certain death, nineteenth century operations tended to be almost as likely to kill the patients as the inflictions which plagued them. Before the latter half of the nineteenth century and the emergence of ‘germ free’ surgery, the materials that many surgical tools were made from could not be properly sterilized, if an attempt at sterilization was even made at all (Dittrick Medical Museum). Mortality rates of amputations performed at the London Hospital in 1842 were around fifty percent, the majority of the deaths occurring from sepsis and shock post-surgery (Chaloner).
Due to the procedure’s significant mortality, amputation was deemed a “capital” operation and reserved as a last resort in the avoidance of sepsis from injury (Goddard). Surprisingly, risk of the patient bleeding out during an amputation was minimal due to the use of tourniquets and the speed at which the operation was performed. Nineteenth century surgeon Doctor Robert Liston was one of the finest and fastest surgeons of the time, and an example of both the benefits and detriments to performing such high speed operations (Soniak). Before the widespread use of anesthetic, speed was paramount in minimizing pain and reducing the chance that the patient would die from shock mid-surgery. While “only about one of every ten of Liston’s patients died on his operating table at London’s University College Hospital, the surgeons at nearby St. Bartholomew’s, meanwhile, lost about one in every four,” a testament to how quick operations spared patients both pain and deadly stress (Soniak). High speed surgery, however, also greatly hindered the surgeon’s accuracy and precision while operating. Robert Liston was no exception to this rule. His most famous mishap occurred while amputating a patient’s leg. He was cutting so fast that he also took off the fingers of one of his surgical assistants, and while switching between instruments, accidentally slashed a spectator’s coat. The patient and assistant both died from infection and the spectator was so frightened by his near stabbing that he died from shock, resulting in the only known surgery to garner a three hundred percent mortality rate (Soniak). Thankfully, the discovery of anesthetics made the use of such reckless speed obsolete in favor of rendering the patient passive and unconscious.
The use of anesthesia not only made surgery more comfortable for the patient, but safer as well. Surgeons were able to use more precision and take their time whilst operating, so shock was no longer just as likely to kill the patient as their affliction. The discovery of microorganisms and germ theory brought about the shift to using surgical implements made from metals as opposed to porous substances such as wood (Dittrick Medical Museum). Wooden handles on surgical instruments retained the infectious diseases from one patient and were liable to transfer them to another, resulting in deadly post-surgical sepsis. By changing to instruments entirely crafted of metal, a material which could be sterilized easily, the chances of patients dying from infections after surgery were reduced.
Surgical conditions continued to improve throughout the twentieth century, and due to the creation of antibiotics, surgery was no longer the only treatment for serious infections. Surgical operations lacking anesthesia were associated with a less than stellar success rate due to complications related to the pain response of the patients and a lack of understanding in regards to germ theory. The introduction of pain relievers and ethers into surgical practice greatly reduced the probability that the patient would die outright from shock or other complications caused by writhing around in pain, improving the survival rate dramatically. Today, infections are diagnosed in a timely manner, before they can cause any serious complications that require surgical amputation to treat, and are purged with non-invasive medications. Amputations are rare, only to be performed in cases of reoccurring or serious disease, in part due to the increasing precision of surgical instruments and techniques today. Like any other surgery, anesthetic is used to render the patient unconscientious, preventing pain and allowing the surgeon to operate on a still, relaxed individual as opposed to a patient who is struggling against him. What once would have required a painful, traumatic, and unsanitary ordeal that resulted in the complete loss of a limb can now be corrected with the precise and painless removal of the infected area with only a small incision scar as proof of the event. Current surgical implements tend to be small, and some surgeries are not even performed directly by surgeons, but instead with robotic arms and lasers, all lending to a safer, less invasive, and more comfortable experience for patients today, who recover far better than those of the nineteenth century.
Chaloner, E J, H S Flora, and R J Ham. “Amputations at the London Hospital 1852-1857.” Journal of the Royal Society of Medicine 94.8 (2001): 409–412. Print.
Dittrick Medical Museum. “No title.” Cleveland, Ohio: Dittrick Medical Museum, no date. Plaque.
Goddard, Jonathan Charles. “The Navy Surgeon’s Chest: Surgical Instruments of the Royal Navy During the Napoleonic War.” Journal of the Royal Society of Medicine 97.4 (2004): 191–197. Print.
Soniak, Matt. “‘Time Me, Gentlemen’: The Fastest Surgeon of the 19th Century.” The Atlantic. Atlantic Monthly Group, 24 Oct. 2012. Web. 6 Feb. 2015.