History of Medicine

History of Medicine – What kind of social, intellectual, and technological developments allowed surgeons to venture routinely into the abdomen in the nineteenth century?

Introduction

Surgeons before the 19th Century had very little technological and intellectual knowledge compared to their counterparts at the end of the century. Surgery had to be done quickly and therefore only basic surgeries on broken bones and small growths could be done. Surgeons had to look after their reputation meaning that they would often only operate on patients who they thought had a good chance of surviving. Major developments in anaesthesia, hygiene, surgical techniques and public acknowledgement over the importance of doctors throughout the 19th century lead to a massive improvement in survival rates and increase in the abdominal surgeries that could be performed. Nearly all modern techniques used were developed by surgeons in the 19th century, showing us how important a role they played in modern medicine.

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Before anaesthetics surgeons had to operate on patients as quickly as possible to reduce the amount of pain the patient was in, this meant only external operations and amputations could be performed as they didn’t require as much skill and time to carry out [1]. Many patients would die during the operation because of the amount of pain suffered. This meant complex surgery in the abdomen was virtually impossible as the patients would suffer too much. During operations many patients had to be held down by assistants because they couldn’t hold still [1]. This meant that something had to found that would reduce the pain felt by the patients during the operation. The discovery of anaesthetics was the first big step towards complex surgery of the abdomen. Humphrey Davies was the first person to discover a form of anaesthetic; he used Nitrous Oxide (laughing gas) on patients and discovered that it had anaesthetic properties that reduce the patients’ sensitivity to pain. However the gas didn’t work on all patients and doctors didn’t know how much of it to administer to patients, meaning it didn’t get a large following so was never widely used. This gas is mainly used in dentistry as it doesn’t put the patient to sleep. Because of this it has never been used in surgery of the abdomen as it isn’t a strong enough anaesthetic. Henry Hickman used Carbon Dioxide in the 1820s on animals, making them unable to feel pain. He would perform amputations on them to see how effective the anaesthetic was. His findings were published to the Royal Society. His work received a lot of criticism and therefore Carbon Dioxide was not used as an anaesthetic for surgery [7].

The use of ether in surgery was the first big step towards fully unconscious patients that could be operated on. Ether frolics were a form of public demonstration where volunteers would take ether in front of a large crowd in order to spread the knowledge and effectiveness of ether as an anaesthetic. Robert Liston used ether on a patient in 1846, sending the patient to sleep. The operation was successful, but the patient suffered irritations of the lungs as a side effect [2]. Quite a few patients died from the side effects of ether meaning another form of anaesthetic had to be found for use in operating theatres. In 1847 James Simpson discovered that chloroform had anaesthetic properties [3]. It would put patients fully to sleep without them having any ability to feel pain. Chloroform unlike previous anaesthetics had no obvious side effects making it more popular as an anaesthetic. The death of Hannah Green in 1848 lead to a large opposition to chloroform as people believed it to be unnatural and thought pain should be felt during operations. The reason for her death was because surgeons were not sure on the correct dose to administer before a surgery as chloroform had only been used for a year. The most important movement towards the wide acceptance of chloroform was Queen Victoria using it for the birth of her eighth child in 1853. These developments in anaesthetics allowed many new operations to be performed: surgeons could now easily operate on the kidneys and liver [3]; The removal of one of the kidneys was now possible; Organs could be attached in place if they had moved out of place [3]; parts of the small intestine could be cut away without causing any damage to the alimentary canal; intestinal wounds could be fixed quickly enough to prevent any leakage of waste matter; The veins and arteries of patients could be operated on; and tumours could be removed from anywhere within the body [3].

The improvements in hygiene levels within the operating theatre and the wards lead to a massive reduction in the death rate due to operations. Prior to this the surgeons would operate in dirty theatres and use unwashed operating tools that would have been used on other patients. The surgeons also did not wash themselves between operations; [1] in some instances surgeons would be working with corpses and then go straight into an operation without any form of sterilization. This meant that many patients would suffer from gangrene and other forms of infection that would often take the life of the person [3]. The first person to discover that this lack of hygiene was causing fatalities was the Hungarian physician Ignaz Semmelweis. He noticed this after seeing that the doctors who were giving birth to babies after working with corpses lead to a higher mortality rate amongst the mothers. He concluded that the doctors must have been passing infected matter from the corpse to the mothers. All doctors and nurses working with him were ordered to thoroughly wash their hands with chlorinated lime between handling different patients. This lead to a massive drop in death rate from 30% to 1.5% within a 12 month period. His ideas were heavily opposed and he was forced back to his hometown in Bulgaria. The death rate increased again to 15%, whereas is was down to below 1% in his hometown where he now worked [8].

John Lister’s work in the 1860’s had a lot more success [9]; he discovered that spraying carbolic acid on bandages would reduce infection levels in the wound. He then sprayed carbolic acid in the theatres killing most of the bacteria. Death rate dropped from 46% in 1864 to 15% in 1870. The downside to carbolic acid was that it irritates the lungs, so there was still quite a lot of opposition to it. This was the first form of aseptic surgery that had a massive role in the movement towards abdominal surgery in the 19th century. Louis Pasteur discovered that bacteria in the air were causing the infection of wounds. His findings were published in 1867, causing the knowledge on infection to be more widely recognised [3]. These findings helped eliminate gangrene, erysipelas and septicaemia from patients who had been operated on [3]. In 1880, Charles Chamberland developed a device that would boil the surgeons instruments removing all forms of bacteria from them, making it relatively easy to sterilize the operating tools. Robert Koch later designed a non-pressurised steamer that was used to sterilize dressings. Neuber and Bergmann started to sterilize everything that would enter the operating theatre. In 1889 W.Halsted introduced the practice of wearing clean gloves for operations. All these developments in aseptic surgery lead to a massive decline in death rate by the end of the 19th century. They allowed the surgeons to operate with more confidence and allowed harder surgeries of the abdomen to be performed on a regular basis [3].

A lot of new surgical techniques were being discovered over in America during the first part of the 19th Century, mainly due to the fact that surgeons were more inclined to try out new surgical procedures on the coloured slaves: The first ovariotomy was done by Dr Thomas McDowell on a black slave in 1809. In 1883, Robert Lawson Tait successfully removed the fallopian tube from a woman who had suffered from an ectopic pregnancy. The operation was a success due to these new developments in surgery. His new technique had a success rate of 40 out of 42 cases in 1888 [4]. The French surgeon Jules-Emile Pean made ligatures popular in the late 19th Century. Ligatures allow blood vessels and arteries to be closed off during operation to reduce blood loss during operations. Because of this he was able to do quite hard operations without the patient losing too much blood, including the first surgery on a diverticulitis of the bladder [10].

The discovery of X-rays allowed surgeons to locate the area that requires surgery without having to cut open and look around the body. Wilhelm Rontgen discovered X-rays in 1895 when he was studying the effects of passing electric currents through gases [5]; he tried using these x-rays on human tissue and noticed that it left an image of the bones and metal within the human body. This meant that any abnormalities within the abdomen could be found using the x-rays before any surgery was done. His findings were widely accepted and X-rays were being used in clinics all over America for broken bones and gunshot wounds. In February 1896 an x-ray was used to successfully locate and diagnose sarcoma on the tibia of a young boy. The first military uses of x-rays were on two Italian soldiers in 1896 that had gunshot wounds from fighting in the Italian’s Ethiopian campaign [6].

The industrial revolution in the 19th Century played a major role in the improvements in surgery. The large growth of the chemical industry meant that doctors had a wider range of chemicals to experiment with, ultimately leading to the discovery of chloroform as a form of anaesthetic. This was also the time period where the microscope was developed. This piece of equipment allowed Pasteur to discover bacteria within the blood, which lead to his important findings on the germ theory [11].

The 19th Century was the major steppingstone between ancient surgery and modern day surgery, which has been fully influenced by the medical findings from this century. The new techniques and discoveries allowed the once impossible surgeries of the abdomen to be performed. The discovery of anaesthetics allowed the patient to feel no pain during surgery meaning all forms of surgeries could be performed. Before these anaesthetics only basic operations could be performed because the patient would usually die from the pain. Chloroform was the first widely accepted anaesthetic as it had no obvious side effects and Queen Victoria used it for her eighth birth and acknowledged its effects making it popular amongst the public. These anaesthetics allowed very complex abdominal surgeries to be performed as the surgeons had a lot more time and peace to perform the surgeries. Aseptic surgery followed anaesthetics and meant that infection rates, and therefore death rates amongst surgery patients was much lower. Ignaz Semmelweis in 1847 was the first person to make sure that his theatres and surgeons were washed before surgeries. He had noticed that the death rate amongst the mothers being handled by doctors who had previously handled corpses was higher than that of the women who had been looked after by doctors who hadn’t previously been in contact with corpses. Making his surgeons wash before surgeries lead to a very large decrease in death rate within his theatres. Medical developments around the world after this lead to a completely sterile operating theatre where carbolic acid would be sprayed around creating a sterile environment; all surgical instruments would be boiled; everything coming into the theatre would be disinfected; and the aftercare wards would be kept in much better condition. These combined lead to a massive drop in infection rate, meaning that surgeons could operate without the fear of their patients dyeing afterwards. The discovery of x-rays in 1895 meant that areas requiring operation could be located without any intrusive operations required. Areas requiring surgery could be located without the surgeon causing any internal damage trying to find the area manually.

References

[1] – http://encyclopedia.farlex.com/medicine,+19th-century

[2] – Fenster, JM (2001). ‘’Ether Day: The Strange Tale of America’s Greatest Medical Discovery and the Haunted Men Who Made It.’’ New York: HarperCollins. Accessed on 4th April 2011.

[3] – www.oldandsold.com/aticle35/19th-century-18.shtml . Accessed on 6th April 2011.

[4] – Tim Lambert. ‘www.localhistories.org/surgery.html ’. Accessed on 6th April 2011.

[5] – Aaron G Filler. ‘The history, development, and impact of computed imaging in neurological diagnosis and neurosurgery: CT, MRI, DTI’. Accessed on 6th April 2011.

[6] – http://mks76.com/x-rays_origin/1800s.html . Accessed on 6th April 2011.

[7] – Page, F.G. ‘Henry Hill Hickman a Shropshire Medical Practitioner’. Accessed on 7th April 2011.

[8] – http://www.nndb.com/people/601/000091328/ . Accessed on 6th April

[9] – ‘The Hutchinson Encyclopedia’. P 720. Century Hutchinson 1988. Accessed on 5th April 2011.

[10] – http://www.medarus.org/Medecins/MedecinsTextes/pean.html . Accessed on 6th April 2011.

[11] – ‘The Hutchinson Encyclopedia’. P 907. Century Hutchinson 1988. Accessed on 5th April 2011.

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