At 3:15 p.m., the emergency ward was notified that a patient was being transferred in from an outlying hospital: a young man with a nearly severed arm resulting from an industrial accident.
He arrived an hour later and was seen first by Dr. Hopkins, the triage officer, who ordered him sent to OR 1. The surgical residents, Drs. Eugene Appel and Terry Mixter, were called to examine the new patient.
He was twenty-two years old, of medium height and muscular build, looked quite pale, and was speaking weakly. His left hand was bandaged and splinted. An intravenous line had been inserted in his right arm, but it had infiltrated. There was also a bandage over his chin. The bandages were removed and a new intravenous line started. He had a moderately deep two-inch laceration in his chin; the medical student, Sue Rosenthal, was called to suture it. Meanwhile, Appel and Mixter turned their attention to the injured arm.
Three inches above the left wrist the forearm had been mashed. Bones stuck out at all angles; reddish areas of muscle with silver fascial coats were exposed in many places. The entire arm above the injury was badly swollen, but the hand was still normal size, although it looked shrunken and atrophic in comparison. The color of the hand was deep blue-gray.
Carefully, Appel picked up the hand, which flopped loosely at the wrist. He checked pulses and found none below the elbow. He touched the fingers of the hand with a pin and asked if Luchesi could feel it; results were confusing, but there appeared to be some loss of sensation. He asked if the patient could move any of his fingers; he could not.
Meanwhile the orthopedic resident, Dr. Robert Hussey, arrived and examined the hand. He concluded that both bones in the forearm, the radius and ulna, were broken, and suggested the hand be elevated; he proceeded to do this.
Outside the door to the room, one of the admitting men stopped Appel. "Are you going to take it, or try to keep it?"
"Hell, we're going to keep it," Appel said. "That's a good hand."
The patient was started on two grams of cephalothin antibiotic intravenously, and was given more tetanus toxoid. He had received pain medication at the other hospital, and so far had not requested more.
As a workmen's compensation case, the operation would be done by private surgeons: Dr. Hugh
Chandler for orthopedics, Dr. Ashby Moncure for general surgery. At 5:15, Moncure arrived and looked at the hand, satisfied himself that it was indeed viable, and put the patient on call for the operating room. He also called Chandler and summarized the case: "It's a circumferential crush injury to the left hand with compound fracture of both radius and ulna. Innervation and arterial supply look pretty good."
Meantime, the portable X-ray machine was brought in to take a chest film, and two views of the injured hand. The medical student finished suturing the chin laceration. Moncure came back to check that a sample had been sent to the blood bank. He then went off to try to hasten scheduling for the operating room.
At 5:30, the patient complained for the first time of pain in his hand. The surgeons were debating what pain medication to give him when a nurse came in to say the patient was on call to the OR and would get pre-operative medication. He received atropine, Nembutal, and Demerol, which settled the question of pain medication.
Dr. Hussey, looking at the now-elevated hand, concluded that it appeared a little better; the color had improved. He wrapped the injured area in soft gauze, and went off to the X-ray unit to examine the films. He went directly to the residents' reading room, a cubicle with lighted, frosted glass walls for examining X rays. The resident was busy reading other films; Hussey went back into the developing room, past signs which forbade him to do so, to get Luchesi's films. A female technician scolded him; he said he was in a hurry.
He gave the films to the radiologic resident, who put them up and dictated: "Unit number zero zero six, AP and lateral of the left forearm. There is a transverse fracture of the radius in the distal third, as well as the ulna, period. Numerous fragments of bone are scattered around the fracture site, period. Considerable soft tissue swelling…" Here he stopped, realizing Hussey was impatient. "Chest film normal," he dictated, and gave them all to Hussey, who returned to the patient and supervised his transport to the operating room on the third floor.
It was now six o'clock. The operation was scheduled for 6:15, at which time on the OR blackboard was written:
KM 7 PVT. SERVICE SEVERED ARM MONCURE/CHANDLER
In the operating room, Dr. Brian Dalton, the first of three anesthetists who would work during the six-hour procedure, was administering an axillary block, injecting lidocaine (a novocaine-like drug) deep into the armpit, to dull, during the preparation, sensation in the nerves that ran out to the hand. While this was being done, Moncure discussed the operation: "What we're going to do here is stabilize his bones, and then deal with soft tissues as need be. I think we'll find a lot of crush damage to muscle bellies, particularly flexors, but intact vessels and nerves." He observed that while clinically there was questionable nerve damage, a crush injury could produce this without any actual cutting of nerve fibers; under such circumstances the damage was probably fully reversible.
At 6:10, while the axillary block was being administered, Hugh Chandler, the orthopedic surgeon, arrived and looked at the X rays. He said that he would stabilize one bone, the radius, and worry about the other, the ulna, later. Moncure was outside the OR, scrubbing according to the MGH version of the ritual: three minutes of washing to the elbow with a hard bristle brush, using orange sticks to clean under the nails, followed by a dunking to the elbows in an alcohol-germicidal solution. When he finished his scrub he came in, put on a pair of sterile rubber gloves, and began to wash the arm with a safety soap and alcohol. The nerve block was beginning to take effect, and it was possible to move the arm less gently without hurting the patient.
The patient was still awake, but dazed. He stared at his arm curiously, as if it did not belong to him. Moncure asked him how it had happened. Peter Luchesi explained that he had been working in a private shipyard and a boom had fallen on him. It weighed seven hundred pounds and it had struck his shoulder glancingly, knocking him overboard. But as he fell, the boom had somehow landed on his hand, leaving him dangling over the side, with his hand pinned down. This was just after lunch. The other workmen were not on the boat, so Luchesi had managed to get back up on the deck alone, and attempted to lift the boom. He could not do it without help. Fifteen minutes passed before the others arrived and were able to lift the boom.
He delivered the entire story in a monotone, while he stared at his hand. Moncure asked him how it felt now, and he said it was beginning to hurt again. As the surgeons began to drape the injured arm with sterile cloths, which entailed considerable manipulation of the hand, he complained more. The axillary block was not working well. With all preparation made, now was the time to produce general anesthesia.
Dalton, the anesthetist, leaned over Luchesi and said: "I'm going to put this mask over your face. You'll breathe only oxygen. Then I'll give you an injection that will make you fall asleep. Don't worry about a thing, just breathe and relax."
Luchesi nodded. The mask was put over his face and he breathed, staring up at Dalton, who proceeded to inject pentathol intravenously. Luchesi blinked once and closed his eyes. He was sleeping soundly, but would continue to do so for only a few minutes. Then he would wake up, unless more pentathol, or a different anesthetic, was administered.
Luchesi was fed pure oxygen for several moments, to be sure he was fully oxygenated. Then Dalton injected succinylcholine, a substance that paralyzes the entire body-including respiratory muscles-briefly. He removed the mask, opened the mouth, squirted a jet of cocaine down the throat to anesthetize the windpipe and prevent reflex coughing, and slipped a tube down the mouth into the windpipe. This provided a direct channel from the mouth into the windpipe and lungs, and prevented a major cause of death from anesthesia, namely, vomiting up of food from the stomach and blockage of the windpipe with this material.
The entire process of intubation took only a few seconds. Once intubated, Luchesi was fed oxygen and nitrous oxide, a mild anesthetic. Alone, nitrous oxide would not provide sufficiently deep anesthesia to permit surgery, but the axillary block was also helping. When it wore off, halothane, a more potent gas, would be added.
The operation began shortly before seven. There were seven people in the operating room at that time. Five were scrubbed: Moncure and Chandler, sitting on one side of the outstretched hand; Dr. Charles Brennan, an orthopedic resident, and Steven Kroll, a medical student, on the other side; and the scrub nurse, standing with two trays of instruments at her fingertips. Also in the room but not scrubbed were the anesthetist and the circulating nurse.
Around the hand, it was tight quarters. The scrub nurse first pinned sterile towels across the backs of Moncure and Chandler; this was because the upper-most portions of their backs, where the sterile gowns were tied, were unsterile, and she did not want to touch them by accident.
In general, the operating room is divided conceptually into "clean" and "dirty" areas. The operative field, meaning the exposed area of skin which has been shaved, scrubbed-and generally covered with plastic-is clean. The rest of the patient, covered with sterile drapes, is dirty. The fronts of the surgeons are clean; their backs are dirty. Anything above the level of the table is clean; anything below is dirty, and surgeons never let their hands fall to their sides. Hands, scrubbed and rubber-covered, are clean; faces, capped and masked, are dirty, and it is poor form to get one's face too close to the operative field or to touch one's mask with one's gloved hand.
The first incision was made over the underside of the wrist, just back from the thumb. The object was to find and locate the radial artery in that area. Moncure and Chandler discussed their procedure as they went, and agreed to find and evaluate the principal structures first: the radial and ulnar arteries, which run toward thumb and little finger respectively; the radial and ulnar nerves, which run with the arteries; and the median nerve, which enters the hand at mid-wrist.
As they began work, they found that the crush injury, with its hemorrhage and swelling of tissues, made identification of structures difficult. Five minutes into the operation, the radial artery was accidentally nicked. A fine, thin stream of blood spurted up in a foot-long arc. This was quickly clamped, and Moncure sewed it up with a small needle, perhaps no larger than twice the size of a typewriter parenthesis mark, and the operation proceeded. Moncure isolated the radial artery for a distance of several inches through the wrist. Everyone commented on the fact that pulsations through the artery were not as strong as they would like. The artery was flushed with heparin to prevent clotting further along its course in the hand.
At 7:20, Dr. Leslie Ottinger, another surgeon, entered the operating room. He had been working next door in OR 8 for six hours, repairing a crush injury to a man's thigh. Moncure, without looking up, said to Ottinger: "Were your vessels intact?"
"No," Ottinger said. "The femoral artery and vein were completely crushed. They were separated by three centimeters." "How's he doing now?" "Fine," Ottinger said, "if he stays open." He watched the dissection of the hand for some moments. "You find the radial artery yet?" "We nicked it," Moncure said. "Well, that's a good way to find it," Ottinger said, and left.
As the operation progressed, Moncure noted that the surgical field was more bloody. He felt the radial artery and concluded that it was pulsating more fully now.
By eight o'clock, the contrast between the area of surgical dissection and the area of crush injury was clear. One was clean and smooth, nicely exposed, bleeding very little; the other was mashed and oozing blood. Moncure, still working, glanced up at the clock and said: "Ottinger and I had a squash game for eight o'clock. We both ended up here. That'll teach us."
The operation itself proceeded slowly, impeded by the difficulty of identifying structures within the injured area. When damaged, a tendon, vein, and nerve can all look remarkably alike, but identification must be made with certainty. Nearly any vein in the body can be cut without consequence; to cut a tendon is an irritation, but not irreparable; to cut an important nerve is a disaster of major proportions.
Eventually all the structures were identified. All were found to be intact except for the ulnar artery, which was completely torn. The muscular coat of the artery was in spasm, pinching it off; the ends were clipped for the time being, and Chandler took over to begin work on the bones.
His first decision was to shorten the left arm by half an inch. This was necessary because there was a fragment missing from the ulna, and both radius and ulna had to be the same length. Also, shortening would make repair of tendons easier. He pointed out that this shortening would not be noticeable to the patient or anybody looking at him.
He began by filing the ends of the radius smooth and then joining them together with a vitalium plate, made of an alloy of cobalt, chromium, and molybdenum. It is electrically neutral and well tolerated by bone and the tissues around it. Screwing the plate onto the bone was difficult; it was not completed until 10:30.
Meanwhile, the anesthetist had been making some changes. "The axillary block has worn off by now," he said. "So we're supplementing the nitrous oxide with halothane in low concentrations. If he needs more for pain, we'll raise the halo-thane." He indicated that he could judge the need for anesthetic by watching the patient who, while not waking up, would become restless and would breathe irregularly if he was "too light."
"The idea," he said, "is to give the minimal anesthetic necessary to do the job, and to give it in such a way that the patient wakes up as soon as possible after the operation."
After Chandler repaired the radius, Moncure resumed vascular and soft-tissue reconstruction. He first re-examined the radial artery and decided it was not flowing as well as it should, as judged by squeezing the artery wall and feeling the pulsations. To make certain it was clear, he called for a small Fogarty catheter. This is a small, flexible tube with an inflatable rubber bulb at one tip. From the opposite end, water can be injected into the tube, and the bulb will expand. Thus the catheter can be inserted down an artery, and the bulb inflated within the artery. It can then be drawn back while inflated, and in doing so, it will clean out the inner wall of the artery, removing clots and other obstructions.
The Fogarty catheter is a relatively new device, named for its inventor, a surgeon at Stanford Medical Center. The discussion that ensued is typical of medicine in the modern day. So many developments and products are becoming available that it is difficult for anyone to keep track.
Moncure: "Get me the smallest Fogarty you have."
The circulating nurse came back with one. "This is a number four."
Moncure: "Let's have a look at it." He removed it from its plastic container; it looked too large. "Are you sure you haven't got something smaller?"
Scrub nurse to circulating nurse: "I know we have a six, at least."
"But a six is larger than a four," the circulating nurse said. She said it hesitantly, since numbers to designate sizes do not always run the same way. For instance, urinary catheters and nasogastric tubes run in proportion to size-a number fourteen is larger than a number twelve. But needles and sutures run in the opposite direction: an eighteen is much larger than a twenty-one needle. "Well, see if there's something smaller." It turned out there wasn't. Moncure meantime had made a small cut in the artery wall, and had found he could slip in the number four Fogarty without difficulty. He inflated the bulb, drew back, and found that the subsequent pulse was much improved. He sewed the cut shut, and felt the pulse. "Bounding now," he said.
He directed his attention to the ulnar artery, which had been completely severed by the injury. The ulnar was smaller than the radial artery; it was about the size of a pencil lead. As Moncure began to sew the ends together with fine sutures, he said, "Microsurgery. Watchmaking." It was now 11:30. He sewed it quite quickly, and the remainder of the operation, which dealt with larger structures, went rapidly. The tendons that had been torn were resewn. A heavy pin was run down the hollow interior of the ulna. By 12:30, the surgeons began to close.
It had been known from the outset that the wound area could not be completely closed. The tissues were damaged and swollen; to pull the skin tight across it would compress the arteries and cut off circulation to the hand, negating all the efforts of surgery. The incision was therefore only partially closed, with an area of the inner wrist left open. This area was expected to close by itself, to a degree, and to scar over for the remainder; after four or five days, they would reevaluate the area to consider skin grafting. The surgeon's major concern was infection. It was decided to continue the patient on cephalothin.
The operation was finished at one in the morning. The patient awoke in the operating room and was taken to the recovery room. For the first twenty-four hours, he was kept heavily sedated, but by the third day his pain was considerably less. Two weeks later he was discharged from the hospital. Two months later, on an office visit, Moncure found that the patient had essentially full function and sensation in the nearly severed hand.
The growth of modern surgery within the hospital is chiefly attributable to three factors. The first is the discovery of anesthesia. The second is the introduction of aseptic techniques. And the third, much more recent, is the improved medical understanding of the patient, with attendant improvements in pre-operative and, especially, postoperative care.
Consider anesthesia first. One hundred and three years before Peter Luchesi's hand was sewn back on, John C. Warren wrote: "Surgery has ceased to be the spectacular occupation it once was." It is impossible to miss the regret in his words, but he did not mean it regretfully, for he was talking about the difference anesthesia had made to surgery.
It is hard to imagine how ghastly, dangerous, and hasty surgery was before anesthesia. In Warren's own recollection:
In the case of amputation, it was the custom to bring the patient into the operating room and place him upon the table. [The surgeon] would stand with his hands behind his back and would say to the patient, "Will you have your leg off, or will you not have it off?" If the patient lost courage and said "No," he was at once carried back to his bed in the ward. If, however, he said "Yes," he was immediately taken firmly in hand by a number of strong assistants and the operation went on regardless of whatever he might say thereafter.
Relief from pain was not the only benefit of anesthesia. Equally important was muscular relaxation, which prior to ether was produced as follows: "In the case of a dislocated hip, where it was necessary to effect complete muscular relaxation, an enema of tobacco was freely administered, and while the victim was reduced to the last stages of collapse from nicotine poisoning the dislocated femur was forced back into its place."
One might expect this deplorable state of affairs would lead surgeons to search for ways to kill pain and to be constantly alert for new drugs that might accomplish the job. But in fact this did not happen: pain-killing drugs were known for forty years before they were applied to surgery. If, as Poincare says, discovery favors the prepared mind, doctors must be counted strangely unprepared. Briefly, the story is this:
Nitrous oxide was isolated by the English chemist Joseph Priestly in 1772. Around 1800, another Englishman, Humphrey Davy, experimented with the gas, noted its exhilarating and pain-killing properties and suggested it might be used in surgery. The suggestion was ignored. Instead, "laughing gas" became a popular form of amusement on both sides of the Atlantic. In 1818, ether was found to have the same effects as nitrous oxide. Soon thereafter, "ether frolics" came into vogue, especially among medical students and house officers-indeed, a whole generation of young doctors toyed with immortality, but missed the point. The observation was repeatedly made that one could bruise himself while under ether and have no recollection of the cause later, but no one connected the phenomenon to surgical applications. The blindness of these young men is sobering. (It also makes one think more highly of Alexander Fleming, whose culture dishes, contaminated with mold, might have been thrown out. One wonders how many hundreds of researchers before him had seen penicillin-producing molds, and had attached no significance to them.)
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.
Although the method of induction was primitive, it was not very dangerous. Profound anesthesia was difficult to accomplish and serious complications, Warren says, "were not commonly encountered."
Thus in a sense surgery has come a full circle, from the time when anesthesia opened new horizons to the time when anesthesia provides a serious hazard to operation. It is the kind of ironic twist that one frequently encounters in medical history.
A classic example of the full circle is the story of appendicitis. This is a very old disease-Egyptian mummies have been found who died of it-but it was never accurately described until 1886.
During most of the nineteenth century, surgeons were well aware of diseases which produced pain and pus in the right lower quadrant of the abdomen. Some attempts were even made to operate for the condition, by draining the abscess. But results were not encouraging and in 1874 the English surgeon Sir John Erickson said that the abdomen was "forever shut from the intrusion of the wise and humane surgeon." Note that pain was not a consideration here-surgical anesthesia was nearly thirty years old. Rather it was the fact that pus collections in the abdomen were not understood and did not appear to be helped by surgical intervention.
Twelve years later, an MGH pathologist named Reginald H. Fitz, who had traveled in Europe and studied under the great German pathologist Rudolf Virchow, published the results of an intensive study of 466 cases of "typhlitis" and "perityphlitic abscess," as the disease processes were then rather vaguely called. Fitz concluded that what the surgeon found at operation-a large area of inflamed bowel and widespread pus in the abdominal cavity-had resulted from an initial, small infection in the appendix. By describing "appendicitis," he created, in effect, a new disease.
The new disease was not readily accepted by the medical profession. Nor was Fitz's assertion that proper treatment required operation before rupture, instead of afterward. Today the idea of "operative intervention" is commonplace, but in Fitz's day surgery was generally the last resort, not the first.
Even after his clinical description of appendicitis was accepted, the surgical treatment remained a matter of dispute. In many hospitals, appendectomy was considered a bizarre procedure of questionable value. In 1897, when Harvey Gushing was a house officer at Johns Hopkins (after having interned at MGH and having seen several appendectomies performed), he diagnosed appendicitis in himself. He had great difficulty convincing his colleagues to operate; both Halsted and Osier advised against it. Finally, however, the surgeons gave in and agreed to do the procedure. Gushing did all the rest: he admitted himself to the hospital, performed the admission physical examination on himself, diagrammed the abdominal findings, wrote his own pre-operative and post-operative orders. It was said that he would have performed the operation himself as well, had he been able to devise a way to do so.
In the next few years, appendicitis became not only an acceptable but a fashionable disease; in 1902, it was diagnosed in King Edward VII of England, who was operated on for the condition. This signaled the onset of a great vogue for diagnosis and surgical treatment of appendicitis.
As a reasonably safe, reasonably simple abdominal operation, it encouraged surgeons to be more daring in exploring this body cavity. Their encouragement was not without its drawbacks, however: surgeons were so enthusiastic that nearly every bellyache was likely to receive an operation, and there sprang up a vogue for removal of ovaries and tubes in women, along with the appendix. The end result of this was the institution of quality-control checks on surgical procedures, through the "tissue committees" headed by pathologists.
Dr. Francis D. Moore has said: "[Fitz] was a student of pathology telling the surgeons to do more operations… How ironical it was that within thirty years it was to be the pathologists who applied the brakes to a surgical profession that was running wild with the operation for appendicitis."
Remembering Mr. O'Connor's case, it may be well to go into some of the differences, and some misconceptions, regarding the relationship of surgeons and internists. The two groups have never been too congenial. Traditionally, physicians have considered themselves more intellectual than surgeons. Descendants of Hippocrates, they look down upon surgeons as descendants of barbers. Surgeons, on the other hand, see themselves as action-oriented and regard internists as procrastina-tors, unwilling and unable to take action.
Temperamentally and philosophically, the two groups are at loggerheads. At mealtimes in the doctors' dining room, medical and surgical house officers can be heard berating each other about the care their respective patients have received. The surgeons say that an internist will sit hapless by the bedside and watch a patient die; the internists say that the surgeon will cut anything that moves. Most of this talk represents a time-honored outlet for black humor, but there is a long history of genuine conflict.
Dr. Paul S. Russell quotes the surgeon Sir Heneage Ogilvie in a most revealing passage:
A surgeon conducting a difficult case is like the skipper of an ocean-going yacht. He knows the port he must make but he cannot foresee the course of the journey… The physician's task is more comparable to that of the golfer… If he judges the direction and the wind right, estimates each lie correctly, finds the right club for each shot and uses it successfully, he will get an eagle or a birdie. If he makes a mistake he will make a poor score but he will get there in the end. The ground will not split beneath his feet, the game will not change suddenly from golf to bullfighting.
That was written in 1948. Six hundred years earlier, the French surgeon Henri de Mondeville set down his reasons for considering surgery superior to medicine:
Surgery is undoubtedly superior to medicine for the following reasons: 1. Surgery cures more complicated maladies, toward which medicine is helpless. 2. Surgery cures diseases that cannot be cured by any other means, not by themselves, not by nature, nor by medicine. Medicine indeed never cures a disease so evidently that one could say that the cure is due to medicine. 3. The doings of surgery are visible and manifest, while those of medicine are hidden, which is very fortunate for physicians. If they have made a mistake, it is not apparent, and if they kill the patient, it will not be done openly. But if the surgeon commits an error… this is seen by everybody present and cannot be attributed to nature nor to the constitution of the patient.
For hundreds of years, surgeons have been better paid than physicians. Internists will not be surprised to know how ancient is the surgeon's concern with fees. In medieval times, Mondeville was preoccupied with the matter:
The surgeon who wants to treat his patient properly must settle the matter of fee first of all. If he is not assured of his fee, he cannot concentrate on the case. He will examine superficially, and will find excuses and delays, but if he has received his fee, things are different.… The surgeon must have five things in mind: first, his fee; second, to avoid gossip; third, to operate cautiously; fourth, the malady; fifth, the strength of the sick man. The surgeon must not be fooled by external appearance. Wealthy people when they go to see a surgeon dress in poor clothes, or, if they are richly dressed, will tell stories in order to reduce the surgeon's salary… I have never found a man rich enough, or rather, honest enough to pay what he promised without being compelled to do so.
On the other hand, enthusiasm for operation is not an ancient vice of surgery, but a quite modern one. It was heralded by the development of anesthesia and antisepsis, both less than one hundred fifty years old. Operative restraint is still newer, a consequence of quality-control checks that are less than forty years old.
Mr. O'Connor was in the hands of the surgeons for two weeks. He was not operated upon; there was insufficient evidence of surgically treatable disease and therefore he received essentially medical treatment on the surgical wards. This is a far cry from the days when an MGH surgical chief resident told his staff (perhaps apocryphally): "Every person has at least three surgical diseases. All you have to do is find them." And it is a far cry from the days when the medical residents could accurately claim that surgeons didn't know how to read an electrocardiogram-and furthermore didn't care. In fact, there is a great deal of evidence that surgery and internal medicine are merging. It is a process that has taken several centuries, but today the cardiologists and cardiac surgeons work hand in hand, as do the immunologists and transplant surgeons; the tumor chemotherapists and the tumor surgeons; one need only look at the number of surgical house officers at the MGH who have done basic research in biochemistry and molecular biology to recognize the trend.
Bertrand Russell once said that we describe the world in mathematical terms because we are not clever enough to describe it in any more profound way. Similarly, surgeons and internists have come to see that surgery and medicine have the common goal of altering the functional status of tissues within the body. However, altering tissues with a knife is a relatively crude way of going about things; the finest surgeons are always the most reluctant to operate.
This is not to say that the scalpel will become a museum piece in our lifetime. Far from it. As surgery moves from a business of excision to a business of repair and implantation, it will be ever more important to the conduct of medicine. But the trend toward cooperation with internists, rather than competition with them, is likely to be extended as time goes on.
Indeed, the dramatics of the operating room have obscured the fact that most of the advances in surgery have taken place in terms of pre-operative and post-operative care. Modern surgery is immensely more complex than it was a century ago, but this complexity has more to do with electrolyte balances than with ligature points.
One can argue that in the last twenty years surgical advance has been largely dependent on para-surgical innovation, more involved with what goes on outside the operating room than with what goes on inside it. The paradoxical effect of this has been to increase the range and variety of services directed toward the operating rooms. Vast areas of the hospital are now given over to support and maintenance of a heavy surgical schedule, involving more than 16,000 operations a year. Two clear examples are Central Supply and the Blood Bank.
"Central Supply" consists of a single large room located one floor above the operating rooms. As its name implies, it serves as the central supply room for the hundreds of sterilized articles required for the operating rooms, as well as the other floors, of the hospital. All sterilization is done here; forty-three people are employed to keep the room in operation around the clock, seven days a week. Its operating budget is more than $600,000 a year.
Excluding operating instruments, Central Supply stocks nearly 500 separate items. These include 44 kinds of Foley catheters, 29 kinds of drains, 10 kinds of needles, 15 kinds of sponges, and 55 kinds of "sets"-prepackaged collections of equipment used in carrying out special procedures. They range from alcohol nerve-block sets to arterial-oxygen sets to liver-biopsy sets to suture sets and venous-pressure sets. Each set is handed out, used, returned for re-sterilization and repackaging, and handed out again.
Altogether, Central Supply hands out 12,000 items a day, or nearly 4.5 million items a year. The work of Central Supply has been increasing markedly in recent years. For example:
1966 27,000 37,000 485,000
1968 38,000 61,000 1,208,000
Hospital Use Dressing sets Suture sets Thermometers
These are real figures, in the sense that they do not represent absorption of work previously done by some other area in the last two years, but rather a simple increased demand by the hospital for these items.
It should be stated at once that Central Supply does not handle all the items now required by medical technology. For instance, the ten kinds of needles it carries do not include needles for routine intramuscular and intravenous use; these are purchased presterilized and are thrown away after use. Rather, Central Supply stocks intracardiac needles, spinal needles, sternal puncture needles, ventricular needles, and other similarly specialized nondis-posable apparatus.
The question of whether Central Supply should be doing as much as it does is the subject of debate. The cost of everything used in the hospital has grown so enormously that even the simplest details of patient care have undergone renewed scrutiny-revealing them, suddenly, as not so simple. Consider the Great Thermometer Controversy.
Thermometers were first used clinically in 1890, when they were delicate gadgets a foot long, but they are now a staple of modern care, and the largest item of business for Central Supply, which hands out between 3,000 and 4,000 thermometers a day. The MGH employs a method of reprocessing thermometers-unclean thermometers are returned to Central Supply, washed, sterilized, spun dry, and repackaged for use again.
The hospital recently commissioned a cost analysis of thermometer systems, which concluded that the average patient had 2.5 thermometer readings a day, and a total of 32 readings during an average admission of 13 days. Within this framework, three possible systems were examined: the reusable thermometer; a disposable probe used in conjunction with a portable sensing unit; and a personal-thermometer system in which each patient is given his own thermometer at admission, and keeps it at his bedside throughout his stay.
The conclusions on cost per year were as follows:
Reprocessable, reusable $30,113.00
Probe and sensing unit $49,786.00
Personal thermometer $13,250.00
This does not tell the full story, however. There are some complicating factors. First, the present MGH system is inefficient. Central Supply does not get back all the thermometers it gives out; in 1968, it spent $30,000 to replace lost thermometers, thus effectively doubling the cost of the present system. Second, the probe and sensing unit has an important front-end cost, namely the sensing units, which cost $190 each. Amortization has not been figured into the above accounting. Neither has nursing time been assessed-and the sensing units, unlike regular thermometers, are virtually instantaneous.
The situation is further confused by fear that a personal-thermometer system may not provide adequate patient safeguards. Some have envisioned a situation in which a tuberculous patient is moved to a different room, and a new patient put in his place, with the thermometer inadvertently remaining at his bedside, to be popped into the mouth of the unsuspecting new admission. The example is farfetched, but certainly any new system deserves close scrutiny to assess its reliability and safety.
The upshot of all this is that it is difficult to be certain what is the best, safest, and cheapest way to take a patient's temperature. The problems in determining cost for this relatively simple matter are magnified many times when one attempts to unravel the cost of a radiological unit or a chemistry laboratory. Given the vagaries of accounting methods, and the uncertainty of reliability with different systems, it becomes extraordinarily difficult to decide which costs are justified and which are not.
The controversy rages on, but on balance the cost advantages are too great, and the potential for danger too little, to permit the hospital to disregard the personal-thermometer system. Converting to this system would save the hospital only five hun-dredths of one per cent of its annual budget. But one can see how a series of similar minor cost changes could ultimately affect total hospitaliza-tion cost.
The Blood Bank is another large and expensive facility. The MGH now has what is believed to be the largest single hospital blood bank and transfusion service in the world. Located on two floors of the Gray Building, it accounts for one fifth of all the blood used in the state of Massachusetts. The great majority of the blood goes to surgical patients, with a large proportion going to open-heart cases. At times as much as a third of all hospital blood has gone to the cardiac surgical service. This massive consumption, in turn, is largely the consequence of the heart-lung machines, which require large amounts of blood to "prime" the pump.
Although the size of the Blood Bank is closely related to the increasing demand of cardiac surgery, its growth preceded the development of open-heart techniques. The MGH Blood Bank was begun in 1942, under the part-time direction of Dr. Lamar Soutter. The hospital, skeptical of the need for such a thing, contributed $5,000 in equipment and a basement room in one of the buildings. Soutter recalls that "in the beginning everything went wrong [but] the effort paid off with unexpected rapidity. In November of 1942 the Hospital was flooded with victims of the Cocoanut Grove [fire] disaster. The Bank had more than enough plasma to give the patients adequate care. This single episode swept away the last of the opposition to the Bank and it became firmly established as a necessary part of the Hospital."
The Bank has always operated in the black, though its operating budget has grown from $5,000 in 1942 to $144,300 in 1951, and finally to more than $1 million yearly at the present time. The staff has grown from one nurse, one technician, and a part-time physician in 1942 to more than one hundred technicians and nurses and secretaries at present.
By definition, an organ is a mass of specialized cells serving some specific function. According to this definition, blood is an organ, though one does not often think of it in this way.
As a developing organ in the embryo, blood is formed from the same tissue which also differentiates into cartilage, connective tissue, and bone. This helps explain why, for example, blood is formed in bone marrow.
In the adult man, blood consists of five quarts of liquid, accounting for 7 per cent of adult body weight. This makes it, on a weight basis, a respectably large organ-much larger than either the lungs (1 per cent) or the liver (2 per cent). The functions of blood are suitably complex, ranging from transport of oxygen and nutrients to defense of the body against infection.
If blood is an organ, a blood transfusion is an organ transplantation. It is not idle to think of transfusions in this way, for nearly all the problems of modern organ transplantation were first met, and solved, in dealing with blood transfusion. Only our familiarity with modern transfusion makes us forget that it is, in fact, a transplant-a gift of vital cells from donor to recipient.
No one knows when the first transfusion was performed, but it was certainly a long time ago, for the efficacy of blood was highly regarded in ancient times. In early accounts, it is not clear whether the blood was transfused or drunk, since both methods were considered useful. Celsus, in Roman times, refers to treatment of epilepsy by drinking the hot blood from the cut throat of a gladiator. The Mongols, living in a horse culture, often drank horse blood for sustenance.
The idea of intravenous injection is also old. Ovid relates that Jason was helped by Medea with an injection of "succis" into his jugular vein.
Behind the early interest in transfusion was the quite logical notion that an illness involving blood loss was best treated with blood replacement. Early materials for this were primitive-needles made of quills and bone, tubing formed from bladders or leather. In many cases, animal blood was transfused to human beings, often with the addition of semen, urine, and other substances thought to be invigorating.
It is not surprising that patients often died from this procedure. Donors often died, as well. In a famous instance, Pope Innocent VIII received a transfusion from three young boys in 1492. The donors as well as the recipient expired within a few days.
In the eighteenth century, when better materials were available and more careful observation the rule, it became clear that certain patients benefited from transfusion but others did not. This early notion of the "transfusion reaction" evolved slowly, culminating in Karl Landsteiner's discovery in 1900 of A, B, and O blood groups. This represented the first clear, unequivocal statement that all blood was not the same. For more than a decade after Landsteiner's work, there was no practical clinical method of differentiating blood groups. The search for such techniques is a direct forerunner of modern tissue-typing methods for transplantation of other organs.
Just as the matching of donor and recipient was a problem, so was storage of the organ. Untreated, blood clots soon after it is drawn. It was not until 1916 that blood could be kept refrigerated for two weeks in glass bottles, with the addition of anti-coagulating substances. And it was not for more than twenty years after that that clinical blood banking began on any scale in this country. There was no important improvement in storage techniques until 1952, when glass bottles were replaced by plastic bags, which preserved blood elements much better.
More recently has come the ability to store frozen blood. This single technical capability has solved several traditional banking problems, and indeed is now integral to the MGH function: most open-heart cases are done with frozen blood [Dr. Charles Huggins, an MGH surgeon, was one of the pioneers in making frozen blood practical for clinical use].
Formerly, all blood had to be used within three weeks. Now it can be stored at -120° F. for five years or more. In the past, patients had to be matched to their own blood type. Now, the freezing-thawing process washes out serum antibodies, which means that type O frozen blood can be transfused to anyone, regardless of his blood type. The need for the bank to stock many different blood types is therefore reduced.
And, finally, there is evidence that the risk of hepatitis, a traditional problem with transfusions, is reduced when frozen blood is used.
There are, of course, some drawbacks to frozen blood. It is more expensive at the present time. Also, some blood components, notably platelets, which are important to clotting, are lost and must be supplied separately. But there are easy techniques for this.
In fact, the products of the modern blood bank are increasingly sophisticated. In 1942, the bank produced only two products-whole blood and plasma (the liquid portion without the cells). But it is now possible to give whole blood, or packed red cells without plasma, or platelets; it is possible to give plasma, or only the protein from the plasma, or only specific parts of the total protein without the others. Each of these specialized blood bank products is becoming increasingly important to the conduct of modern medicine.
What has all this meant to surgery? As it has become more scientific and more complex, a certain amount of the drama and flair, the spectacle that Warren remembered, has disappeared-or at least become muted, until it is hardly recognizable.
On Saturday mornings at the hospital, surgical clinics are held for students in which patients are presented pre-operatively and then the students are invited to watch the procedures from the several overhead viewing galleries. This teaching exercise is the last remnant of a proud tradition of surgical spectacle. Dr. E. D. Churchill, former MGH Chief of Surgery, gives the following account:
The display of operations at the Hospital on Saturday mornings continued well into the 1920's. Unusual cases were assembled so that the senior surgeons on duty could have an impressive list of operations scheduled for the amphitheater. The two services, East and West, vied with each other in trying to stage the better show. In the Surgical Building, opened in 1900, the display reached major proportions. When the morning's list was a long one, an operation would be started in a small room and then the entire outfit trundled like a troupe of gypsies into the pit of the amphitheater, where the crucial phase of the procedure was demonstrated to the visiting doctors. The surgeons would be allotted, say, fifteen minutes. Whether or not the operation had been completed, at the expiration of the allotted time the tents were folded, the troupe moved off stage to complete the operation elsewhere, and a new act took over… Great weight was placed on the speed and daring of the operator… Tension mounted when some prima donna showed reluctance to withdraw from the spotlight and overstayed his time to hold the audience spellbound in an ad lib recounting of his surgical prowess.
The prowess of the surgeon has steadily increased since then, to the point where reconstructing a nearly severed hand is, if not commonplace, at least nothing to get very excited about.
And if, in this age of television, the surgeon shows more flamboyance than is scientifically necessary, more sense of drama than is medically indicated, he can at least be excused for upholding the traditions of his calling-and, in a deeper sense, the facts of his life.