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.