Five Patients

Five Patients Page 8

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.