Blood and Guts (10 page)

When, with my current convictions, I look into the past, I can
endure the miseries to which I have been subjected only by
looking at the same time into the future?If I am not allowed
to see this fortunate time with my own eyes, therefore, my
death will nevertheless be brightened by the conviction that
sooner or later this time will inevitably arrive.

The rambling and sometimes vitriolic nature of the book revealed
Semmelweis's declining mental health. He had become even more
irritable, absent-minded and depressed. He wrote to doctors accusing
them of murder for failing to listen to him. He went to the
hospital chapel to pray for forgiveness for the deaths he had caused.
He took to heavy drinking and visited prostitutes. His wife was being
driven to despair. His own doctors suggested he take a holiday.

The Semmelweis family took a train to Vienna, where they were
met by an old friend, Professor Hebra. The professor seemed keen
to show Semmelweis his new hospital. Leaving his wife and children
behind, he accompanied the professor to see the facilities. The
hospital turned out to be the Lower-Austrian Mental Home.
Semmelweis was held, tied into a straitjacket and confined to the
ward for maniacs.

When his wife came to visit him the next day she was forbidden
from seeing him. It seemed Semmelweis had tried to escape and had
been restrained by six attendants. He was being held in a secure cell
for his own protection. Accounts are confused about what happened
next. Some believe that in being restrained he had in effect been
beaten up; others say that he cut his finger (this could also have
happened when he was restrained). Within days Semmelweis had
become seriously ill: he was feverish, his body swollen, covered in
abscesses and sores. Two weeks after entering the asylum, Ignaz
Semmelweis was dead. He died from the same disease that had killed
his friend Jakob Kolletschka and all those thousands of women.

At the time, few mourned his passing. They had always thought
he was a madman, and the nature of his death only confirmed this
belief. Anyway, as soon as he had entered the doors of the asylum
Semmelweis was effectively dead, and his ideas with him. It was
many years before his research was re-examined and his discovery –
that cleanliness can prevent the spread of infection – fully appreciated.
^*
But by that time, someone else had got the credit.

^*
Decades after his death Semmelweis finally got the recognition he deserved. He now has a
university named after him in Budapest, and is known by many as 'the saviour of mothers'.

Glasgow, 1865

Joseph Lister was walking his ward. The professor of surgery
stopped at each bed in turn to talk to the patients. He would ask the
nurse to remove the sheets so that he could have a look at their
wounds. It could be a depressing experience. The sweet, sickly smell
of putrefying flesh pervaded the room. Patients would arrive at the
hospital in good spirits, confident of recovery. Two weeks later they
would be dead. Despite all the advances in surgery, patients all too
often succumbed to gangrene, fevers and blood poisoning. Any
exposed wound was likely to become diseased. Even the most minor
procedures, such as the removal of a small growth or wart, could
end in a lingering death.

It saddened Lister how many amputations he had to carry out.
A young child would come in with a fractured leg, having fallen
awkwardly while playing or been knocked over by a cart or tram
(there were increasing numbers of traffic accidents). If the child's
skin was broken, Lister knew that within days infection would set in,
the flesh would begin to rot and the limb would have to be amputated.
Too many limbs were being lost because surgeons could not
control disease.

Then there were the new operations that surgeons were trying
to develop. They should be able to do more than hack off limbs or
growths. With anaesthetics, they could take their time during
surgery and try new techniques. Surgeons ought to be able to open
up the body and operate on the organs. But, like any sensible
surgeon, Lister would not operate unless absolutely necessary. He
would not cut into the flesh unless he had to, and certainly not
into the abdomen. Any wound was a potential source of disease
and death.

The cause of this disease, or any disease, was still a mystery.
Perhaps it was spread by bad air – some sort of miasma. But this was
a new hospital. The wards had high ceilings, the beds were well
spaced, there were large windows down the sides. With hard wooden
floors and whitewashed walls, the wards were light and airy.
Admittedly, the air was full of the smoke and smog of industrial
Glasgow, but could that really be causing all this disease? Some of
the more superstitious patients blamed it on the position of the
hospital: it was built over the graves of cholera victims. Maybe they
were right? Lister was prepared to consider anything.

Lister was a good but not particularly exceptional surgeon. He
had risen gradually through the ranks to reach his position at
Glasgow. Ever since he had been a medical student at University
College London under Robert Liston, his overwhelming desire had
been to save lives. Lister had witnessed Professor Liston's first use of
anaesthetics and had closely followed advances in surgical techniques,
as pain relief enabled surgeons to take more time with their
operations. But the mortality rates from the amputations Lister
carried out were still typical of the period. Around half the patients
he operated on would die.

The development of surgery had ground to a halt. Surgeons
knew how the body worked and they could control blood loss.
They could even put their patients safely to sleep while they operated.
Despite all this, far too many people who were admitted to
hospital were dying. Until the problems of infection were solved,
surgery could go no further. And opening up the abdomen to
remove an appendix or operate on the organs was completely out
of the question.

In his spare time Lister was also a scientist. There were few full-time
scientists as such, apart from those in the chemical industry.
For a gentleman, studying science wasn't really a vocation, more of
a hobby. Science ran in the family. Lister's father, a wine merchant,
was a respected microscopist and had devised significant refinements
to microscopic technique. The younger Lister started his own
experiments on frogs. He used a microscope to observe what
happened when wounds became inflamed. He found that gangrene
was a process of rotting – the flesh was decomposing. What he could
not understand was why a simple fracture – a bone broken beneath
the skin – healed, whereas a compound fracture – where the bone
penetrated the skin and was exposed to the air – became infected.

One of the greatest tragedies in the history of medicine is how
long it took the medical profession to realize that disease and infection
were caused by micro-organisms. The invention of the microscope
in the seventeenth century had revealed these 'germs' for the
first time, but the work was never pursued and the connections
never made between these 'microscopic' creatures and disease.

For all his achievements, not even Semmelweis had worked
it out. He died believing that disease was spread by dead matter
itself, rather than anything on the dead matter. Furthermore, few
surgeons made the connection between dirty conditions and rates
of infection. Florence Nightingale had shown how sanitary hospital
conditions reduced death rates significantly, and even old-school
surgeon Robert Liston had probably lost fewer patients than his
rivals thanks to his attention to cleanliness. The fact that Liston operated
so quickly also probably kept the death rate down. With anaesthetics,
most operations were often taking longer, so wounds were
exposed for a greater amount of time, increasing the opportunity
for infection.

Doubtless more surgical patients survived in Victorian Britain
than elsewhere, thanks to the obsession with order and cleanli-
ness. But while most surgeons might be smartly turned out when
they arrived at the hospital, when they came to operate they would
don their old frock coat, encrusted with blood and pus – the result
of years of messy surgery – and would pick up the same instruments
they had used on the previous patient, wiped down to stop
them rusting.

A professor of chemistry at the university, Thomas Anderson,
told Lister about some experiments that had been conducted in
France by Louis Pasteur. Lister found Pasteur's work simple but
compelling. In one of his experiments, Pasteur sterilized a flask of
broth by boiling it. He plugged the top of the glass vessel with cotton
wool to allow the passage of air but nothing else. He left the flask for
a few days and found the broth remained sterile. When the cotton
wool was removed, the broth became putrid. Pasteur had proved
that it was something in the air, not the air itself, that caused a
substance to rot. The something, he surmised, was germs – micro-organisms
in the air.

Pasteur's most famous refinement of this experiment was
conducted using a swan-necked flask – a specially made glass
container with a long, curved glass stem protruding from the top.
Air could pass freely through the stem, but any dust or microscopic
organisms in the air would become trapped. He filled the flask with
broth and?it remained sterile.
^*

^*
Pasteur's research was published in a series of papers between 1857 and 1860. Semmelweis
was still working on his book during this period, but there is no evidence that he knew of
Pasteur's work or that he ever made the connection between hospital infection and micro-organisms.
Given that Semmelweis's achievements were published in only a very limited way,
it is assumed by historians that Pasteur never came across his research.

Reading through Pasteur's published research was heavy going,
but Lister's efforts were rewarded. He started to piece together the
evidence and began to realize what was happening to his patients:
they were being killed by germs. So, he surmised, if he could kill the
microscopic organisms or prevent them getting into wounds, there
would be no infection. But Pasteur had sterilized his experiments
using heat (a process that would later become known as pasteurization).
How on earth could Lister sterilize a wound on a living person?

Lister tried a few experiments with various chemicals and
compounds but with little success. The answer was to come from
sewage. A hundred miles south, on the other side of the Scottish
border, the authorities in Carlisle were trying out a new type of
sewage treatment on the drains and cesspools of the city. The chemical
they were using – carbolic acid – removed the terrible smell.
Made from coal tar, carbolic acid had been shown in studies to kill
germs. Lister reasoned that a chemical used to destroy micro-organisms
in sewage might also be used to destroy micro-organisms in
wounds and prevent infection. After all, the septic smell of rotting
flesh pervading the surgical ward was not unlike that of untreated
sewage. In the best traditions of surgery, Lister decided to try out his
new 'antiseptic' principle on a patient.

On 12 August 1865, eleven-year-old James Greenlees was run
over by a cart. He was admitted to the Glasgow Royal Infirmary later
that day with a compound fracture of the left leg. The wheel of the
cart had broken his tibia (the main bone of the lower leg) in two.
The broken bone had punctured the skin, leaving a wound some
one and a half inches long and three-quarters of an inch wide.
When Lister examined the boy, he passed a metal probe into the
wound to feel the broken bone. He observed that there was surprisingly
little blood.

Under normal circumstances, the wound would have been
covered and the boy rested. Splints would have been applied in the
hope that the injury would heal, but Lister knew that eventually he
would have little choice but to amputate. The boy would be left a
cripple, his chances in life appallingly diminished.

Instead, Lister orders his house surgeon, Mr Macfee, to dress
the wound using lint dipped in undiluted carbolic acid. The lint is
laid across the wound and then covered with a sheet of tinfoil. The
foil will prevent the carbolic acid from evaporating. Two wooden
splints are then strapped on either side of James's broken leg.

Four days later, James says the wound is feeling sore, so Lister
decides to take off the dressings to see what is happening. Urging
the boy to keep still, he carefully removes the splints and peels back
the dressings. Lister has never got used to this moment. Normally he
would be forced to step backwards as his nostrils were hit by the
smell of rotting flesh and putrefaction. This would normally be the
time he would have to sit down and calmly tell the patient that
amputation is the only option.

The final piece of lint is removed. He has never seen anything
like it. There are no signs at all of suppuration; the wound is
completely clean. The only smell is from the carbolic. The worst that
could be said about the wound is that the edges are red – probably
burnt, he thinks, by the acid. The soreness the boy has been
complaining of is from the dressing, not, thank God, from disease.

Lister reapplies the lint, this time diluting the carbolic with clean
water. Five days later he looks at the wound again – there is no pus or
other sign of infection. However, the carbolic is still burning the skin,
so Lister tries a mixture of carbolic and olive oil. After another few
days he replaces this with a dressing of lint soaked in water. Six weeks
later the wound is completely healed, the splints are removed and
James walks home. It is, says Lister, 'a most encouraging result'.

By 16 March 1867, when the first results of Lister's work were
published in the
Lancet
, he had treated a total of eleven patients
using his new antiseptic method. Of those, only one had died, and
that was through a complication that was nothing to do with Lister's
wound-dressing technique.