Anaesthesia was a revolution in surgery; the next step was the introduction of hygiene. In 1847, the Hungarian Ignaz Semmelweis discovered that childbed fever – an infection contracted by mothers shortly after childbirth – occurred when medical students returning from the dissecting-room after practising anatomy on dead bodies did not wash their hands before assisting with births. No one believed, however, that something as simple as washing your hands could make the difference between life and death and Semmelweis was dismissed as mad. (It did not help that he unfortunately suffered from a neurological disorder that was gradually driving him insane.) Semmelweis’s basic principle of hygiene was not accepted until Louis Pasteur exposed bacteria as the cause of disease and Joseph Lister was the first, in 1865, to prevent the infection of a surgical wound by using an antiseptic. Though revolutionary, these methods were, initially, very painful, because of the corrosive effect of disinfectant in the wound and the length of time they took to administer. They could therefore only be applied thanks to the invention of anaesthesia.
The chloroform that so delighted Queen Victoria was abandoned in the twentieth century, after it was discovered that it could damage the liver and cause irregular heartbeat. Ether, too, was replaced by something else: nitrous oxide (N2O), also known as laughing gas, a powerful anaesthetic. But it too went out of use when it proved to be a significant greenhouse gas 300 times more damaging to the environment than carbon dioxide.
In modern anaesthesia, the drugs are injected directly into the bloodstream, which means they take effect more quickly and the dose can be more precisely adjusted during the operation. The most commonly used anaesthetic drug at this time is 2,6-Diisopropylphenol, better known as propofol. Propofol has significant advantages and the effects wear off quickly once it is no longer administered. And even better, when patients wake up, they feel as though they have slept very soundly. Because of its milky appearance, it is also known as ‘happy milk’ or ‘milk of amnesia’. But this miracle anaesthetic is not without risks: pop star Michael Jackson became addicted to propofol and died after using it in 2009, because the doctor who administered it to him had not paid sufficient attention to Jackson’s state of health. That is a real medical error; as a good anaesthetist will ensure that a patient is closely monitored for twenty-four hours after waking up.
We do not know whether John Snow was able to monitor his patient in this way. And despite his services to the queen, Dr Snow is not remembered as a great anaesthetist. He is, however, remembered for a completely different reason. In 1854, he described an outbreak of cholera in London, identifying a single public water pump as the source of the infection. He was the first to show how a disease can be contagious, and the founding father of epidemiology, the study of how diseases spread.
Victoria insisted that Snow be present, with his anaesthetic, at the birth of her next child on 14 April 1857. It was a girl, Princess Beatrice. And, much to everyone’s surprise, this time the queen did not suffer from post-natal depression. Beatrice was her ninth – and last – child.
11
Gangrene
The Battle of Little Bay: Peter Stuyvesant
ON HIS SECOND voyage westward in search of India, the first land that Christopher Columbus saw rising up on the horizon was an island that he named after that day, Dominica (Sunday). He sailed on, to the north-west, and arrived eight days later at another island, which he again called after the day it was sighted, Monday 11 November 1493. But Columbus had of course not discovered new land. People had already been living there for thousands of years. The original inhabitants, the Carib Indians, called their island Soualiga, which means ‘salt-land’. From 1627, Dutch ships regularly visited the island for the salt that was extracted from an extensive salt pan between the hills overlooking a large bay. In the seventeenth century there was great demand for salt in the Netherlands to preserve herring. To gather it, there were plenty of slaves available from the adjacent island of Sint-Eustatius, where they arrived directly from Africa to be shipped to further destinations in the New World. The Spanish, however, still considered the island to be theirs. What’s more, they were at war with Holland and were not prepared to tolerate the Dutch grabbing ‘their’ salt. In 1633, they reoccupied the island and built a number of forts. One of these was on the headland that extends far into the sea between Great Bay and the adjacent Little Bay. From there, they made life difficult for the Dutch fluyts, the ships carrying the salt. In 1644, the director of the West India Company in Curaçao came to resolve the situation.
Today, the island – incidentally not called Monday but Saint Martin, as the day on which Columbus sighted it (11 November) is St Martin’s Day – is loved for its thirty-four excellent beaches. Peter Stuyvesant could therefore have chosen thirty-three other beaches for his attack on the island. But he wanted to conquer Little Bay, as it gave access to the Spanish fort. Stuyvesant knew that if he could take that beach, where tourists now lie in the sun and go snorkelling in the crystal clear turquoise water, he could take the whole island.
Stuyvesant was no great strategist. The attack was an utter disaster for the Dutch troops and a painful humiliation for him personally. His ships had taken many days to sail the 500 nautical miles across the Caribbean Sea from the distant Leeward Islands to Sint Maarten. They encountered no resistance at all when the Blauwe Haan, Stuyvesant’s flagship, approached the island and, on 20 March 1644, Palm Sunday, entered Cay Bay, a small inlet just past the beautiful Little Bay. They crossed the shallows to the shore in rowing boats. Proudly, the Frisian minister’s son stepped into the warm water and strode up the beach. Under the command of Jacob Polak, the governor of Bonaire, the men dragged a cannon up the hill overlooking Little Bay and the Spanish fort on the headland on the other side. But Little Bay was too big, or the cannon was too small, and the cannonballs did not reach the fort. So they had to find an emplacement closer to the target. With a flanking movement, Stuyvesant led the way to a hillock directly above the beach of Little Bay, called Bel-Air. There, he planted the Dutch flag, well within range of the cannons in the Spanish fort immediately in front of him.
Boom! The first shot the Spaniards fired was a direct hit and shattered Stuyvesant’s right leg. The captain of the Blauwe Haan, who was standing next to Stuyvesant, was also hit and lost a cheek and an eye. Stuyvesant was immediately carried off, rowed back to the ship and hoisted aboard.
What we, fortunately, have not had to face for a very long time must have been immediately clear to Peter Stuyvesant as he lay groaning in the sloop. He may not have dared to look at his leg, but he would immediately have understood – whatever the seriousness of the injury or the size of the wound – that it would have to be amputated. Until about a hundred and fifty years ago, amputation was the only effective treatment for an open leg fracture. Even if the wounds were less complex, the consequences of not amputating immediately would usually be fatal, as gas gangrene – the greatest adversary of wound healing – was always a danger.
The word gangrene is a general term to describe the dying off of living tissue. It is the terrifying final stage of a shortage of oxygen in the skin, the subcutaneous tissue, the muscles or even an entire limb. Although the dead tissues feel as cold as ice, the victim develops a high fever. Gangrene can be caused by a blocked artery. You could then speak of an infarction. That leads to a sharply defined black mummification of part of the limb. The dead part dries out. That is referred to as dry gangrene. But tissue can also die off due to infection of a wound. Because of the pus and the rotting fluids that this produces, it is called wet gangrene. Some bacteria also produce gas, resulting in a form of wet gangrene called gas gangrene.
Gas gangrene is the deadliest form of gangrene and is mostly caused by a micro-organism with the appropriate name Clostridium perfringens, from the Latin verb perfringere, which means ‘crush’, ‘demolish’, ‘assault’ or ‘break through with violence’. It can be found everywhere on the planet. Sand, soil, faeces and street refuse are full of it. Pe
rfringens comes from a dangerous family. Clostridium tetani causes the lethal disease tetanus, or ‘lockjaw’, Clostridium difficile a life-threatening great bowel infection and Clostridium botulinum deadly food poisoning. In unhygienic conditions, Clostridium perfringens also causes the much-feared childbed fever, which unnecessarily cost the lives of so many women in childbirth in the past.
The Clostridium perfringens bacteria is an anaerobic life-form, meaning that it only survives in an oxygen-free environment. The bacteria has two dangerous properties: it emits rotting gases and produces toxic substances known as toxins. For many centuries, surgery was frustrated by gas gangrene and wound infections. But why does one wound become infected and another not, and why would gas gangrene have developed in Peter Stuyvesant’s wound? And why does it hardly occur in the present day?
Three elements determine whether an infection or gangrene develop in a wound. Firstly, of course, there has to be a wound. The size of the opening in the skin is not that important. Bacteria are small enough to enter through even the smallest wounds. The second determining factor is the quantity of bacteria that succeed in multiplying in the wound. That can be minimised by cleaning the wound and keeping it clean. But most important is the damage to the tissues surrounding the wound, called the ‘wound bed’. The state of the wound bed is crucial to what follows.
In a wound caused by a sharp knife, the wound bed will hardly be damaged. The edges of the wound will remain unharmed and the healthy tissues will allow the immune system to kill any bacteria that enter the wound. A clean cut with a sharp knife can even be closed up again immediately, if you rinse it out quickly with water, soap or disinfectant. This is primary healing or healing in the first instance (per primam). If the cut is not clean, the wound will become infected, producing pus. The infected wound can then no longer be closed up per primam and will have to heal per secundam, through secondary healing or ‘healing in the second instance’. However, the healthy wound bed also guarantees a sufficient supply of oxygen. As the Clostridium perfringens bacteria cannot survive in the presence of oxygen, gas gangrene has little chance in a healthy cut, no matter how dirty the wound may be.
In the case of a crush wound, by contrast, the tissues are damaged by bruising, crushing or tearing. Consequently, the blood vessels in the wound bed are also damaged, reducing the supply of oxygen. That will cause much more tissue to die off than the size of the wound would suggest. This dead tissue is referred to as necrosis and provides an ideal breeding ground for all kinds of bacteria. But, because of the lack of oxygen in the wound, the Clostridium perfringens bacteria will thrive the most. That is how gas gangrene starts.
For anyone who knows all this, the solution is relatively simple. Clean the wound as quickly as possible. Rinse it out with clean water (for example, the crystal clear sea water in the bays of Saint Martin) and leave it open. Then use a sharp knife to cut away all the dead material until you come to healthy tissue. There are fine-sounding surgical terms for this: debridement or nettoyage in French, anfrischen in German, or necrosectomy in English (from the Latin/Greek). Then keep the wound clean until it is fully healed, per secundam.
Unfortunately, in the past surgeons always did exactly the opposite. Rather than cleaning wounds by rinsing or washing, they burned them. That does kill the bacteria, but also the tissues and blood vessels in the wound bed, increasing the shortage of oxygen. Surgeons also treated the resulting fever by bloodletting, causing anaemia and thus restricting the supply of oxygen to the wound even more.
Peter Stuyvesant’s wound had even more collateral damage. The impact of the cannon ball had shattered his bone, which protruded through the wound. Stuyvesant’s leg had undoubtedly become a veritable feast for the minute Clostridium perfringens. In these conditions, the anaerobic bacteria would have been able to multiply very rapidly. The immune system responds to such an attack with an inflammatory reaction, causing fever and the production of pus. The microbes then produce toxins that kill the still healthy cells in their vicinity. That generates rotting juices that, together with the pus, form wet gangrene. The rotting gas exuded by the bacilli comes under pressure and forces its way into the healthy tissues, which are consequently cut off from their blood supply. The gas can be felt under the skin, and is crunchy,
* * *
Knives and forks
Just as a knife, fork, spoon, glass and serviette are standard attributes at the dining table to enable us to enjoy a meal, standard instruments are required on the operating table to enable a modern operation to be performed. A surgical knife – formerly a one-piece scalpel – now consists of a handle into which disposable blades can be clicked. That means the blade is always sharp, clean and undamaged. Various blades can be used, indicated by a number. The most commonly used are the number 10 (large, curved blade), the number 15 (small, curved blade) and the number 11 (pointed, stabbing blade). Tissue is held with tweezer-like forceps. There are blunt ‘anatomical’ forceps and atraumatic ‘surgical’ forceps with pointed ends. There are scissors to cut or spread tissue and scissors to cut thread. The suture needle is held in a special clamp, known as a needle holder. The wound is held open with retractors. The blood is wiped away with sterile gauzes of different sizes. Rinsing fluid and disinfectant are kept in small bowls on the instrument table and there is a wide range of clamps, in all shapes and sizes, for all kinds of uses. For bone operations, there are screwdrivers, saws, gouges, chisels, drills, hammers and files. There are surgical probes, dilators, specula and suction tubes. Stapling machines in wide varieties are used in modern operations to make joins in the abdomen between the stomach and the intestines. Lastly, almost no operation can be performed without electrocoagulation, using an electric probe to cut or sear tissue.
* * *
like walking in fresh snow. The gas and toxins kill more and more tissue and the infection spreads more quickly. As the amount of dead tissue increases, the supply of oxygen decreases further, making the environment progressively more favourable for the pathogen. This mass attack was always fatal.
Peter Stuyvesant’s wound was full of Clostridium perfringens. They were in the soil of Bel-Air, on the cannonball that had lain on the ground on the Spanish side, in the dirty sloop that had taken him back to the ship, on the dirty hands of the surgeon and in the black edges of his fingernails, on the dirty operating table, on the surgeon’s dirty saw and in the dirty bandages. The ship’s surgeon did not know all that, but he did know that an amputation could save Stuyvesant’s life, if he did it high enough up the leg, in the healthy tissue. For him, it was a routine operation, for which he needed four instruments.
The patient was laid on the table. The surgeon applied a tourniquet to the upper leg. That served not only to stem the flow of blood, but also to somewhat numb the leg. After half an hour, it would cause the patient sufficient pins and needles to distract him from the pain of the cut.
The surgeon then took the amputation knife. This was not a small instrument like a scalpel, but a kind of butcher’s knife, 30 centimetres long and 3 centimetres wide, razor sharp, with a pointed end and a sturdy handle. He used the knife to cut through to the bone in one go, just above the knee. The cut alone was of course enough to cause excruciating pain, but it was mainly when the surgeon sliced through the large nerves, that run right down the leg like thick cables, producing a sudden, icy pain that would certainly have made the patient scream in agony. Placing a piece of wood between Stuyvesant’s teeth to bite on helped to dampen that awful sound.
Between the muscles, tendons and nerves run the major blood vessels, which of course also had to be cut through. Thanks to the tourniquet around the upper leg, the blood did not spurt out, but the bandage could not prevent the blood vessels from emptying out on the other side. The lower leg contained about a litre of blood, which now started to flow out of the amputation wound over the table, so that everything was soon covered in blood.
The cut had to be made in the healthy part of the leg, well above the wound c
aused by the cannonball. But the bone had to be sawn through a little higher still, so that the end could be well covered with muscle and skin. The next step was therefore to scrape the muscles from the bone, over a length of about a hand’s width. The surgeon did that with a scraper with the rather macabre name ‘raspatory’. He scraped away the periosteum, the membrane covering the bone, with four or five forceful strokes, as though he were planing a piece of wood. That would have been met with four or five horrendous screams from the patient, if he had not by now lost his voice. Then the surgeon took the saw. With a robust, sharp saw, you can cut through the thigh bone with less than ten strokes. The patient would have felt the vibrations of the saw teeth literally ‘to the bone’. Bone dust, blood, vomit, urine and sweat, all mixed together – it would have been a filthy mess. And then there would be a solid thump as the leg fell away. A leg is surprisingly heavy, much heavier than you would expect. Or perhaps surprisingly light if you no longer have it.
The stump was left open and wrapped thoroughly in bandages, after which the tourniquet could be removed. If the wound continued to bleed, the surgeon could always use the branding iron. The patient had long ago fallen into a dead faint anyway. The open wound healed per secundam.
Tens of thousands of legs must have been removed in this way in the history of warfare. The record is held by Dominique Jean Larrey, a surgeon in the French army, who is alleged to have performed 700 amputations in four days during the Battle of the Sierra Negra in 1794 in Spain. That amounted to around four minutes for each leg, if he had been sawing all day long for four days. He was able to do this thanks to an invention that still bears his name, the Larrey retractor, a shield that could be opened and fitted around the bone, so that the muscles and the skin could be scraped off with one firm tug, leaving the way clear for the saw. That made the scraping with the raspatory unnecessary. The unfortunate victims were probably lined up and fitted with a tourniquet. Then came Larrey with his knife and retractor, followed by an assistant with the saw, and another with the bandage.
Under the Knife Page 11