Authors: Richard Hollingham
Cauterizing was not only brutal, it was also ineffective. By the
time the surgeons had amputated a limb, a tremendous amount of
blood had already been lost. Many soldiers bled to death before the
arteries could be sealed shut. Even if they didn't die immediately,
they would often lose so much blood that their chances of recovery
became even slimmer.
*
*
Paré also had to deal with increasing numbers of casualties suffering severe burns. Lines of
gunpowder would be laid by the enemy to create explosive walls of flame, cannons could
misfire, and there were regular accidents with powder flasks and kegs. The salves available for
burnt skin caused horrible blistering, and wounds often became infected as a result. Paré
developed new treatments for burns and revised traditional ones. In one instance he used the
juice of onions mixed with salt, which he applied to the wound with a cloth. He reported it as
being a remarkable treatment.
Paré started desperately looking for better and more humanitarian
ways of treating battle wounds. His priority was to work out a
more effective method of stemming the flow of blood. What little
spare time he had was devoted to studying anatomy texts. When the
guns went silent, he spent the evenings drawing diagrams and
making reams of notes. His aim was to seal the arteries themselves –
rather than the entire wound – block them off to prevent the worst
of the blood loss.
His solutions were simple. His first invention he called a 'crow's
beak'. The beak consisted of a set of curved forceps that could be
clamped across the artery to block the flow of blood. Although
other, smaller blood vessels would still be open, this device stopped
the worst of the bleeding and bought him time during operations.
Next Paré devised a way of tying off blood vessels during
amputations. This was not a completely new idea, but there is no
evidence that it had been tried in practice before. Once the artery
was clamped off using the crow's beak, he would tie off the vessel
downstream of the forceps using silk thread. This 'ligature' would
permanently block the artery. Starved of blood, the portion below
the ligature would eventually die and drop off.
Paré published his first book,
Treatise on Gunshot Wounds
, in
1545. In it he detailed his experiences in combat and the lessons he
had learnt. His practice of not using a cauterizing iron or boiling oil
was widely adopted by those who read his work. The book revolutionized
trauma surgery, or at least it did in many parts of mainland
Europe. Unfortunately, because the book was written in French and
not translated into Latin or English, other surgeons – particularly in
Britain – continued to use cauterizing as a 'treatment'.
From a young, inexperienced, barely qualified surgeon, Paré
went on to become one of France's most celebrated medical practitioners.
His treatise was finally translated into English in 1617 as
The Method of Curing Wounds Made by Gun Shot (Also by arrows and
darts)
. The book is gloriously illustrated with a gruesome woodcut
of a 'man of wounds'. The man has an axe through his head, a
bullet through his leg and a dagger in his side, in addition to
wounds from swords, arrows, spears and darts. Seventeen wounds
in total. Even an accomplished surgeon like Paré would be hard
pushed to treat him successfully.
Paré's crow's beak and ligature, although brilliant innovations,
were less effective in practice. To stem the flow of blood completely
following a thigh amputation, for example, more than fifty ligatures
are required – although around ten would probably suffice to stop
the worst of the bleeding. But in the dirt, smoke and poor light of a
makeshift field hospital, even applying ten ligatures would prove
completely impractical.
Likewise, trying to apply the crow's beak to a slippery artery
that was spurting out blood at high pressure, while struggling to
hold down a screaming patient, was an appalling challenge. It
wasn't until the invention of an effective tourniquet (such as the
'Petit' type used by Liston) that ligatures really came into their
own. But Ambroise Paré's contributions to modern surgery are
nevertheless considerable. Above all, his efforts to reduce his
patients' suffering shines through as a fine example to future
generations of surgeons.
Thanks to Vesalius, Galen's mistakes had been corrected and
surgeons now knew how the body fitted together. Paré had worked
out how to tie off blood vessels and prevent patients from bleeding
to death. What both men had in common was the courage to question
the status quo; to challenge incorrect medical dogma. These
were surgeons who trusted what they saw with their own eyes and
learnt from their own experiences. Two major barriers to successful
surgery had been broken. It would be more than three hundred
years before the next major obstacle – pain – was overcome.
University College Hospital, London, 1846
Frederick Churchill of 37 Upper Harley Street was admitted to
hospital on 23 November. Unmarried, and employed in service all
his life, he had started as a footman and for the past sixteen years
had worked as a butler.
A clerk noted down everything as the dresser asked a series of
questions. The case notes would later run to some ten pages.
Aged thirty-six, Churchill was five feet eight inches tall with a
fair complexion. His state of mind was cheerful and his sleep was
generally sound. His habitual state of health was good, although not
as strong as it had been eight or nine years ago. He was, the dresser
noted, rather thin. Churchill's medical history included an attack of
gonorrhoea eighteen years previously, and another attack around
ten years after that.
In the year 1840 the patient had experienced a swelling in his
right knee that became very painful. Severe pain was also experienced
following a later fall in which the same knee was violently
bent. In 1842 'considerably more' swelling and a 'discoloration of
the leg ensued' following an injury to the left limb.
There had, the dresser recorded, been some outpatient treatment
ordered by a medical man, but this had been discontinued.
Then, in 1843, the swelling had been opened up – cut into with a
knife – and 'a number of irregularly shaped bodies' were pressed
out. These bodies appeared to have a fibrous, granular structure
and varied in size from a pea to a large bean. They were preserved
in alcohol and examined under a microscope. There were sufficient
of these bodies to fill a two-ounce bottle.
'It is Professor Liston's opinion,' the dresser concluded, 'that
these bodies are the remains of extravasated [forced out] blood.'
Churchill's appearance was described as like that of someone
in 'good but not robust health'. The right knee was much swollen
and a probe could be passed through the cavity in the joint.
Following this, Churchill was ordered to remain in bed. 'A thin
serous discharge is given out. Pulse 80. Ordered to have a full diet
and milk 1 pint.'
On 25 November Professor Liston examined the patient
himself. He passed a probe into the knee and made an incision.
Probing with his finger he could feel bare bone and the head of the
tibia, one of the lower bones of the leg. He pulled on the bone to
see if it was loose but this did not appear to be the case. Liston
ordered that clean warm-water dressings should be applied and
Churchill should undergo complete rest.
Churchill's condition began to deteriorate. He lost his appetite
and the dressers noted that his tongue had become furred.
More substantial food was ordered – a chop daily, a pint of beef tea
and a pint of porter. On 27 November he experienced a terrible
attack of pain extending from the hip to the toes. The swelling in
the knee had increased and he suffered shivering, sickness and
headache. Hot fomentations (poultices) were applied, which
helped to relieve the pain.
On 17 December the dresser recorded that the patient 'had a
kind of hysterical attack and was much excited', but by 20 December
his appearance had improved and he appeared to be 'more healthy'.
The next day he would go to the operating theatre to have the limb
removed. Frederick Churchill had yet to be told that he would be
part of a groundbreaking experiment.
At twenty-five minutes past two on the afternoon of 21
December, the porters carry Churchill into the operating theatre. As
usual the galleries are filled with undergraduates nervously anticipating
what was usually a dramatic, and often horrific, event.
Churchill is utterly terrified. He had known when he was
admitted to hospital that it would probably come to this. At least
with Professor Liston the ordeal would be over in a matter of
seconds. Could he bear the pain? Could he appear strong in front
of all these men?
Liston enters. The room goes quiet. 'We are going to try a
Yankee dodge today, gentlemen, for making men insensible.' For
the first time in the United Kingdom an amputation is about to be
attempted using an anaesthetic. There had already been some trials
at the hospital using hypnotism, or 'mesmerism', but the results had
been mixed. Fundamentally, it was difficult to prove the scientific
rationale for mesmerism, and among men of science it was considered
superstitious nonsense.
The 'Yankee' Liston spoke of was the American inventor of the
ether anaesthetic, William Morton, a Boston dentist. Morton had
been trying a gas called ether – a pungent mixture of alcohol
and sulphuric acid – on his patients during the extraction of
teeth. (Given the generally poor state of dental health, there was no
shortage of subjects.) Morton's process of 'insensibility' reached
the attention of surgeons at the Massachusetts General Hospital
in Boston, who were keen to use ether during operations. In a
submission to the American Academy of Arts and Sciences, a
surgeon at the hospital, Henry Bigelow, described the effects of
ether both for dentistry and more serious operations. He reported
a tooth extraction on a 'stout' boy of twelve. Upon wakening, the
boy declared it was 'the best fun he ever saw'. The boy insisted on
having another tooth extracted. In early November 1846 ether was
tried on a young girl having her leg amputated above the knee. She
lasted the whole operation without feeling a thing.
But Churchill doesn't know any of this. He lies on the operating
table. A rubber tube is held to his mouth and he is told to breath
through it for two to three minutes. The tube is connected to a flask
containing ether gas. As Liston stands ready with his knife, the only
sound in the room is Churchill's deep anxious breaths. Eventually
the man becomes still.
After the rubber tube is removed from Churchill's mouth, a
handkerchief laced with some drops of ether is laid over his face.
Liston looks up at the galleries. The students are more excitable
than usual – this would truly be one for the history books.
'Now gentlemen, time me!'
Liston slices his knife into Churchill's thigh. The tourniquet is
tightened, Liston's swift movements cut the familiar U-shaped incisions,
sweeping around the leg, pulling aside the flesh to expose the
bone, to and fro with the saw, the ligature ready and the stitches in,
the severed limb lying in a pool of congealing blood in the sawdust.
'How long, gentlemen?'
'Twenty-eight seconds.'
'Twenty-six seconds'
'No, I made it thirty!'
'Thirty?' exclaims Liston.
'Twenty-five seconds!'
This last figure has the time recorded in the case notes for the
operation. Churchill has remained insensible throughout, not a
sound came from his lips, not a groan, not even the slightest grimace.
'When are you going to begin?' exclaims the patient a few
moments later.
This is greeted with peals of laughter from the gallery. There
was rarely laughter after an operation. Churchill looks terrified.
'Take me back, I can't have it done!' Only when his amputated leg
is held up for him to see does he believe that the operation has
already taken place. He looks down to see his gently weeping stump.
Later Churchill recalled feeling only a sense of great coldness and
the memory of 'something like a wheel going round his leg'. The
porters come forward with the stretcher to take him back to the
ward. 'This Yankee dodge, gentlemen, beats mesmerism hollow!'
declares Liston.
Later in the day another patient is given ether inhalation
during an operation for an ingrowing toenail – previously an
unbearably painful procedure. Flushed with success, Liston rushes
off a quick letter to the
Lancet
, writing of the 'most perfect and
satisfactory results'.
It is some minutes after Churchill is laid back in bed that he
starts to feel any pain. By seven in the evening it has become excruciating.
A dresser ties off more ligatures, making a total of ten altogether.
Later, the two U-shaped flaps of skin are tied together with a
series of sutures. Considering the agony, Churchill is remarkably
cheerful, and as the evening progresses the pain begins to subside.
The patient is to remain in hospital for another seven weeks. On
31 December the dressers report that he is improving daily, the
stump is healthy and 'discharging a small quantity of good pus'. A
bandage is applied. By the end of January he is walking around on
crutches. Frederick Churchill's case notes record that he was
'discharged, cured' on 11 February.
Soon, thanks to the pioneering efforts of a Boston dentist and
Liston's reputation in Britain, almost every surgeon wanted to try
ether. This Yankee dodge was surely the future of surgery. Some still
felt that pain was an essential part of the healing process, but given
the choice, what patient would want to go to
them
for an operation?
During the Crimean War (1853–6), for instance, by which time
anaesthetics were commonplace, surgeon John Hall was reported as
saying, 'I like my patients to feel the smart of the knife.'