Friday, May 21, 2004

Ideas: Medical Developments

The is only part of an article that appeared in Science. We will practice annotating in our head today as we read.

The Victorian Revolution in Surgery
J. T. H. Connor*

The 1944 Hollywood movie The Great Moment tells of the discovery of ether anesthesia in Boston in the 1840s. This discovery was one of a trio of clinical innovations between the 1840s and the 1890s that collectively made up the Victorian revolution in surgery: anesthesia, antisepsis, and x-rays. [3 medical innovations from 1840-1890: anesthesia, antisepsis, and x-rays] But did these "moments" really represent a revolution in surgery alone, or did they set in motion an even larger revolution in medicine? [Were they the cause of something bigger?] Viewed historically, these "discoveries" help us understand how medical innovations relate to science and technology. They also reveal how a new medical marketplace came to be and how market forces shaped modern medicine.[This may be the theme of the piece: how a new medical marketplace shapes modern medicine. Be on the watch for marketplace talk.]

The first of the three clinical innovations was the introduction of ether in America in 1846 and chloroform in Britain in 1847. Inhalation of the vapors of these compounds not only put people to "sleep," making them insensible to pain, but, as one Victorian surgeon declared, its use meant that patients were "rendered unconscious of torture" (1). This was a boon not only for those who chose to go under the knife but also for those who wielded it, because surgeons no longer had to contend with patients who squirmed around on the operating table during an amputation--or who tried to escape altogether.[Medical innovation helps patient and doctor alike.]

Twenty years later, the Glasgow-based surgeon, Joseph Lister, put forward his system of antiseptic surgery. Lister [I wonder if this is why we have Listerol, the antibacterial mouthwash.] was correct in his view that surgical wound infection was the result of bacteria. But his methods to combat their action were cumbersome, constantly changing, and confusing. His techniques included varying dilutions of carbolic acid (phenol) and an array of putty, tin, and rubber protective devices. He also used vaporizing sprays that emitted an unpleasant and irritating acidic mist in the vicinity of patient and surgeon, but later denounced the use of this equipment.[Techniques were cumbersome, although perhaps they worked. Will something better come along?]

By the 1880s, antiseptic surgery (or "Listerism") had transformed into aseptic surgery as knowledge about pathogenic bacteria accumulated. Surgeons now concentrated their efforts on excluding disease-causing bacteria from incisions and amputation sites by ensuring that their own hands had been thoroughly cleaned and their street clothes were covered by clean white gowns; later, they began to wear caps, masks, and rubber gloves (see the figure, below).[Instead of killing the bacteria after it was in the wound, doctors prevent the bacteria from getting into the wound by washing their hands.]

Aseptic precautions became universal by 1900. Surgeons and nurses wore white caps and gowns to reduce postoperative surgical infections.

By the late 1890s, white-robed surgeons replaced their earlier, black and bloody frock-coated confreres. [You mean that surgeons once walked around with blood all over them. Unsanitary] Sterilization became the order of the day as hospitals installed autoclaves and water treatment equipment; dry iodoform dressings supplanted earlier wet carbolic acid-impregnated devices; and instruments made out of a single piece of steel that could be readily sterilized replaced bone- and wooden- handled surgical tools that could not. Operating rooms and their furniture, too, were remodeled to incorporate smooth, impervious surfaces that did not harbor germs and could be readily cleaned (2, 3).

Coeval with these developments [coeval means at the same time or the same age], in 1895 the German physicist Wilhelm Roentgen began to experiment with x-rays. With the assistance of his volunteer wife, whom he exposed to an uncontrolled stream of cathode rays, he photographed the skeletal structure of her hand. Roentgen's ability to "photograph the invisible" (see the figure below) immediately became front-page news around the world. For the first time, doctors could view the internal bone structure of a living body without slicing it open (4).[Huge development]

The implications of x-rays for surgery were obvious. The most vivid illustration was their immediate impact on military medicine. During the Spanish-American war in 1898, for example, American hospital ships sent to Cuban and other war zones were fully equipped with bacteriological laboratories, aseptic operating suites, and radiological apparatus. Radiographs of bullets embedded in bone, soft tissues, and shattered joints guided army surgeons in their work (5).

The surgical world of the mid-1890s was thus radically different from that of the 1840s; indeed, it remains closer to that of today. How did scientific knowledge, medical technology, and society contribute to this fundamental change? The historian George Basalla has argued that technology is not the servant of science and that necessity is not the mother of technological invention (6). The components of the surgical revolution are grounded in techniques and mechanical devices--innovations that, at heart, are technological. Did they depend on the scientific theory and social needs of their day?

Surprisingly, the answer is--not really. Knowledge of chemical or physiological principles had little to do with the advent of anesthesia or with explaining its action. Even today, we do not know the scientific grounds for profound anesthetic states. Listerism, too, was based less on solid scientific research than on an interesting hunch: In the mid-1860s, there was little scientific basis for it, except for an unsubstantiated germ theory of disease. Physics was better developed than many of the biological sciences, but the theoretical explanation for x-rays was not made until a couple of years after Roentgen's pioneering work in radiology. In these examples of innovation, at least, science was not technology's master.[What does this really mean: science was not technology's master. Is it the opposite: that we have the technology and then we figure out the science later. Is there anything in the article that I have read so far to make me think I am corect?]

The inventions were also not always responses to necessity. [There is a say: necessity is the mother of invention. We invent what we need.] For many, anesthesia was not a solution to a pressing need. Victorian doctors were not engaged in a relentless search for ways to reduce the pain of surgery. The means and methods to induce general anesthesia in the form of nitrous oxide and ether had been available and successfully tried for many years before the "great moment" in Boston (resulting in a long-running priority dispute). Even after formal demonstrations of the effects and benefits of ether and chloroform, many patients refused to consent to surgery while under the influence of such noxious gases. Reports of unconscious women being raped by their doctor or dentist further fueled popular mistrust of this innovation. Accounts in newspapers, medical journals, and coroners' inquests of "healthy" people dying after the administration of ether or chloroform added to people's skepticism (7). Several decades after the announcement of anesthesia, some Victorian surgeons still considered it an unnecessary luxury.

Similarly, Victorian surgeons were well aware of the dangers of wound suppuration [to suppurate means to discharge pus], especially after amputations, but they attributed this problem to impure air from crowded and improperly designed hospital wards. Joseph Lister's original idea appeared at first to have little to do with solving this issue. Prolonged resistance to Listerism only subsided when laboratory scientists showed that hospital infection was microbiological, not environmental in nature. [It seems that in this article big conclusions come at the end of paragraphs. I wonder if this is how it works on the SAT?]


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