Monday, April 28, 2014

AEther Salon: Chirurgia! (Edited transcript)

Baron Klaus Wulfenbach (klauswulfenbach.outlander): Fraulein Bookworm, if you would.

Bookworm Hienrichs: Welcome to this month's Aether Salon! Today, Jimmy Branagh takes on a new role and regales us with a discussion of Victorian medicine and surgery!  Before we proceed, some housekeeping reminders:

1) To ensure you can hear the speaker, stand or sit on the patterned carpet.
2) If you do not have a wearable chair and wish one, please contact Baron Wulfenbach.
3) Please remove all lag-feeding whatevers you might be wearing.
4) A tip jar is out for our speaker. Do please show your appreciation!
5) Any tips to help support the establishment will also be welcome - just click on one of the support signs, or on the floating dirigible!
6) If you're not a member of the AEther Salon group, there are signs that will let you sign up. You'll be most heartily welcome!
7) Edited and unedited transcripts of these proceedings will be posted at

And now, to introduce our speaker, here is Baron Klaus Wulfenbach.

Baron Klaus Wulfenbach (klauswulfenbach.outlander): Welcome to the AEther Salon, everyone, it is good to see so many interested in medical techniques.  Our speaker hardly needs any introduction in New Babbage, or, in fact, most of the Steamlands. Herr Doktor Jimmy Branagh, inventor of the mechanical musical liver, has been a contributor in many ways in many lands.  Therefore, without further ado - from Weffingham Medical Hospital and University, Surgeon Laureate and the BAR's Man of the Year, Doctor Jimmy Branagh and his lovely assistant, Nurse Practitioner Myrtil Igaly.

Dr. Jimmy Branagh: Thank you Herr Baron
Dr. Jimmy Branagh checks the patient on the table, then walks to the front of the stage, spreads his arms dramatically, and screams "I'VE BROKEN MY ARM! IT HAS SPLIT THE SKIN! MY GOD,  Dr. Jimmy Branagh lowers his arms slowly.

Dr. Jimmy Branagh: Good evening ladies and gentlemen, and thank you for coming.  That statement, as dramatic and hyperbolic as it may seem, is true in our time. Today infection kills an average of one in six surgical patients. It is our greatest enemy!

What you see behind me is a fair representation of a modern operating theater, with the galleries filled with anxious medical students and other learned men and women and mere interested persons ready to see the current techniques in modern surgical procedures.  A description by Dr. John Flint South is most amusing.

“The first two rows ... were occupied by the other dressers, and behind a second partition stood the pupils, packed like herrings in a barrel, but not so quiet, as those behind them were continually pressing on those before and were continually struggling to relieve themselves of it, and had not infrequently to be got out exhausted. There was also a continual calling out of 'Heads, Heads' to those about the table whose heads interfered with the sightseers."

Patients put up with the audience to their distress because they received medical treatment from some of the best surgeons in the land, which otherwise they could not afford. Wealthy patients of the surgeons would have been operated on, by choice, at home probably on the kitchen table.

The risk of death at the hands of a surgeon was greatly increased by the lack of understanding of the causes of infection. Although cleanliness was a moral virtue, descriptions suggest that a surgeon was as likely to wash his hands after an operation as before.  The old frock coats surgeons wore during operations were, according to a contemporary, 'stiff and stinking with pus and blood'. Beneath the table was a sawdust box for collecting blood.  The death rate was further heightened by the shock of the operation, and because operations took place as a last resort, so patients tended to have few reserves of strength."

Today I'd like to discuss some of those techniques and practices prevalent in our Enlightened Age, and also the development of some methods of anesthesia, and the growing trend of use of "antiseptics" to reduce the risk of infection following surgery, which takes the lives of one in six patients.  These new developments enhance the not only the level of comfort and quality of life in our time, but are also blazing a new path for upcoming generations.

Now, we surgeons and doctors frequently receive high rank and prestige in our society, but even with all this new medical knowledge being discovered at a high speed, most of the people in our age still rely on home remedies, herbal treatments and homemade prescriptions.  Health suggestions are given either by a household manual or by word of mouth. Matrons, heads of households and frequently servants had adequate medical knowledge and remedies for minor ailments.  Even in affluent neighborhoods where the residents can afford doctors at will at least one member of any household will be well versed in herbal medicine, and people will frequently lance boils, soothe coughs and make poultices for wounds at home.  This home-grown confidence and knowledge serves both as an alternative to and as ongoing support for professional aid.

Common treatments given to people during the Victorian age included bleeding, purging, plastering, sweating, and amputation.  These techniques help many people alleviate symptoms of a variety of painful disorders. Allow me to describe them briefly, as they are all quite useful. Please attend the viewer above.

Plastering is a treatment that uses a paste made from a range of ingredients, including mud or plaster, and then applying such substances in the affected area of the patient to relieve internal pain or cold.  Bleeding is done in an attempt to relieve high blood pressure, sweating was thought to expel poisons from the body, and amputation has been available for some time as a viable alternative to gangrene.

Poultices are used for bites, boils and wounds. Poultice ingredients could be as commonplaces as milk and bread to exotic herbs and cow manure.  Purging involves providing a patient with a heavy dose of emetics or laxatives to expel "poisons" from the individual's body.

Now, let us delve into some of the tools found in the most well equipped surgeries in the civilized world. Attend the pictographometer, please. Hopefully, these pictures will set you at ease as to the advancements available in the best hospitals.  An amputation knife, for which purpose I believe obvious.  A bone saw, also obvious.  This is known as a trephine, a fine precision instrument used for boring holes in the skull to relieve pressure, and to present the brain.  The skull saw, for use when one is required to remove a large part of the cranium.

Who can tell me what this little gem is?

Stereo Nacht: For bleeding?

Dr. Jimmy Branagh: Excellent Miss Nacht!  It is an artificial leech! When the little creatures are unavailable, this will bore into the skin and permit bloodletting.

And finally, a general surgery kit containing most of the instruments necessary for on-location surgeries, carried by most doctors.  We do not have the time today to cover the mechanics and machineries of modern medicine, but I found this remedy for scoliosis most amusing!"

And now, let's briefly note some matters of anesthesia.  Anesthesia has been often limited to a mug of rum and a stick to bite on. However, there is a history of interesting techniques and agents that have shown much promise. Unfortunately, these have been dismissed or oft forgot by medical science, and slow communications often limit the spread of ideas.

Ignaz Philipp Semmelweis was a Hungarian physician of German extraction now known as an early pioneer of antiseptic procedures. Described as the "savior of mothers", Semmelweis discovered that the incidence of puerperal fever could be drastically cut by the use of hand disinfection in obstetrical clinics. Puerperal fever was common in mid-19th-century hospitals and often fatal, with mortality at 10%-35%.

Semmelweis proposed the practice of washing with chlorinated lime solutions in 1847 while working in Vienna General Hospital's First Obstetrical Clinic, where doctors' wards had three times the mortality of midwives' wards. He published a book of his findings in Etiology, Concept and Prophylaxis of Childbed Fever.  Despite various publications of results where hand-washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. Some doctors were offended at the suggestion that they should wash their hands and Semmelweis could offer no acceptable scientific explanation for his findings.

Semmelweis's practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister, acting on the French microbiologist's research, practiced and operated, using hygienic methods, with great success.  In 1865, Semmelweis was committed to an asylum, where he died at age 47 after being beaten by the guards, only 14 days after he was committed."

Dr. Jimmy Branagh pulls a flask from his coat pocket and takes a glug.

Dr. Jimmy Branagh: 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.”  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.

In 1867, the Glasgow-based surgeon, Joseph Lister, put forward his system of antiseptic surgery. Lister 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.  He noted that Friedlieb Runge had discovered "creosote", which later was processed into carbolic acid. Although Runge had no understanding of how decomposition occurred, the chemical had been used to treat the wood used for railway ties and ships since it protected the wood from rotting.  Later, it was used for treating sewage in England, Belgium and Holland. The same chemical was also used to fight parasites and reduce the odors during cholera and cattle plague.

Therefore, Lister tested the results of spraying instruments, the surgical incisions, and dressings with a solution of it. Lister found that carbolic acid solution swabbed on wounds remarkably reduced the incidence of gangrene.  In August 1865, Lister applied a piece of lint dipped in carbolic acid solution onto the wound of an eleven-year-old boy at Glasgow Infirmary, who had sustained a compound fracture after a cart wheel had passed over his leg. After four days, he renewed the pad and discovered that no infection had developed, and after a total of six weeks he was amazed to discover that the boy's bones had fused back together, without the danger of suppuration.

His techniques included varying dilutions of carbolic acid, also known as 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.

By the 1880s, antiseptic surgery, “Listerism” as it has come to be known, 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.  These practices are not yet widespread, however. An operating table is most likely cleaned by a splash from of bucket of water, leaving the previous patient's bodily fluids free to mingle with the next patient's.

And now, a word on amputations.  The best of the best surgeons can remove an arm off at the shoulder in 17 seconds, whereas trainees (as they don't have anything to practice on) will often hack away, and then use pliers to snap off bones, and tweezers to remove splinters, and for the final act the stump was then sealed with boiling tar. Sadly the patients usually die.

Here's a story. "Submitted for your approval ..."

It's just after midday on a late spring day in 1842 and the wooden viewing galleries that surround the operating room of University College Hospital in London are packed.  Sir Robert Liston, the foremost surgeon of his age, and a man whose temper is as sharp as his chiselled features, is about to begin work.  The assembled crowd of anxious medical students dutifully check their pocket watches, as two of Liston's surgical assistants - 'dressers' as they are called - take firm hold of the struggling patient's shoulders.  The fully conscious man, already racked with pain from the badly broken leg he suffered by falling between a train and the platform at nearby King's Cross, looks in total horror at the collection of knives, saws and needles that lie alongside him.

Liston clamps his left hand across the patient's thigh, picks up his favourite knife and in one rapid movement makes his incision.  A dresser immediately tightens a tourniquet to stem the blood.  As the patient screams with pain, Liston puts the knife away and grabs the saw.  With an assistant exposing the bone, Liston begins to cut.  Suddenly, the nervous student who has been volunteered to steady the injured leg realises he is supporting its full weight. With a shudder he drops the severed limb into a waiting box of sawdust.  Liston, however, is still busy, tying off the main artery of the thigh with a reef knot and then tying off other smaller blood vessels, at one point even holding the thread in his mouth. As the tourniquet is loosened, the flesh is stitched.  The operation is over. And it has taken just 30 seconds."

Dr. Jimmy Branagh grins.

Dr. Jimmy Branagh: I had planned to give you today, ladies and gentlemen, a demonstration of the hammer-and-leather punch method of pre-frontal lobotomy.  But unfortunately I have received news that my scheduled subject has recently been elected to high political office and is unavailable.


Dr. Jimmy Branagh pauses dramatically.

Dr. Jimmy Branagh: I have decided to attempt to better Dr. Liston's famous time of amputation right here before your eyes!

The man you see here on the table has a leg already infected with gangrene, and it simply must come off if the man is to survive the week.  He is securely restrained, and appears… to be quite unconscious. Drunk in fact. With luck, he will sleep through the entire procedure and be none the worse for wear.

Dr. Jimmy Branagh grins and claps his hands.  "Well, shall we begin?"

Dr. Jimmy Branagh cinches up the tourniquet around the man's leg, then picks up the large amputation knife, and begins.  "As some of you may know ... it's much like ... cutting into a moderate sized ham ..."
Dr. Jimmy Branagh tosses the amputation knife into the pan and grabs the bone saw.
Dr. Jimmy Branagh saws rapidly with the bone saw.
Dr. Jimmy Branagh: "Whoopsie!"
Dr. Jimmy Branagh then ties off the main arteries with a great flourish.
Dr. Jimmy Branagh hums while he works "Dumdeedum deedum ..."
Dr. Jimmy Branagh slaps a glob of boiling hot tar to the stump, instantly cauterizing it.

Dr. Jimmy Branagh: "I believe, success! You may applaud now!"

Dr. Jimmy Branagh whips the blanket over the again unconscious patient.  "The dressers will come down soon and finish up."

Dr. Jimmy Branagh: And that, ladies and gentlemen completes today's presentation. I again thank you for attending, and should you have questions, I will do my best to answer them now, or later should that be necessary.

Nika Thought-werk raises her hand.
Dr. Jimmy Branagh: Yes Miss Nika?
Nika Thought-werk: People never sued the doctors for killing them?
Stereo Nacht: wrong century, I'd think! ;-)
Nika Thought-werk: Oh!
Dr. Jimmy Branagh: I'm sure there were lawsuits, but few. Doctors were extremely respected
Nika Thought-werk nods and feels sorry for all the people that suffered.
Dr. Jimmy Branagh (jimmy.branagh): We will be the barbarians, and they centuries after them

Bookworm Hienrichs: Well, I want to thank you all for coming, and hope we'll see you again next month, at our usual date of the third Sunday of the month (May 18th), when Miss Nika Thought-werk pulls double-duty for this season and talks about the mail service!

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