Three Hundred Per Cent

As a doctor currently training in the fabulous speciality of obstetrics, (with a background in the even more fabulous specialty of General Practice) your correspondent stands on the hallowed ground halfway between medicine and surgery.

In that while she performs a great deal of surgery in her day to day life, she still has the ability to mock surgeons (gently of course, as they are her rather friendly and useful colleagues).

Thus how the following adventurous tale of Dr. Robert Liston first came to her ears.

Dr. Liston was a Scotsman, born in 1794 and from his description sounds like quite a character.  In a pre-anaesthetic era speed of surgery was a patient's only hope to avoid pain and infection.  Liston was famous for removing a 20 kilogram scrotal tumour in 4 minutes.

Rather than try to describe the man myself, I will let his contempory, Dr. Richard Gordon, do so for me:

"He was six foot two, and operated in a bottle-green coat with wellington boots. He sprung across the blood-stained boards upon his swooning, sweating, strapped-down patient like a duelist, calling, 'Time me gentlemen, time me!' to students craning with pocket watches from the iron-railinged galleries. Everyone swore that the first flash of his knife was followed so swiftly by the rasp of saw on bone that sight and sound seemed simultaneous. To free both hands, he would clasp the bloody knife between his teeth."

Liston was an imposing and acerbic fellow.  He left Edinburgh, where he had trained and practiced throughout his early career, in 1834 principally because he was so unpopular in the medical community there.  Not least of that was due to knocking down the infamous anatomist Dr. Knox in front of his students.  He assumed that some of the students had slept with the young woman being dissected while she was alive and that their behaviour was voyeuristic.  (As it turned out there was even worse foul play at foot!)

However, his somewhat abrasive personality was not always in the best interest of patients.  In one of the most famous cases associated with his name, Dr Liston was involved in an argument with a junior doctor about whether a mass on a boy's neck was a carotid artery aneurysm (a large swelling of a blood vessel) or an abscess (an infection).  Dr. Liston proceeded to settle the argument by removing his scalpel and lancing the mass there and then. The young boy bled to death in a matter of minutes. 

The remainder of Liston's career was spent in London, where he pioneered some amazing accomplishments, including the first British operation under anaesthesia in 1846.  A leg amputation, performed in 28 seconds, which of course makes one wonder if anaesthesia was required at all.

(in this photo Joseph Lister is actually the gentleman on the top left - I may be geeking out slightly.)

He also invented the Bulldog artery forceps.  I used a variation of them the other day. 

But this is, of course, not why I am telling this story.  

Legend has it that one day Dr. Liston was performing an amputation.  He proceeded to do so in his usual 2 and a half minutes but in his enthusiasm also amputated the fingers of his young surgical assistant, and cut through the coattails of a distinguished spectator who had leaned in too close.  

The spectator perished from fright instantly, the patient a few days later from overwhelming infection, and the assistant a few days after that, also from infection.

It remains the only operation in history with a three hundred percent mortality rate.  

As I tell my surgical colleagues - they've got a lot to live up to ;). 

Louis' Penis Problem

Poor old Louis the 16th. Reportedly a shy, overweight and somewhat uncouth teenager, his father’s mistress referred to him as a “fat, ill-bred boy.” An Austrian courtier in fact stated, “nature seems to have refused everything to the dauphin.” (1)

They weren’t wrong. The poor boy’s life ended on the executioners block at the age of thirty-eight.


Louis XVI

However, he was the heir to the throne of France, so fat or not, the short life he did live was carried out in the lap of luxury. At the age of 14 he was married to the young Marie Antoinette, Archduchess of Austria, aged 13 at the time. She was a young, poised girl, who grew into a woman of fair beauty.


Marie Antoinette

At 13 and 14, one might have expected that it would have taken a while for the marriage to be consummated.

I’m fairly certain that nobody expected it to take seven years.

The Queen of Austria had a strong sense of duty, one which she had vigorously instilled in her children. The young dauphine knew that her position in the French court and the stability of the alliance between France and Austria depended on her producing an heir. The Queen wrote often to her daughter and urged her time and time again to ‘inspire passion’ in her new husband(2). However, despite due diligence in this regard, night after night Marie Antoinette lay down next to her husband and... nothing happened.

Eventually the royal doctors were consulted. They made conciliatory noises and suggested that the Prince was not yet mature. They advised time and patience.

Obviously they failed to actually lay hands on the royal personage. Had they examined the young Prince, they would almost certainly have discovered his phimosis.

Phimosis is a condition in which the foreskin of the penis is adherent. It tends to cause pain during intercourse, as the foreskin can only partially retract and constricts the glans.

Management involves either circumcision, or a small incision in the skin of the foreskin, and blunt dissection. These are both fairly simple operations, however it is generally true that most men become squeamish with just the concept of knife near a penis. Imagine this in the pre-anaesthetic era, and perhaps you understand some of Louis’s problem.

Louis outright refused surgery initially. However, he and Marie Antoinette apparently discussed the problem and he eventually agreed that he would undergo the procedure by his sixteenth birthday (after much persuasion I would imagine!).

However Louis’s sixteenth birthday came and went without surgery.

In 1774, another attempt was made. The surgeon got as far as exposing the site of surgery and spreading out his instruments, before the patient fainted clean away. It seems that this would have been the perfect opportunity, but obviously the surgeon was to timid to incur the Dauphin’s displeasure, and the royal jewels remained untouched.

Eventually in 1775, Louis the 15th passed away, and his son became king. However, his marital woes with Marie Antoinette continued. The situation became even more precarious when two months after the coronation Louis’s sister-in-law, Marie Therese, gave birth to a son (quite originally named Louis Antoine). This child would be the heir to the French throne for a further seven years.

The situation left the couple exposed to a great deal of ridicule by the French public. The rumours of infidelity that dogged Marie Antoinette for the rest of her life have their origins in this time.

Finally in 1777, Emperor Joseph, Holy Roman Emperor and Marie Antoinette’s older brother, arrived for a six week visit designed in part to sort the couple out. He spoke to both his sister and brother in law.

We know of the advice he gave a couple from a letter that Joseph wrote to his own younger brother. Louis it seemed, was able 'to have strong, well conditioned erections',(3), however was unable to carry out the sexual act. Joseph stated that ‘this is incomprehensible, because with all that, he sometimes has nightly emissions, but says plainly that what he does, he does from a sense of duty but never from pleasure.' The Emperor stated quite frankly that if he had a chance to solve the problem sooner Louis, “would have been whipped so that he ejaculated out of sheer rage like a donkey”.(2).



Emperor Joseph

I’m not sure if any donkey’s or whips were involved in the final solution, but whatever Joseph said to Louis, it worked. Louis finally submitted to surgery, and on April 30 1777, the marriage was finally consummated.

The couple went on to have four children together. However, two died in infancy, one died in prison after the revolution, and only one daughter survived to adulthood and exile.

Louis and Marie Antoinette on the other hand, barely had a chance to enjoy their adulthood. Nonetheless, we can say with certainty that despite their early problems, neither of them died a virgin.


Louis faces his executioners

(1) (1) http://www.readinggroupgold.com/product/product.aspx?isbn=0312361505&show=more

(2) (2) http://en.wikipedia.org/wiki/User:Papirini/Marie_Antoinette

(3)(3) http://www.abc.net.au/rn/science/ockham/stories/s13875.htm

Merry Christmas

Merry Christmas to you and yours.

Hopefully you have a better one than it looks like these poor fellows were having...


(From the U.S National Library of Medicine) This image shows men in a medical ward during WWII at christmas time.

Semmelweis and the great Handwashing mystery

In Vienna in the early 1800s two wards of the General Hospital delivered babies. In Ward One the babies were delivered by medical students and in Ward Two by midwives. Both wards were free and provided care to the poorer women of Vienna, yet strangely Ward One had a very poor reputation outside the hospital.

This had nothing to do with the care the women received from their medical professional. The techniques of delivery were the same whether performed by medical students or midwives. Yet in Ward Two the death rate from ‘childbed fever’ was 4-5%. In Ward One it was double that at 9- 10%.

Childbed fever was a horrid illness that is virtually unheard of today. Aftrr birthing her baby a young woman would develop an high fever, abdominal pain and virulent red streaks across her belly (erysipelas). Eventually this overwhelming infection would result in unconsciousness and death.

At the time, no one was overly interested or concerned about this disparity. The difference between the care these patients received was only in who provided the care. What seems so obvious to us now was simply not seen by the practitioners of the day. Childbed fever was known to occur in clusters. Even though this kind of ongoing affliction could not have a random basis, it was accepted because there was no better explanation. Keep in mind that this was all some fifteen years before Louis Pasteur came up with the concept of bacteria.

Up until a young physician named Semmelweis came along.

Ignaz Philipp Semmelweis (1818-1865) was born in Buda, Hungary. He studied medicine at the Universities of Pest and Vienna. In 1846 he was appointed to the General Hospital in Vienna.



It is important for us to note that Semmelweis had been greatly affected by the death of his friend, Jakob Kolletschka some years prior. Kolletschka, a professor of forensic medicine, had cut his finger whilst performing a post-mortem examination. Gloves, of course, were not brought into widespread use until some fifty years later. Kolletschka had developed an high fever, abdominal pain and erisypelas and had quickly passed away.

To modern day doctors, this is the classic presentation of septicaemia, or blood poisoning.

Semmelweis noted that women who had their babies outside the hospital, prior to admission, rarely suffered from childbed fever. He also noted that medical students would attend deliveries straight after handling corpses in the autopsy room. He deduced that the medical students were carrying some kind of poison on their hands which was infecting the labouring women.

As a result he insisted that anyone in the hospital attending the delivery of a baby would first have to wash their hands in chlorinated water. Within a year the mortality rate from childbed fever in both Ward’s One and Two had dropped to one percent.

Despite this success, Semmelweis’s changes were deeply resented by the medical fraternity. Doctors of the time were actually proud of the ‘hospital odour’ they carried on their hands, considering it as a mark of their status. Semmelweis's protocol for handwashing was also time consuming. Similarly, they were angry at the suggestion that they could have been responsible for the women’s deaths. Semmelweis published several papers of his findings, which were ignored, and he was eventually forced out of his job in 1850.

Undettered, he began teaching midwifery at the Pest University, and continued to publish papers. In 1861 he published a book, his seminal work, entitled Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers (the Cause, Theory and Prevention of Childbed Fever).

Unfortunately this was a rambling and dense tome where the point about handwashing was deeply buried and not easily extractable or understandable. Unsurprisingly that most important conclusion, therefore, fell on deaf ears.

The book was probably one of the first signs of Semmelweis impending breakdown. He became increasingly irrational and psychotic and was eventually admitted to a mental hospital. Here he became violent and was beaten by attendants. As a result of the injuries he suffered, he developed blood poisoning, and passed away some two weeks later.

The cause of Semmelweis’s own breakdown is unclear. It’s somewhat romantic to think that that the ignorance and frustrations of the medical profession caused him to go insane. However, it is much more likely that he already suffered a psychotic tendency and his professional frustration was simply the trigger.

Either way, the cause of his death is deeply ironic.

As to the actions of the maternity community, Semmelweis's work was largely unknown. Fourteen years after his death, a gynaecologist went to present a paper denouncing the idea that a contagion was responsible for childbed fever. Fortunately, Louis Pasteur was present at the same conference, and the great man stood up and silenced the audience with the announcement that a bacteria, streptococcus, was the causative agent. That’s when things finally began to change.

War can no longer be confined to the Battlefield

When discussing wartime heroes it is often easy to focus on those stories that occurred at the frontlines. This is no less true of war time medicine which generally conjures up images of Weary Dunlop operating by firelight in the middle of a prisoner of war camp or the slice and dice of MASH tents of Korea.

While I’m sure I will find time to bring you those stories eventually I thought today I would start with a slightly less known one.

During World War II the British government made a concerted effort to be more organised in providing medical care to their population. While in World War I the conflict between being a doctor and soldier had led to many medical students leaving their courses to go and die on the fields of Flanders, this time around medical students were granted exemptions from drafting and rushed through truncated courses. Doctors and medical students were then drafted into the Emergency Medical Service and deployed throughout the country to deal with anticipated causalities both from the war and expected air raids. This service, coordinated through the ministry of health, became the precursor for the modern national health service.