Cutting

Since ancient times, doctors have been cutting open bodies, sawing through bones or sewing up wounds. In the early modern period, wound surgeons who learn their trade in a professional apprenticeship by performing operations – but these are painful and dangerous. Many patients died from blood loss or infections. In the 19th century, surgeons managed to bring various dangers under control: They used effective anaesthetics, they disinfected their instruments and stopped blood loss. This enabled them to perform even complicated procedures and learn how to successfully treat numerous diseases and injuries. This made surgery the leading discipline in medicine. Smaller procedures became routine and more demanding operations were made possible.

Fight the Germs

Wound infections were a problem for surgery well into the 19th century. Most medical experts assumed that processes inside the body cause the "fire". It was only after the advent of bacteriology that medical practitioners associated infections with microorganisms. As a result, hospitals began trying to combat the pathogens in the operating theatre. Only when the surgical area was sprayed with disinfectant before use and later the instruments and materials are sterilised beforehand, did wound infections actually decrease.

«Carbolic fog»

The British physician Joseph Lister focussed on the research by the bacteriologist Louis Pasteur and suspected that microorganisms from outside infected the wounds. As a consequence, he propagated a germ-reducing method for the first time in the 1860s. For this purpose, Lister went on to develop a steam atomiser for the disinfectant carbolic acid. Before operations, a "carbolic fog" would be diffused in the room to kill the pathogens.

Workwear

With the efforts to reduce germs (antisepsis) and keep areas free of germs (asepsis), surgical clothing also began changing. For a long time, surgeons operate in everyday clothes – such as a dark coat. In the late 19th century, operating theatre staff gradually began to wear white coats, gloves and face masks, setting themselves apart from their predecessors. However, the white colour also brought about problems: It had a blinding and tiring effect on those working. Today's green and blue colours prevent the afterimage effect of bloodstains and are even said to have a calming effect on patients.

Sterilisation plants

Around 1900, surgeons – in close cooperation with bacteriology – expanded their efforts against wound infections. They tried not to eliminate the pathogens in the operating theatre, but to keep them away from the beginning. Hospitals such as the Inselspital would soon have large sterilisation facilities that sterilise instruments, dressings and work clothes with either dry air or steam. The material was placed in metal containers. The side walls of these containers have small openings through which the steam would enter.

Gloves and masks

Instruments, cloths and clothing are relatively easy to sterilise. However, it is more difficult to ensure that surgical staff are sterile. Moreover, even in the early 20th century, the measures to be taken in order to protect patients were still disputed. Surgeons disagreed on whether wearing masks and gloves was appropriate or whether careful hand disinfection and precise surgical techniques were not preferable.

Theodor Kocher's gloves

Around 1900, many surgeons were reluctant to wear gloves. They saw no advantages or even felt restricted in the freedom of movement of their hands. This ambivalent assessment was also evident in Theodor Kocher, who was considered a careful and cautious surgeon. Kocher initially used cotton gloves, which he changes several times during the operations. In an analysis, he found no difference between operations with and those without gloves. He, therefore, considered thorough hand disinfection to be of central importance, but also wore rubber gloves himself.

With or without a mask?

For Kocher, the problem is not breathing in and out, but coughing and spitting. He, therefore, recommended only wearing a mask in case of catarrh. However, it required every surgeon to thoroughly clean the mouth and teeth before surgery. The aim was to rid the mucous membranes of pathogens to the greatest extent possible. This assessment long determined how surgeons would prepare for operations. Operation scenes from 1938 with Fritz de Quervain show: The protective mask covered the mouth but not the nose.

The problem of blood loss

Even in the 19th century, bleeding prevented major surgical procedures. To keep blood loss to a minimum, surgeons operate as quickly as possible – using a method referred to as "heroic surgery". New technical aids opened up a different path. The tissue would be cauterised with a red-hot instrument, limbs are bound or bandages are applied. Ultimately, new surgical tools – such as clamps and standardised procedures – improved the planning of operations. In this way, blood loss was able to be better controlled. There was no longer any need to operate quickly and with a high degree of risk, but slowly and carefully.

Small change – Big effect

In the late 19th century, Theodor Kocher developed a new forcep in response to the problem of local haemostasis. He shaped them to be slim and provided them with hooks so that even the smallest arteries can be grasped. Now, surgeons could use numerous clamps and prevent even the smallest bleeding. Kocher himself uses up to 100 forceps in a single operation. The Kocher forcep spread all over the world and is still used today in an unchanged form.

Anaesthetised and pain-free

Even in the 1800s, it was clear to many surgeons: Pain-free surgery was impossible – the means used to alleviate the pain were too unreliable. Moreover, it was controversial whether the elimination of pain was desirable at all. This is considered a "signpost" for the surgeon. A little later, scientists began to systematically investigate the analgesic effect of gases. When the dentist William Morton removes a jaw tumour from a patient in Boston in front of an audience in 1846, he demonstrated the effectiveness of ether anaesthesia. The new method of pain control quickly spread around the world. Doctors then tried out different substances and systems – always with the aim of being able to control the anaesthesia as precisely as possible.

The anaesthetic mask

Like many of his colleagues, the German surgeon Curt Schimmelbusch (1860-1895) developed medical instruments. His anaesthetic mask features an innovation: It was equipped with a trough to catch the excess active substances. The frame of the mask was made of chrome and could be sterilised. The mask, therefore, complied with aseptic requirements. The gauze compresses could also be stretched over the frame and replaced with a simple movement of the hand.

A bestseller in anaesthesia

Louis Ombrédanne, a surgery professor in Paris, is commissioned to develop a safe ether anaesthesia apparatus after fatal anaesthetic accidents. In 1908, he presented the result: a metal ball filled with gauze and a face mask with a rubber seal. A control tube with pointer allows the dosage to be precisely monitored and adjusted. The gas mixture would be injected into the patient via a balloon. This is missing from the model shown here. The machine went on to become a bestseller. Numerous manufacturers produced and sold it worldwide until the 1950s.

Body opener

Surgeons have been using various cutting instruments since ancient times. Using the scalpel, they would cut open the skin; with the knife, they would sever muscles and tendons, and with the saw they would amputate limbs. The instruments would always adapt to contemporary surgical-medical knowledge. In the 19th century, surgeons increasingly succeeded in controlling blood loss, pain and wound infections. The shift in surgical methods required new instruments that were adapted to the change in surgical methods. Instrument manufacturers often developed them together with surgeons according to their ideas.

The precision instrument

Today, the scalpel is considered the epitome of surgical precision. It often consists of disposable blades that are put on a solid handle. However, the basic principle is old: Surgical cutting instruments have been known since ancient times. They were first made of stone or bone and later of metal. Since the late 19th century, small but decisive changes have taken place: Wood, ivory or ornate handles disappeared. The instruments were now chrome- or nickel-plated and, finally, they were made of stainless steel. Thus, they met the necessary hygienic requirements and could be easily sterilised.

A chain bone saw?

Historical cutting instruments often differ from today's models in detail only. An exception is the so-called osteotome. The orthopaedist and instrument maker Bernhard Heine developed a type of chainsaw around 1830. To do this, he experiments on cadavers and animals for years. The advantage of the osteotome: Surgeons can cut through bone more gently and precisely – without the blows of a hammer or the jarring of a common bone saw. The specimen in the medical collection comes from the possession of Hermann Askan Demme, who was one of the first to publish about the successful use of the instrument. Demme became the first professor of surgery in Bern in 1834.

Standards instead of heroes

Around 1900, surgeons like Theodor Kocher wrote detailed textbooks that recorded the procedures of operations. The exact instructions concerned the use of the scalpel, the correct cutting directions and handles for special interventions. The aim of the instructions: Operations should be repeatable and done independently of the individual surgeon. Whereas in the past, individual techniques were only mastered by a few "heroes" of the profession, standards were now increasingly being established that could basically be used by all surgeons.

Cutting with electricity

The knife is an ancient instrument that will not disappear completely in the future. However, it has seen its fair share of competition in certain moments throughout history. High-frequency surgery specifically passes alternating current through the body to cut or remove tissue through the heat caused. For example, diseased tissue can be removed endoscopically from the bladder using a resectoscope. An electric sling is used for this purpose. High-frequency technology is also used for haemostasis, as the heating supports blood clotting. Therefore, this method is an alternative for wound closure in small vessels.

The operating theatre

The operating theatres are architecturally designed to meet the needs of surgery. There is a clear order here: The material, the processes and the space must be perfectly coordinated. This is the only way the team can carry out the operations in a controlled manner. The room is fully lit and the instruments are neatly laid out and sorted. The nursing staff prepares the patient meticulously. Then the person is taken to the operating theatre at the right moment.

OP lamp

The controlled surgical environment includes lighting conditions. For a long time, operating theatres had windows so that surgeons could operate in daylight. It was not until around 1900 that reliable surgical lights became established, allowing operations at any time of day or night. Surgical lamps, such as the "Scialytique", use a mirror system to illuminate the entire surgical field, even when a surgeon is leaning over the patient.

The OP team

He is barely recognisable behind the white mask: Bernese surgeon Fritz de Quervain poses in an operating theatre at Inselspital. The hall meets the requirements of the time so that the surgeons could operate under controlled conditions. A large operating lamp illuminates the room, sterilised instruments are ready, the operating table developed by de Quervain himself allows different lying positions to be set. A matter of course in 1912: An assistant monitors the anaesthesia during the operation.

From big to small

The hygienic requirements also had an impact on the architecture: The large halls with the auditoriums for classes were now disappearing. In 1902, Kocher had a second, smaller hall built next to the large one, and its furnishings were considered exemplary. 30 years later, things went one step further: In the New Surgical Clinic, the operating rooms were tiled in green, and an extraction air device ensured a clean operating field. The new halls were complemented by ancillary rooms, such as sterilisation and washing rooms with alcohol wash stands for hands and autoclaves for instruments.

Sewing and scars

Surgeons open the human body with an incision and close it again at the end of the procedure. A clean suture is an indispensable prerequisite for good wound healing. In order to ensure a durable wound closure, the wound edges must lie against each other without tension. Detailed descriptions of surgical suturing techniques have been handed down since the late antiquity. For centuries, surgeons used threads made of natural silk, sheep's intestine or wires made of metal. The central developments in surgery in the 19th century also had an impact on surgical suturing techniques: Surgeons developed new suture forms and knots for wound closure and used sterile sutures and needles.

The needle

Surgical suturing places high demands on the material used. The needles must be small and at the same time very robust. Such needles are difficult to handle with bare fingers. That is why needle holders first appeared in the 18th century. Anti- and aseptic measures affected the manufacture of needles at the end of the 19th century. They were given a chrome or nickel coating. Later, they were made of stainless steel. They were stored in tins. These containers were placed in hot steam for sterilisation. The steam flowed into the inside of the container through the small holes on the side. In this way, germs were killed or viruses inactivated.

Suture material

Since ancient times, doctors have been closing wounds with different materials. One particularly popular option: Silk and the so-called "catgut", which was mainly made from the intestines of sheep. The advantage of the material? The threads dissolve through the body's own enzymes after a few days. In the 19th century, the question of wound infection also arose during suturing. Sterilisation procedures with germicidal agents for the suture material were being developed. Since the 1930s, the first synthetic threads have been produced, gradually replacing threads made of organic material.

Non-cutting

Control of pain, wound infection and blood loss gradually began to improve. That is why ever more complex surgical interventions have been possible since the 19th century. Although surgeons now performed many operations routinely, cutting open the human body still involved a degree of risk. For this reason, efforts have been made since the 1980s to perform surgical interventions with the smallest possible injuries to the tissue, i.e. minimally invasive, or – if possible – without an incision at all.

Minimally invasive interventions

Even with minimally invasive procedures, a surgeon must be able to see his operating field. Therefore, he uses both an endoscope and various cutting instruments. An important instrument for this is the trocar. It consists of a tube, and a puncture instrument. The surgeon uses this to gain access to the body cavities. After piercing, the puncture instrument can be pulled out of the tube. The tube is now free. The instruments are now introduced into the body through this point, e.g. an endoscope. The surgeons can use additional gripping or cutting instruments for the surgical interventions via further punctures.

From the cut to the push

Urinary stones can cause extremely severe pain. Since the Middle Ages, the so-called "stone cutters" used an incision to enter the urethra and pull out the stone. Wilhelm von Fabry, a surgeon working in Bern, wrote one of the most important papers on this procedure in 1626. The dangerous procedure has been replaced by a lower-risk procedure since the middle of the 19th century. The development of the cystoscope enables stone removal without incision via the urethra. Finally, in 1985, a small revolution ensues: The so-called extracorporeal shock wave lithropsy makes interventions in the body unnecessary. Shock waves generated outside the body break up the urinary stones, which are then excreted through the urine.

Auswahlbibliografie

Germann, Markus (1997): Theodor Kochers Operationssäle: Der Übergang von der Antisepsis zur Asepsis am Inselspital Bern (Diss. med. Bern).
Schlich, Thomas (2008): Ein Netzwerk von Kontrolltechnologien. Eine neue Perspektive auf die Entstehung der modernen Chirurgie, in: NTM 16, S. 333–61.
Schlich, Thomas (2013): Negotiating Technologies in Surgery: The Controversy about Surgical Gloves in the 1890s, in: Bulletin of the History of Medicine 87 (2), S. 170–97.
Schlich, Thomas (2007): Surgery, Science and Modernity: Operating Rooms and Laboratories as Spaces of Control, in: History of Science 45, S. 231–56.
Schlich, Thomas (Hg.) (2018): The Palgrave Handbook of the History of Surgery, London.
Strasser, Bruno, Thomas Schlich (04.07.2020): A History of the Medical Mask and the Rise of Throwaway Culture, in: Lancet 396. S. 19-20.