Antisepsis and women in surgery 12 The Gross ClinicThe, byPharos Thomas/Winter Eakins, 2019 1875. Photo by Geoffrey Clements/Corbis/VCG via Getty Images The Agnew Clinic, an 1889 oil painting by American artist Thomas Eakins. Universal History Archive/UIG via Getty images Don K. Nakayama, MD, MBA Dr. Nakayama (AΩA, University of California, San Francisco, Los Angeles, 1986, Alumnus), emeritus professor of history 1977) is Professor, Department of Surgery, University of of medicine at Johns Hopkins, referring to Joseph Lister North Carolina School of Medicine, Chapel Hill, NC. (1827–1912), pioneer in the use of antiseptics in surgery. The interpretation fits so well that each surgeon risks he Gross Clinic (1875) and The Agnew Clinic (1889) being consigned to a period of surgery to which neither by Thomas Eakins (1844–1916) face each other in belongs; Samuel D. Gross (1805–1884), to the dark age of the Philadelphia Museum of Art, in a hall large surgery, patients screaming during operations performed TenoughT to accommodate the immense canvases. The sub- without anesthesia, and suffering slow, agonizing deaths dued lighting in the room emphasizes Eakins’s dramatic use from hospital gangrene, and D. Hayes Agnew (1818–1892), of light. The dark background and black frock coats worn by to the modern era of aseptic surgery. In truth, Gross the doctors in The Gross Clinic emphasize the illuminated was an innovator on the vanguard of surgical practice. head and blood-covered fingers of the surgeon, and a bleed- Agnew, as lead consultant in the care of President James ing gash in pale flesh, barely recognizable as a human thigh. A. Garfield after he was shot in 1881, had been denounced Across the room, the entire canvas of The Agnew Clinic because antiseptics had not been used. seems to glow, the surgeon and his assistants all in white. Appropriate to his prominence in American art, Eakins' The patient, a woman, is placid under anesthesia, her scholarship covers all aspects of his artistry, antecedents, healthy right breast in full view. Unlike the companion and influences. Receiving less attention are the subjects piece, surgery is hidden, the only evidence being small themselves, two of the foremost surgeons of their time. splatters of blood on linen and the surgeons’ gowns. Why were surgeons immortalized by the greatest American For the viewer, especially a surgeon, the paintings are artist of the 19th century? As Brieger notes, the two por- breathtaking images of the past and future of surgery. traits span the era of antiseptic surgery, one of the great Eakins’s message is clear: “We are now iconographically advances in medicine.1 Eakins, a master of Realism, per- in the age of Lister,” 1 writes Gert Brieger (AΩA, David ceived another trend that would forever change the field: Geffen School of Medicine at the University of California; The entry of women in surgery. The Pharos/Winter 2019 13 Antisepsis and women in surgery A comprehensive book on Eakins and The Gross Clinic is medical schools across the United States came to Gross Thomas Eakins: The Heroism of Modern Life, by Elizabeth with offers of professorships. He accepted two: the first Johns, art historian at the University of Pennsylvania.2 at the University of Louisville in 1840, then his alma ma- Sidney Kirkpatrick, a bestselling author, has a more recent ter, Jefferson Medical College, in 1856. At the latter, he biography of Eakins, The Revenge of Thomas Eakins, with wrote two more widely influential texts: in 1859, the first added background on The Agnew Clinic.3 The definitive bi- of what would be six editions of the comprehensive text- ography of Eakins and his works remains Lloyd Goodrich’s book, System of Surgery;7 and in 1861, Manual of Military two-volume Thomas Eakins.4 Surgery, used by both sides in the Civil War. His clinical reputation rested on conservative surgery, the Samuel Gross, MD approach of avoiding amputation, specifically in osteomy- Gross was one of the few elitis.1 If the child survived the acute infection, removal of American physicians with an in- devitalized bone hastened healing and allowed the regenera- ternational reputation.5 He was tion of the remaining bone, thereby preserving a functional brought up on a Pennsylvania limb.7 This was the operation that Eakins portrayed in The Dutch farm near the Lehigh Gross Clinic.1 When antibiotic therapy cured osteomyelitis Valley town of Easton. He at- without surgery, conservative surgery became obsolete. tended school in a log cabin, and Gross led the American Surgical Association in 1880, read the Old Testament. After the first professional organization in the U.S. devoted a frustrating experience trying to the advancement of surgical science. He was its first to learn medicine from one of president.1 Today, the association continues as the leading Easton’s practitioners, he ab- academic forum in the field. sorbed himself in study at pri- Samuel D. Gross, MD, circa D. Hayes Agnew, MD 1875. PD-US-expired vate academies in Wilkes-Barre and Lawrenceville, New Jersey. Thirteen years junior to Gross, He discovered an aptitude for languages, polishing his D. Hayes Agnew was also in German and English, then mastered Latin, Greek, French, Philadelphia, at the University of and enough Italian to read technical articles. After an Pennsylvania School of Medicine. unsatisfying apprenticeship under an indifferent doctor, In contrast to Gross’ modest Gross enrolled at Jefferson Medical College in 1826 as a background, Agnew’s family was student in its inaugural class.6 prominent in Lancaster County, From the beginning of his career, Gross was devoted Pennsylvania, able to trace its to academic publication. During his first years in practice lineage through four centuries of he translated texts on anatomy, obstetrics, typhus, and landed gentry in Scotland to 13th operative surgery from the original French and German, century French nobility.8 and authored a text on the diseases of bones and joints. At 18-years old Agnew at- D. Hayes Agnew, MD, circa Dissatisfied with his practice in Easton, in 1833 Gross found tended medical school at Penn 1890. PD-US-expired work in Cincinnati, first at the Medical College of Ohio, following in the footsteps of his then two years later at the short-lived Medical Department father, also a physician and Penn graduate. In 1848, he taught of the Cincinnati College as chair of pathological anatomy. at the Philadelphia School of Anatomy, a private facility.8 Passionate in his study of anatomy, he spent hours every He joined the University of Pennsylvania in 1862, at- day dissecting both normal and diseased bodies. At both taining the top rank as professor of surgery in 1871. He Easton and Cincinnati, he received specimens and bodies published the textbook, Principles and Practice of Surgery, from colleagues who knew of his interest. He published that had two editions—1878 and 1889. his findings in 1839 in the two-volume work, Elements of At the apex of his career Agnew was called as the lead Pathological Anatomy, the first work on morbid anatomy consultant to assist in the care of U.S. President James A. in English. Immediately popular, Gross’s text went into Garfield after he was shot in the flank on July 2, 1881. In the three editions before it was made obsolete by the develop- early morning hours of July 4, a special train sped Agnew ment of microscopic pathology in the 1850s.6 from Philadelphia to Union Station in record time.8 The A national and international figure at 34 years of age, President, in hypovolemic shock, had undergone repeated 14 The Pharos/Winter 2019 probing of his wound for the bullet by his primary surgeon, dissections, and surgical opera- the surgeon general of the Navy, then by both Agnew and tions, including some by Gross. his fellow consultant, Frank Hamilton of New York. The He likely did the same at group decided not to operate after Garfield appeared to Parisian medical schools when rally later that evening.8 he was at the École des Beaux- The President began to die a slow, agonizing death from Arts from 1865 to 1869. When sepsis, two subsequent operations doing little to slow his he returned stateside in 1870, he deterioration. Death came on September 19, 1881, two-and- was a prosector at the Academy a-half months after he was shot. Postmortem examination under another Jefferson sur- found a ruptured splenic aneurysm as the terminal event. geon, William W. Keen (AΩA, Thomas Eakins, Self-Portrait, The bullet was nearby, encysted, adjacent to a non-healed Sidney Kimmel Medical College, 1902. National Academy Museum, New York fracture of the first lumbar vertebra. Pus had tracked from 1903, Honorary).1 there through the retroperitoneum to the groin.8 For Eakins, knowledge of anatomy was as essential to Daily bulletins on Garfield’s condition were on the front painting as it was to surgery. “To draw the human figure,” pages of both the lay press and the medical newsletters.8 he said, “it is necessary to know as much as possible about Fascinated by the drama of a President’s life in the balance, it, about its structure and its movements, its bones and the public became familiar with arcane medical jargon. muscles, how they are made, and how they act.” 1 The debate intensified after Garfield died. Were the His career had a slow start. He saw opportunity when President’s wounds necessarily fatal? Was his care botched? plans for a world’s fair in Philadelphia were announced, Charles Guiteau, Garfield’s assassin, and his attorneys tried to a celebration of the 1876 centennial of the Declaration of take advantage of the second-guessing.