To perform in a theater, sans its audience

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A theater it is, with performances that are all a matter of life and death. It is not an act, but all that happens is real. Human lives are wheeled in, and their senses go blunt. Some others dare to correct, remove or fix aberrations. Mostly, lives are repaired, and sometimes new ones are created. It all happens on a daily basis in an operation theater. However, amidst all those who are playing their part, there is hardly any audience. Word theater is more of a legacy from the past, that lives on almost like a ritual.

Origin of theaters

About 500 years ago, renascence was sweeping Europe. One of the advancements was our ability to understand human anatomy. Andreas Vesalius (1514-64) also started a tradition of dissecting human bodies in public. The place had a central stage, and stepped platforms on all sides, for onlookers to stand and observe a dissection. Often there was also a ticket, as well as some live music.

Surgery was not yet a well recognized profession. Till 17th century, surgeons (barber surgeons) performed surgeries inside their homes, basements, and even in fairs or carnivals. Religious laws forbade physicians, who trained in religious universities, from shedding blood, so surgeons often worked outside the medical establishment.

Surgery, theaters and audience

By the 18th century, live dissections had become an important part of medical training. As the popularity of these performances boomed, medical students had to compete amongst rowdy crowds to get a good seat. Later surgeries also started to occupy the same theaters. The anatomy theater would double up both for dissection as well as for surgeries in live humans.

By the early 19th century, surgery on live patients, such as amputations, also began taking place in front of a live audience. The surgical theaters were also based on the anatomical theaters. A painting by Robert Hinckley, titled “the first operation under ether” depicts a 1846 event in a theater at Massachusetts General Hospital in Boston.

For most part of 19th century, surgery was rather crude. In the pre-anesthetic period, focus was on speed with which an amputation could be performed, or a growth that could be removed. No one would penetrate the chest wall, abdomen or the cavity of the brain. Surgical tools were also simple and limited.

Surgical instruments

The older instruments used during a surgery were crude, and designed to be quick. These included forceps, pliers, hooks, saws and elevators. (See here for more details)

These tools were not designed for a fine, prolonged surgery. Rather these were developed by blacksmiths, some of whom would double up as surgeons. These tools were not sterilized either, as the concept of microbes, and infection were yet to be proven.

From amphitheaters to asepsis

Joseph Lister, was a medical student in training, when in 1851 he performed his first surgery. This was a lady with a stab wound in abdomen, and Lister’s surgery was done in full public view. A surgeon was not required to wash his hands before seeing a patient; in the absence of any theory of bacterial infection, such practices were not considered necessary. It was not until 1865, when Louis Pasteur proved Germ theory of disease.

Initially Lister used Carbolic acid to clean skin and wounds. Later he used Carbolic acid sprays to disinfect operation theaters. While the choice of the substance was problematic, the concept of asepsis became popular.

A few years later, Stephen Smith, a New York surgeon, in 1878 advised abolition of operating amphitheaters as dangerous to the patient and useless for the purpose of instruction. Initially glass partitions separated the operating room from the visitors’ gallery, allowing demonstrations without contamination. In 1882, a French Surgeon Octave Terrilion advocated the procedure of using boiling water, a heat sterilization technique for disinfecting surgical instruments

In 1884, the German surgeon Gustav Neuber designed and built the first aseptic operating theatre where the walls, floors, shelves and other surfaces were all washable, and all instruments had flat surfaces and were sterilized. Towards the end of the 19th century, surgical amphitheaters disappeared. They were rebuilt to incorporate separation of the performers from the observers.

The surgeons operating attire

In the past, surgeons did not wear gowns, masks or gloves. Coats were not removed and sleeves were rarely rolled up. Hands and clothes were cleaned only after the operation to remove the messy blood.

With asepsis, came the surgical gowns, caps and masks. Rituals such as scrubbing hands, shaving operating areas, and maintaining silence all have their roots in preventing infections. The credit for the introduction of surgical gloves is generally given to the American surgeon William Halsted. Paradoxically, his reason for the use of gloves was not asepsis, but to protect the hands of his scrub nurse from reaction to mercuric chloride solution.

Lights, and action

A couple of more things have changed in a modern operation theater. These are operation theater lights and other equipments. Postage stamps from 1950s show simpler candescent lights. Later images have multiple bright lights.

Operation theaters are a special zone

A surgeons hand-wash and operating room rituals were reinforced in 1980s, when we learned that infections like hepatitis B, C and HIV can have a percutaneous transmission. A more cautious approach to protect patients as well as healthcare workers is now followed. Entry into an operation theater is much better regulated.

Thus, operation theaters have come of age. They are still called theaters. However, a more appropriate nomenclature is Operating room. Large hospitals have many operating rooms as part of a complex. With advancement in digital and fiber optic technologies, live surgery videos can be transmitted to audience outside the theaters. However, this is not a routine practice anymore. So theaters remain, sans an audience.