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The Universally Accepted Methods

The universally accepted methods and procedures in the medical field today were once all ideas. These ideas were planted into brilliant minds, then developed into theories. Then somehow those theories became universally acknowledged and verified. When talking about some of the major theories in the medical community, it tends to be in a “before and after” format. Before this notion was discovered, and how we use it now. But what about the in between? Instead of focusing on the before and after, let us focus in on the during. The time where a theory has been developed, but is grasping for acceptance. It’s not as black and white as how we tend to discuss acceptance. It’s not as if everyone goes to sleep one night believing the sky is purple, then wake up the next morning and agree that it is now blue. These grey areas of time are ones where people have to question their core beliefs and be open to newness and change. As these new ideas grow in popularity, are we supposed to “punish” those who don’t readily accept the new?

The change in belief surrounding where disease and infection come from was one of the most revolutionary changes in medical history. The medical world during the mid 1800s believed that infectious diseases came from air contaminated with “miasmas”. It seems like a simple theory: that there is something in the air that infects people with disease. But it is actually more rooted in the religious overture of the time. Rather than infecting everyone that they came in contact with, miasma clouds seemed to select those lacking in moral uprightness. The people at this time reached this conclusion by saying that the “foul-smelling” air that caused disease seemed to only be in poor neighborhoods. The upper classes thought that this was god’s way of punishing the poor, as the poor were thought of as “less than” at this time. This theory was the accepted idea, until it was challenged by today’s idea of germ theory.

The theory really begins development in the 1850s and 60s. It started as an idea without many scientific facts backing it. To get an accurate depiction of the development and controversial backlash of germ theory we need to look specifically at the Cholera outbreak of 1854 in London. To find a cure, it needed to be discovered where this disease was coming from. The “dispute was divided between two camps: the contagionists and the miasmatists”. The contagionists believed that it was contracted through contact with the infected. The miasmatists believed that the “foul inner-city air was (…) the source of most disease”. But neither of these theories suggested that it could be transmitted through microorganism in the water. Jon Snow is the researcher who came closest to discovering germs in this case. His search for cause was based on the reconciliation of two facts: you could be in the same room as an infected, and leave unscathed; and you could avoid all direct contact, but still contract the disease because you live in an infected neighborhood. After investigation, Snow came up with the argument that, “cholera was caused by some as-yet-unidentified agent that victims ingested, either through direct contact with the waste matter of other sufferers or through drinking water that had been contaminated with waste matter.”. Cholera was contagious, and sanitary conditions were crucial to fighting the disease. But not in the ways that contagionists and miasmists suggested. It was not contagious the way smallpox was (through direct contact); and it foul air had nothing to do with its transmission. It was all about this thing that today we would call germs.

While Snow’s argument was correct, he did not have the science behind it at the time. Instead we look to Louis Pasteur for the scientific evidence. From 1862 to 1864 Pasteur was conducting experiments that raised the question: “Where do they (ferments) come from these mysterious agents?”. Pasteur’s experiment showed us that “fermentation and growth of microorganisms in nutrient body did not proceed by spontaneous generation”. His experiment consisted of boiling meat broth in a flask, then forming the opening of the flask into an S shape. This made it so that air could enter, but the microorganisms in the air could not (instead gravity would make them “settle” in the neck). Pasteur’s hypothesis was correct, no microorganisms grew in the broth. That is until you tilted the flask, causing the broth to reach the point that the microorganisms “settled” in the neck. At that point the broth became “cloudy with life”. With this experiment Pasteur had “demonstrated that microorganisms are everywhere, even in the air; the revolutionary germ theory was a reality”.

This major change from miasma to germ theory contains a very crucial subplot: antisepsis. Antisepsis is the solution to the problem of germs in the medical field. Sterilization is now one of the most basic elements in the medical world, but like all current day commonly accepted theories it had to start somewhere. Today’s sterilization standards all started with a man named Joseph Lister. His seminal article published in The Lancet was title, “On the Antiseptic Principle in the Practice of Surgery”. It is strange to imagine a world that didn’t believe in sterilization, but that was the world Lister was writing to. In his seminal article, Lister expresses that the cause of supparation in wounds “is decomposition brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury”. Lister explains that in the past it has seemed as though supparation prevention was unattainable because it seemsed “hopeless to attempt to exclude oxygen”. From here Lister references Pasteur’s discovery that the “septic property of the atmosphere depended, not on the oxygen or any gaseous constituent, but on minute organisms suspended in it.”. Pasteur’s research spurred Lister’s hypothesis that he might be able to avoid decomposition in the wound by “applying, as a dressing, some material capable of destroying the life of the floating particles”. From here Lister uses his article to provide a guide on his antisepsis techniques and particular case studies in which these techniques have been successful. This look at preventing supparation kickstarted the rest of his career in sterilization.

While Joseph Lister’s story is an important one and one that we will further unpack later, let us now look at the broader topic of controversy. In the medical community, it can be hard to reach acceptance with a new idea because these theories effect the sick. It is quite literally a life or death situation. The quickness of acceptance is based on a variety of variables. In the case of Jon Snow and Cholera, his argument came in a time of desparation. Many people were dying from a disease that no one could pinpoint or cure. Because of this people allowed Snow to attempt his solution of cutting off the water supply because they were out of options. When his solution worked, his idea was given credence. However Lister’s idea was met with much disagreeance. His theory relied on the validation of Pasteur, but many people still doubted Pasteur’s idea. Lister’s proposition was also complicated. It wasn’t just a way of thinking and it didn’t just deal with one technique in one surgery. Instead it proposed a complete change in the way doctors thought, stated the solution as an extensive set of techniques, and seemed to suggest that by attempting to help their patients, doctors had some blame in the patients getting infections. While widespread acceptance wouldn’t come until the 1890s, after Heinrich Koch, a German bacteriologist, effectively proved that germs caused disease, Lister still has his supporters. It was still evident that Lister’s techniques were having sucess. Yet many people, specifically in the United States, did not accept his idea.

This new idea, that surgical infection could be prevented by sterilization, was not met with acceptance. There was a lot of controversy and disbelief. But while the disbelievers eventually changed their mind, can we fault those who took longer to come around to this new notion? While it’s easy to say, maybe they didn’t know about the new technique, or it can be hard to accept new ideas, looking at the specifics of a case may change our perspective when we take into account the fact that a man’s life was lost. Especially when we know that this man was the President of our country.

On July 2, 1881, President James Garfield was the victim of an attempted assassination. His assailant was a man by the name of Charles Guiteau. While at a train station Garfield was shot twice. However when Guiteau was on trial he stated that he did not kill Garfield, the president’s doctors did. At the time this was written off as the ramblings of a mad man, but based on what we know now: he was technically correct. If someone was inflicted with the same wounds as Garfield today, they would survive. His gun shot wounds were not fatal. What killed him was infection. Infection that could have been prevented with Lister’s antisepsis technqiues. So can these doctors be blamed for the death of Garfield? While the technical answer is yes, it is much more complicated than that. Instead let us ask the question: can these doctors be held accountable? Should their more “heroic” title gained from attempting to save the President be replaced with a title of ignorance and stubborness? To answer this question we must first go back and delve into Joseph Lister’s story.

To understand the controversy surrounding sterilization and antisepsis, we must first understand the development of germ theory that was also going on at the time.

Germ theory required a drastic change in belief about where disease and infection came from. The medical world during the mid 1800s believed that infectious diseases came from air contaminated with “miasmas”. On the surface it is a relatively simple concept: that there is something in the air that infects people with disease. This assumption is partly true, but does not grasp the whole story of where diseases come from. This belief’s main fault lies in the religious element. Rather than infecting everyone that they came in contact with, miasma clouds seemed to select those lacking in moral uprightness. The people at this time reached this conclusion by saying that “foul-smelling” air that caused disease seemed to only be in poor neighborhoods. The upper classes believed that this was God’s way of punishing the poor, as the poor were thought of as “less than” at this time. This theory was the accepted idea, until it was challenged by the later idea of germ theory.

Germ theory really began development in the 1850s and 60s. It started as an idea without many scientific facts backing it. A milestone in the development of germ theory was the Cholera outbreak of 1854 in London. To find a cure, one had to know where this disease was coming from. The “dispute was divided between two camps: the contagionists and the miasmatists.” The contagionists believed that it was contracted through contact with the infected. The miasmatists believed that the “foul inner-city air was (…) the source of most disease.” But neither of these theories suggested that it could be transmitted through microorganisms in the water. Jon Snow is the researcher who came closest to discovering germs in this case. His search for a cause was based on the reconciliation of two facts: you could be in the same room as an infected, and leave unscathed; and you could avoid all direct contact, but still contract the disease because you live in an infected neighborhood. After investigating, Snow came up with the argument that “cholera was caused by some as-yet-unidentified agent that victims ingested, either through direct contact with the waste matter of other sufferers or through drinking water that had been contaminated with waste matter.” Cholera was contagious, and sanitary conditions were crucial to fighting the disease. But not in the ways that contagionists and miasmists suggested- it was not contagious the way smallpox was (through direct contact); and foul air had nothing to do with its transmission. It was all about this thing that today we would call germs.

While Snow’s argument was correct, he did not have the science behind it at the time. Instead we look to Louis Pasteur for the scientific evidence. From 1862 to 1864 Pasteur was conducting experiments based on the question: “Where do they (ferments) come from these mysterious agents?” Pasteur’s experiment showed us that “fermentation and growth of microorganisms in nutrient body did not proceed by spontaneous generation.” His experiment consisted of boiling meat broth in a flask, then forming the opening of the flask into an “S” shape. This made it so that air could enter, but the microorganisms in the air could not (instead gravity would make them “settle” in the neck). Pasteur’s hypothesis was correct, no microorganisms grew in the broth. That is until you tilted the flask, causing the broth to reach the point that the microorganisms “settled” in the neck. At that point the broth became “cloudy with life”. With this experiment, Pasteur had “demonstrated that microorganisms are everywhere, even in the air; the revolutionary germ theory was a reality.”

This major change from miasma to germ theory contains a very crucial subplot: antisepsis. Antisepsis is the solution to the problem of germs. Sterilization is now one of the most basic elements in the medical world, but like all current day commonly accepted theories, it had to start somewhere. While germs were being discovered by Pasteur, the eventual solution to combating them was being developed by Lister. His research kickstarted in 1861. Lister reported that somewhere between 45 and 50 percent “of his amputation cases died from sepsis between 1861 and 1865.” It was in this ward that Lister began testing possible antisepsis techniques. His early work and research depended “upon the microscope and were directly connected with the healing of wounds.” This put him on the right track to correlate germs, a microscopic organism, with post-surgical sepsis.

Lister’s introduction to Pasteur’s experiments pushed his own research further. Lister’s “familiarity with the microscope, the process of fermentation, and the natural phenomena of inflammation and coagulation of the blood compelled him to accept Pasteur’s theory as the full revelation of a half-suspected truth.” In light of this new information, Lister attempted to create an antiseptic barrier between the wound and the air (based on his incorrect assumption that all germs were in the air), but it ended up “protecting the site of operation from infection by the surgeon’s hands and instruments.” He found that carbolic acid was an effective antiseptic. Lister’s first success using his new method was on August 12th, 1965. The results were substantial. He had proven that sepsis could be prevented with sterilization.

In 1967 he published his seminal article in The Lancet titled, “On the Antiseptic Principle in the Practice of Surgery”. It is strange to imagine a world that doesn’t believe in sterilization, but that was the world Lister was writing to. In this article, he expressed that the cause of suppuration in wounds “is decomposition brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury.” Lister explains that in the past it has seemed as though suppuration prevention was unattainable because it seemed “hopeless to attempt to exclude oxygen.” From here Lister goes on to reference Pasteur’s discovery that the “septic property of the atmosphere depended, not on the oxygen or any gaseous constituent, but on minute organisms suspended in it.” Pasteur’s research spurred Lister’s hypothesis that he might be able to avoid decomposition in the wound by “applying, as a dressing, some material capable of destroying the life of the floating particles.” Lister then uses his article to provide a guide on his antisepsis techniques and particular case studies in which these techniques have been successful.

It is important to note that Lister was not the first doctor to try and prevent sepsis with a type of sterilization. Rather he was the one who had access to Pasteur’s work and could apply it as factual backing to his results. A man named Ignaz Semmelweis also had positive results when he took sterilization precautions, but because he could not show proof of where these positive results were coming from, he was not taken seriously. His story unfolds mostly around 1847. Semmelweis’ published his findings in his book “The Etiology, Concept, and Prophylaxis of Childbed Fever”. He begins by explaining how in the two clinics in which childbirth occurred, the “mortality rate in the first clinic was consistently greater than in the second clinic.” There was no noticeable difference in patient care in the two clinics, but the staggering difference in mortality rates called for further research. They tried to replicate clinic two’s methods exactly, even “delivering from the lateral position, so that everything would be exactly as in the second clinic.” Still nothing was discovered. That is until the death of Professor Kolletschka. He died after getting cut by an autopsy knife. What was strange was that the disease from which he died “was identical to that from which so many maternity patients died.” Semmelweis came to the conclusion that the wound by the “autopsy knife had been contaminated by cadaverous particles. Not the wound, but the contamination of the wound caused his death.” Semmelweis then goes on to explain that “because of the anatomical orientation of the medical school, professors, assistants and students, have frequent opportunity to contact cadavers.” He also explain that washing with soap is not enough to remove particles picked up from cadavers (“proven by the cadaverous smell that the hands retain for a longer or shorter time”). Semmelweis connected this with maternity patients by telling the reader that “in the examination of pregnant or delivering maternity patients, the hands, contaminated with cadaverous particles, are brought into contact with the genitals of these individuals, creating the possibility of resorption. With resorption, the cadaverous particles are introduced into the vascular system of the patient. In this way, maternity patients contract the same disease that was found in Kolletschka.” Semmelweis’ solution was to wash hands using chlorina liquida or chlorinated lime. Beginning in May of 1847, this practice was used. By removing the cadaverous particles with chlorine washings, mortality in the “first clinic fell below that of the second.” The correlation caused Semmelweis to conclude that “cadaverous matter adhering to the hands of the physicians was the cause of the increased mortality rate in the first clinic.” At the time his findings came with a harsh response. He was “dismissed from the hospital and harassed by the medical community.” This infuriated Semmelweis. He even begin writing “open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers.” FIND PRIMARY SOURCE OF RIDICULE His practice was only gained acceptance after his death, when Pasteur’s germ theory gave Semmelweis’ findings a theoretical explanation.

Lister and Semmelweis are the pioneers of sterilization, but while we can see the correctness in their techniques today, they were not met with open arms.

In the medical community, it can be hard to reach acceptance with a new idea because these theories affect the sick. It is quite literally a life or death situation. The quickness of acceptance is based on a variety of variables. In the case of Jon Snow and Cholera, his argument came in a time of desperation. Many people were dying from a disease that no one could pinpoint or cure. Because of this, Snow was allowed to attempt his solution of cutting off the water supply because there were no other options. When his solution worked, his idea was given credence. However Lister’s idea was met with much disagreeance. His theory relied on the validation of Pasteur, but many people doubted Pasteur’s idea. Another hindrance: Lister’s proposition was complicated. It wasn’t just a way of thinking and it didn’t just deal with one technique in one surgery. Instead it proposed a complete change in the way doctors thought, stated the solution as an extensive set of techniques, and seemed to suggest that by attempting to help their patients, doctors had some blame in the patients getting infections. In the case of Semmelweis, he was completely written off, ridiculed, and even lost his job. Even with statistical evidence, because he could not define “germs” he was not taken seriously. Widespread acceptance of germ theory (and in turn sterilization techniques) would not come until the 1890s, after Robert Koch, a German bacteriologist, effectively proved that germs caused disease. But during Lister’s time, the community was split, with most disbelief and resistance coming from the U.S. and the U.K.

Joseph Lister’s antisepsis proposal was met with various responses. For example, in Germany acceptance was widespread. There are a few different reasons that explain why Lister’s ideas were “favorable” in Germany. One reason: “the sense of crisis due to the rapid increase in wound disease”. The crisis of post-surgical sepsis was widespread, but seemed to be more acute in Germany. At this time poor sanitation and cleanliness was very present in German surgical wards. Lister has also expressed that sanitary conditions were lacking in Germany, specifically in hospitals where his supporters were coming from. I.H. Upmalis claims the German doctors’ “passive attitude” when it came to cleanliness could be a result of the miasma theory. Belief in this theory caused doctors to acknowledge the fact that disease was coming from something that was out of human control, so why bother with cleanliness. But People were dying from these conditions. The mortality rate reported by hospitals in Germany was very high. J. Israel for example “reported 62.5% mortality in operated patients and 37.5% of the non-operated one.” Simply put, the more widespread search for a solution was more dire in Germany, making the “threshold for unknown methods lower than in other countries.” Another reason for Lister’s acceptance was put forth by Michael Worboys. He stated that in Germany, Listerians “work with the grain of advanced medical science rather than against it.” “German doctors found it easier than their British colleagues to accept and integrate new ideas that were based in laboratory science. In a medical culture in which experimental science carried high prestige, the notion that the patient body was in significant ways comparable to a bacterial culture in the library was a natural step to take.” Germany was a prime candidate to accept Lister’s ideas, which is why Listerian instructions thrived there.

It is also important to note that the major breakthrough in gaining acceptance in Germany can be partially credited to A.W. Schultze and Volkmann. Schultze “was already familiar with carbolic acid dressings” when he visited Lister in order to learn his new method. When he returned home, he was a full supporter of Listerism. He later published two periodicals in which he described Lister’s technique in great detail. His paper examined some of the essential parts of Lister’s original idea that had since been overlooked – “the antiseptic treatment of Lister does not consist of the mere use of the antiseptic; it is not just a mere disinfecting treatment, but, as Lister himself clearly says: a treatment which prevents the onset of putrefaction.” He also emphasized one of the main problems disbelievers had with Lister: germ theory. Schultze made sure to explain that “Lister himself did not state categorically that wound infections are caused by germs, that is “organized matter”.” Schultze was a tremendous help in gaining Lister acceptance, but he did have one hole in his advocacy that was filled by Volkmann: personal case studies.

Volkmann combined “a profound understanding of the method with a conviction of its great value in surgery that was supported by personal experience.” Volkmann emphasized cleanliness, seen in his footnote: “If I have, for example, three operations at the clinic in the morning, I change my gown three times for a freshly washed one.” After Volkmann presented his paper, “many surgeons described their experiences with Lister’s method. All reports were in favor of Lister’s treatment.”

Lister gaining acceptance in Germany is what allowed him to gain universal acceptance. “Germine medicine dominated the world, and the medical thinking of North America in particular mat that period.” The “rest of the world was waiting to hear what its verdict on Lister’s treatment would be.”

So while Germany quickly approved of Lister’s techniques and can be attributed some of the credit for helping Lister reach universal acceptance, let us examine why certain areas did not initially accept Lister. Why certain areas needed this push from Germany to come around to his method. There were two main things that disbelievers held against this new idea. One was the time-consuming, intricate technique Lister was proposing. A technique with numerous steps that all needed to be performed (there was no picking and choosing, it was all or nothing). The second issue doctors found with Lister was his reliance on germ theory. This however was a misunderstanding. Lister was “prepared to compromise on whether germs were the cause of putrefaction, but he insisted that, whatever the cause of wound infection, carbolic acid applied with his methods prevented its development, or halted its progress.” Lister believed that as long as the practice was implemented, the principle it is based on should not hold so much importance. This can be seen in a footnote to the published lecture from his address in Edinburgh in August 1875:

If anyone chooses to assume that the septic material is not of the nature of living organisms, but a so-called chemical ferment destitute of vitality, yet endowed with a power of self-multiplication equal to that of the organism associated with it, such a notion, unwarranted though I believe it to be by any scientific evidence, will in a practical point of view be equivalent to a germ theory, since it will inculcate precisely the same methods of antiseptic management. It seems important that this should be clearly understood, because it appears to be often imagined that authors who are not satisfied by the strict truth of germ theory, but substitute for it some other hypothesis, invalidate antiseptic practice, which I must repeat, is not affected in one tittle by this theoretical discrepancy.

Today we know that Pasteur was correct about germ theory, and Lister was on the right path to prevent post-surgical sepsis. However, because certain doctors initially refuted his idea we need to track their change closely. Specifically through two cases in the United States. Both of these cases reveal a lot about this time period, because they are well-documented as they have to do with two president: Abraham Lincoln and James Garfield. Both men were victims of assassination. Lincoln’s doctor, Charles Augustus Leale, changed his story about how he cared for Lincoln after antisepsis was universally accepted. This change was only realized when his initial recounting of events was found 6 years ago. Garfield’s death came less than twenty years later. But during that short time period antiseptic techniques were widespread, so Garfield’s death by sepsis called for the discussion of his doctors being murderers. Lincoln’s case came before Germany’s support of Lister was in its prime, Garfield’s came after. Yet Leale received honors for his attempt at saving the President’s life, while Garfield’s doctors were seen as the direct cause of death.

Let us start with the Lincoln case. The following is a summary of the events that unfolded on April 14th, 1865, through the eyes of Charles Augustus Leale. On this night, Leale was in the audience at a theatre. It was a pleasant evening until around half past 10, when a gunshot was heard. A minute later a man lept to the stage with a dagger in his hand. The man ran off. Leale remembers then hearing cries from the audience: “the President has been murdered” “kill the murderer”. Leale immediately ran to the President’s box. Here he was introduced to Mrs. Lincoln who pleaded for him to do whatever he could to help. Leale sent for brandy and water, then approached the President and discovered that “he was in a state of general paralysis.” Leale requested two men to help place the President in a recumbent position. While holding his head and shoulders, Leale’s hand felt a blood clot near his left shoulder. He examined that area, but soon discovered that the wound was one inch below the superior curved line of the occipital bone. Leale then inserted his little finger of his left hand into the wound. Once he removed his finger, “a slight oozing of blood followed, and his breathing became more regular and less stertorous. The brandy and water now arrived and a small quantity was placed in his mouth, which passed into his stomach where it was retained.”

Two more doctors now arrived, and after a quick consultation, they agreed to move him to the nearest house. Once in this new location, they placed the President in bed diagonally (as he was too tall), the windows were opened, and everyone except the medical gentlemen and friends were made to leave the room. They removed his clothes and covered him in blankets; during this process Leale found his lower extremities cold so he applied bottles of hot water and hot blankets. During this night various doctors examined the President and attempted to extract the foreign substance. After exploring the wound, nothing was done besides keeping the wound free of coagula. The President continued deteriorating the rest of the night. Until, at 7:20 A.M., “he breathed his last and ‘the spirit fled to God who gave it’."

This shortened summary of the night comes from Charles Augustus Leale’s account of events written in the same year. Leale “rarely spoke of his actions on the night of April 14th.” In fact, there are only “seven extant accounts by Leale of his experience as one of Lincoln’s final doctors.” Five of these come from 1865, one from 1867, and one from 1909. This initial account that we have just seen summarized seems relatively simple. It is straightforward and fits into how we understood the medical field to be during this day. The interesting part of this case study occurs more than 40 years later. In 1909, in honor of the centennial of Lincoln’s birth, Leale gave his account once again. It was “rich in sentimentality” with an “acute sense of his own importance.” The 1865 report “offers a first draft of history by a man who had little time to ponder the life-changing events he had just experienced.” The 1909 report offers a draft of history by a man with “a keen sense of the importance of his role in the events of that night.”

While the later account is more sentimental and self-important compared to his accounts closer to the time of the crime, it is more important to focus on the fact that Leale “added details that are not present in his 1860s accounts.” For example, he states that “other doctors present wanted to administer more brandy and water to the President, but Leale resisted.” Another example was more extreme as he claimed “to have performed a form of cardiopulmonary resuscitation on the stricken Lincoln. However, doctors did not begin performing chest compressions to stimulate the heart until the 1890s.”

Now let us specifically look at how he changed his story regarding sterilization. In the original account there are two main red flags regarding antisepsis. One being Leale’s probing in the President’s wound; and the other being the location (moving the President, the many people around him, and going to a nearby house to perform procedures as opposed to going to a hospital). Regarding the first red flag, Leale grazes over this in his 1909 speech. This area was one he went into depth about in 1865, while in 1909 in simply said, “the President had been shot in the back part of the head, behind the left ear. I easily removed the obstructing clot of blood from the wound, and this relieved the pressure on the brain. “ This quick nod to his removal of the blood clot would be almost unnoticeable in the grand scheme of his address. He does not even refer to the fact that he was probing with his hand in the wound, or even that his tool was his unclean hand that removed the blood clot (although it may be inferred). Immediately after this is when he describes in detail for quite some time, performing procedures that were not around at this time. Perhaps to make the audience focus on this more heroic procedure as opposed to his one that would have killed the President if he recovered from the actual gunshot. The second red flag is not one that he skims over, but rather one that he justifies. In the original account, he tells of the location, people around, and location moving rather simply. In his mind there was nothing wrong with what was happening, and the events regarding location were decided as a group (him and the other doctors present). In 1909, he makes sure to tell us how he was adamant not to move the President to the White House as he would die along the way. This makes the movement to the nearby house seem more logical (at least he did not go all the way to the White House like the doctors of Garfield). He also mentions how he stationed an officer at the door to only admit a few people at any time. This once again puts him in a more active position and makes it seem like he was only letting in a few people which would help with the spread of germs. In the 1865 case this is not present at all. He does say that he requested only medical personal and friends to be in the room, but it seemed more of an issue of space than anything else.

A man changed his story so as not to be remembered as a lesser doctor who did not apply antisepsis techniques. Why did he do this? One may argue that it is simply because he wanted to be remembered as an even greater doctor. While this could be partially true, because he so rarely talked about these events, there must be more to the story. Perhaps he changed his story because of those doctors who were called murderers by some. Doctors who followed steps much like the ones Leale did (working in unsanitary conditions, moving the patient). We need to now examine those doctors. These doctors were on the case of James Garfield. This case had a major impact on the medical community.