The Butchering Art

by Lindsey Fitzharris

  On the other side were the anti-contagionists, who believed disease was generated spontaneously from filth and decaying matter, in a process known as pythogenesis, and then transmitted through the air via poisonous vapors, or miasma. (That the name of a disease like malaria derives from the Italian words mala, or “bad,” and aria, or “air,” suggests that people believed the disease had miasmic origins.) Anti-contagionism was popular among the medical elite, who opposed the draconian restrictions on free trade that contagionists advocated during epidemics. Proponents of anti-contagionism believed their theory was grounded in sound observation. One only had to look to the squalid conditions of an overcrowded city to recognize that highly populated areas were most often at the epicenter of outbreaks. In 1844, the physician Neil Arnott summarized anti-contagionism when he argued that the immediate and chief cause of disease in metropolitan areas was “the poison of atmospheric impurity arising from the accumulation in and around [people’s] dwellings of the decomposing remnants of the substances used for food and from the impurities given out from their own bodies.” Anti-contagionists advocated their own program of prevention and control that placed an emphasis on environmental improvements that would eradicate the conditions in which diseases could arise.

  While many medical practitioners recognized that neither of the two theories provided a comprehensive explanation for how infectious diseases spread, most hospital surgeons sided with the anti-contagionists by pointing to contaminated air in overcrowded wards as the cause of hospitalism. The French called the phenomenon l’intoxication nosocomiale (hospital poisoning). At University College Hospital, Erichsen concurred. He maintained that patients were infected by miasma arising from corrupt wounds. The air, he thought, would become saturated with poisonous gases, which in turn were inhaled by patients: this miasma might appear “at any season of the year, and under any circumstances, acquire extreme virulence, if the crowding together of the operated or injured … be excessive.” Erichsen estimated that more than seven patients with an infected wound in a fourteen-bed ward could lead to an irreversible outbreak of any one of the four principal hospital diseases. He could hardly be blamed for thinking so.

  While comparing mortality rates of country practitioners with those operating in the large, urban hospitals of London and Edinburgh during this period, the obstetrician James Y. Simpson discovered some shocking differences. Of twenty-three double amputations performed on patients in the countryside over a twelve-month period, only seven died. Although this statistic may seem high, it is low when compared with the mortality rate at the Royal Infirmary of Edinburgh for the same period. Of the eleven patients who received double amputations there during this time, a shocking ten of these died. A further breakdown shows that the leading cause of death in amputees in the countryside during the mid-nineteenth century was shock and exhaustion, whereas the leading cause of death in the urban hospitals was postoperative infection. Many surgeons began to question the impact that large hospitals were having on their patients’ ability to recover.

  University College Hospital had a swift isolation policy when it came to dealing with hospitalism’s conditions. The Lancet reported that the hospital “had been extremely healthy, and quite free from any erysipelas originating within its walls,” when Lister came to work for Erichsen in January 1851. And yet it was during that same month that a patient presenting with necrosis of the legs was brought into the wards from the Islington workhouse. He also happened to be infected with erysipelas. Although he only occupied the bed for two hours before Erichsen ordered his isolation, it was too late. The damage was done. Within hours, the infection spread over the entire ward, killing numerous patients. The outbreak was finally contained when the infected patients were moved off the ward to a different area of the hospital.

  Many of these victims would have undoubtedly been carried to the dissection room to be anatomized, emphasizing for Lister and his colleagues the apparently unbreakable nature of the cycle of disease and death, with the hospital ward forming its axis. Success or failure of treatment at a House of Death was a lottery. But occasionally, opportunities would arise for the surgeon to take the initiative to save lives in unexpected ways, as Lister would soon discover.

  3.

  THE SUTURED GUT

  We should ask ourselves, whether, placed under similar circumstances, we should choose to submit to the pain and danger we are about to inflict.

  —SIR ASTLEY COOPER

  THE FLAME OF LISTER’S CANDLE flickered in the window of the casualty and outpatient department of University College Hospital at one o’clock on the morning of June 27, 1851. Other wards had recently installed gaslit ceiling pendants, but this area of the hospital still relied on candlelight. Candles had always been problematic in a medical setting. They provided inconsistent lighting, and surgeons were forced to bring them dangerously close to patients in order to inspect them properly. One of Erichsen’s patients had only recently complained after hot wax dripped onto his neck during an examination.

  Lister often took advantage of the quiet nocturnal hours to write up case notes and check on patients. On this particular night, however, there would be no peace. Suddenly, a commotion erupted on the street outside the hospital. Lister snatched the candle from the window, its light receding deeper into the building as his footsteps echoed on hardwood floors. The flame briefly illuminated each room he passed through as he strode toward the main entrance. Just then, the doors burst open. Lister raised the candle to reveal the face of a frantic policeman. In the officer’s arms was an unconscious woman. She had been stabbed in the gut, and although the wound was small, slick coils of her intestines had started to protrude from her body. Lister was not just the most senior surgeon on duty. He was the only surgeon on duty.

  He set the candle down and got to work.

  * * *

  The young woman now in Lister’s care was Julia Sullivan, a mother of eight, who had fallen victim to her husband’s alcohol-fueled temper. Domestic abuse was not a rarity in Victorian England. Wife-beating was a national pastime, and women like Julia were often treated like property by their husbands.

  Some men even put their own wives and children up for sale after they tired of them. One deed for such a sale declared that a Mr. Osborn “does agree to part with my wife Mary Osborn and child to Mr William Sergeant for the sum of one pound, consideration of giving up all claim.” In another instance, a journalist wrote of a butcher who had dragged his wife to Smithfield Market “with a halter about her neck, and one about her waist, which tied her to a railing.” The husband ended up selling his wife to a “happy purchaser” who paid the man three guineas and a crown for “his departed rib.” Between 1800 and 1850, there were more than two hundred recorded cases of wife sales in England. Undoubtedly, there were more that went unreported.

  There was little legal protection for a victimized woman in the mid-nineteenth century. The editor of The Times criticized the lenient sentences handed out by magistrates of the court to abusive husbands, opining that the “conjugal tie appears to be considered as conferring on the man a certain degree of impunity for brutality towards the woman.” These violent men lived in a society that turned a blind eye to their abuse. The general populace had grown so accustomed to the idea that men were allowed to beat women and children that it practically sanctioned this behavior. On May 31, 1850, a writer for The Morning Chronicle commented,

  It is evident to all who take any pains to read the indications of the feelings of the populace that they are impressed with the belief of their having a right to inflict almost any amount of corporal violence on their wife or their children. That anyone should claim to interfere with this supposed right causes them unaffected surprise. It is not their wife or child? Are they not entitled to do as they will with their own? These phrases are not, to their apprehension, metaphorical. The shoes on their feet, the cudgel in their hand, the horse or ass that carries their burden, the wife and children, all are “theirs” and a
ll in the same sense.

  This was the world in which Julia Sullivan lived when her fifty-nine-year-old husband, Jeremiah, lunged at her with a long, narrow-bladed knife that he had concealed in his sleeve, just an hour before she was rushed to University College Hospital.

  The tension between the unhappy couple had been mounting for some time before the attack. Sullivan’s alcoholism and violent outbursts had driven his wife from their home five weeks earlier. Flight was one of the few options available to Julia in 1851, when a woman’s initiation of divorce proceedings was contingent on the husband’s committing both adultery and assault (the same was not true for the husband). And even if these criteria could be met, the expense of divorce was beyond the means of most lower-class women, who often lacked the funds to support themselves and risked being denied contact with their children should they obtain a legal separation. In Julia’s case, being beaten on a regular basis by her alcoholic husband was simply not enough to warrant filing for divorce under English law.

  Julia had recently moved out of her home and was sharing a room with an elderly widow in Camden Town, an area of London with a mixed crowd of poor working-class folk. Three weeks before the attack, a mob of local people had heard Sullivan shout obscenities and make threats against his wife’s life on the new street where she lived. His behavior was paranoid and delusional, and he thought that Julia was having an affair. One man, a Francis Poltock, confronted Sullivan, telling him to go away and that his wife wouldn’t come out and see him. According to court documents, Sullivan was seething with anger when he spat back, “If she don’t let me come in I will do for her.”

  That night, Sullivan surprised Julia outside her apartment as she was coming home from work. He grabbed her and demanded she return home with him, before tapping his sleeve in a threatening manner. Julia, thinking this was strange, asked him what he had hidden in there. He sneered, “Why, you foolish woman, do you think I have anything in my jacket-sleeve to take away your life, and send my soul to the devil?”

  The two fell into a blazing argument that brought the neighbor Bridget Bryan to the door to complain about the noise. Sullivan implored his wife to accompany him to a local pub. She refused, so he put his hand on her back and pushed her into the street. Bridget urged Julia to comply with Sullivan’s wishes for the sake of peace, and all three walked to the pub. While there, the spouses resumed their fight after Julia once again refused to leave with Sullivan. At last, the two women left on their own and started to make their way back home. Just when they dared hope they were free of Sullivan and his drunken ranting, he leaped at them out of the shadows. Julia, who thought her husband was about to strike her, put her hands up to cover her face. It was then that he sank the knife deep into her belly, crying, “There, I have done that for you!”

  As Julia lurched forward in pain, Bridget frantically put her hands underneath her friend’s clothes to feel for the wound. She shouted, “Sullivan, you have killed your wife!” He stood there watching the scene unfold before replying, darkly, “Oh no, she is not dead yet.”

  Thomas Gentle, a police officer on duty that night, later recalled seeing Julia limping down the street, escorted by Sullivan and her neighbor. When he asked her what was wrong, she groaned, “Oh, policeman, my life is in your hands; this man has stabbed me,” indicating her husband standing next to her. Instinctively, she put her hand on her abdomen. It was then that she made a horrific discovery and gasped, “Oh, my entrails are coming out!” Gentle took the panicked woman to the house of the nearest surgeon, one Mr. Mushat, but found he wasn’t home. He enlisted the help of two other constables, one of whom escorted Julia to University College Hospital on Gower Street, while Gentle and the other officer took Sullivan into custody. The drunken perpetrator ranted that he was only sorry that the lover he had imagined his wife to be sleeping with hadn’t been around as well, or he’d have “served them both alike.”

  * * *

  THE MAJORITY OF sick and injured people who came into University College Hospital, including Julia Sullivan, did so through the casualty and outpatient department. Very few were granted admission onto the wards. This wasn’t unusual. In general, a sick person had a one-in-four chance of gaining entry onto a ward of a city hospital. In 1845, King’s College Hospital treated all but 1,160 of the 17,093 people who came through its doors as outpatients. Most hospitals had a “taking-in day” designated for admitting new patients onto the wards. This might happen only once a week. In 1835, The Times reported an incident in which a young woman suffering from a fistula, inflammation of the brain, and consumption was turned away from Guy’s Hospital in London on a Monday because taking-in day was Friday. Returning on the appropriate day, the woman arrived ten minutes late and was refused admittance because of her lack of punctuality. Dejected and seriously ill, she returned to the countryside, where she died a few days later.

  In the nineteenth century, almost all the hospitals in London except the Royal Free controlled inpatient admission through a system of ticketing. One could obtain a ticket from one of the hospital’s “subscribers,” who had paid an annual fee in exchange for the right to recommend patients to the hospital and vote in elections of medical staff. Securing a ticket required tireless soliciting on the part of potential patients, who might spend days waiting and calling upon the servants of subscribers and begging their way into the hospital. Preference was given to acute cases. “Incurables”—people with cancer or tuberculosis, for instance—were turned away, as were people with venereal infections.

  Julia Sullivan was lucky in at least one respect that evening. The life-threatening nature of her injury guaranteed her immediate attention, and although Lister had never performed an operation on his own and was woefully inexperienced when it came to treating trauma patients, it was nevertheless her great fortune that she was placed in his care. After she was rushed through the doors of the hospital on a stretcher, Lister quickly examined her lower abdomen. Both her outer garments and her undergarments had been slashed, and the vertical cut was about two-thirds of an inch long and was wet with blood. Underneath her clothes, nearly eight inches of her intestines had slipped out of the wound.

  Lister remained calm during what was a terrifying moment. After administering an anesthetic, he washed the fecal matter off the entrails with blood-warm water and gently attempted to return the intestines to their rightful place. But the young surgeon realized the opening was too small to allow this and that he would have to widen it.

  Lister reached for a scalpel and cautiously enlarged the wound, upward and inward, by about three-fourths of an inch. He eased the greater part of the protrusion back into the abdominal cavity until only the knuckle of the intestine, which had been sliced by Sullivan’s knife, lingered outside the wound. Proceeding very carefully, he used a fine needle and silk to stitch up the opening. He closed the wound, knotted the silk, cut off the ends, and returned the injured part of the intestine to the cavity, using the skin gash as a valve to hinder further bleeding and soiling. After Lister dealt with the gut, some red watery fluid escaped from Julia’s bruised and swollen abdomen. He was happy that very “little blood had been lost, and the patient was perfectly sensible, though somewhat faint.”

  Returning the entrails in two stages allowed Lister time to concentrate on sewing up the wound using a single thread. His bold decision to suture Julia’s gut was an extremely controversial procedure that even the most experienced surgeons often refused to undertake. Where Lister had been successful with this method, many others were not. The surgeon Andrew Ellis remarked in 1846 that “you will meet with much discrepancy of opinion when you read the various works which treat [incised intestines].” Some preferred to do nothing, keeping instead a careful watch on the situation, as in the case of the aptly named surgeon Mr. Cutler and his patient Thomas V——, who sustained a knife wound to the gut while wrestling with a friend. When Thomas arrived at the hospital, the surgeon noted that he was suffering no significant outward bleeding and prescrib
ed twenty drops of laudanum to the poor man writhing in pain. The next day, his bowels began to fail, and the patient’s abdomen became painfully distended. Cutler ordered that the man be given an enema to ease his discomfort, but this produced no effect, so the surgeon gave him four ounces of brandy. On the third day, the patient continued in his agonized state. His skin and extremities became very cold, his pulse very faint. He was once again given an enema of senna with castor oil, which produced a small quantity of feces. Afterward, he rallied a little, only to collapse later that day and die.

  Although the use of sutures was widespread at the time, stitched wounds or incisions often became infected. The risk was even higher when dealing with a punctured bowel. Most surgeons preferred to cauterize the opening with a narrow iron blade, heated on a brazier until it was red-hot. “The more slowly [the flesh] burns, the more powerful is the effect,” the surgeon John Lizars remarked. If it burned deeply, the lesion could remain open for weeks or even months, healing from the inside out. The pain, of course, was excruciating, and the procedure carried with it no guarantee of survival, especially because the patient would have to convalesce on a poorly ventilated ward of a Victorian hospital crawling with bacteria and other germs.

  These were the medical realities facing most people unfortunate enough to sustain an abdominal injury during the Victorian period. Lister’s success with Julia Sullivan’s operation was due to a combination of skill and luck. Certainly, he took his lead from hernia cases, which involved returning protrusions of the bowel back into the body. Very early in Lister’s residency, Erichsen cared for a patient who had sustained a kick to the abdomen as a child and as a consequence suffered from a persistent hernia. Decades later, the hernia became swollen and painful. Erichsen was forced to cut through the man’s intestines to relieve pressure in his gut before returning the bowel to its rightful place. The man seemed to recover immediately following the surgery, only to die the next day.