The Butchering Art

by Lindsey Fitzharris

  Like most hospitals in the 1860s, the Royal Infirmary attracted patients who were too poor to pay for private care. Some were uneducated and illiterate. Many doctors and surgeons viewed them as socially inferior and treated them with a clinical detachment that was often dehumanizing. Lister, true to his Quaker roots, exhibited an unusual level of compassion for those on his wards. He refused to use the word “case” when referring to specific patients, choosing instead to call them “this poor man” or “this good woman.” He also recommended to his students that they use “technical words” so that “nothing was said or suggested that could in any way cause them anxiety or alarm”—something that would undoubtedly be viewed as unethical today but was born purely of compassion when Lister suggested it. One of his students later recounted a time when Lister admonished an instrument clerk who had brought an uncovered tray full of knives into the operating theater. The seasoned surgeon quickly threw a towel over the tray and said in slow, sorrowful tones, “How can you have such cruel disregard for this poor woman’s feelings? Is it not enough for her to be passing through this ordeal without adding unnecessarily to her sufferings by displaying this array of naked steel?”

  Lister understood that being in a hospital could be a terrifying experience and followed his own golden rule: “Every patient, even the most degraded, should be treated with the same care and regard as though he were the Prince of Wales himself.” He went above and beyond the call of duty when it came to putting at ease the children who were admitted to his wards. Lister’s house surgeon Douglas Guthrie related a touching story later in life about a little girl who came into the hospital suffering from an abscess of the knee. After Lister treated and dressed her wound, the girl held up her doll to him. He gently took the toy from her and noticed that it was missing its tiny leg. The girl fumbled around under her pillow and—much to Lister’s amusement—produced the severed limb. He shook his head ominously as he inspected his newest patient. Lister turned to Guthrie and asked for a needle and cotton. Carefully, he stitched the limb back onto the doll and with quiet delight handed it back to the little girl. Guthrie said that her “large brown eyes spoke endless gratitude, but neither uttered a word.” Surgeon and child seemed to understand each other perfectly.

  When pain was an unavoidable part of treatment, it was often difficult to win the trust of those who didn’t fully comprehend the procedures to which they were subjected. Lister certainly had his fair share of troublesome patients, and yet this never seemed to perturb him. In one instance, a forty-year-old mill worker named in the records as “Elizabeth M’K” came into the Glasgow Royal Infirmary with an injury to her hand. Lister operated and in the coming weeks attempted to bend her fingers back in order to restore flexibility to the muscles and tendons. Unfortunately, the woman mistook his efforts for attempts to break her fingers and fled the hospital in a panic. She returned five months later, her hand all but paralyzed because she had kept it in a splint the entire time. Displaying seemingly infinite patience, Lister resumed the therapy, and the patient eventually regained some movement.

  Lister personally accompanied the more serious cases back to the ward after an operation and insisted on helping to transfer the patient from the stretcher to the bed. To ensure the patient’s comfort, he would arrange an assortment of small pillows and hot-water bottles, warning his attendees that the latter should be covered with flannel so the anesthetized person would not inadvertently burn him- or herself during recovery. He even helped dress the sick after surgery. One of Lister’s house surgeons described how “with almost womanly care he would replace the bedclothes” of the patient, “putting them all trim and square.” To those who were awake, he would first ask, “Now are you quite comfortable?” before moving on to the next bed.

  Even in his private practice, he exhibited an acute empathy with patients that extended to their pockets. Consequently, Lister objected to issuing bills to those whom he treated and lectured his students that they should “not charge for [their] services as a merchant does for his goods.” Reflecting the ideals of his faith, Lister believed that the greatest reward for a surgeon was the knowledge that he had performed an act of beneficence for the sick. “Shall we charge for the blood which is drawn, or the pain which we cause?” he asked his students.

  When he wasn’t immersed in his work at the hospital, Lister began experimenting in his home laboratory again, publishing various findings on the coagulation of the blood and inflammation. He discovered that blood remained partially fluid for several hours in a vulcanized India-rubber tube but clotted promptly if placed in an ordinary cup. He concluded that blood coagulation is caused by “the influence exerted upon it by ordinary matter, the contact of which for a very brief period effects a change in the blood, inducing a mutual reaction between its solid and fluid constituents, in which the corpuscles impart to the liquor sanguinis a disposition to coagulate.” He also turned his attention to observing suppurative tissues under the microscope, including the eyeball of a rabbit, the jugular vein of a large pony, and a fresh batch of tissues excised from his own patients.

  Lister designed and patented several surgical instruments, showing himself to be an innovator in operative methods as well as in wound management. These included a needle for stitching wounds, a small hook that could remove objects from the ear, and a screw tourniquet for compressing the abdominal aorta—the largest blood vessel in the human body. His best-known surgical tool was the sinus forceps. With ring handles like those of scissors, the slender six-inch blades could pick fluff out of the smallest hole.

  These instruments, though useful, did little to improve mortality rates at the hospital. People continued to die in alarming numbers when hospitalism broke out on the wards. In August 1863, Lister performed surgery on the wrist of a twenty-year-old laborer named Neil Campbell. Lister had developed a method for removing diseased bone from the wrist without resorting to amputating the hand. A few months later the boy returned, his wrist once again carious. Lister repeated the operation, this time removing more of the diseased bone. While the surgery was a success, Campbell’s recovery was not. Shortly afterward, he developed pyemia and died. Lister grew increasingly frustrated by his inability to prevent and manage septic conditions in his patients. His case notes catalogue the questions plaguing him: “11 P.M. Query. How does the poisonous matter get from the wound into the veins? Is it that the clot in the orifices of the cut veins suppurates, or is poisonous matter absorbed by minute veins & carried into the venous trunks?”

  * * *

  DESPITE HIS PROFESSIONAL DILIGENCE, Joseph Lister’s personal life was troubling him. On a dreary day in March 1864, Agnes embarked on a journey to Upton to visit her in-laws. Lister’s mother, Isabella, was once again very ill. She was suffering from one of the many skin conditions that preoccupied her son: erysipelas. Her daughters lived nearby, but they had families of their own and couldn’t provide the level of care she needed. Although Lister had hinted, in a letter to his father during the first year of their marriage, that Agnes might be pregnant, a child had not appeared and never would. The task of caregiver fell to the childless couple.

  In the meantime, a professorship at the University of Edinburgh opened up in June of that year. His good standing with his devoted students aside, Lister’s relationship with the directors of his current hospital remained tense. Moreover, his hectic schedule meant he had very little time to conduct personal research. In addition to his daily visits to the Royal Infirmary, he had to deliver a lecture each day—no small task for a man as meticulous with his lesson planning as Lister was. And then there was his absence from Syme. Lister missed his time working alongside a like-minded intellectual who was never satisfied with the status quo, unlike so many of his colleagues in Glasgow. Lister also saw this Edinburgh post as an opportunity yet again to find a route back to London. As his nephew later wrote, “Lister always looked upon himself as possibly only a bird of passage in Scotland … and he thought, if ever a move south were co
ntemplated, Edinburgh would be a better stepping-off place than Glasgow.”

  Once again, Lister faced a bitter setback. Only after he had received news of his rejection and the appointment of his opponent, James Spence, did Syme reason that Lister was better off in Glasgow. His father-in-law believed that Lister’s Edinburgh candidacy, though unsuccessful, would still serve to increase his reputation in the surgical community.

  With the cloud of professional defeat hanging over him, Lister received word soon after that his mother’s condition had rapidly deteriorated. The situation was critical, so he packed his bags and traveled down to Upton to be at her side. On September 3, 1864, Isabella Lister lost her battle with erysipelas, the same disease that continued to haunt Lister on the wards of his own hospital.

  * * *

  TO FILL THE VOID left by his wife’s death, Joseph Jackson began communicating ever more frequently with his children. “The thought that thou wilt allow me to look for letters from thee weekly, & the letters when they come, are alike gratifying to thy poor father,” he wrote to his son. Lister pledged to write to his father every week—a promise he faithfully fulfilled. It was in one of these many letters that Joseph Jackson reminded his son of his advancing years. Lister reflected on this: “As thee say, I have now arrived at middle life.… It seems strange to think that I am half as old as a man of 70! and yet I suppose the remaining half, if passed at all in this world, will go much quicker than that which is gone. Not that it matters how quickly, if it takes us to the right goal at last.”

  It was during this time that Lister attempted to improve hygiene at the Royal Infirmary in the hope that it would minimize incidences of hospitalism. “Cleanliness” in hospitals often meant no more than sweeping floors and opening windows in the operating theater, and the Royal Infirmary was no exception. Lister suspected that if he could make the wards cleaner, his patients might stop dying.

  And so he began subscribing to what was known in the 1860s as the “cleanliness and cold water” school of thought, which drew analogies between the tarnishing of silver and the infections caused by bad air. Advocates of this philosophy knew that if a person dipped a spoon in cold water, it would delay the formation of a sulfide coating. Using that same logic, they thought that by boiling water and letting it cool before washing both the instruments and the wound site, a surgeon could prevent postoperative infections from developing. Their emphasis on cold water specifically was meant to counteract the heat that they believed caused inflammation and fever.

  Lister’s focus on cleanliness was still linked to his belief that outbreaks of hospitalism were due to the poisonous atmosphere on the wards. Others had already started to question this theory. Between 1795 and 1860, three doctors put forward the idea that puerperal (or childbed) fever—which, like sepsis, was accompanied by both localized and systemic inflammation—was caused not by miasma but by materies morbi (morbid substances) transmitted from doctor to patient. Each believed the disease could be prevented by following strict rules of cleanliness in the hospitals.

  The first of these three doctors was a Scotsman named Alexander Gordon, who was working in Aberdeen when a prolonged outbreak began there in December 1789. Over the course of three years, Gordon treated seventy-seven women who had contracted puerperal fever, twenty-five of whom died in his care. In his report published in 1795, he argued that “the cause of the epidemic Puerperal Fever under consideration was not owing to a noxious constitution of the atmosphere” [that is, miasma] but rather to the medical staff itself, which spread the fever to new patients after attending those afflicted with it. Gordon was convinced that the cause of puerperal fever was something on the practitioners themselves. He claimed he could “foretell what women would be affected with the disease, upon hearing by what midwife they were to be delivered, or by what nurse they were to be attended during their lying-in.” In almost every instance, his prediction was correct. In the light of this evidence, Gordon advised that the clothing and bedsheets of the infected be burned after death and that the nurses and midwives who cared for these patients “ought carefully to wash themselves, and get their apparel properly fumigated, before it be put on again.”

  The second person to make this connection was the American essayist Oliver Wendell Holmes, who was also a physician and later professor of anatomy at Harvard University. In 1843, he published a pamphlet titled The Contagiousness of Puerperal Fever. His work was based heavily on Gordon’s and laid the groundwork for a revival of the Scotsman’s ideas fifty years after they were first published. Unfortunately, Holmes failed to make an impression on his contemporaries and in the 1850s was attacked for his beliefs by two prominent obstetricians, who thought it was a personal insult to be accused of being the carrier of the very disease they were trying to combat.

  And then there was Ignaz Semmelweis, who solved the problem of how to prevent childbed fever in Vienna at the same time Holmes was writing about it in America. Semmelweis, who was working as an assistant physician at the city’s General Hospital, noticed a discrepancy between the hospital’s two obstetric wards. One was attended by medical students, while the other was under the care of midwives and their pupils. Although each ward provided identical facilities for its patients, the one that was overseen by the medical students had a significantly higher mortality rate, by a factor of three. Those within the medical community who took notice of this imbalance attributed it to the male students’ rougher handling of the patients than the female midwives’, which they believed compromised the vitality of the mothers, making them more susceptible to developing puerperal fever. Semmelweis wasn’t convinced.

  In 1847, one of his colleagues died after cutting his hand during a postmortem examination. To his surprise, the Hungarian physician realized that the disease that had killed his friend was identical to puerperal fever. What if doctors working in the deadhouse were carrying “cadaverous particles” with them onto the wards when they assisted in the delivery of babies, and it was this that was causing infection rates to spike? After all, Semmelweis observed, many of these young men went directly from an autopsy to attend to the pregnant women at the hospital.

  Believing that puerperal fever was caused not by miasma but by “infective material” from a dead body, Semmelweis set up a basin filled with chlorinated water in the hospital. Those passing from the dissection room to the wards were required to wash their hands before attending to living patients. Mortality rates on the medical students’ ward plummeted. In April 1847, the rate was 18.3 percent. After hand-washing was instituted the following month, rates in June were 2.2 percent, followed by 1.2 percent in July and 1.9 percent in August.

  Semmelweis saved many lives; however, he was not able to convince many physicians of the merits of his belief that incidences of puerperal fever were related to contamination caused through contact with dead bodies. Even those willing to carry out trials of his methods often did so inadequately, producing discouraging results. After a number of negative reviews of a book he published on the subject, Semmelweis lashed out at his critics. His behavior became so erratic and embarrassing to his colleagues that he was eventually confined to a mental institute, where he spent his final days raging about childbed fever and the doctors who refused to wash their hands.

  In fact, Semmelweis’s methods and theories had little impact on the medical community. Lister visited a clinic in Budapest where the beleaguered physician had recently worked, and he later reflected: “Semmelweis’s name was never mentioned to me having been, as it seems, entirely forgotten in his native city as in the world at large.”

  * * *

  Try as Lister might, none of the measures he instituted affected mortality rates, not even the improved hygiene on his wards. Patients continued to die, and there seemed to be little he could do to stop it. In one week, Lister lost five of his patients to pyemia, while a majority of the others lay ill in the same ward, suffering from hospital gangrene. His house surgeon said of Lister that a divine discontent began to p
ossess him. His mind, he said, “worked ceaselessly in an effort to see clearly the nature of the problem to be solved.” Lister’s exasperation spilled over into the classroom, where he turned to his students with the question that had been haunting him for some time: “It is a common observation that, when some injury is received without the skin being broken, the patient invariably recovers and that without any severe illness. On the other hand trouble of the gravest kind is always apt to follow, even in trivial injuries, when a wound of the skin is present. How is this? The man who is able to explain this problem will gain undying fame.”

  Then, at the end of 1864, while Lister was struggling to prevent the deaths of his patients at the Royal Infirmary, a chemistry professor and colleague, Thomas Anderson, drew his attention to something that would help him tease out the solution to the medical riddle that consumed him. It was the latest research on fermentation and putrefaction by a French microbiologist and chemist by the name of Louis Pasteur.

  8.

  THEY’RE ALL DEAD

  No Scientific subject can be so important to Man as that of his own life. No knowledge can be so incessantly appealed to by the incidents of every day, as the knowledge of the processes by which he lives and acts.

  —GEORGE HENRY LEWES

  UPON INQUIRING AFTER THE WELFARE of one of his patients, a surgeon at Guy’s Hospital in London was informed by his assistant that the man in question had died. The surgeon, who had become inured to this kind of news, replied, “Oh, very well!” He moved on to the next ward to ask about another patient. Again, the answer came, “Dead, sir.” The surgeon paused a moment. Frustrated, he cried, “Why, they’re not all dead?” To this, his assistant responded, “Yes, sir, they are.”