The Butchering Art

by Lindsey Fitzharris

  Then, one day, Lister remembered reading that engineers at a sewage works in Carlisle had used carbolic acid to counteract the smell of rotting garbage and to render odorless nearby pastures that were irrigated with liquid waste. They had done this at the recommendation of Frederick Crace Calvert, an honorary professor of chemistry at the Royal Institution of Manchester, who was first introduced to the compound’s miraculous properties while studying in Paris. An unexpected benefit of the engineers’ efforts was that the carbolic acid also killed the protozoan parasites that had caused outbreaks of cattle plague in the livestock that grazed in these fields. Lister wrote that he was “struck with an account of the remarkable effects produced by carbolic acid upon the sewage of the town.” Could this be the antiseptic he had been searching for?

  Carbolic acid, also known as phenol, is a derivative of coal tar. It was first discovered in 1834 and used in its raw state as creosote to preserve railway ties and ships’ timbers. It was unknown in British surgery. More often than not, it was recommended indiscriminately, sometimes as a preservative of food, sometimes as a parasiticide, sometimes as a deodorant.

  Lister obtained a sample of the crude acid from the ever-resourceful Thomas Anderson and observed its properties under the microscope. He soon realized that he would need a lot more of the compound in order to test its efficacy on patients. Anderson put him in direct contact with Calvert up in Manchester, who had just started manufacturing the acid on a small scale in the form of white crystals that liquefied when heated. Calvert had long been an advocate of the use of coal tar in medicine, particularly with regard to the sloughing of wounds and the preserving of corpses for dissection. He eagerly supplied Lister with a sample of his carbolic acid.

  Lister didn’t have to wait long before he was able to test it on a subject. In March 1865, he carried out an excision of caries (decaying bone) from a patient’s wrist at the Royal Infirmary. Afterward, he carefully washed the wound with carbolic acid, hoping it would debride it of any contaminants. Much to his dismay, infection set in, and Lister was forced to admit that the trial had been a failure. Another opportunity presented itself a few weeks later when a twenty-two-year-old named Neil Kelly was brought to the Royal Infirmary with a broken leg. Once more, Lister applied Calvert’s carbolic acid to the injured limb—and suppuration soon appeared. But Lister still believed that carbolic acid was the key and blamed himself for the failure: “It proved unsuccessful, in consequence, as I now believe, of improper management.”

  Lister needed to implement a better system if he was going to continue trying carbolic acid on patients. He couldn’t just test it haphazardly, because there were too many variables from case to case preventing him from understanding the substance’s true efficacy. For that reason, he ruled out surgical cases for the time being. And because simple fractures did not involve a tear in the skin, he reasoned that microbes could not gain access by any channel other than an open wound. He decided to limit his trials of carbolic acid to compound fractures: injuries in which splintered bone lacerated the skin. This particular kind of break had a high rate of infection and frequently led to amputation. From an ethical standpoint, testing carbolic acid on compound fractures was sound. If the antiseptic failed, the leg could still be amputated—something that would have likely occurred anyway. But if the carbolic acid worked, then the patient’s limb would be saved.

  Lister was cautiously optimistic about this approach. All he had to do was wait for someone with a compound fracture to arrive at his hospital.

  * * *

  THE RATTLING AND RUMBLING of carriages down the busy streets of Glasgow began at sunrise and didn’t stop until most of the city’s occupants had gone to bed. Top-heavy stagecoaches moved precariously along uneven roads, while omnibuses packed with passengers clattered through congested thoroughfares. Hackney carriages trundled at a stately pace, and tradesmen’s carts piled high with goods zigzagged through the traffic in a mad dash to supply the marketplaces. Occasionally, a hearse draped in black with its procession of mourners would slow the tumult to a respectful crawl, but most days the roads were a bustling river of wheeled and pedestrian traffic. Overcrowded cities like Glasgow sounded “as if all the noises of all the wheels of all the carriages in creation were mingled and ground together in one subdued hoarse, moaning hum,” one contemporary wrote. The city’s everyday cacophony was an assault on the eyes and ears of the uninitiated.

  It was into this chaos that eleven-year-old James Greenlees stepped one humid day in early August 1865. He had crossed these streets countless times, but for a moment his attention had wandered. No sooner had he stepped into the traffic than a cart came crashing past him, throwing him to the ground and crushing his left leg under one of its metal-rimmed wheels. The driver halted the cart and jumped down in panic. Onlookers rushed to the scene of the accident. Greenlees lay there screaming, tears streaming down his face. His tibia had cracked under the weight of the cart and was protruding through a bleeding gash in his shin. If there was any hope of saving his leg, he would need to get to the hospital quickly.

  It wasn’t easy getting Greenlees to the Royal Infirmary in his condition. The heavy cart had to be moved off his leg, and he had to be gingerly lifted onto a makeshift stretcher and carried across the city. He arrived at the Royal Infirmary three hours after the accident. By the time he was admitted to the wards, Greenlees had lost a lot of blood, and the situation was critical.

  As one of the surgeons on duty that afternoon, Lister was alerted to the case as soon as the boy was brought into the hospital. Lister remained calm while assessing the situation. The break was not clean. Even more worryingly, the open wound on Greenlees’s leg was contaminated with dirt and dust from the journey across town. Amputation could not be ruled out. Lister knew that many patients had lost their lives because of compound fractures that were far less severe than the one this boy had endured. His father-in-law, James Syme, would probably have operated immediately. But Lister also recognized that Greenlees was very young. Losing a leg would almost certainly relegate the boy to the status of a second-class citizen, severely limiting his job opportunities in the future. How would the boy earn a living if he couldn’t walk?

  And yet the hard truth remained: delaying amputation would undoubtedly put Greenlees’s life in danger. If the boy developed a hospital infection as a result, sawing off his leg afterward might not be enough to stop the relentless pursuit of sepsis once it took hold. At the same time, Lister still believed that carbolic acid could stave off infection, and if it did, Greenlees’s leg—and his livelihood—could be saved. This was the opportunity he had been waiting for. Lister made a split-second decision. He would take his chances with the antiseptic.

  Acting quickly, he administered chloroform to the boy, who at that point was delirious with pain. The open wound on Greenlees’s leg had been exposed for hours. He needed to clean out the bloody gash before any microbes that had already gotten into the opening had a chance to multiply. With the help of his house surgeon Dr. MacFee, Lister began washing the wound thoroughly with carbolic acid. He then covered it with putty so that the solution could not be washed away by any discharges of blood and lymph. Finally, he placed a tin cap over the dressing to stop the carbolic acid from further evaporating.

  Over the next three days, Lister managed Greenlees’s recovery, lifting the cap and pouring more carbolic acid on the dressing to flush the wound every few hours. Greenlees was in good spirits despite the trauma he had just experienced, and Lister noted that his appetite was normal. Most important, Lister detected no rancid smell emanating from the dressings when he inspected the boy’s leg each day. The wound was healing cleanly.

  On the fourth day, Lister removed the bandages. He wrote in his casebooks that the skin had a slight blush of redness around the wound but that no suppuration was present. The fact that there was no pus was a good sign. But the redness bothered Lister. The carbolic acid was clearly irritating the boy’s skin and creating the very type of
inflammation that Lister was desperately trying to avoid. How could he counteract this side effect without undercutting the carbolic acid’s power as an antiseptic?

  Lister tried diluting the carbolic acid with water for the following five days. Unfortunately, this did little to offset the irritation caused by the antiseptic. So Lister turned to olive oil to dilute the chemical compound. This appeared to have a soothing effect on the wound without compromising the antiseptic qualities of the carbolic acid. Soon, the redness on Greenlees’s leg faded, and the wound began closing up. The new solution had done the trick.

  Six weeks and two days after the cart had shattered his lower leg, James Greenlees walked out of the Royal Infirmary.

  * * *

  Now confident that the carbolic acid was the antiseptic he had been looking for all along, Lister treated patient after patient at the Royal Infirmary using similar methods over the coming months. There was a thirty-two-year-old laborer whose right tibia was shattered after a horse kicked him, and a twenty-two-year-old factory worker whose leg was smashed to pieces after an iron box weighing 1,350 pounds slipped from its chains four feet above him. One of the more heartbreaking cases involved a ten-year-old boy who was working in a factory when he got his arm caught in a steam-powered machine. Lister reported that the boy cried out for assistance but no one came to his aid for two minutes. Meanwhile, the machine continued to move, “cutting into the ulnar side of the forearm, breaking through [the bone] about its middle, while the radius was bent [backward].” The boy was taken to the Royal Infirmary, at which point the upper fragment of his bone was protruding through the skin and two strips of muscle two to three inches in length were hanging out of the gaping wound. Lister was able to save the boy’s arm, as well as his life.

  It wasn’t all smooth sailing. Lister experienced two failures at this time. One was a seven-year-old boy whose leg had been run over by a crowded omnibus. He developed hospital gangrene after Lister went on a vacation and handed over his care to Dr. MacFee, who was not as scrupulous as Lister in his management of the wound. The boy ultimately survived, minus one limb. The other died suddenly, weeks after he incurred his original injury. “Some days later,” Lister wrote, “a very profuse haemorrhage occurred, the blood soaking through the bed, and dropping upon the floor beneath” before it came to the attention of the medical staff. It turned out that a sharp bone fragment from the man’s leg fracture had pierced the popliteal artery in his thigh, causing the fifty-seven-year-old laborer to bleed to death.

  Of ten compound fractures that came under his care at the hospital in 1865, eight recovered with the aid of carbolic acid. If one discounts the amputation that occurred under Dr. MacFee’s care, Lister’s failure rate was 9 percent. If the amputation is counted, his failure rate was 18 percent. For Lister, it was an unqualified success.

  * * *

  In his typical way, Lister felt it was important to be as thorough as possible and wanted to assess the efficacy of carbolic acid on other types of wounds before announcing his findings. The ultimate test would be whether Lister’s methods would work on operative cases. It had been twenty years since he had witnessed Robert Liston’s historic operation with ether that signaled a new age of painless surgery. Since then, surgeons had become daring with regard to how deep into the body they were prepared to cut. As operations became more invasive, postoperative infection became more and more likely. If Lister could reduce or eliminate this threat, it would change the nature of surgery forever by allowing the surgeon to perform increasingly complex operations without fear of the patient’s wounds developing sepsis.

  He first turned his attention to abscesses, particularly those that arose as a complication of spinal tuberculosis. Known as psoas abscesses, these develop when a large amount of pus collects on one of the long muscles in the back of the abdominal cavity. They usually grow so large that they begin to distend into the groin, requiring incision and drainage. Given the area of the body in which they form, however, psoas abscesses are prone to infection, and surgical intervention was extremely dangerous.

  Over the coming months, Lister developed a technique for disinfecting the skin around the incision with carbolic acid and then dressing the cavity with a puttylike substance similar to the one he used on Greenlees. He mixed ordinary whiting (carbonate of lime) with a solution of carbolic acid in boiled linseed oil. Between the wound and the putty, he placed a piece of lint that had also been soaked in carbolic oil. The blood that soaked through the lint formed a crust underneath it. The dressing was changed daily, but the piece of oiled lint was left in place. When it came time to remove it, there was a firm cicatrix, or scar, left behind. In a letter to his father, Lister boasted: “[The] course run by cases of abscess treated in this way is so beautifully in harmony with the theory of the whole subject of suppuration, and besides the treatment is now rendered so simple and easy for any one to put in practice, that it really charms me.”

  In July 1866—while Lister was still refining his methods with carbolic acid—he discovered that the chair of systematic surgery at UCL was vacant. Although things were going well in Glasgow, Lister still yearned to return to his alma mater so that he could be closer to his father, who was now eighty years old. Making the prospect all the more attractive to him was the fact that the professorship also came with a permanent post at University College Hospital, where he had started his career.

  Lister wrote to Lord Brougham, the president of both UCL and the hospital, asking him to support his candidacy. Accompanying his letter was the printed “Notice of a New Method of Treating Compound Fractures.” In it, Lister supported the germ theory of putrefaction. Outside his own circle of friends, family, and colleagues, this was Lister’s first announcement of his antiseptic principle. Shortly after he appealed to Lord Brougham for support, Lister was notified that he had lost the election. Yet Lister didn’t let this news distract him from his research for long. “I have been sometimes thinking lately that I could not have been working thus had I been at University College,” Lister wrote to Joseph Jackson a short while after he had received his rejection notice. “I am probably employed here much more usefully, though more quietly.”

  Lister returned to experimenting with carbolic acid, expanding treatment to include lacerated and contused wounds. In one instance, he removed a large tumor from a man’s arm. It was situated so deeply that Lister believed the wound would have suppurated had it not been for the employment of his antiseptic system. The man escaped with both his life and his arm when he left the hospital a few weeks later.

  The implications of his methods began to dawn on Lister as each year provided more proof that they worked. “I now perform an operation for the removal of a tumour, etc., with a totally different feeling from what I used to have; in fact, surgery is becoming a different thing altogether,” he wrote to his father one day. If Lister could convince the world of the efficacy of his techniques, then the possibilities for the future of his profession were endless.

  And so it came to be that two years after he began experimenting with carbolic acid at the Glasgow Royal Infirmary, Lister published his findings in The Lancet. On March 16, 1867, the first installment of a five-part article titled “On a New Method of Treating Compound Fracture, Abscess, etc., with Observations on the Conditions of Suppuration” appeared in print. The other four followed in the coming weeks and months. In these articles, Lister demonstrated that he had instituted a system based on Louis Pasteur’s highly contested view that putrefaction was caused by germs in the air. He wrote that the “minute particles suspended in [the air], which are the germs of various low forms of life, long since revealed by the microscope, and regarded as merely accidental concomitants of putrescence,” had now been shown by Pasteur to be its “essential cause.” It was necessary to “dress the wound with some material capable of killing these septic germs.” Lister’s system involved using the antiseptic properties of carbolic acid in order to prevent germs from entering wounds, as well as destroyi
ng those that had already invaded the body.

  His articles were instructive rather than theoretical, though his commitment to Pasteur’s scientific tenets was clear. The majority of each paper laid out detailed case histories in which Lister spoke about his struggles to prevent or control putrefaction in the wounds of each patient. His intent was to show the readers, who were invited to feel that they were standing at Lister’s shoulder, how to replicate his methods. Throughout the series of articles, he also demonstrated how his system evolved by explaining why he rejected certain types of dressings and why he tried different approaches when others had failed. The unashamedly scientific method Lister had applied to his experiments was plain for all to see.

  Also evident was Lister’s laudably altruistic purpose in discovering and then advocating his antiseptic method. Evincing the selflessness inculcated in him by his Quaker upbringing, he wrote: “[The] benefits which attend this practice are so remarkable that I feel it incumbent upon me to do what I can to diffuse them.” Anyone seeking physical proof of these benefits could find it on his two wards at the Glasgow Royal Infirmary. Though these had previously been among the unhealthiest in the hospital due to their having limited access to fresh air, he reported that his use of antiseptic treatment on patients had greatly reduced the number suffering from infection. Not a single instance of pyemia, gangrene, or erysipelas had occurred on Lister’s wards since he had introduced his system.

  Lister made the first step in evangelizing for the antiseptic methods that he felt certain held the key to saving countless lives. But any sense of satisfaction would soon be tempered by troubles close to home.

  9.

  THE STORM

  Medical disputes … are the inevitable accidents of scientific progress. They are like storms which purify the atmosphere; we must be resigned to them.