—JEAN-BAPTISTE BOUILLAUD
AS SHE STEPPED FROM THE HACKNEY CARRIAGE onto the front step of the two-story Georgian home in the summer of 1867, Isabella Pim felt the weight of the world on her shoulders. She had traveled nearly four hundred miles through the stifling summer heat to stand before this door. A few weeks earlier, Isabella—or “B.,” as she was affectionately referred to by members of her family—had found a hard mass in her breast. Fearing the worst, she decided to make the arduous train journey to Glasgow by way of Edinburgh, to consult the best surgeon she knew: her brother Joseph Lister.
The sad truth was that most women of this era waited too long to seek help after finding a breast lump. During the first stages of breast cancer, the tumor is relatively painless. But surgery was an extremely painful option, and a woman would likely die even after submitting to the knife, because most surgeons didn’t remove enough tissue from the breast to stop the cancer’s progress. One of the most renowned surgeons in London, James Paget, lamented that cancer often returned even after he had cut away the diseased parts. “All that is locally wrong may be removed,” he wrote, “but something remains, or, after a time, is renewed, and similar disease reappears and, in some form or degree, is usually worse than the first, and always tending towards death.”
The risk that cancerous tissue would be left behind during an operation was especially high before anesthetics in the earlier part of the century, when such an agonizing procedure had to be performed as quickly as possible. In a letter to her daughter, sixty-year-old Lucy Thurston described the horrific ordeal that she endured during her mastectomy. When the surgeon arrived, he opened his hand to show her the knife:
Then came a gash long and deep, first on one side of my breast, then on the other. Deep sickness seized me, and deprived me of my breakfast. This was followed by extreme faintness. My sufferings were no longer local. There was a general feeling of agony throughout the whole system. I felt, every inch of me, as though flesh was failing.… I myself fully intended to have seen the thing done. But on recollection, every glimpse I happened to have, was the doctor’s right hand completely covered with blood, up to the very wrist. He afterwards told me, that at one time the blood from an artery flew into his eyes, so that he could not see. It was nearly an hour and a half that I was beneath his hand, in cutting out the entire breast, in cutting out the glands beneath the arm, in tying the arteries, in absorbing the blood, in sewing up the wound, in putting on the adhesive plasters, and in applying the bandage.
Thurston survived the operation and went on to live another twenty-two years, but many did not.
With the dawn of anesthetics, breast operations became steadily more invasive now that pain was no longer a check upon the surgeon’s knife. This had its own dire impact on mortality rates, for various reasons. In 1854, Alfred Armand Velpeau—the lead surgeon at the University of Paris—urged his surgical colleagues to treat breast cancer more aggressively to ensure that all the cancerous tissue was excised. To do this, he suggested that not only the breast but also the underlying chest muscles be removed in what is known as an en bloc mastectomy. This, of course, left the patient vulnerable to infection afterward.
Isabella now found herself facing a similar dilemma. A surgeon at St. Bartholomew’s Hospital in London had already refused to operate, and during her stopover in Edinburgh, James Syme also advised against a mastectomy. The tumor was large, and it would require extensive removal of tissue if the surgery was to be effective. Even if Isabella survived the operation, Syme was concerned that the open chest wound would become septic and that she would die. Although he had employed Lister’s antiseptic system successfully on his own patients, Syme still worried that a wound of this size would be difficult to manage with or without carbolic acid. Better to live out the remaining time she had, of whatever duration that might be.
But Isabella had not yet abandoned hope. She knew that her brother had removed many cancerous tumors in his lifetime. More recently, she had heard from her brother that he had reduced the risk of postoperative infection through the use of carbolic acid. As Lister wrote, “B. seems to have thorough confidence in me.”
After examining Isabella, Lister agreed to perform what would be his first mastectomy. In so doing, he was going against the medical advice of two well-respected men in his profession. But if there was a small chance he could stop the cancer from spreading deeper into his beloved sister’s body, he had to try. “Considering what the operation is to be,” he wrote to his father, “I would rather not let anyone else do it.” Not that anyone else had volunteered.
First he visited the dissection room at the university, where he practiced the mastectomy on a corpse. Just as he was steeling himself to operate, however, he decided at the eleventh hour to visit Edinburgh to consult with Syme. Clearly, the fact that a man whose counsel he held in such high esteem had initially advised against the surgery was on his mind. Syme capitulated. “No one can say that the operation does not afford a chance,” he told his son-in-law after a lengthy conversation. The two men discussed Lister’s recent work with carbolic acid. Syme suggested that using it on Isabella might obviate much of the danger involved. “I felt his true kindness & manifest, though little expressed, sympathy, very much, & left Edinburgh much relieved,” Lister wrote of his meeting with Syme.
With his mind somewhat at ease, he returned to Glasgow and made preparations to operate on Isabella. A day before the appointed moment, he sent a letter back home to Joseph Jackson: “I suppose before this reaches thee the operation on darling B. will be over. It was evidently undesirable to delay a day longer than was necessary as soon as it was determined that it was to be: so last evening I finally made arrangements … and we intend that the operation shall be at half past one o’clock to-morrow.” Isabella’s mastectomy would not take place at the Royal Infirmary, because this would only increase her risk of developing some form of hospital infection. Instead, Lister decided to carry out the mastectomy in his own home, using his own dining table—a common choice for those who could afford private care.
On June 16, 1867, Isabella Lister Pim entered the makeshift operating theater, where her brother was standing with three assistants. The instruments, which had been dipped in carbolic acid beforehand, were hidden underneath a cloth so she wouldn’t be perturbed by the sight of them. She settled herself on the table at which she had dined just the previous evening, and before long she was in a deep slumber due to the effects of chloroform. Lister and the three surgeons proceeded to dip their hands in a solution of carbolic acid. They then cleansed the site of Isabella’s operation. Lister stepped forward, knife in hand. Carefully, he divided both of the pectoral muscles and cleared out the armpit. After he had removed the breast tissue, muscles, and lymph nodes, Lister turned his attention to dressing the wound.
Lister covered her chest with eight layers of gauze that had been presoaked in an antiseptic solution consisting of carbolic acid and linseed oil. Over the course of his experiments, he had discovered that porous materials were not ideal for antiseptic dressings because the carbolic acid could be washed away by blood and discharge. He slipped a less permeable piece of cotton cloth called a jaconet—which had also been soaked in an antiseptic lotion—underneath the top layer of gauze. This enabled discharge to seep from the wound but prevented the carbolic acid from escaping with it. He applied these dressings to both her front and her back. Each strip of gauze reached from the acromion (the bony prominence at the top of the shoulder blade) to a little below the elbow and traversed the spine to the arm. Lister also placed a substantial mass of gauze between her side and the lower part of her arm to prevent it from being too close to her body. Although the position was uncomfortable for Isabella, he believed it was especially important that the wound be nowhere near her arm so that it could drain freely. Bandaged like a mummy, Isabella was moved to a guest bedroom and left to convalesce.
His assistant Hector Cameron remarked on how much it cost Lister mentally and e
motionally to undertake such a bold procedure on one so dear to him. When it was over, a sense of relief washed over Lister: “I am very glad it has been done.… I may say the operation was done at least as well as if she had not been my sister. But I do not wish to do such a thing again.”
Isabella’s wound healed without suppuration due to Lister’s careful application of carbolic acid during and after her procedure. Because of his efforts, Isabella lived another three years before the cancer returned, this time in her liver. Unlike before, there was nothing Lister could do for her. His antiseptic system, however, brought about a new hope for the future of breast surgery. One day soon, the surgeon would be able to base his decisions to perform mastectomies on prognosis alone—not on whether a patient was at risk of developing postoperative sepsis.
* * *
Bolstered by the achievement with Isabella’s mastectomy, as well as his continued success at the Royal Infirmary, Lister presented a paper about his work with carbolic acid to the British Medical Association. On August 9, 1867, he delivered the paper, titled “On the Antiseptic Principle in the Practice of Surgery.” Only weeks earlier, the last article in his five-part series had appeared in The Lancet. As yet, there had been no negative reactions to his research by the medical community. Indeed, the response so far had been overwhelmingly positive. Syme had thrown his support behind Lister when he reported in The Lancet seven successful cases involving the application of carbolic acid to both compound fractures and surgery. And shortly after Lister’s lecture at the British Medical Association, the editor of The Lancet expressed cautious optimism: “If Professor Lister’s conclusions with regard to the power of carbolic acid in compound fractures should be confirmed … it will be difficult to overrate the importance of what we really call his discovery.”
A storm was brewing, however. As the first voices of dissent arose, the initial resistance to Lister’s antiseptic methods had little to do with whether they actually worked. What seemed to be the most contentious issue was that many of his critics mistakenly believed Lister was claiming credit for discovering the antiseptic qualities of carbolic acid, which surgeons on the Continent had been using for years. On September 21, a letter appeared in the Edinburgh Daily Review, signed by “Chirurgicus.” In it, the author wrote that he feared Lister’s recent article on the use of carbolic acid in surgery was “calculated to bring down on us some discredit—particularly among our French and German neighbours—in as far as it attributes the first surgical employment of carbolic acid to Professor Lister.” Chirurgicus went on to point out that the French physician and pharmacist Jules Lemaire had written on carbolic acid long before Lister’s first use of it: “I have … lying before me, a thick volume on the subject … written by Dr. Lemaire, of Paris, and the second edition of which was published in 1865.” Lemaire had shown carbolic acid’s “utility in arresting suppuration in surgery, and, as a dressing to compound fractures and wounds,” the author maintained.
Although it had been written under a pseudonym, everyone knew Chirurgicus’s letter had been penned by the influential doctor who had discovered chloroform, James Y. Simpson. The renowned obstetrician had enthusiastically distributed the text to people in the medical community, including to the editor of The Lancet, James G. Wakley. A week later, the letter appeared in the journal with an accompanying note from Wakley: “To Professor Lister is due the credit of having made the agent extensively known in this country.” With these words, the world’s leading medical journal had made it seem as if Lister’s only achievement had been to replicate a Continental practice in Britain, when in fact he was proposing a revolutionary approach to wound management based on a scientific theory.
Simpson had his own motivations for wishing to minimize the significance of Lister’s antiseptic treatment. The truth was that if Lister’s methods worked, they would come into direct conflict with Simpson’s technique of acupressure, which also aimed at promoting healing without suppuration. (This was the same method that Syme denounced when he shredded Simpson’s pamphlet in front of an audience in the operating theater of the Royal Infirmary in Edinburgh.) Acupressure halted bleeding during surgery by using metal needles to fasten the severed ends of large blood vessels to the underside of the skin or muscular tissue, thus eliminating the need for ligatures, which often became a source of contamination after an operation. Lister had already rejected acupressure in a paper published in 1859, and Simpson could not let the slight go. The obstetrician even sent Lister a copy of his pamphlet on the technique with a covering letter criticizing the profession’s “strange and inexplicable” use of ligatures that “sedulously and systematically implant[ed] … dead and decomposing arterial tissue in every large wound.” He obsessed over the fact that so few surgeons had adopted his technique. An early biographer said that Simpson was jealous of everything that challenged acupressure: “Nothing, he thought, should be tolerated whose tendency was to continue the use of the ligature in amputations, after the superiority of acupressure had, as he believed, been established.”
Lister found himself once more locking horns with the bullheaded Simpson. Several weeks after the original attack appeared in the Edinburgh Daily Review, Lister responded to Chirurgicus in The Lancet. He admitted that he had never read Lemaire’s book but claimed that this was “hardly surprising,” because the French surgeon’s work “does not appear to have attracted the attention of our profession.” He went on to defend his own system, saying that visitors to Glasgow who had seen his antiseptic treatment firsthand had not questioned its originality. “The novelty,” he wrote, was “not the surgical use of carbolic acid (which I never claimed), but the methods of its employment with view of protecting the reparatory processes from disturbances by external agency.” Lister ended his response with a gibe at the author: “Trusting that such unworthy cavils will not impede the adoption of a useful procedure, I am, Sir, Yours etc.”
Lister sought out the book by Lemaire in order to prepare for what was to come. The seven-hundred-page volume was nowhere to be found in Glasgow, so he traveled to Edinburgh, where he obtained a copy from the university’s library. It had conveniently turned up only a few days earlier—possibly placed there by Simpson himself, though Lister never voiced that suspicion. During the course of his reading, Lister discovered that Lemaire had recommended carbolic acid for nearly every conceivable ailment. Most important, he offered no method or guiding principle for its use. And while it was true that Lemaire reported the effectiveness of carbolic acid in disinfecting the atmosphere and improving the healing of wounds, he also recommended it as a means of decreasing the smell emanating from bodily discharge. He did not believe that pus was the result of corruption. After reading the book, Lister vented to his father that he was skeptical of Lemaire’s claims: “I find reason to believe that he looks with most rose-coloured spectacles at the results of his experiments” because the French surgeon had used an “extremely weak watery solution of the acid.”
On October 19, Lister published a second response to Chirurgicus. He reiterated that he had never claimed to have been the first to use carbolic acid in surgery: “The success which has attended its employment here depends not so much on any specific virtue in it, as on the wonderful powers of recovery possessed by injured parts when efficiently protected against the pernicious influence of decomposition.” Did this mean that carbolic acid wasn’t the key factor driving his encouraging results? Perhaps as an attempt to steer the conversation away from Lemaire and back toward his core treatment methods, Lister claimed that had he “made the experiment with other antiseptics in ordinary use … I really think it likely I should have got very much the same results, had I gone upon the same principles.”
Accompanying his reply was a letter that had been sent to Lister by a medical student named Philip Hair who lived in Carlisle, the same town that had treated its sewage with carbolic acid years earlier. Lister asserted that the young man had “no difficulty in distinguishing between the mere use of carboli
c acid and the practice which I have recommended.” In his letter, Hair testified that he had studied in Paris the previous winter and that he had seen nothing comparable to Lister’s antiseptic treatment practiced there. Since his return, Hair had also witnessed Lister’s techniques being used successfully in Edinburgh and wrote that he would be happy to furnish Lister with the names and addresses of eight fellow graduates who could bear testimony to his statements.
Simpson didn’t like to be challenged, and Lister’s reply only angered him further. The obstetrician abandoned his alias and replied to Lister directly in The Lancet. He began with a sarcastic reference to Lister’s phrase “unworthy cavils,” which all but outed him as the author of the letter in the Edinburgh Daily Review. Again, Simpson alluded to Lemaire and accused Lister of having almost culpable ignorance of the existing medical literature. He went on to say that William Pirrie at the University of Aberdeen Hospital had employed acupressure to stop suppuration in two-thirds of his cases involving the removal of tumors from breasts and that acupressure was the superior method for preventing the formation of pus, regardless of whether or not Lister’s antiseptic treatment worked. In case no one had understood him clearly the first time, Simpson added, “Let me here take the liberty of briefly pointing out that Mr. Lister has been most undoubtedly preceded by other authors in all his leading theories and uses in connexion with this subject.”
Lister didn’t take the bait. He sent a short reply to The Lancet: “As I have already endeavoured to place the matter in its true light without doing injustice to anyone, I must forbear from any comment on [Simpson’s] allegations.” Instead, he told readers that he would prove the merits of his system in a series of papers that would appear in the coming months, and let the medical community decide for itself whether Simpson’s criticisms were justified. Lister believed his system should be judged on its scientific evidence, not on how eloquently he defended himself.
The Butchering Art Page 17
