The Butchering Art

by Lindsey Fitzharris

  Lister packed his bags and headed to London. He arrived in the nick of time. Five days later, on October 24, 1869, Joseph Jackson died. The loss hit Lister hard. Whenever Lister was vexed by, and uncertain of, his life and career choices, Joseph Jackson had been a guiding light and voice of reason. When Lister considered abandoning a career in medicine to become a Quaker minister, his father had foreseen that this was the wrong path for his son and gently steered him back toward the right one. Lister would miss his father’s cherished counsel.

  Deep in the throes of grief, Lister wrote to his brother-in-law Rickman Godlee. He described a strange dream he had on his last night in his childhood home. In the dream, Lister came down from his bedroom at Upton House and was greeted heartily by his father. “He shook me warmly by the hand and kissed me as he used to do when I was a little boy,” Lister wrote. They exchanged a few words before Lister asked his father if he had slept well after his long journey. Joseph Jackson replied that he hadn’t but that he was quite well, and the two rejoiced. It was then that Lister noticed that his father was clutching a little book, which he understood contained notes of Joseph Jackson’s journey. At that moment, Lister awoke and thought how interesting it would have been to read them.

  He ended his letter with an earnest, almost poetic wish: “May I but meet thee on that peaceful shore.”

  * * *

  Two weeks after his father’s death, Lister delivered the introductory lecture to his new students at the University of Edinburgh. He paid homage to Syme, who was in attendance. “We may all rejoice that our master is still among us,” Lister said, perhaps thinking of his own father. He told the young men who had gathered that because he had “free access to [Syme’s] inexhaustible store of wisdom and experience, he will, in some sense, through me be still your teacher.”

  Syme’s condition had been deteriorating. A few months after Lister’s inaugural lecture, the old surgeon lost the ability to speak. The ability to swallow then deserted him too, which was a fatal situation in an era when feeding tubes did not exist. It was clear that Syme was not going to recover this time. On June 26, 1870, “the Napoleon of Surgery” died.

  The medical world mourned the loss of such an eminent surgeon. Writers at The Lancet lamented, “In Mr. Syme there dies one of the compactest thinkers, and perhaps the best teacher of surgery, in the world.… [He] will not be forgotten while any of his pupils live, and as a surgeon he will be remembered as long as men need the art of surgery.” Similarly, editors at the British Medical Journal said of him, “There can be no hesitation in placing Mr. Syme in the first rank amongst our modern surgeons.”

  Lister grieved the death more than most. He had lost two father figures within a year. And now that Syme was gone, there were few senior surgeons left with whom he could consult. Lister’s nephew later said that as long as Syme lived, he would be recognized as “the first surgeon in Scotland.” With his death, the nation would now look to confer that honor upon Joseph Lister.

  * * *

  SO FAR THE MEDICAL COMMUNITY seemed reluctant to accept the idea that microscopic organisms caused disease. As one of Lister’s assistants astutely observed: “A new and great scientific discovery is always apt to leave in its trail many casualties among the reputations of those who have been champions of an older method. It is hard for them to forgive the man whose work has rendered their own of no account.” If it was difficult for an older surgeon to “unlearn” decades of orthodoxy, Lister reasoned it would be a lot easier to convert the incoming students to his theories and methods. He had already created a dedicated following in Glasgow, and now he hoped to do the same in Edinburgh.

  The principal feature of Lister’s course was demonstration. His lectures often focused on theories of infection that were complemented with case histories and laboratory demonstrations. Lister offered a treasury of recommendations, warnings, and illustrations—all based on his own experiences. He even brought patients from the wards into the operating theater when he addressed his students at the hospital. Lister’s goal was not to enumerate facts but to inculcate principles. One student remembered that although the subject was new to him, the “facts were so clear and logically set out that I thought there could hardly be any other side to the question.” William Watson Cheyne—who would later become a celebrated surgeon and an advocate of antisepsis—remarked on the difference between Lister’s course on systematic surgery and one given by another professor, when he was a student in Edinburgh. The latter consisted of “very dreary performances full of curious theories about the reactions of the body and inflammation” and were “quite unintelligible to me,” he wrote. In contrast, Cheyne reported feeling “entranced by the wonderful vision laid before us by Lister” and left the lecture room on the first day of class “an enthusiast for the profession.”

  Lister’s students expected a lot from their instructor, and he, in turn, expected much from them. He managed his classroom like a policeman. As was customary during this time, students presented tickets inscribed with their names when they attended a lecture. This allowed an instructor to note absentees. Using this system, Lister banned those who habitually missed his class. He collected admission tickets personally at the door as the young men filed into his inner sanctum. This was to ensure that students didn’t submit two cards on behalf of an absent friend—a common practice that Lister abhorred. “Anything that leads a man to think it a matter of indifference whether he writes or tells a lie is most pernicious,” Lister wrote; “he comes to write lies afterwards with the same indifference.” He also monitored access to the classroom so that students couldn’t interrupt him with tardy arrivals. “I have all the entrances or exits so arranged that nobody can come into the class-room after a certain time,” he wrote, “and the students can only go out by a single door.”

  Many professors at the University of Edinburgh were known to lose their tempers and storm out of a classroom when they couldn’t control their unruly pupils. But Lister commanded an audience in a way his colleagues did not. His classroom was a revered place where people could come to worship science. As one of his former students said, “[A] pin-drop could be heard in his presence; he riveted attention and cast a spell of seriousness and earnestness over all.” Only once was that spell broken, when a young man joked in “sonorous and clerical tones” about Lister’s antiseptic treatment. Lister raised his eyes to the joker and shot him a sad and pitying glance. The effect was magical, said the same student, who noted that a year later the heckler in question died of a general paralysis. “We knew nothing then of spirochetes [the bacteria responsible for syphilis] and it was playfully suggested Jove had smitten him for the sacrilege.”

  Lister held his surgical assistants to the same high standards that he did his students. He caused quite the scene one day when he asked his surgical dresser for a knife while attending to a patient on the wards. The dresser handed a scalpel to Lister, who carefully tested the edge of the knife against his palm and found it to be defective. Solemnly and slowly, Lister walked across the room and placed the instrument onto the fire. He repeated his request. Again the dresser handed him a scalpel, and again Lister discarded it in the fire. “The patients were amazed at the extraordinary sight of the Professor burning his instruments; the students were galvanised to attention, glancing now at Lister, then at me, and those on the outskirts of the crowd suddenly aroused to extraordinary curiosity to discover what it was all about,” the dresser later wrote. Lister returned once more and asked for a knife. Fearful and trembling, the young man handed him a third scalpel. This one was finally accepted. Lister looked directly into the dresser’s face before reprimanding him: “How dare you hand me a knife to use upon this poor man that you would not like to have used on yourself?”

  Lister had reason to be strict with his students and his assistants. Every successful procedure and every successful application of antiseptic dressing served as evidence against the doctrine of spontaneous generation. Life did not develop de novo, as h
is students could plainly see when infection failed to develop. His reports in The Lancet might not have been enough to convince some surgeons of the validity of the germ theory, but his students saw with their own eyes the antiseptic system working every time they accompanied him onto the wards. If seeing was believing, Lister was creating a group of disciples: men who would graduate and spread his ideas beyond the narrow confines of the university. His followers, who later became known as the “Listerians,” soon came to dominate the institutions and ideology of British surgery, spreading the doctrine of antisepsis with a reverential devotion.

  * * *

  The announcement of Lister’s antiseptic system in 1867 was just the beginning of his work on putrefactive wounds. He continued to experiment with carbolic acid, which involved fine-tuning and making adjustments in his methods. Indeed, Lister’s students—who might attend a demonstration with their minds settled on one technique, only to discover that their professor had already developed a new method since their last encounter—came to expect these changes. For them, it underlined the value of experimentation in medicine and illustrated that observational acuity and accuracy could lead to improvements in surgery.

  From the beginning, Lister had advocated the wholesale sterilization with carbolic acid of everything from the instruments to the surgeon’s hands, a protocol that led to the corrosion of his own skin over time. But ligatures—which were essential for tying off blood vessels during amputations or cutting off the blood supply in aneurysms—remained problematic even after he began dousing them with carbolic acid. It was customary to tie ligatures tightly and leave one or both ends of the knot long enough to protrude from the wound. Surgeons did this partly to allow for drainage and partly to make it easier to remove the ligature once the wound had healed. Unfortunately, this method also provided an easy path for contaminants.

  Lister reasoned that if he could eliminate infection, there would be no drainage, and thus no need for ligatures to hang outside the wound. What he needed was a strong, flexible material that could be easily knotted, remain intact until its purpose had been fulfilled, and either become inactive or somehow be absorbed by the body. At first, Lister chose silk soaked in carbolic acid because its smooth surface was unlikely to irritate tissues. He sliced open the neck of a horse and tied off the major artery using a silk ligature. Six weeks later, the horse died unexpectedly of an unrelated cause. Lister was in bed with a cold at the time, and so he asked his assistant Hector Cameron to dissect out the left side of the horse’s neck and report to his home later that day. At 11:00 p.m., Cameron brought the specimen to the ailing surgeon, who forced himself out of bed and worked until the early hours of the morning to isolate the ligated site. It was as he had predicted: the silk remained but was now encapsulated in fibrous tissue.

  The opportunity soon presented itself for Lister to test the silk ligatures on a human patient. A woman had come to him suffering from an aneurysm in the leg. Lister soaked the silk in carbolic acid before using it to tie off the artery that was feeding the swelling. The patient survived, only to die ten months later when a second aneurysm ruptured. Lister obtained the dead body and performed a postmortem examination. He discovered that the silk ligature had been absorbed; however, there was a tiny pocket of pus near the opening, which he worried was the beginning of an abscess. Clearly, silk ligatures were not going to be the long-term solution he had hoped. So Lister turned his attention to another organic material: catgut.

  The term “catgut” is something of a misnomer. The type of cord is actually prepared from the intestines of sheep or goat, although sometimes it can be made from the innards of cattle, hogs, horses, mules, or donkeys. Once again, Lister tested the ligature on an animal before moving on to humans, this time choosing a calf. His nephew Rickman John Godlee assisted Lister in the experiment: “I have a vivid recollection of the operation … the shaving and the purification of the part, the meticulous attention to every antiseptic detail, the dressing formed of a towel soaked in carbolic oil; and my grandfather’s alabaster Buddha on the mantelpiece contemplating with inscrutable gaze the services of beast to man.” A month later, the calf was slaughtered, the meat divided up among Lister’s assistants, and the artery examined. The catgut ligature had been entirely absorbed by surrounding tissue.

  Unfortunately, when Lister began testing the catgut on humans, he discovered that the material was absorbed so readily that it put the patient at risk of secondary hemorrhaging. He experimented with a wide variety of carbolic acid solutions and was able to slow the process down. After he published his report in The Lancet, the journal’s editors commented that catgut ligature promised to be “far more than a mere contribution to practical surgery” because it demonstrated how dead organic material could be absorbed into a living body. Catgut quickly became a standard part of Lister’s antiseptic treatment and was one example of the many ways in which his system evolved during these formative years.

  Indeed, his obsession with improving the catgut ligatures spanned his entire career. After he moved to Edinburgh, he began meticulously recording notes from his experiments in three-hundred-page folio-sized notebooks, of which there were four by the time he retired. The very first entry in the first of these notebooks was about catgut, dated January 27, 1870. And the research notes conclude on the same subject in 1899.

  * * *

  As Lister’s methods evolved, skeptics characterized these constant modifications as admissions on his part that the original system did not work. They didn’t see these adjustments as part of the natural progression of a scientific process. James Y. Simpson waded back into the controversy, suggesting an almost fatalistic approach to the problem plaguing the country’s hospitals. If cross-contamination could not be controlled, he argued, then hospitals should be periodically destroyed and built anew. Even Lister’s old instructor John Eric Erichsen adopted this view. “Once a hospital has become incurably pyemia-stricken, it is impossible to disinfect it by any known hygienic means, as it would to disinfect an old cheese of the maggots which have been generated in it,” he wrote. There was only one solution in Erichsen’s mind, and it wasn’t his former pupil’s antiseptic system. He advocated the wholesale “demolition of the infected fabric.”

  But for all the opposition Lister faced, he was fighting the battle with like-minded people who recognized the revolutionary nature of his work. Initially, his antiseptic system received more support on the Continent than it did in Britain, so much so that in 1870 Lister was asked by both the French and the Germans to furnish some guidelines for treating wounded soldiers fighting in the Franco-Prussian War. As a consequence, the German physician Richard von Volkmann became a spirited devotee after his hospital at Halle—overcrowded with wounded soldiers from the war and so dreadfully overcome with infection that its closure was imminent—achieved astonishing results by employing Lister’s methods. Following this, Lister’s system was taken up by other European surgeons, including a Dane named M. H. Saxtorph, who reported success in a letter to Lister. Armed with this testimony, Lister goaded the surgeons in London who had been the most critical of his antiseptic treatment: “It may seem strange that results like these should have been obtained in Copenhagen, when so little approach to them has yet been made in the capital of England.”

  Slowly but surely, surgeons in his own country began to rise in his defense. One of these men was Thomas Keith, a pioneer in ovariotomy, which was a dangerous procedure that involved the excision of ovarian tumors within the abdominal cavity. For most of the nineteenth century, ovariotomy remained extremely controversial. Those who dared to undertake such an invasive procedure were nicknamed “belly-rippers” on account of the long incision they made across the abdomen of their patients, which frequently became a source of sepsis.

  Keith defended Lister against earlier attacks by Donald Campbell Black, who had not only dismissed Lister’s work as the latest toy in medical science but also invoked Keith’s name in his criticism of the antiseptic system
. Keith replied to Black in the British Medical Journal. Contrary to what Black had implied, Keith had been dressing wounds “exactly as I have seen Mr. Lister do” and with great success. He was dismayed by the fact that Black, himself a surgeon from Glasgow, would attack a colleague when Lister had raised the reputation of the medical school in the city and given it a name. In his opinion, the antiseptic system was the future: “I think I am only now beginning to realise what Mr. Lister’s antiseptic method and his carbolised animal-ligatures are yet to do for surgery.” E. R. Bickersteth, a surgeon at the Royal Infirmary in Liverpool, also reported numerous cases in which he had effectively employed antiseptic catgut ligatures. He considered the antiseptic method “an immense step towards the perfection of our art.”

  By this time, Lister had already responded to charges that mortality rates hadn’t decreased at the Glasgow Royal Infirmary after he introduced his antiseptic treatment. He compared the number of deaths on his wards from 1864 and 1866 with those from 1867 and 1868, after he began using carbolic acid. What he found was that sixteen of the thirty-five people who had undergone amputations had died prior to his introduction of his antiseptic treatment in 1864 and 1866, compared with only six of forty in the later years.

  The report prompted the editor of The Lancet to call on hospitals in London to test Lister’s antiseptic methods “fairly and crucially” a second time. He suggested that Lister’s own students oversee the experiments. What had been achieved in Glasgow “ought to be procurable in London,” the editor at the journal concluded. And so, in 1870, all eyes turned to the capital.