The Butchering Art: Joseph Lister's Quest to Transform the Grisly World of Victorian Medicine

by Lindsey Fitzharris

At a time when surgeons believed pus was a natural part of the healing process rather than a sinister sign of sepsis, most deaths were due to postoperative infections. Operating theaters were gateways to death. It was safer to have an operation at home than in a hospital, where mortality rates were three to five times higher than they were in domestic settings. As late as 1863, Florence Nightingale declared, “The actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases amongst patients treated out of the hospital would lead us to expect.” Being treated at home, however, was expensive.

Like many surgeons operating in a pre-anesthetic era, Liston had learned to steel himself against the cries and protests of those strapped to the blood-spattered operating table. On one occasion, Liston’s patient, who had come in to have a bladder stone removed, ran from the room in terror and locked himself in the lavatory before the procedure could begin. Liston, hot on his heels, broke the door down and dragged the screaming patient back to the operating room. There, he bound the man fast before passing a curved metal tube up the patient’s penis and into the bladder. He then slid a finger into the man’s rectum, feeling for the stone. Once Liston had located it, his assistant removed the metal tube and replaced it with a wooden staff, which acted as a guide so the surgeon wouldn’t fatally rupture the patient’s rectum or intestines as he began cutting deep into the bladder. Once the staff was in place, Liston cut diagonally through the fibrous muscle of the scrotum until he reached the wooden staff. Next, he used the probe to widen the hole, ripping open the prostate gland in the process. At this point, he removed the wooden staff and used forceps to extract the stone from the bladder. Liston—who reportedly had the fastest knife in the West End—achieved all this in just under sixty seconds.

Liston handed the knife to one of the surgical dressers, who, in return, handed him a saw. The same assistant drew up the muscles, which would later be used in forming an adequate stump for the amputee. The great surgeon made half a dozen strokes before the limb fell off, into the waiting hands of a second assistant, who promptly tossed it into a box full of sawdust just to the side of the operating table. Meanwhile, the first assistant momentarily released the tourniquet to reveal the severed arteries and veins that would need to be tied up. In a mid-thigh amputation, there are commonly eleven to secure by ligature. Liston tied off the main artery with a square knot and then turned his attention to the smaller blood vessels, which he drew up one by one using a sharp hook called a tenaculum. His assistant loosened the tourniquet once more while Liston stitched the remaining flesh closed. It took all of twenty-eight seconds for Liston to remove Churchill’s right leg,

Within the space of a hundred years, London’s population soared from one million to just over six million inhabitants in the nineteenth century. The wealthy left the city in search of greener pastures, leaving behind grand homes that soon fell into disrepair as they were appropriated by the masses. Single rooms might contain thirty or more people of all ages clad in soiled rags and squatting, sleeping, and defecating in straw-filled billets. The extremely poor were forced to live in “cellar homes,” permanently shut off from sunlight. The rats gnawed at the faces and fingers of malnourished infants, many of whom died in these dark, fetid, and damp surroundings. Death was a frequent visitor to London’s inhabitants, and disposing of the deceased was a growing problem. Churchyards were bursting at the seams with human remains, posing huge threats to public health. It was not uncommon to see bones projecting from freshly turned ground. Bodies were crammed on top of one another in graves, most of which were merely open pits with row after row of coffins.

Arrangements for the disposal of human waste were equally rudimentary before the passing of the Public Health Act in 1848, which established the centralized General Board of Health and initiated a sanitarian revolution. Before then, many streets in London were effectively open sewers, releasing powerful (and often deadly) amounts of methane. In the worst housing developments, lines of domiciles known as “back-to-backs” were separated only by narrow passageways four to five feet wide. Trenches brimming with piss ran down the middle. Even the increased number of water closets between 1824 and 1844 did little to solve the problem. Their construction forced landlords to hire men to remove “night soil” from overflowing cesspools in the city’s buildings. An entire underground army of “bone boilers,” “toshers,” and “mud-larks” developed to exploit the tide of human waste underneath the city. These scavengers—whom the author Steven Johnson calls history’s first waste recyclers—would pick through the thousands of pounds of garbage, feces, and animal corpses and then cart off these foul goods to market, where they could be reused by tanners, farmers, and other traders. The business conducted elsewhere wasn’t any more wholesome. Fat boilers, glue renderers, fellmongers, tripe scrapers, and dog skinners all went about their malodorous tasks in some of the most densely populated areas of the city. For instance, in Smithfield—just a few minutes’ walk from St. Paul’s Cathedral—was a slau...

In spite of token efforts to make hospitals cleaner, most remained overcrowded, grimy, and poorly managed. They were breeding grounds for infection and provided only the most primitive facilities for the sick and the dying, many of whom were housed on wards with little ventilation or access to clean water. Surgical incisions made in large city hospitals were so vulnerable to infection that operations were restricted to only the most urgent cases. The sick often languished in filth for long periods before they received medical attention, because most hospitals were disastrously understaffed. In 1825, visitors to St. George’s Hospital discovered mushrooms and maggots thriving in the damp, dirty sheets of a patient recovering from a compound fracture. The afflicted man, believing this to be the norm, had not complained about the conditions, nor had any of his fellow ward mates thought the squalor especially noteworthy.

In England and Wales in the 1840s, approximately 3,000 mothers died each year from bacterial infections such as puerperal fever (also known as childbed fever). This amounted to roughly 1 death for every 210 confinements.

Potter carefully sliced his way deeper into the corpse, pausing to make meticulous notes as he did so. Suddenly his lancet slipped, causing him to puncture the knuckle of his forefinger. Unaware of the precarious situation he now found himself in, Potter continued with the anatomization. Days later, the young surgeon began to develop pyemia, a form of septicemia that results in the development of widespread abscesses all over the body—a condition doubtless brought on by his exposure to Leach’s bacteria-riddled corpse. The infection traveled up his arm, eventually spreading all over his body. Over the next three weeks, five doctors—including Robert Liston—attended Potter’s bedside, purportedly draining three pints of pus from his sacral region and an additional two pints from his chest, before the young man finally died. The official report concluded that had Potter eaten breakfast before rushing into the dissection room, he might have lived, because a full stomach would have aided the absorption of the toxic substances that had entered his body when dissecting Leach. In an era that knew nothing of germs, this explanation seemed entirely plausible.

Erysipelas was one of four major infections that plagued hospitals in the nineteenth century. The other three were hospital gangrene (ulcers that lead to decay of flesh, muscle, and bone), septicemia (blood poisoning), and pyemia (development of pus-filled abscesses). Any one of these conditions could prove fatal depending on a wide range of factors, not least the age and general health of the sufferer. The increase in infection and suppuration brought on by “the big four” later became known as hospitalism, which the medical community increasingly blamed on the establishment of large urban hospitals wherein patients found themselves in close contact with one another. Although the construction of these buildings met the needs of a rapidly growing population, many doctors believed that hospitals counteracted surgical advancements, because a majority of patients died of infections they would not otherwise have contracted had they not been admitted in the first place. Indeed, one contemporary argued that the medical community could not hope for “progress in the public practice of the healing art, till our system of hospitalism is more or less changed and revolutionized.” The problem was that no one knew exactly how infectious diseases were transmitted.

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.

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.

Due to the mounting pressure of London’s overcrowded prisons, 162,000 convicts were transported to Australia between 1787 and 1857. Seven out of eight of these were men. Some were as young as nine, others as old as eighty. Transportation was no easy alternative to imprisonment or hanging. The convicts were first sent to hulks, or floating prisons, on the Thames. The conditions on these decommissioned, rotting ships were horrendous, and even the hospitals could not compete with them as breeding grounds for disease. Prisoners were locked in cages belowdecks in appalling surroundings. One guard remembered “seeing the shirts of the prisoners, when hung out upon the rigging, so black with vermin that the linen positively appeared to have been sprinkled over with pepper.” During cholera outbreaks, the chaplain often refused to bury the dead until there was deemed to be a sufficient quantity of bloated, decomposing corpses of which to dispose. If a prisoner survived the hulks, he was shipped to Australia. One in three died on the grueling sea passage, which could take as long as eight months. If convicts behaved themselves, their sentence could be reduced by a “certificate of freedom,” which would allow them to return home. The majority, however, never made it back to Britain, choosing to live out the remainder of their miserable lives in exile rather than endure the treacherous sea passage to an English port.

Between 1834 and 1850, Charing Cross Hospital treated 66,000 emergencies, including 16,552 falls from scaffolds or buildings; 1,308 accidents involving steam engines, mill cogs, or cranes; 5,090 road crashes; and 2,088 burns or scalds. The Spectator reported that almost a third of these injuries were caused by “broken glass or porcelain, casual falls … lifting of weights and incautious use of spokes, hooks, knives and other domestic implements.” These accidents often involved children, such as thirteen-year-old Martha Appleton, who was employed at a cotton-spinning mill as a “scavenger,” which entailed picking up loose material from beneath the machinery. Overworked and undernourished, little Martha fainted one day, and her left hand was jammed in an unattended machine. She lost all five of her fingers, as well as her job. Her story was a familiar one.

Many treatments for syphilis involved the use of mercury, which could be administered in the form of an ointment, a steam bath, or a pill. Unfortunately, the side effects could be as painful and as terrifying as the disease itself. Most patients who underwent extensive treatments experienced multiple tooth loss, ulcerations, and neurological damage. Frequently, people died from mercury poisoning before they died of the disease itself.

What had brought him to Lister’s ward was a hacking cough that was accompanied by white discharge tinged with blood, sometimes amounting to as much as one and a half pints. The diagnosis was plain: first-stage phthisis, or pulmonary tuberculosis—a respiratory disease for which there was no cure in the 1850s. Hospital policy dictated that incurables not be admitted, and so Lister sent Chappell back out into the general population. The medical community did not yet know that tuberculosis is a highly infectious disease. The fact that Chappell was forced to sleep in the same room with five or six of his shop mates leaves one wondering how many other people he infected. Such was life for the typical Victorian worker who came to frequent the wards of London’s hospitals.

In 1884, the American physician William Pancoast injected sperm from his “best-looking” student into an anesthetized woman—without her knowledge—whose husband had been deemed infertile. Nine months later, she gave birth to a healthy baby. Pancoast eventually told her husband what he had done, but the two men decided to spare the woman the truth. Pancoast’s experiment remained a secret for twenty-five years. After his death in 1909, the donor—a man ironically named Dr. Addison Davis Hard—confessed to the underhanded deed in a letter to Medical World.)

The Scottish surgeon John Bell wrote about the horror of hospital gangrene after treating numerous patients who had died from it. In the first stage, “the wound swells, the skin retracts … the cellular membrane is melted down into a foetid mucus, and the fascia is exposed.” As the disease progresses, the wound enlarges and the skin is eaten away, exposing the deep layer of muscles and bone. The patient goes into shock and begins experiencing intense nausea and diarrhea as the body tries to expel the poison from within. The pain is excruciating, and alas, delirium is rare. The patient remains conscious throughout the whole miserable ordeal. Bell wrote, “The cries of the sufferers are the same in the night as in the day-time; they are exhausted in the course of a week and die: or if they survive, and the ulcers continue to eat down and disjoin the muscles, the great vessels are at last exposed and eroded, and they bleed to death.”

In the summer of 1799, one surgeon saw a sailor punched in the ear during a brawl. He suffered a slight wound from the blow. Within days, however, an ulcer had appeared that devoured one side of the man’s face and neck, exposing his trachea and the inside of his throat before killing him.

On the HMS Saturn, a malignant ulcer appeared on the tip of a seaman’s penis. After several days of agonizing pain during which the wound blackened and festered, the organ finally fell off. The surgeon on board reported that the “whole length of the urethra to the bulb sloughed away, and also the scrotum, leaving the testes and spermatic vessels barely covered with cellular substance.” As if the inevitable outcome needed underlining, the surgeon added, “He died.”

Bell advised that patients be removed from the hospital as quickly as possible: “Without the circle of infected walls men are safe.” Anything was better than “this house of death,” as Bell put it. Let the surgeon “lay them in a school-room, a church, on a dung-hill, or in a stable.” Others agreed: “This hospital gangrene … no doubt depends on the unwholesome atmosphere exciting preternatural irritability, ...

When Lister saw filmy discharge seeping through a patient’s dressings one day in 1852, this must have been on his mind. As he peeled back the damp bandages, he was met with a powerful odor emanating from a rotting, ulcerating wound. An epidemic of hospital gangrene soon swept Erichsen’s wards as a result of this single patient. Lister was quickly put in charge of carrying out treatment on the infected—a task that reflects just how far he had come in his residency to be trusted with such important work. At the height of the outbreak, Lister observed something peculiar. He routinely scraped away the brown pultaceous slough from patients’ infected wounds while they were anesthetized. He then applied mercury pernitrate, a highly caustic and toxic solution, to them. Afterward, he recorded in his notebook: “As a rule … a perfectly healthy granulating sore was disclosed which healed kindly under ordinary dressings.”

Lister’s curiosity had been piqued. Why was it that a majority of the ulcers healed when they were debrided and cleaned with the caustic solution? Although he didn’t dismiss the idea that miasma could be partly to blame, he wasn’t convinced that the foul air was entirely responsible for what was happening on the wards of University College Hospital. Something in the wound itself had to be at fault—not just the air around the patient. From the pus that he had scraped out of the infected wounds, he carefully prepared microscopic slides to examine under the lens. The implications of what he saw would take root in his mind and eventually make him question an entire belief system upheld by no less a figure than his superior and mentor, John Eric Erichsen. He later recorded, “I examined microscopically the slough from one of the sores, and I made a sketch of some bodies of pretty uniform size which I imagined might be the materies morbi [morbid substances] … the idea that it was probably of parasitic nature was at that early period already present in my mind.”

On the day of the operation, Penman was seated upright in a chair, with his arms and legs restrained. Because neither ether nor chloroform had yet been discovered, Penman was administered no anesthetic. The patient steadied himself as Syme stepped forward, knife in hand. Most jaw tumors were gouged out during this time, beginning at the center of the growth and extending to the periphery. Syme had a different approach in mind. He proceeded to cut into the unaffected part of the man’s lower jawbone, in order to remove the tumor and some of the healthy tissue around it, and ensure that it was completely eradicated. For twenty-four excruciating minutes, Syme hacked away at the bony growth, dropping slices of tumor and jawbone with a sickening rattle into a bucket at his feet. It was incredible to those watching how anyone could endure such a horrific ordeal. And yet, against all odds, Penman survived.

Although overcrowding was a problem for most industrializing cities in Britain, Edinburgh’s claustrophobic living conditions were compounded by housing shortages in the 1850s and by the thousands of Irish immigrants pouring into the city, seeking refuge from the devastation caused by the potato famine, which had only ended two years earlier. In one district of Edinburgh, there was an average of twenty-five inhabitants living in each house. Over a third of these households occupied single-room homes, typically no bigger than fourteen by eleven feet. Many houses were packed tightly together in narrow enclosed courtyards. The twelfth-century city walls, built to protect Edinburgh’s residents, constrained the outward expansion of the Old Town. As a consequence, houses grew upward, reaching dangerous heights at a time when building regulations were far from rigorous. The district’s rickety structures could easily exceed ten stories, each level protruding and looming over the one before, so that the tops of these ramshackle buildings blocked out the sunlight. Those who lived on the ground floors were the poorest residents. They were surrounded by cattle and by open sewers that overflowed with human excrement just outside their front doors.

At the time of Lister’s appointment, nursing was not a calling that required skill or training, nor did it command much respect. Educated, well-to-do women didn’t dare enter a profession that would expose them to the intimate workings of the male body or leave them alone and unsupervised with men. Florence Nightingale—the woman who would later revolutionize nursing—had not yet fully developed the protocols of cleanliness for which she would become celebrated. Furthermore, it would be another nine years before the founding of the International Red Cross, which would be instrumental in training nurses in the latter half of the nineteenth century. As a result of the profession’s low recruitment standards, many of the nurses with whom Lister worked were a motley crew. Nightingale herself once visited the Royal Infirmary and found it to be a “lawless” place when it came to managing the nursing staff. She explained that it was the senior house surgeon’s duty to have the “drunken night nurses carried in on stretchers every night.” This unpleasant task would have fallen to Lister in his first year working under Syme. Indeed, there was a woman who used the hospital beds to sleep off her frequent hangovers and whom Lister had to reprimand on several occasions.

Those who survived the combat and loss of limbs were not clear of danger just yet. Shortly after the guns fell silent, there was an outbreak of Asiatic cholera. It stalked Mackenzie’s battalion across water, over hills, and through valleys. It was relentless in its pursuit. Generated by the bacterium Vibrio cholerae, this disease is usually transmitted through water supplies contaminated by the feces of the infected. At the time of the Crimean War, the disease was making its way across Europe—and it’s possible that the cholera was carried to the front line in the guts of soldiers. After an incubation period of two to five days, a victim will suffer the sudden onset of severe diarrhea and vomiting, giving rise to massive fluid loss and dehydration. Death can follow within hours, as Mackenzie noted in a letter back home: “Many were struck down at morning parade, and died in three, four, or five hours.… I need scarcely say, that any treatment in such cases was utterly vain.” If left untreated, Asiatic cholera has a 40–60 percent mortality rate.

Syme’s family was large by modern standards. There was Syme’s second wife, Jemima Burn, and their three children, plus his daughters Agnes and Lucy by his previous marriage. His first wife, Anne Willis, had died giving birth to their ninth child some years earlier. Seven of Syme’s children from his first marriage and two from his second had died of various diseases and accidents. These bereavements served as a reminder of how impotent medicine still was in the face of death.

Like many of his colleagues, Lister recognized that excessive inflammation often preceded the onset of a septic condition. Once this occurred, a patient would develop a fever. The underlying factor linking the two seemed to be heat. Inflammation was localized heat, whereas the fever was systemic heat. In the 1850s, however, preventing either was difficult because wounds rarely healed cleanly, to the extent that many doctors considered “laudable pus” essential to the healing process. Moreover, there was a debate within the medical community as to whether inflammation was in fact “normal” or a pathogenic process that needed to be countered. Lister was determined to better understand the mechanisms behind inflammation. What was the connection between inflammation and hospital gangrene? Why did some inflamed wounds become septic while others didn’t? In a letter to his father, he wrote that he “felt that the early stages of [inflammation] had not been traced as they might be, so as to see the transition from the state of healthy increased redness to inflammation.”

The biggest problem was that while a majority of surgeons tried to prevent wound infections, there was no consensus as to why they happened in the first place. Some believed that the cause was some kind of poison in the air, but it was anybody’s guess what the nature of that poison actually was. Others thought that wound infection could arise de novo through the process of spontaneous generation, especially if a patient was already in a weakened state. Nearly everyone in the medical community recognized that hospital settings were a contributing factor to the rise of infection rates in recent years. More and different types of patients were admitted to hospitals as they grew in size during the nineteenth century. This was especially true after the advent of anesthesia in 1846, which gave surgeons more confidence to take on operations that they would not necessarily have dared undertake before that innovation.

The level of hygiene that we expect in hospitals today simply did not exist, and certainly was not present at the Royal Infirmary when Lister began his work there. Finding some route to an understanding of the nature of inflammation and infection had become more critical than ever.

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.

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?”

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 i...

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.

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.

Back in the late 1840s, a physician from Bristol named William Budd argued that the disease was spread by contaminated sewage carrying “a living organism of a distinct species, which was taken by the act of swallowing it, which multiplied in the intestine by self propagation.” In an article published in the British Medical Journal, Budd wrote that “there was no proof whatever” that “the poisons of specific contagious diseases ever originate spontaneously” or were transmitted through the air via miasma. During the latter outbreak, he prioritized disinfecting measures with an antiseptic, advising, “All discharges from the sick men to be received, on their issue from the body, if possible, into vessels containing a solution of chloride of zinc.” Budd wasn’t the only one to question the spontaneous origin and aerial transmission of cholera’s spread. The surgeon John Snow also began investigating the matter when a deadly outbreak occurred near his house in Soho, London, in 1854. Snow started plotting cases on a map, and that was when he noticed that a majority of people who fell ill were receiving their water from a pump on the southwest corner of the intersection of Broad (now Broadwick) Street and Cambridge (now Lexington) Street. Even cases that were at first glance unconnected with the pump turned out to be associated with it after all, such as that of the fifty-nine-year-old woman who lived quite a distance from the water supply. When Snow interviewed her son, he was told ...

There was a perceptible shift away from miasma and toward contagion theories in the 1850s and 1860s, due in part to these events. Many doctors, however, remained unconvinced. Snow’s investigations in particular still didn’t suggest a plausible mechanism for the transmission of the disease. His conclusions correlated cholera with contaminated drinking water. But, like other contagionists, Snow didn’t explicitly state what it was that was being transmitted through that water. Was it an animalcule? Or a poisonous chemical? If the latter, wouldn’t it be infinitely diluted in large bodies of water like the river Thames? What’s more, Snow himself acknowledged that contagionism didn’t provide a satisfactory explanation of all diseases, and he continued to allow for the possibility of spontaneous generation in the development of diseases that caused putrefaction, like erysipelas. The voices crying out for a better explanation of contagious and epidemic diseases were growing ever louder.

In a series of experiments, Pasteur boiled fermentable substances to rid them of any existing microorganisms. He then placed these substances in two different kinds of flasks. The first was an ordinary flask with an open top. The second had a neck shaped like an S that prevented dust and other particles from entering the flask. This flask also remained open and exposed to the air. After a certain amount of time, the first flask began to teem with microbial life, while the swan-neck flask remained uncontaminated. From these experiments, Pasteur finally proved that microbes were not generated spontaneously; otherwise, the flask with the curved neck would have become reinfected. His experiments established what is now considered one of the cornerstones of biology: Only life begets life. In a speech on his findings delivered to the Sorbonne, Pasteur said, “Never will the doctrine of spontaneous generation recover from the mortal blow of this simple experiment.” It wasn’t long before the word “germ” was being used to describe these protean microbes.

Lister took away from Pasteur’s work the idea that it wasn’t the air as such but its constituent of microbial life that was the source of hospital infection. In those early days, he probably thought that the contamination of the air and the infection of the wound were attributable to the invasion of a single organism. Lister could not yet conceive of the vast number of airborne germs and their varying degrees of virulence, nor did he understand that germs could be transmitted in many different ways and by many different media. Lister came to the vital realization that he couldn’t prevent a wound from having contact with germs in the atmosphere. So he turned his attention to finding a means of destroying microorganisms within the wound itself, before infection could set in. Pasteur had conducted a number of experiments that demonstrated that germs could be destroyed in three ways: by heat, by filtration, or by antiseptics. Lister ruled out the first two because neither were applicable to the treatment of wounds. Instead, he focused on finding the most effective antiseptic for killing germs without causing further injury:

Inflammation is not a disease in and of itself, and it often signifies that something more sinister is going on. Until this distinction was made, it was difficult for surgeons to understand the rationale behind using antiseptics before infection set in, especially because many in the medical community believed inflammation and pus were integral parts of the healing process. Good, clean, and limited laudable pus was necessary for normal wound healing, but excessive or contaminated pus was seen to be a dangerous medium for putrefaction.

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?

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.

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.

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.

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 destroying those that had already invaded the body.

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.

Lister’s colleague Morton didn’t just find fault with his methods. He also didn’t accept the premise that germs were to blame for putrefaction. Morton characterized Lister’s published research as fearmongering. “Nature is here regarded as some murderous hag,” he wrote, “whose fiendish machinations must be counteracted. She must be entrapped into good behavior, she is no longer to be trusted.” Even the editor of The Lancet refused to use the word “germs,” instead calling them “septic elements contained in the air.” It was difficult for many surgeons at the height of their careers to face the fact that for the past fifteen or twenty years they might have been inadvertently killing patients by allowing wounds to become infected with tiny, invisible creatures.

The most publicly damning critique came from Thomas Nunneley, an English surgeon in Leeds who took great pride in having not permitted a single patient of his to be treated with carbolic acid. In his address to the British Medical Association in 1869, he said that Lister’s antiseptic system was based on “unsupported fancies, which have little other existence than what is found in the imagination of those who believe in them.” He thought that Lister’s advocacy of the germ theory was preposterous: “This speculation of organic germs is, I fear, far more than an innocent fallacy,” he told conference attendees, among them James Y. Simpson. “It is a positive injury,” he continued, “for teaching … that those desperate consequences which so often follow wounds result from one cause alone, and are to be prevented by attending to it alone … leads to the ignoring of those many and often complicated causes.” In his response to Nunneley, Lister could barely disguise his disgust: “That he should dogmatically oppose a treatment which he so little understands; and which, by his own admission, he has never tried, is a matter of small moment.”

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.

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 his 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.