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

by Lindsey Fitzharris

Medical voyeurism was nothing new. It arose in the dimly lit anatomical amphitheaters of the Renaissance, where, in front of transfixed spectators, the bodies of executed criminals were dissected as an additional punishment for their crimes. Ticketed spectators watched anatomists slice into the distended bellies of decomposing corpses, parts gushing forth not only human blood but also fetid pus. The lilting but incongruous notes of a flute sometimes accompanied the macabre demonstration. Public dissections were theatrical performances, a form of entertainment as popular as cockfighting or bearbaiting.

Liston arrived on the scene in London at a time when “gentleman physicians” held considerable power and influence over the medical community. They were part of the ruling elite, forming the top of a medical pyramid. As such, they acted as gatekeepers for their profession, admitting only men whom they believed had good breeding and high moral standing. They themselves were bookish types with very little practical training who used their minds, not their hands, to treat patients. Their education was rooted in the classics. It was not uncommon during this period for physicians to prescribe treatment without first performing a physical examination. Indeed, some dispensed medical advice through letters alone, never laying eyes on the patient in question. In contrast, surgeons came from a long tradition of being trained through apprenticeships, the value of which depended heavily on the master’s capabilities. Theirs was a practical trade, one to be taught by precept and example. Many surgeons in the first decades of the nineteenth century didn’t attend university. Some were even illiterate.

Liston’s speed was both a gift and a curse. Once, he accidentally sliced off a patient’s testicle along with the leg he was amputating. His most famous (and possibly apocryphal) mishap involved an operation during which he worked so rapidly that he took off three of his assistant’s fingers and, while switching blades, slashed a spectator’s coat. Both the assistant and the patient died later of gangrene, and the unfortunate bystander expired on the spot from fright. It is the only surgery in history said to have had a 300 percent fatality rate.

As it turned out, the two decades immediately following the popularization of anesthesia saw surgical outcomes worsen. With their newfound confidence about operating without inflicting pain, surgeons became ever more willing to take up the knife, driving up the incidences of postoperative infection and shock. Operating theaters became filthier than ever as the number of surgeries increased. Surgeons still lacking an understanding of the causes of infection would operate on multiple patients in succession using the same unwashed instruments on each occasion. The more crowded the operating theater became, the less likely it was that even the most primitive sanitary precautions would be taken.

The surgeon was very much viewed as a manual laborer who used his hands to make his living, much like a key cutter or plumber today. Nothing better demonstrated the inferiority of surgeons than their relative poverty. Before 1848, no major hospital had a salaried surgeon on its staff, and most surgeons (with the exception of a notable few) made very little money from their private practices.

The best that can be said about Victorian hospitals is that they were a slight improvement over their Georgian predecessors. That’s hardly a ringing endorsement when one considers that a hospital’s “Chief Bug-Catcher”—whose job it was to rid the mattresses of lice—was paid more than its surgeons.

The surgeon James Y. Simpson remarked as late as 1869 that a “soldier has more chance of survival on the field of Waterloo than a man who goes into hospital.”

History will remember the whiskered surgeon for his misguided prediction: “There cannot always be fresh fields of conquest by the knife; there must be portions of the human frame that will ever remain sacred from its intrusions, at least in the surgeon’s hands. That we have already, if not quite, reached these final limits, there can be little question. The abdomen, the chest, and the brain will be forever shut from the intrusion of the wise and humane surgeon.”

Of twenty-three double amputations performed on patients in the countryside over a twelve-month period, only seven died. Although this statistic may seem high, it is low when compared with the mortality rate at the Royal Infirmary of Edinburgh for the same period. Of the eleven patients who received double amputations there during this time, a shocking ten of these died. A further breakdown shows that the leading cause of death in amputees in the countryside during the mid-nineteenth century was shock and exhaustion, whereas the leading cause of death in the urban hospitals was postoperative infection.

In the nineteenth century, almost all the hospitals in London except the Royal Free controlled inpatient admission through a system of ticketing. One could obtain a ticket from one of the hospital’s “subscribers,” who had paid an annual fee in exchange for the right to recommend patients to the hospital and vote in elections of medical staff. Securing a ticket required tireless soliciting on the part of potential patients, who might spend days waiting and calling upon the servants of subscribers and begging their way into the hospital. Preference was given to acute cases. “Incurables”—people with cancer or tuberculosis, for instance—were turned away, as were people with venereal infections.

There were some incredibly lucky cases on these fateful Wednesdays, such as that of the young woman who was rushed into the hospital suffering from an acute disease of the larynx. On the day she arrived, Lister stood near Erichsen as he cut into the tender flesh of the woman’s neck. Dark, sticky blood gushed from the incision. Erichsen frantically began slicing through the cricoid cartilage in order to make a free aperture into the air passages, but to no avail. The patient started to asphyxiate on the large quantities of fluid trapped in her chest. Her pulse slowed, and for a moment all that could be heard was the loud whistling of the air that her lungs were trying to draw into her windpipe. At that moment, Erichsen improvised something extraordinary: he clamped his mouth around the open wound in her neck and began to suck out the blood and mucus blocking her air passage. After three mouthfuls, the patient’s pulse quickened, and the color returned to her cheeks. The woman survived against all odds and returned to the wards. But Lister knew that fresh dangers awaited her there. Surviving the knife was only half the battle.

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.

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

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?”

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.

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.

There was one group who never doubted Lister’s antiseptic treatment: the people who survived because of it.

Gone were the filthy wards crammed with patients wasting away in squalid conditions; gone were the bloodied aprons and the operating tables soiled with bodily fluids; and gone were the unwashed instruments, all of which once had the operating theater reeking of “good old hospital stink.” The Royal Infirmary was now bright, clean, and well ventilated. No longer a house of death, it was a house of healing.

No longer lauded for their quick hand with a knife, they were revered for being careful, methodical, and precise. Lister’s methods transformed surgery from a butchering art to a modern science, one where newly tried and tested methodologies trumped hackneyed practices. They opened up new frontiers in medicine—allowing us to delve further into the living body—and in the process they saved hundreds of thousands of lives.