The Butchering Art: Joseph Lister's Quest to Transform the Grisly World of Victorian Medicine
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the use of ether was seen as a suspect foreign technique for putting people into a subdued state of consciousness. It was referred to as the Yankee dodge due to its being first used as a general anesthetic in America. It had been discovered in 1275, but its stupefying effects weren’t synthesized until 1540, when the German botanist and chemist Valerius Cordus created a revolutionary formula that involved adding sulfuric acid to ethyl alcohol.
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That moment came in 1842, when Crawford Williamson Long became the first documented doctor to use ether as a general anesthetic, in an operation to remove a tumor from a patient’s neck in Jefferson, Georgia.
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On November 18, 1846, Dr. Henry Jacob Bigelow wrote about this groundbreaking moment in The Boston Medical and Surgical Journal: “It has long been an important problem in medical science to devise some method of mitigating the pain of surgical operations. An efficient agent for this purpose has at length been discovered.” Bigelow went on to describe how Morton had administered what he called “Letheon” to the patient before the operation commenced. This was a gas named after the river Lethe in classical mythology, which made the souls of the dead forget their lives on earth. Morton, who had ...more
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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.
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Equally momentous to Liston’s triumph with ether was the presence that day of a young man named Joseph Lister, who had seated himself quietly at the back of the operating theater.
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Nevertheless, as Lister made his way through the crowds of men shaking hands and congratulating themselves on their choice of profession and this notable victory, he was acutely aware that pain was only one impediment to successful surgery. He knew that for thousands of years, the ever-looming threat of infection had restricted the extent of a surgeon’s reach.
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Only with amputations did the surgeon’s knife penetrate deep into the body. Surviving the operation was one thing. Making a full recovery was another.
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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.
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Lister escaped many of the dangerous medical treatments that some of his contemporaries experienced while growing up, because his father believed in vis medicatrix naturae, or “the healing power of nature.” Like many Quakers, Joseph Jackson was a therapeutic nihilist, adhering to the idea that Providence played the most important role in the healing process.
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The use of these nerve tonics, as they were called, was advocated by adherents of the prevalent medical orthodoxy of the time known as allopathy, meaning “other than the disease.” In short, the theory held that the best way to treat a disease was to produce the somatic condition opposite to the pathological state in question. With a fever, for instance, one had to cool the body down. With disorders of the mind, one had to restore strength and firmness to the patient’s frayed nerves.
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“Naturopathy”—the treatment of disease through the promotion of the body’s own healing powers—also played a significant role in Victorian medicine. Doctors put great stock in a change of air and scenery to combat what they considered the source of shattered nerves: stress, overwork, and mental anxiety. It was important that patients remove themselves from the environment in which they had broken down.
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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.
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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.”
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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.
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Because surgeons saw suffering on a daily basis, very few felt any need to address an issue that they saw as inevitable and commonplace. Most surgeons were interested in the individual bodies of their patients, not hospital populations and statistics.
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But Erichsen was shortsighted about the future of surgery, which he believed was rapidly approaching the limits of its powers by the middle of the nineteenth century. 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 ...more
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Erichsen observed, “It is long since the hand has been [the surgeon’s] sole dependence; and it is now by the head, as much or more than by the hand, that he exercises his avocation.”
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Erichsen was quickly promoted. His appointment to the chair of surgery in 1850 at the age of thirty-two so offended his senior colleague Richard Quain that the latter refused to talk to Erichsen for fifteen years. Such is the timelessness of hospital politics.
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Partly in an attempt to rid himself of the stammer that had preceded his breakdown, Lister joined the Medical Society, where he engaged in lively debates with other students over the merits of the microscope as a tool for medical research. He also led a scathing attack on homeopathic medicine, which he argued was “perfectly untenable scientifically.” Such was his oratorial heft that a year after he joined, he was elected president of the society.
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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).
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The increase in infection and suppuration brought on by “the big four” later became known as hospitalism,
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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.
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While comparing mortality rates of country practitioners with those operating in the large, urban hospitals of London and Edinburgh during this period, the obstetrician James Y. Simpson discovered some shocking differences. 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.
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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.
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Very few were granted admission onto the wards. This wasn’t unusual. In general, a sick person had a one-in-four chance of gaining entry onto a ward of a city hospital.
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Most hospitals had a “taking-in day” designated for admitting new patients onto the wards. This might happen only once a week.
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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.
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He also ordered that Julia be given a regular dose of opium, a drug that had become more popular than alcohol in the nineteenth century due to the ever-expanding British Empire. Before the Pharmacy Act of 1868 limited the sale of dangerous substances to qualified druggists, a person could buy opium from just about anyone, from barbers and confectioners to ironmongers, tobacconists, and wine merchants. Lister administered the powerful drug to patients of all ages, including children.
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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.
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By 1853, the body snatchers’ nefarious activities had ceased throughout Britain due to the passing of a law that made it legal to dissect the unclaimed bodies of the poor, thus giving medical practitioners access to a large supply of corpses.
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The dressers and clerks dubbed Syme “the Master” and Lister “the Chief”—a term of endearment that stuck with him for the rest of his life. One member of the staff in particular took a shine to the handsome surgeon: the formidable Mrs. Janet Porter, matron of the hospital and head of the nursing staff at the Royal Infirmary.
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When Lister returned to work at the Royal Infirmary, he continued to face the same problems that had presented themselves at University College Hospital in London. Patients were dying from gangrene, erysipelas, septicemia, and pyemia. Frustrated by what most hospital surgeons accepted as an inevitability, Lister began taking samples of tissue from his patients to study under the lens of his microscope so he could better understand what was happening at a cellular level.
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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.
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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.
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One phenomenon many surgeons noticed was that simple fractures resulting in no break of the skin often healed without incident. This reinforced the idea that something had entered the wound from outside, which in turn gave rise to the popular “occlusion method” that sought to exclude air from a wound.
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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.
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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.
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Put plainly, Lister believed that there were two kinds of inflammations: local and nervous.
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He was ultimately incorrect in believing that there were two types of inflammations, but through his groundbreaking work he secured a better grasp of the effects that inflammation had on the loss of vitality in tissues.
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He opened with a quotation from the sixteenth-century surgeon Ambroise Paré, who famously said, “I dressed him, God cured him,”
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Lister, true to his Quaker roots, exhibited an unusual level of compassion for those on his wards. He refused to use the word “case” when referring to specific patients, choosing instead to call them “this poor man” or “this good woman.” He also recommended to his students that they use “technical words” so that “nothing was said or suggested that could in any way cause them anxiety or alarm”—something that would undoubtedly be viewed as unethical today but was born purely of compassion when Lister suggested it.
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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.
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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 ...more
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Lister personally accompanied the more serious cases back to the ward after an operation and insisted on helping to transfer the patient from the stretcher to the bed. To ensure the patient’s comfort, he would arrange an assortment of small pillows and hot-water bottles, warning his attendees that the latter should be covered with flannel so the anesthetized person would not inadvertently burn him- or herself during recovery. He even helped dress the sick after surgery. One of Lister’s house surgeons described how “with almost womanly care he would replace the bedclothes” of the patient, ...more
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Even in his private practice, he exhibited an acute empathy with patients that extended to their pockets. Consequently, Lister objected to issuing bills to those whom he treated and lectured his students that they should “not charge for [their] services as a merchant does for his goods.” Reflecting the ideals of his faith, Lister believed that the greatest reward for a surgeon was the knowledge that he had performed an act of beneficence for the sick.
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He discovered that blood remained partially fluid for several hours in a vulcanized India-rubber tube but clotted promptly if placed in an ordinary cup. He concluded that blood coagulation is caused by “the influence exerted upon it by ordinary matter, the contact of which for a very brief period effects a change in the blood, inducing a mutual reaction between its solid and fluid constituents, in which the corpuscles impart to the liquor sanguinis a disposition to coagulate.”
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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?”
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With the cloud of professional defeat hanging over him, Lister received word soon after that his mother’s condition had rapidly deteriorated. The situation was critical, so he packed his bags and traveled down to Upton to be at her side. On September 3, 1864, Isabella Lister lost her battle with erysipelas, the same disease that continued to haunt Lister on the wards of his own hospital.
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It was during this time that Lister attempted to improve hygiene at the Royal Infirmary in the hope that it would minimize incidences of hospitalism. “Cleanliness” in hospitals often meant no more than sweeping floors and opening windows in the operating theater, and the Royal Infirmary was no exception. Lister suspected that if he could make the wards cleaner, his patients might stop dying.
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Using that same logic, they thought that by boiling water and letting it cool before washing both the instruments and the wound site, a surgeon could prevent postoperative infections from developing. Their emphasis on cold water specifically was meant to counteract the heat that they believed caused inflammation and fever.
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