review Surgery: From butchery to a healing art
Every operation starts the same way. Chlorhexidine scrubbed under nails, lathered over wet hands, palm- topalm, fingers interlaced, thumbs, wrists, forearms. A soothing routine accompanied by the sound of water hitting a steel trough sink. Washing is an act of safety but also humility. It acknowledges a doctor’s capacity to cause disease as well as cure it. More than once I have thought of Joseph Lister — the father of antisepsis ( killing germs) and forefather of asepsis ( excluding germs completely) — as I perform this hygienic setpiece. Not that he would have liked the idea of me, his sister’s great- great- great granddaughter, studying medicine. Lister “could not bear the indecency of discussing with women the secrets of the ‘ fleshly tabernacle’, and sought to block their membership of the profession”.
In the 1860s, much of the surgical establishment dismissed antisepsis as “hocus- pocus”. They didn’t believe that current techniques might actually be harming patients. Instruments were rarely cleaned between cases, surgical aprons stiffened with blood, and surgeons had been known to suck patients’ wounds in the middle of an operation. Professional assets included a firm fist that could double as a tourniquet, and the dexterity to flay flesh to the bone in seconds. A surgeon’s currency was speed not sanitary practice.
Joseph Lister ( 1827– 1912) — with his “indescribable air of gentleness, verging on shyness”, a stutter and almost “womanly” concern for others — was not the obvious candidate to overhaul this filthy mess. Medicine didn’t run in the family. Devout Quakers, the Listers believed that homeopathy and divine intention were the best healers. Nevertheless Lister found himself in the overcrowded stench of central London embarking on a surgical education.
Lindsey Fitzharris has written a brilliant biography that embeds Lister in his medical moment. The smells and sights of rotting flesh seeped through the capital’s streets, into the teaching hospitals and around the graveyards. It was the time of cholera, smallpox and typhoid. Amid the gore, the intellectual scene of the city was flourishing. Lister rubbed shoulders with Thomas Hodgkin ( whose father had identified the lymphoma that bears his name). Professor William Sharpey encouraged Lister’s enthusiasm for the new experimental science of physiology. Lister spent his evenings peering into the achromatic microscope invented by his father, Joseph Jackson, to inspect animal specimens and swatches of human iris.
By the time of Lister’s graduation, ether and chloroform had ended surgery’s “age of agony”. No longer constrained by a patient’s reaction to pain, surgeons ventured deeper into the body with ever more radical procedures. As a result, surgery actually became riskier and infection rates increased. A patient in recovery was interpreted very differently to today: inflammation around the surgical site and “laudable pus” were seen as reassuring signs. Why certain patients developed systemic sepsis was unclear. Perhaps disease travelled from one person to another via a pathogenic agent. Or, as the anti- contagionists believed, maybe illness arose spontaneously from dirty conditions.
Lister was unconvinced by both theories. He observed that a patient’s environment mattered, but doubted that infective life could arise de novo. Prompted by scepticism rather than Archimedean revelation, Lister went back to Joseph Jackson’s microscope. Louis Pasteur’s
recent work in France inspired Lister to make a connection with the microbes he observed in a sample of gangrene. Could infective processes be halted in a similar way to fermentation and putrefaction? Lister developed a regimen for washing hands and tools in carbolic acid, tending wounds with saturated dressings and spraying a chemical mist over the unconscious patient. As his conviction grew, he agreed to remove a cancerous lump from his own sister’s breast, which had already been declared inoperable by two surgical colleagues.
Fitzharris subtly demonstrates how Lister eventually secured his medical reputation not in spite of, but perhaps because of, his religious upbringing. Quakerism has tended to be portrayed as a distraction from his scientific interests, particularly as Lister considered leaving medical school to enter the ministry. But once satisfied that surgery was an altruistic path, Lister recognised that evidence alone would not change the status quo. The art of persuasion would be critical to converting non- believers. The “scientific Germans” eagerly adopted antisepsis, but the “plodding and practical English surgeon” and cautious Americans were more resistant. Touring the US, Lister made the most of his platform to evangelise to roomfuls of students and sceptics. By interweaving case histories, demonstrations and rhetoric, he won over a generation of disciples. It wasn’t long before he became president of the Royal Society and personal surgeon to Queen Victoria. He was now part of the establishment.
Despite The Butchering Art’s admirable detail and vivid storytelling, Fitzharris is slightly heavy- handed with her conclusion that Lister raised the dark curtain of surgical barbarism to let in the light. Without question, ward conditions and operative hygiene have been transformed. But the scourges of gangrene, erysipelas, pyemia and septicaemia — collectively known as “hospitalism” to Lister’s contemporaries — did not disappear. Even with today’s antibiotics, surgical patients are not invulnerable. Nosocomial infections are a new strain of hospitalism: MRSA and resistant superbugs threaten to undermine Listerian modernity, and send us back to a time when a scalpel’s trace could spell death.