This was the path Lister chose. In late April, Lister traveled with Hodgkin to the Isle of Wight on England’s south coast, where they paid a visit to the old Needles Lighthouse, perched on a cliff 472 feet above Scratchell’s Bay. By June, he had arrived in Ilfracombe, a beautiful village in Somerset on the shoreline of the Bristol Channel. From there, he accepted an invitation to visit Ireland from a prosperous merchant, Thomas Pim. The Pims were prominent Quakers in Monkstown, which was near Dublin and something of a stronghold for the Society of Friends in that part of Ireland. Joseph Jackson wrote to his son that he hoped these excursions were helping to restore Lister’s mental state: “The things that sometimes distress thee are really only the results of illness, following too close study … thy proper part now is to cherish a pious cheerful spirit, open to see & to enjoy the bounties and the beauties spread around us:—not to give way to turning thy thoughts upon thyself nor even at present to dwell long on serious things.”
Lister traveled around Britain and Europe for twelve months before finally returning to London. In 1849, he overcame his inner demons and reenrolled at UCL, where a passion for surgery was reborn in him. Lister began pursuing his anatomical studies outside the dissection room in his spare time, acquiring various body parts from bone collectors and medical suppliers to further his understanding of human anatomy. These included a bladder, a thorax, and a head with partial spinal cord attached, which he bought for twelve shillings and sixpence. In December of that year, he purchased a complete human skeleton from his former roommate Edward Palmer for five pounds, which he paid off over the next two years.
After the first year of medical school, Lister began his residency at University College Hospital in October 1850. Several months later, the medical committee offered him the position of surgical dresser to John Eric Erichsen, the hospital’s senior surgeon. Lister accepted, despite having turned the post down earlier on account of his poor health.
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.
Admittedly, a number of London hospitals in the first half of the nineteenth century were rebuilt or extended in line with the demands placed upon them by the city’s growing population. For instance, St. Thomas’ Hospital received a new anatomical theater and museum in 1813; and St. Bartholomew’s Hospital underwent several structural improvements between 1822 and 1854, which increased the number of patients it could receive. Three teaching hospitals were also built during this time, including University College Hospital in 1834.
Despite these changes—or because these enlargements suddenly brought hundreds of patients into proximity with one another—hospitals were known by the public as “Houses of Death.” Some only admitted patients who brought with them money to cover their almost inevitable burial. Others, like St. Thomas’, charged double if the person in question was deemed “foul” by the admissions officer. 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.”
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.
Worst of all was the fact that hospitals constantly reeked of piss, shit, and vomit. A sickening odor permeated every surgical ward. The smell was so offensive that doctors sometimes walked around with handkerchiefs pressed to their noses. It was this affront to the senses that most tested surgical students on their first day in the hospital.
Berkeley Moynihan—one of the first surgeons in England to use rubber gloves—recalled how he and his colleagues used to throw off their own jackets when entering the operating theater and don an ancient frock that was often stiff with dried blood and pus. It had belonged to a retired member of staff and was worn as a badge of honor by his proud successors, as were many items of surgical clothing.
Pregnant women who suffered vaginal tears during delivery were especially at risk in these dangerous environments because these wounds provided welcome openings for the bacteria that doctors and surgeons carried on them wherever they went. 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. Many women also died from pelvic abscesses, hemorrhaging, or peritonitis—the latter being a terrible condition in which bacteria travel through the bloodstream and inflame the peritoneum, the lining of the abdomen.
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. They were largely unconcerned with the causes of diseases, choosing instead to focus on diagnosis, prognosis, and treatment. Lister, however, would soon form his own opinions about the parlous state of hospital wards and about what could be done to address what he saw as a growing humanitarian crisis.
* * *
Many of the surgeons with whom Lister came into contact in those early years as a medical student were fatalistic about their ability to help patients and improve hospitals. John Eric Erichsen—the senior surgeon at University College Hospital—was one such practitioner.
Erichsen was a lean man with dark hair and prominent examples of the era’s trademark whiskers. He had limpid, inquisitive eyes set in a kindly face, with a sloping forehead, a long nose, and a slight turn to the lips. Unlike many of his colleagues, he was not a very skilled operator. Rather, he built his reputation on his writing and on his teaching. His most successful book, The Science and Art of Surgery, ran into nine editions and was the leading textbook on the subject for several decades. It was translated into German, Italian, and Spanish and held in such high regard in America that a copy of it was given to every medical officer in the federal army during the Civil War.
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 of the wise and humane surgeon.”
Wayward prophecies aside, Erichsen did recognize the momentous transformation that the surgeon was currently undergoing as a result of recent educational reforms. Whereas before the surgeon was a glorified butcher with steady hands, now he was a skilled operator, guided by greater knowledge. 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.”
Erichsen had come by his position via the kind of misfortune that exemplified the perils of his profession. Four years earlier, his prede
cessor John Phillips Potter had entered the dissection room to anatomize the body of the circus performer and dwarf Harvey Leach, known by many in London as the “Gnome Fly” due to his propensity to flit around the stage like a winged insect.
Leach, who was often billed as the “shortest man in the world,” had made a name for himself as a performing oddity. In addition to his small stature, one of his legs was eighteen inches long while the other measured twenty-four inches, and when he walked, his arms brushed against the ground like an ape’s. According to one of his contemporaries, Leach appeared “like a head and trunk, moving about on castors.”
Leach’s strange appearance eventually attracted the attention of the American showman and hoaxer P. T. Barnum, founder of the Barnum & Bailey Circus. Barnum dressed the dwarf in the skin of a wild beast and covered the walls of London with placards that read “What Is It?” Unbeknownst to Barnum, Leach was so recognizable at that point in his career that people guessed the true identity of this mysterious “beast” within days. Despite this initial bungle, Barnum retained Leach as a performer, until the forty-six-year-old man died as the result of an injured hip that had become infected. At a time when people went to great lengths to ensure their bodies remained intact after death, Leach allegedly stipulated that his be handed over to those who were most likely to cut him up. According to an Australian newspaper, Leach requested that his corpse “be presented to Dr. Liston, the eminent surgeon, not to be buried, but embalmed and kept in a glass case, as the doctor had been a particular friend to him.” Another newspaper in Britain said that Leach had “bequeathed his body over to his most intimate friend and companion, Mr. Potter,” which seems more likely given the fact that it was Potter who ultimately performed the dissection. Whatever the circumstances under which his body was obtained, and whatever his actual wishes might have been, an anatomization of Leach went ahead on April 22, 1847.
Potter, who had proven himself to be a lively, brilliant, and excellent teacher, had just that week been appointed assistant surgeon at University College Hospital. It was said that his kindness and zeal in his previous role as demonstrator of anatomy had made him popular with faculty and students alike, and Lister was among his admirers. As Potter cut into Leach’s stiff body, he noted: “It seems as though the thigh-bones and muscles had disappeared, and the knee-joints been raised up to the hips.” According to Potter, in place of a normal structure, Leach appeared to have “an immensely strong bone of triangular form, with the base upwards,… knit to the hip with very strong ligaments.” Potter reckoned it was because of this that the famous circus performer could jump ten feet into the air.
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.
Two hundred mourners followed Potter’s coffin into the sprawling expanse of London’s Kensal Green Cemetery for his funeral, turning out to pay their respects to the man who had shown so much promise in his short career. The Lancet later lamented that it was “a most melancholy and disheartening instance of brilliant talent and promise blighted in the blood.” Potter’s misfortune, however, was Erichsen’s good luck. The dirt shoveled back into poor Potter’s grave had barely settled before the Danish-born surgeon stepped into his dead colleague’s shoes.
* * *
As it turned out, 1847 was a bad year for many of the hospital’s surgeons. On December 7—nearly one year after his historic operation with ether—the great surgeon Robert Liston died unexpectedly of an aortic aneurysm at the age of fifty-three. His death was felt deeply by the medical staff at University College Hospital, many of whom resigned their positions in search of other surgical giants to follow. The loss of such well-loved instructors as Potter and Liston also diminished the number of students wishing to study there, which in turn led to a substantial decrease in revenue. By the end of the 1840s, the hospital was three thousand pounds in debt and had to scale back the number of beds from 130 to 100. Only half of these were designated for surgical cases.
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. Erichsen had three dressers assigned to him when Lister came on board as a fourth. The dressers were required to take a case history for each patient, prepare diet tables, and assist in postmortem examinations. Lister and his three colleagues reported to Erichsen’s house surgeon, an eccentric young man named Henry Thompson who later became known in London for hosting “octaves”—dinners of eight courses for eight people served at eight o’clock. Thompson supervised the dressers and attended to Erichsen’s patients each morning. As a fully qualified surgeon, he also assisted Erichsen with operations, whereas Lister and the other dressers could not.
All five men lived in the housing quarters within the hospital. It was a healthy change from the stifling existence Lister had known as a lodger in Edward Palmer’s house while studying for his arts degree. For the first time in his life, Lister came into contact with young men from differing educational and religious backgrounds who held many views that were at odds with his own. He thrived in this new environment and became an active member of the student body. 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.
* * *
Back at the hospital, Lister had only been acting as Erichsen’s dresser for a short period when there was an outbreak of erysipelas, an acute skin infection sometimes referred to as “St. Anthony’s Fire” because it turns the skin bright red and shiny. The condition is caused by the streptococcus bacterium and can develop rapidly over a period of a few hours, causing high fevers, tremors, and eventually death. Most surgeons at this time considered erysipelas all but incurable. Its terrible effects were ubiquitous. It was so contagious that institutions like Blockley Almshouse in Philadelphia (later Philadelphia General Hospital) imposed a moratorium on operations from January until March, when they believed erysipelas was at its seasonal peak.
Lister was more familiar with the condition than most of his classmates. His mother, Isabella, had suffered from recurring outbreaks of erysipelas since Lister was a small boy. (It was probably due to her ongoing ill health that Lister himself became something of a hypochondriac later in life. The most obvious outward manifestation of his neurosis was a fixation with his shoes, which he always ensured had unusually thick soles. One of his friends speculated this was a result of Lister’s “unreasoned dread of wet feet,” which most people of his generation believed were the root of sickness.)
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. By the 1840s, the formulation of an effectual public health policy was hostage to a debate between the so-called contagionists and anti-contagionists. The former posited that disease was communicated from person to person or via the medium of goods being shipped in from pestilent areas of the world. Contagionists were vague about the agent by which disease was passed. Some suggested it was a chemical or even small “invisible bullets.” Others thought it might be transmitted via an “animalcule,” a catchall term for small organisms. Contagionists maintained that the only way to prevent and control epidemic diseases was through the use of quarantines and trade restrictions. Contagionism seemed plausible when it came to diseases such as smallpox, where fluid in the pustules could easily be seen as the mode of transmission; however, it did little to explain sicknesses that arose through indirect contact, like cholera or yellow fever.
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