During his final year at UCL, Lister was awarded several distinctions and gold medals that elevated him above his peers. The prizes were prestigious and fiercely contested among medical students at the university and among those studying at London’s teaching hospitals. He won the Longridge Prize for “Greatest Proficiency … for Medical Honours and credible performance of duties of offices at the Hospital” and was awarded the considerable sum of forty pounds because of it. He also received a gold medal and a scholarship worth a hundred pounds for the results of his second examination in medicine. Lister began to overcome his shyness, due in part to the recognition of his talents and his newfound authority among the student body. His friend and fellow lodger Sampson Gamgee wrote to Lister, “Had it not been for you, University College would have been a nonentity at the examinations for honours at the University, whereas it now stands second school in London, placing Guy’s first and St. George’s third.”
Even so, not everyone was enamored with Lister’s mercurial, questing mind. When the time came to graduate, he was placed last on the honors list for physiology and comparative anatomy. His professor William Carpenter cited the reason for this slight in a letter to him: “I think it as well to let you know the reason why I found it requisite to place you there.… As answers to my questions, your papers were so defective, that if it had not been for the amount of original observation of which they bore evidence, I could not have placed you in the honours list at all.” Lister was irritated by Carpenter’s decision. As he wrote to his brother-in-law Rickman Godlee (later, father of Rickman John Godlee), “I care but little comparatively for this, for I find from conversing with him that it is just a question of whether you have or have not read his book.”
It was true that Lister wasn’t disposed to accept something simply because his professors told him it was so. One of the more interesting cases that came his way as a house surgeon—and one that best demonstrates his inability to accept the authority of his superiors as the final word—involved a sixty-four-year-old man with hepatitis. In addition to an excess of biliary matter in the man’s urine, Lister noted that it contained too much sugar and wondered whether the latter was a normal constituent of the bile. He turned to the recently appointed professor of chemistry at UCL for answers but found he was not prepared to give him a clear one. Instead of letting the matter rest, Lister obtained bile from two different sheep and applied sulfate of copper and caustic potash to both samples. In neither experiment was there any evidence of sugar, which led Lister to conclude that his patient’s present condition was in fact unusual. He won another gold medal for his research on the case.
At the end of 1852, Lister sat for his examinations at the Royal College of Surgeons and became fully qualified to practice surgery. Still, he vacillated, unable to make a final commitment to the profession. In February 1853, he returned to Dr. Walshe’s side, this time as a physician’s assistant. His hesitancy to enter surgical practice by extending his medical studies was facilitated by his father’s financial support. Partly as a consequence of coming last on the honors list for physiology and comparative anatomy, he remained diffident and doubtful. Taking a post as a fully fledged surgeon meant accepting complete responsibility for those under his care. Perhaps he fretted about what harm he might do to his future patients when confronted by obscure and rare manifestations of diseases.
Underneath the outward indecision, Lister’s scientific curiosity remained steadfast and undiminished. He continued to conduct experiments and carry out his own dissections. The microscope enabled him to probe the secrets of the human body more deeply than he or the overwhelming majority of his predecessors, peers, and superiors ever had before. And there was still the question of those microbes that he detected under the lens after the outbreak of hospital gangrene on Erichsen’s wards. What exactly were they, and how were they linked to what was happening to patients on the wards of the city’s largest hospitals?
Professor Sharpey, always the keen observer, recognized that Lister was drifting and suggested that he spend a year touring Continental medical schools. There, Lister would learn more about recent advances made in medicine and surgery, as Sharpey himself had done decades earlier when he traipsed around Europe. Paris—with its welcoming wards, lectures on emerging clinical specialties, numerous private courses, and countless opportunities for dissection—should top Lister’s itinerary, in Sharpey’s opinion. But first, he wanted his pupil to spend a month in Scotland with his good friend James Syme, the renowned professor of clinical surgery at the University of Edinburgh and fourth cousin to the great Robert Liston, now very well known for his work with ether. Sharpey suspected that Syme would find in Lister an enthusiastic student eager to participate in the investigations that the two men were conducting into the nature of inflammation and the circulation of blood. He also believed that Lister would find in Syme an inspirational mentor.
And so, in September 1853, Lister boarded a train to “Auld Reekie” (or “Old Smokey”), Scotland’s capital city, for what was intended to be a short stay.
5.
THE NAPOLEON OF SURGERY
Were I to place a man of proper talents, in the most direct road for becoming truely great in his profession, I would chuse a good practical Anatomist, and put him into a large hospital to attend the sick and dissect the dead.
—WILLIAM HUNTER
THE DEEP BAGS UNDERNEATH Professor James Syme’s eyes were indicative of the endless hours he spent inside the operating theater of Edinburgh’s Royal Infirmary. He was short and stout, but otherwise unremarkable in his appearance. His fashion choices were singularly unbecoming, consisting of a jumbled mixture of oversized clothes that rarely changed from day to day. His habitual apparel was a black long-tailed coat with a stiff high collar and a checkered cravat tied tightly around the neck. Like the promising surgeon from London whom he was about to meet, Syme had a slight stutter, which plagued him his entire life.
Despite his small stature, Syme was a giant of his profession by the time Lister traveled to see him. His colleagues called him “the Napoleon of Surgery,” a reputation that the fifty-four-year-old had acquired through his Herculean attempts to simplify traumatic procedures over the last twenty-five years of his career. Syme despised crude instruments like the hand-cranked chain saw and eschewed difficult methods when straightforward ones would suffice. Economy of time and technique was something Syme tried to achieve with nearly every form of operation he undertook. This attitude was mirrored in the characteristic brevity with which he spoke. Syme’s former pupil John Brown said of his great teacher that he “never unnecessarily wasted a word, a drop of ink, or of blood.”
Syme’s fame was largely attributable to his groundbreaking development of an amputation at the ankle joint—a procedure that still bears his name and is performed by surgeons today. Prior to his innovative technique, surgeons amputated below the knee for compound injuries and for incurable diseases of the foot, with dire effects upon a person’s mobility. This was often done because it was assumed that the long stump would be a nuisance and that the patient would not be able to walk on it. Syme’s method made it possible for the patient to bear weight on the ankle stump, which was a remarkable advancement in surgery, and his method was also easier and faster than amputating below the knee.
Like many surgeons who were trained before the dawn of anesthetics, Syme was lightning-fast—as was his cousin Robert Liston. He once removed a leg at the hip joint in approximately one minute, a feat made even more extraordinary by the fact that neither he nor any other surgeon in Scotland had ever before performed this type of procedure. Of course, the operation was not without complications. When Syme made the first cut into the thighbone, just under the socket, a resounding crack could be heard throughout the operating theater. He quickly removed the leg, and his assistant relaxed his grip in order to release the arteries that needed tying off. Syme recalled the horror that followed:
Had it not been for thorough seasoning in
scenes of dreadful haemorrhage, I certainly should have been startled.… It seemed indeed, at first sight, as if the vessels which supplied so many large and crossing jets of arterial blood could never all be closed. It may be imagined that we did not spend much time in admiring this alarming spectacle; a single instant was sufficient to convince us that the patient’s safety required all our expedition, and in the course of a few minutes haemorrhage was effectually restrained by the application of ten or twelve ligatures.
He would later call the procedure the “greatest and bloodiest operation in surgery.”
Syme was fearless. When other surgeons refused to operate, the Scotsman was at hand with his knife poised. In 1828, a man named Robert Penman approached Syme in desperation. Eight years earlier, he had developed a bony, fibrous tumor in his lower jaw. At the time, it was about the size of a hen’s egg. A local surgeon excised the teeth embedded in the growth, but the tumor continued to grow. When that procedure failed, Penman consulted Liston, who had recently made a name for himself by removing a forty-five-pound scrotal tumor from a patient at the Edinburgh Infirmary. Upon seeing Penman’s bloated and swollen face, however, even the indomitable Liston blanched. The size and position of the tumor, he thought, made it impossible to operate. This refusal to act was tantamount to a death sentence from a surgeon who usually embraced difficult cases. If Liston wouldn’t operate, who would?
Penman’s condition worsened until he reached a point where eating and breathing became extremely difficult. The tumor now weighed over four and a half pounds and obscured most of his lower face. So Penman sought out Syme, who at the age of twenty-nine was already known for his maverick approach to surgery.
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.
Long after the operation, Syme bumped into his former patient on the street and was surprised to see that the scarring on his face was minimal. His receding chin was concealed by a luxuriant beard. Anyone looking at Penman, Syme concluded with satisfaction, would never guess that he had undergone such a traumatic procedure.
* * *
It was operations like the one done on Penman that gained Syme his reputation as one of the most daring surgeons of his generation. On a dreary day in September 1853, Joseph Lister arrived in Edinburgh to meet this surgical pioneer. He clutched the letter of introduction penned by his UCL mentor Professor Sharpey. The city was geographically smaller than London but more densely populated. 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.
Within these quarters, crime rates soared in parallel with the growing number of inhabitants. More than fifteen thousand people were brought before the police for various offenses the year Lister arrived. Their crimes ranged from theft and begging to “allowing chimneys to take fire.” Of those miscreants apprehended, thousands were charged with physical assault and public drunkenness. Punishments were meted out, often arbitrarily, without due process. Some offenders received a mere admonishment for their crimes, while others were imprisoned, whipped, or executed. A large proportion of these delinquents were children under the age of twelve, many of whom were subsequently sent to “Ragged Schools”—charitable organizations that provided free education for destitute youngsters.
The slums festered in the Old Town like weeping sores. The absence of conveniences, such as clean water and toilets, made for an atmosphere that was, according to one resident of Edinburgh, “foully tainted, and rendered almost unendurable by its loathsomeness at those periods when offal and nuisance require to be deposited on the streets.” The filth and squalor that resulted from a mass of humanity being crammed into a small area created a perfect incubator for the growth of virulent diseases like typhus, tuberculosis, and relapsing fever.
Underneath this decrepit facade, Edinburgh pulsated with a dark energy. At the time Lister set foot onto its railway platform, the city had already established itself as a world leader in surgery, albeit one tainted by scandal and murder. It had been only twenty-five years since the infamous William Burke and William Hare had skulked around the streets of Edinburgh, looking for their next victim to accost. Over the course of ten months, the pair had strangled sixteen people and sold their suspiciously fresh corpses to Robert Knox, a surgeon running his own private anatomy school in the city who turned a blind eye to the duo’s cagey activities. (Burke and Hare were eventually apprehended after one of their victims was recognized by a spectator in the dissection theater. Fearing for his life, Hare turned king’s evidence and testified against his partner. He was pardoned for his cooperation, while Burke alone was left to swing from the end of a rope. In a poetic twist of fate, the murderer’s body was later dissected publicly, with hundreds of people in attendance. He was flayed meticulously, and his skin was used to make various macabre trinkets, including pocketbooks, which were hawked to a delighted, bloodthirsty public.)
The atrocities perpetrated by Burke and Hare sprang from the lucrative trade that supplied fresh corpses to anatomy schools around Britain in the early decades of the nineteenth century, when the only bodies that could be legally obtained for dissection were those of hanged murderers. With the proliferation of private medical schools, there simply weren’t enough bodies to go around. As a result, the city was crawling with body snatchers, or “resurrectionists” as they were sometimes called. They worked under the cloak of darkness in the dead of winter, when the natural process of decomposition was slowed by the frigid Scottish weather. Using wooden spades and iron hooks, they dug a small hole at the head of each grave, broke apart the lid of the coffin, and dragged the corpse out. The men might steal as many as six bodies in a single night and often worked in small gangs that fought each other for a monopoly over the cadaver trade.
So rife was the problem that drastic measures were taken to protect the dead in graveyards around Edinburgh. The bereaved placed mortsafes—or iron grilles—over burial plots to protect departed loved ones. They capped the surrounding walls with loose stones, which made them nearly impossible to scale without creating a disturbance. Groundskeepers defended churchyards by setting up spring guns and primitive land mines. Local people organized “cemetery clubs” and held vig
il by new graves for weeks until the body therein was too decomposed to be of any use to anatomy schools. In one instance, a father grieving the recent loss of his child enclosed a “small box, [with] some deathful apparatus, communicating by means of wires, with the four corners, to be fastened to the top of the coffin.” As the child was lowered into the ground, he threw gunpowder into this rudimentary piece of ordnance so that “the hidden machinery [was] put into a state of readiness for execution.”
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. But Lister’s new superiors—the very men who taught at the university and would soon welcome him to Edinburgh—were products of that bygone era. Even the late Robert Liston had metaphorical dirt on his hands from his time teaching in Auld Reekie. At the height of the corpse trade, he would send his band of body snatchers to invade the territories of the gangs his peers had employed, leading to irreparable rifts between the competing anatomists.
The unpalatable truth was that without the body snatchers and the thousands of corpses they had procured for anatomists during previous decades, Edinburgh would not have established its enviable global reputation for trailblazing surgery. Without this status, it is unlikely that Lister would have gone out of his way to travel there to meet Professor Syme as a prelude to setting out on his Continental tour to visit Europe’s medical institutes.
* * *
Indeed, Lister might have thought twice about a Scottish hiatus if he had known more of the Royal Infirmary’s combative professional environment. In a letter to his father explaining his decision to go to Edinburgh, he wrote, “I shall not have, as in London, to fight with jealous rivals, and contend or join ingloriously with quacks.… I am by disposition very averse to quarreling and contending with others, in fact, I doubt if I could do it.” But Joseph Lister—the shy, reserved young man entirely unaccustomed to conflict at this point in his life—was about to enter the lion’s den.
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