"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," writes Dr. Lindsey Fitzharris in her new book The Butchering Art, available October 17th. The science and medical historian chronicles the gruesome horrors of an era before antisepsis — when speed was prized over precision — and the pioneering discoveries of Joseph Lister, known as the "father of modern surgery." Lister's antiseptic methods meant that injuries like a compound fracture no longer called for amputation.
Thomas Eakins, The Gross Clinic (1875)
After Lister's discovery of French biologist and chemist Louis Pasteur's advances in microbiology, he applied his knowledge of the microscope and other theories to introduce carbolic acid as an antiseptic — which was already being used to treat sewage. (Lister noted that livestock grazed on carbolic acid-treated fields without issue.) The 19th-century surgeon was greatly opposed during his time (this was when Civil War surgeons were still packing dirt and pieces of clothing into wounds, after all), but Lister transformed the operating theatre from a place of gory spectacle into an arena of science where young doctors studied his sterile surgical techniques and changed the world.
Fitzharris spoke to Gizmodo about her new book, the bloody practices of the early "butchers," and Lister's impact on modern medicine.
Gizmodo: Before Lister introduced his antiseptic methods, you write that surgeons like Robert Liston were sawing off legs in under 30 seconds — and sometimes testicles in the process.
Lindsey Fitzharris: The book starts with Liston, because he's the first surgeon to operate with ether in Britain. In the audience that day was 17-year-old Joseph Lister. Liston is very tall for his time. He's reportedly so strong that he can hold you down with his left arm, which he also used as a tourniquet. He would move so fast that as he was switching instruments, he'd put them in his mouth. You can imagine these blood-soaked knives going into his mouth. There's just no real sense of hygiene or germs.
One of my favourite stories is about a patient who had to have a bladder stone removed. He gets into the operating theatre. This is pre-anesthetic, so he's completely awake and aware. He decides he's not going to do it, so he jumps off the table, runs, and closets himself off. Liston, again 6'2", runs after him in this nightmare scenario, rips the door off, and drags this guy back. He removes the bladder stone, and the guy lives, but I'm sure he was just traumatized for the rest of his life.
Gizmodo: Can you talk about the differences between surgeons like Liston and Lister?
Fitzharris: Liston, who I call one of the last butchers, was mostly operating in a pre-anesthetic era. Whereas when Lister starts operating, there is ether and chloroform, so you don't have the patient struggling against the knife.
When people think about the history of surgery, if they ever think about it, they think about the introduction of anesthetics as being the moment that surgery becomes modern. There's an element of truth to that, but actually surgery became much more dangerous. You no longer have the patient struggling, but the surgeon is much more willing to pick up the knife and go deeper into the body. The operating table becomes this conveyor belt of patient after patient. The table and instruments aren't being washed down. The hands aren't being washed. The surgeon wore an apron he never washed. In fact, it was a distinct sign to have this blood-splattered apron caked in the patients' blood. It showed that you were a senior surgeon. As a result, you have a huge increase of post-operative infection.
With Lister, he turns surgery into the meticulous, slow-moving science that we understand it to be today. Surgeons are no longer working against the clock. They understand how to manage post-operative infections.
He has this instrument that he calls the "donkey engine," which sprayed carbolic acid. That was the antisepsis that he used to clean everything. It would be sprayed all over the theatre.
Joseph Lister's steam spray, Wellcome Collection
There's a distinct shift between someone like Liston and an older Lister after his revolution takes place.
Gizmodo: How were the settings these doctors worked in different?
Fitzharris: In Liston's time, surgery was a spectator sport. There were hundreds of people that would sometimes come to the operating theatre. Sometimes they were ticketed paying people, including royalty, that just came to see the life and death struggle play out before them. They were dragging the dirt of everyday life into the operating theatre. Sometimes the floor of the operating theatre around one of the old butchers was so crowded they would have to clear it before he could begin to operate. There's no sense of hygiene. There's no sense of the patient having any privacy. The patient is awake and struggling. There's one story of a guy named Stephen Pollard in 1828 who had a bladder stone removed. It should have taken five minutes. It ended up taking over an hour. The surgeon was cursing him for having abnormal anatomy. He was basically blaming the patient who was struggling in intense stress that his weird body was the reason for the stone. The guy died 24 hours later of a post-operative infection. His autopsy report revealed it wasn't actually his anatomy — it was the surgeon's fault.
When you get to Lister, once his theories take place, it's very clean. The surgeons weren't wearing their street clothes anymore. The patient was anesthetized. There was a lot more calmness in the operating theatre.
Gizmodo: Were the audiences in Lister's time still gawking spectators or were they mostly other doctors and surgeons?
Fitzharris: By Lister's time, later in his life, it would have been more of a closed operating theatre. There were still people in the theatre, but they were mostly medical students or other surgeons watching. In Liston's crowd, it was mixed.
Thomas Eakins, The Gross Clinic (1875)
The cover of my book is a famous painting by a well-known 19th-century painter named Thomas Eakins called The Gross Clinic. It is gross — but it depicts Dr. Samuel Gross. This guy didn't believe in germs, and he hated Lister. He would walk into the operating theatre, close the door, and say "There! Mr. Lister's germs can't get in anymore." In this painting, you see that he's in his street clothes. He's sticking his finger into the wound. There's a woman shielding her face in horror. Within ten years, Eakins does another painting. That's the cover of my UK edition. This is called The Agnew Clinic. They're all wearing white. There are women and nurses in the operating theatre. There's a sense of cleanliness. In a very short period of time, you get a very distinct before and after. It's a fascinating visual way to demonstrate what happened.
Thomas Eakins, The Agnew Clinic (1889)
Gizmodo: When was Lister's aha moment involving Louis Pasteur's work?
Fitzharris: It's hard to condense such a complex thing into a single moment — but for Lister, there kind of was. He had been struggling for so long to figure out what had been killing his patients. As comical as the stories about surgeons like Liston are, it must have been really horrifying trying to save people's lives, they keep dying over and over again, and you just can't understand why. Lister was working on it and couldn't figure it out. One of his colleagues pointed him to Pasteur's work. He reads about germ theory, this makes sense to him, and now he needs to figure out how to test it out.
He waits for the perfect patient. He knows it has to be a compound fracture. If you had a break and the skin wasn't broken, you typically didn't develop any kind of secondary infection. He knew it had something to do with an open wound. It came in the guise of a young boy named James Greenlees, who had been hit by a carriage. The wheel rolled over this leg. These carriages were so heavy. People died all the time just crossing the chaotic streets in the Victorian period. He probably sat there for a good couple of hours before he was brought to the hospital, because they had to transport him. At this time, he comes onto Lister's ward. This wound is bleeding, it's got dirt in it. Lister takes carbolic acid, an antiseptic, and he cleans the wound. That's his aha moment. Greenlees recovers and doesn't develop any kind of secondary infection. He walks out of the hospital with both legs. From that point on, Lister experiments with carbolic acid in various ways. He sees that his patients are no longer developing septic conditions. He sees that as proof that germs exist, and they can be killed using these antiseptic techniques.
Gizmodo: Some medical professionals were really opposed to his theories, because as you mentioned, they didn't want to believe they were needlessly harming their patients.
Fitzharris: It's a hard pill to swallow, isn't it? Essentially, there's this young guy that comes around, and he says "Well, there are these invisible little creatures. And guess what? They're killing your patients." It sounds crazy to us today, because we know that germs exist — but back then, that was a huge leap. The microscope wasn't used very frequently in medicine. Not only were germs invisible, you had to use this strange contraption to even see them. It was very difficult for the older generation to accept. Lister really targets the younger, incoming medical students. Those were the people he eventually converted. They went out into the world and became known as the Listerians. They spread the gospel about germs, and that's how the revolution began.
Gizmodo: What were some illnesses that people had wild and weird theories about?
Fitzharris: The predominant theory about how disease was spread, was that it was spread through bad smells.
In Lister's own time, there was this thing that happens called the Great Stink in London. There's a terrible sewage backup in the river, and everything smells awful. Everybody thinks that there's going to be a massive epidemic of disease, and nothing actually happens. That was one of the moments, again, where medical people were trying to understand how disease was spread. So, here, it must not be the bad smells.
Gizmodo: How were surgical instruments different during Lister's time versus today, apart from our obvious advancements? Were 19th-century doctors using the same tools to perform procedures like amputation?
Surgical instruments, including a tourniquet, couching needles and amputating knives. Engraving. Alexander Hogg. The Wellcome Collection.
Fitzharris: The instruments haven't changed too much in general. They would be recognisable to a surgeon today. The main difference would be that a lot of times the saws would be really ornate. This is so strange to us today, because you can think about the crevices in which these germs could gather, in these carved saws. Some of them were wood handles. Again, not a great material if you want to keep everything sterile. Funny enough, there was an instrument-maker in the 19th century in London when Lister was a student. He advertised that his knives were pain-free. If you bought a knife from him, your patient wouldn't have any pain — which was hard to believe, especially in a pre-anesthetic era.
Gizmodo: You mentioned that surgeons in the pre-Lister era were wearing street clothes? Wouldn't they wear any special garments?
Fitzharris: There was nothing, really, that they used to protect themselves. They might wear the apron like I referred to. The apron was just encased with blood. It was said that they carried the cadaverous smell around with them referred to as "good old hospital stink," because they went right from the dissection lab straight to the operating theatres. At times, they're carrying pieces of flesh and decaying bits and bobs.
Gizmodo: In the book you explain that it was safer to have surgery at home versus the operating theatre, but the poor could not afford home surgeries. What was the cost involved with these at-home surgeries?
Fitzharris: If you were middle-class or wealthy, you certainly didn't go into these pest houses. You only went in if you were poor. I have to also point out that in order get into the hospital, you needed a ticket. In order to get a ticket, you had to petition a governor or someone on the hospital board. You had to wait weeks sometimes. You might die in the process. The other thing was that hospitals, even though you were poor, still charged you for room and board. There was one hospital in London that charged you for your inevitable burial, because that's how much they thought you would die. One hospital charged extra if they deemed you especially foul. It was for, what historians would call, the deserving poor — people who still had a little bit of money. If you were desperately poor, you had no medical options in the past. To some degree, the hospitals weren't great places either
Gizmodo: Were suicide rates higher during this time since people were left to die?
Fitzharris: That's a really hard thing to pinpoint, because it's so taboo. If someone did commit suicide, if it was your family member, you probably would want to cover it up, because the body couldn't necessarily be buried in consecrated ground.
It's really difficult to understand, even looking at medical records, what people were dying from. There wasn't a one-hundred per cent understanding of how we understand disease today. There were diseases like syphilis, for instance. You wouldn't really want to admit someone you knew died from it — even though it was clear they died from it, because in the final stages of syphilis your nose usually falls off. Syphilis was so common in the 19th century that no-nose clubs popped up all over London. These people would get together and have a good laugh about it. It's such a horrible disease. You could potentially live with it for 10 or 20 years before it killed you, so you looked pretty awful at the end.
The circulatory system: two dissections of the neck, jaw and skull of a man, with aortic arch (?), arteries and blood vessels indicated in red. Coloured lithograph by J. Maclise, 1841/1844. Via the Wellcome Collection.
Gizmodo: It's often assumed that body snatchers stole corpses for shady doctors, but you explain that doctors in general, including famed surgeons like Liston, employed bands of body snatchers.
Fitzharris: Yes. The doctors had to be in on the body snatching. The profession wouldn't want to admit it back then. The body snatchers work in gangs, and they make a lot of money off what they're doing. The body would have to be fresh. In the daytime, they would send a woman dressed as a mourner to go through the graveyard. She would identify the freshly dug graves. The body snatching happened in the dead of night, so there wasn't a lot of light. You had to know where you were going, and you had to be quick. A good body snatcher could dig up a body and replace all the dirt in about 10 to 15 minutes. They had lots of instruments that they dragged the body out with. They could usually steal about 10 to 12 bodies a night. We think of them as these bumbling, comical figures, maybe a bit boozy. But they could be very fast and very professional in the way they organised themselves. If you ticked off the body snatchers, they had ways of getting back at you. For instance, you get stories of the surgeon maybe not paying the full rate or giving them a hard time. The next morning, the body snatchers would leave various body parts outside the surgeon's house — and then there's a riot in town, because people obviously don't like their loved ones being stolen and hacked to pieces. In Lister's time, when he comes into medical school, bodies aren't really being stolen. This is really an early 19th-century activity. The laws changed to allow unclaimed, poor bodies to be dissected. That really helps the medical profession.
Gizmodo: You write about the shortage of housing in England due to rapid urbanisation. Lots of people means lots of sick people. Today, we see photos of people on subways around the world wearing surgical masks in an attempt to stay healthy. What were some of the ways people tried to stay healthy in Lister's time?
Fitzharris: In the 19th century, you do get a hygiene movement, for instance, to hike women's skirts up. These skirts were dragging on the ground, and they were carrying in lots of dirt and dust. Going back to the idea that the bad smells created disease when there were particularly smelly periods in the summer, they would cover their faces with handkerchiefs. A lot of times when you were wealthy or middle-class, the best way to avoid disease was to get out of these city centres. When the plague hit, for instance, before the 19th century, "go far and go long" was the catchphrase. You would get out and stay out as long as you could. Coming into London in the 19th century could be very dangerous before mass vaccinations and antibiotics. If you were coming in from the countryside to get a job you weren't exposed to a lot of diseases there like you were in the city, so obviously mortality rates were really high amongst young travelling people into the city at that time. In general, there wasn't much you could do until the concept of germs was introduced and the hygiene revolution begins. It was a filthy time. I always joke that my job in life is to basically shatter every romantic notion anybody might have about the past. If you think it was great to live in the 19th century, read The Butchering Art. It was pretty awful.
Gizmodo: What did Lister have to do in order to perform surgery on Queen Victoria? Was he interviewed or was it just assumed he was the best and would do the job?
Fitzharris: It kind of fell into his lap. At that time, his father-in-law James Syme had recently died. Syme was seen as the first surgeon of Scotland. He died. Lister filled his shoes and took his place. The Queen was in Scotland on holiday when she fell ill. There was no interviewing. It was just assumed he would operate — but it was his great fortune that he did, because he was able to use the antiseptic techniques. Because she allowed the surgery to go forward, it was like she was giving her acceptance to antisepsis and the idea that germs existed.
Gizmodo: Your stories about people during Lister's time period like Julia Sullivan, the woman who was forced to endure her husband's abuse since there were sketchy laws about divorce and women during that time, are incredibly detailed. Did Lister keep meticulous records?
Fitzharris: There's a huge amount of personal correspondence I was able to look through, like medical records, published case works, and then just lots of records in general about the period and what it was like to live then. There's a lot of medical records that still exist about Lister's cases. As he was nearing the end of his life, he requested that his personal correspondence be destroyed, because he believed his stories should be told through science alone. Thankfully that didn't happen. I joke that if he read my book he'd probably hate it, because there's so much of his personal life in it.
I feel like you can't tell a story of science without talking about the times and the people that affect you. Nobody operates in a vacuum. Lister is very much a product of all the people who supported him, like his very close relationship with his father. Lister has a mental breakdown at one point and leaves medical school. These are all really important parts of his story and his character.