"New opinions are always suspected, and usually opposed,
without any other reason but because they are not already common."
- John Locke
The
Butchering Art is a totally captivating work of creative non-fiction,
made even more remarkable by the fact that it represents the first book written
by author Lindsey Fitzharris. The author received a PhD. in the History
of Science, Medicine and Technology from Oxford University in 2009.
Honors awarded to
The Butchering Art include: Winner of
the PEN/E.O. Wilson Prize for Literary Science Writing, Top 10 Science Books of
Fall 2017 by Publisher's Weekly and a Best History Book of 2017 by "The
Guardian." In addition to this novel, the author has written for
“The Guardian”, “The Lancet” and “New Scientist.” She has a huge social
media presence including a fascinating blog:
"The Chirurgeon's
Apprentice".
You can also follow her on Facebook at
https://www.facebook.com/DrLindseyFitzharris/ but
be prepared for some graphic posts! She also has many multi-media
projects in progress including a British Television Series: "Medicine's
Dark Secrets".
The
Butchering Art is first and foremost a biography of Joseph Lister. Lister was born on April 5,1827 in Wetsham,
Essex, England to devout Quaker parents. His father, Joseph Jackson
Lister was a great devotee of the microscope and developed the "achromatic
lens" which reduced distortions. Young Lister was very interested in
his father's microscope and became proficient in its use. He announced he
wanted to be a surgeon, at that time a profession held in low regard. He
attended the University College of London, beginning in 1844. Lister was
noted to be hardworking and diligent, despite the poor reputation of medical
students of the day (who were described as “lawless, exuberant, and addicted to
nocturnal activities” in one journal). Lister brought a microscope with
him although the use of that instrument in medical studies was more accepted in
Paris than in London. The author
describes the conditions in the medical school in the 1840s. First, there was no protective gear in the
“dissecting rooms” or anatomy labs.
Students routinely went directly from their cadavers to their living
patients without so much as washing their hands. Also, there were two schools of thought in
the field of infectious disease: Contagionists, who believed in an "agent
of disease" vs. Anti-contagionists, or miasmatists, who believed that
diseases were transmitted through the air via poisonous vapors. Only four
types of infections were recognized: eryspielas, hospital gangrene, pyemia and
septicemia. Post-operative infections were routine and mortality rates
were very high.
The author
spends one chapter discussing the rapid urbanization and increased population
density in London. These conditions set the stage for more injuries and
illnesses. Lister was frustrated at the high mortality associated with
surgery and was intent on finding the cause of infection and used his
microscope to investigate. He felt that something in the wound itself had
to be at fault, not just the air around the patient. Lister: "I
examined microscopically the slough from one of the sores, and I made a sketch
of some bodies of pretty uniform size which I imagined might be the materies
morbi (morbid substances). The idea that it was probably of parasitic
nature was at that early period already present in my mind."
Lister
completed his surgical training and sat for examinations by the Royal College
of Surgeons. It was recommended that he tour European medical schools to
learn more about recent advances. His first stop on this tour was the
University of Edinburgh to study with James Syme, renowned professor of
surgery. Syme had achieved quite a bit of notoriety for his economy of
technique and time which he tried to achieve with nearly every form of
operation he undertook. Syme took special interest in Lister, who decided
to stay in Scotland instead of pursuing appointments in London or resuming
travels to Europe. Lister was elected to
membership in The Royal College of Surgeons of Scotland and advanced on staff
of Dr. Syme. Also, during this time he
courted and married Syme's oldest daughter. Lister then began a series of
experiments on frogs to study effects of inflammation on wound healing.
He discovered that "a certain amount of inflammation as caused by direct
irritation is essential to primary union. Inflammation of a wound did not
necessarily presage sepsis." These are concepts which are central to
wound healing physiology today.
Lister applied
for the position of Regius Professor of Clinical Surgery at the University of
Glasgow and was recommended by Dr. Syme: "Lister has a strict regard for
accuracy, extremely correct powers of observation and a remarkably sound
judgment united to uncommon manual dexterity and a practical turn of
mind." While in Glasgow, 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 and carried into the venous
trunks?" He became an advocate of cleanliness in the hospital, even
though his method for antisepsis was still to come. At the same time as
Lister was studying inflammation and infection, there were many surgeons in
Europe interested in the high maternal post-partum mortality from
"puerperal fever." Alexander Gordon in Scotland wrote in 1789
that puerperal fever was secondary to contamination by the medical staff.
This idea was summarily rejected. Oliver Wendell Holmes in America
revived Gordon's ideas fifty years later and Ignaz Semmelweis in Vienna spoke
of "cadaverous particles" which could be transmitted through medical
students from the anatomy labs to the obstetrical wards. He instituted a
chlorine hand wash when leaving the anatomy lab and reduced incidence of
puerperal fever. In the 1840's it was proven that cholera was caused by
contaminated sewage and not "miasma" or bad air and changed the view
of how diseases spread. In France, chemist Louis Pasteur showed that
bacteria ruined fermentation in wine. Finally,
Lister applied this knowledge to the septic wound and proposed the application
of antiseptic agents (first potassium permanganate and then carbolic acid)
which greatly reduced the infection rate in surgically treated compound
fractures. Lister published his findings in “The Lancet” with a five-installment
article which began on March 16, 1867.
Lister's
concepts and method were not immediately accepted. There was conflict
with James Y. Simpson, a noted gynecologist and the discoverer of Chloroform
anesthetic. First Dr. Simpson wrote a letter to “The Lancet” claiming
Lister was only repeating studies already performed in Europe and secondly that
his own method of preventing infection, acupressure, was more effective.
Lister repeatedly defended antisepsis, pointing to the strict scientific method
with which he had reached his conclusions. Lister's method was also
rejected by another distinguished London surgeon, James Padgett, who did note,
however, that he might not have been applying the method correctly.
In 1869 Dr.
Syme passed away and Lister returned to Edinburgh to take his place.
There was still a debate regarding the efficacy of Lister's method.
Improved mortality rates were attributed to better ventilation, improved diet
and improvements in nursing rather than antiseptic technique. However,
Lister's students became believers and marveled at Lister's continued
experimentation and constant adjustments to his antiseptic technique. His
students, who came to be known as "Listerians", realized the value of
experimentation in medicine and that observational acuity and accuracy could
lead to improvements in surgery. Lister's method gained traction with
surgeons in Europe, particularly Richard von Volkmann in Germany and gradually
gained acceptance in Britain. Lister then went on to develop the
atomizer, a device to spray carbolic acid into the air to reduce bacteria.
In 1871 Lister
was called to care for Queen Victoria who was suffering with a large axillary
abscess. He used his carbolic acid atomizer on the Queen and then drained
the infection. When he noted further drainage on the first post-operative
day, he improvised a new treatment. He soaked some rubber tubing in
carbolic acid and placed it into the wound. The Queen recovered and this
was the first use of a surgical drain!
In 1876 Lister
was invited to speak in America where his methods were greeted with much
skepticism. His presentation in Philadelphia was criticized by Samuel
Gross: "Little, if any faith, is placed by any enlightened or experienced
surgeon on this side of the Atlantic in the so-called treatment of Professor
Lister." Listerism gradually gained acceptance in America and
Massachusetts General became the first hospital in America to make
institutional use of carbolic acid as a surgical antiseptic. Lister's
method became universally accepted during his lifetime. He died in 1912
as a hero of medicine and science.
Interestingly,
the change which occurred in surgery through Lister's efforts have been
immortalized in the art of Thomas Eakins. Dr. Gross, who had espoused the
contrarian view to Listerism in Philadelphia, commissioned a painting by Eakins
entitled "The Gross Clinic":
In this painting, Dr. Gross
is operating on the femur of a young man with osteomyelitis. There are
unsterilized instruments displayed and one of the surgical assistants is seen
probing the wound with his bare and bloody fingers. Twenty years later
Eakins painted "The Agnew Clinic":
In contrast, this painting shows
the embodiment of antisepsis and hygiene. It is a cleaner and brighter
surgical theater with the surgeons wearing stark white coats rather than street
clothes.
The
Butchering Art is a meticulously researched scientific exercise and yet it
reads like a novel. It is one of those rare books which educates and at
the same time entertains. It is a biography of Joseph Lister, a history
of medicine as it struggles to enter the modern age, a historical monograph
describing London, Edinburgh and Glasgow in the mid 1800's and a socio-economic
treatise describing urbanization, poverty and social injustice in the Victorian
era. It is a long book, but I recommend it highly. Dr. Fitzharris'
next book will be a similar treatment of Sir Harold Gillies and the development
of the specialty of reconstructive plastic surgery.
