The Butchering Art
Author: Lindsey Fitzharris
This book about Joseph Lister is a comprehensive account of the legendary surgeon’s life-long commitment to ‘elucidating the causes and nature of postoperative infections and finding a solution for them’. The book records Lister’s complete biography starting right from his birth in 1827, and detailing how his father, ‘a great devotee of the microscope‘, influenced his early determination to become a surgeon. The book’s major focus is the role played by Lister in establishing surgical antisepsis at a time when ‘most deaths were due to postoperative infections’ such as erysipelas, hospital gangrene, septicaemia, and pyemia,. The narrative particularly highlighted the challenge Lister faced in convincing other surgeons to abandon their abiding belief that ‘pus was a natural part of the healing process‘, and to jettison their fatalistic notion of septic surgery as ‘inevitable‘. But the book is more than just a profile of one man because it is also a detailed chronicle of the early days of surgery and its operating room practices; with a fast-paced prose appropriate for the subject, the author portrayed the larger-than-life personalities that defined the early days of surgery, and the drama and suspense that still symbolise the specialty (pages 18-22, 5, 17, 47-53).
The book’s arresting title is a symbolic depiction of the state of surgery before the era of antisepsis, and the book’s contents paint a graphic picture of a time when ‘operative surgery was a filthy business fraught with hidden dangers‘. The author represented the typical surgeon of that period as inevitably a man ‘wearing a blood-encrusted apron’ who ‘rarely washed his hands or his instruments and carried with him into the theatre the unmistakable smell of rotting flesh‘. Characterising surgery at the time as ‘a matter of technique, not technology‘, the author described the surgical instruments of the day as crude ‘havens of bacteria‘ which ‘bore bloodstains from past operations’. The author highlighted the paradox whereby the introduction of anaesthesia to surgical practice worsened its unsanitary situation, the higher number of surgeries it enabled only serving to make the operating theatres filthier, and it left little time for ‘even the most primitive sanitary precautions’ to be taken. The hospital wards did not fare any better, the book depicting them as ‘overcrowded, grimy, and poorly managed…breeding grounds of infection’ which ‘constantly reeked of piss, shit, and vomit‘ and ‘provided only the most primitive facilities for the sick and the dying’. The absurdity of the situation was poignantly captured by the author’s observation that most of those who died did so from ‘infections they would not otherwise have contracted had they not been admitted in the first place’ (pages 5, 17, 31-33, 46 and 53).
The book’s historical account of the development of antisepsis was compelling. On one hand it encapsulated the benefits of scientific progress on surgical practice, and on the other hand it illustrated the resistance of surgeons to abandon their cherished traditions even in the face of unimpeachable evidence. One of the challenges that antisepsis faced was the sheer number of contradictory theories of infection prevalent at the time, the author citing such anti-contagionist conjectures as pythogenesis, spontaneous generation of disease, and miasma – disease arising from poisonous vapours in the air. The book also traced the gradually progression of the understanding of germ theory starting with the works of early visionaries such as Scotsman Alexander Gordon, American Oliver Wendell Holmes, and Hungarian Ignaz Semmelweiss who all methodically addressed the problem of puerperal fever and advanced the contagion theory that it was caused by ‘materies morbi (morbid substances) transmitted from doctor to patient’. The author also cited the public health approach of surgeon John Snow who solved the 1854 London cholera outbreak. It was however to the groundbreaking and inspired work of Louis Pasteur that the author attributed the proof of the contagion theory after he observed bacterial putrefaction during wine fermentation. She noted that Pasteur was able to make the bold conclusion that both fermentation and putrefaction were caused by different types of living organisms, and that these microbes were not generated spontaneously but ‘were born of themselves’ (pages 84-85, 53-54, 149-159).
In its biographical narrative of Lister’s professional life, the book provided a vivid depiction of his personality, medical training, and varied career. The author portrayed him as a ‘sober‘ man who was taller than most of his classmates, and whose mind was ‘in a constant whirl of activity’. She described his induction into University College London medical school at the young age of 17 – at a time when London was a filthy and unsanitary city literally ‘crawling with hidden dangers‘. She juxtaposed this image with the equally unsanitary portrait of the medical school’s dissection room where the students wore ‘neither gloves nor other forms of protective gear‘. She further portrayed the hospital itself as ‘a waking nightmare‘ with a high mortality rate, not just among patients, but also among the medical cadre. The book aptly captured the risky state of medical practice at the time when it narrated Lister’s own ‘brush with death‘ when he contracted smallpox, an experience that depressed him and raised doubts in his mind about the wisdom of continuing in his chosen career. He however successfully concluded his medical education and surgical residency, proceeding to take up a position as ‘surgical dresser‘ (pages 23-45).
The most revealing insights into Lister’s surgical skills and research acumen were most evident in the book’s account of his flourishing career at the Edinburgh Royal Infirmary, starting at a time when the surgical community there was ‘rife with feuds, rumors, and jealousy‘, and its members pitted against each other. The author noted that Lister’s success in Edinburgh relied as much on his work ethics as it did on the influence of James Symes, the renowned surgeon who ‘took a keen interest‘ in his career’ and took him on as his ‘right hand man‘. The author depicted Symes as ‘a giant of his profession’ and as ‘one of the most daring surgeons of his generation’ who was noted for his surgical ‘economy of time‘ because of the ‘lightening speed‘ of his operations. The author however also depicted Symes as a ‘volatile’ genius whose ‘dark side‘ manifested in ‘an unnatural inclination to nurture lifelong grudges‘. The book recounted Lister’s subsequent relocation to take up the vacant professorship chair in Glasgow where he cultivated a reputation as an excellent teacher and a humble and empathetic doctor (pages 90-103, 130-133 and 139-141).
In tracing Lister’s sterling contribution to antisepsis, the book first highlighted his expertise with the microscope, an instrument that the author said ‘would eventually help him unlock the medical mystery that had been plaguing his profession for centuries’. The microscope, she added, empowered Lister ‘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’. Already ‘a very capable microscopist’ by that time he entered medical school, the author described how Lister advanced his skills by studying diverse structures such as muscles, eyes, hair follicles, and tumours. She also recounted his initial foray into antisepsis when he observed that wounds that had been ‘debrided and cleaned with caustic solutions’ healed without getting infected. She also detailed how his examination of pus under the microscope revealed ‘bodies of pretty uniform size’ which he presumed were ‘probably of a parasitic nature’. Determined to find ‘the most effective antiseptic for killing germs without causing further injury’, the author described how he discovered that carbolic acid (phenol) effectively prevented infection in ‘patient after patient‘. She concluded that Lister’s ‘pioneering work ensured that the results of surgery would no longer be left to chance‘, adding that his methods ‘transformed surgery from a butchering art to a modern science, one where newly tried and tested methodologies trumped hackneyed practices’ (pages 34-36, 78-85, 159-169 and 234).
This excellent book is not simply a biography of the man who introduced antisepsis to surgical practice, but a thorough history of surgical practice in the 1800’s, and an insightful depiction of the colourful surgeons who defined that period. The author has narrated a gripping and page-turning history of a landmark in the annals of surgical practice with elegant prose. Beyond surgical practices, the book also explored the wider context of infection and its complex relationship to social and public health issues.
The subject of this book, the control of surgical infection, reflects several important lessons for healthcare – from the single-minded determination to solve serious problems, to the importance of new technology in resolving recalcitrant problems. It is as much a lesson in rejecting the status quo when it is unsatisfactory, as it is about viewing existing paradigms and received wisdom with skepticism. This book has lucidly highlighted the importance of establishing the scientific basis for all medical practices, and I recommend it to all doctors.
Publisher, Place, Year: Penguin Books, London, 2017
Number of chapters: 11
Number of pages: 286
Star rating: 5