The Butchering Art: Joseph Lister’s Quest to Reform the Grisly World of Victorian Medicine by Lindsey Fitzharris, is the first medical history book I’ve read since Before the Event. It was a worthy re-introduction to my favourite subject. Joseph Lister is known for pioneering antiseptic principles in medicine, especially in relation to surgical wounds. If you have ever had an operation without subsequently getting an infection, it is not far from the truth to say that you have Joseph Lister to thank. This sweeping biography looks primarily at Lister’s work as a surgeon, researcher, and teacher, though it touches on his personal life as well. I listened to the audiobook over several months, but my slow pace of listening in no way reflects how much I enjoyed the book, because I absolutely loved it. It was well-narrated, engaging, and despite the fact that I’m already quite familiar with this period of medical history, there was plenty in it that I hadn’t known before.
Here’s a lovely place to start. Imagine my joy on discovering that, just this once, a man who has long been one of my medical heroes was also actually a nice person. This is rare for great surgeons, even now, since you have to have fairly high baseline arrogance in order to think that you are the right person to crack open another person’s chest or replumb their kidneys. Over the years, as I’ve read about the people who’ve made remarkable medical discoveries or who have changed the way we think about the body, very often I’ve discovered that ethically they were a mixed bag (for example, there were some home truths about Jonas Salk, pioneer of the polio vaccine, in The Vaccine Race). Yet Lister turns out to have been a lovely man, with endless compassion for his patients and an insistence on treating every one of them equally, whether or not they could afford it, long before the advent of the NHS. He saw his patients back to the ward after their ops, helping them off the stretcher, and settling them in with pillows and blankets before he left. It seems that he was particularly good with paediatric patients, which – I speak from long, weary experience as an ex-surgical children’s nurse – is still very rare among all but specialist surgeons. This great concern for his patients’ wellbeing was the motivating force that led him to work so hard to understand and counteract hospital infections, especially post-operative sepsis.
Despite the fact that this is a biography of one person, Fitzharris avoids the temptation to step into the Great Man approach, and shows over and over how Lister was building on other people’s work. He came of age as a surgeon at a time where the field was expanding rapidly, because the use of first ether and then chloroform for anaesthesia meant that operations that were previously much too involved could be attempted. Pre-anaesthesia, the field wasn’t much removed from the 15th century barbers who’d lop off your leg which you chugged brandy to numb the pain. This was a fascinating time for medical history in general, and a lot of that is captured beautifully in this book. In particular, the battle between the contagion and miasma theories of disease that was raging in the mid-19th century, both a little right and a little wrong, is depicted in wonderful detail, along with the way they evolved into the currently accepted germ theory. The miasma theory blamed bad air, the contagion theory blamed human contact with infectious materials (much closer to being right), but eventually through many people’s experiments, case reports, and campaigns, germ theory was developed – which allowed for an understanding that these tiny “animalcules” could be in the air, but could also be passed from person to person in a more direct route. Lister’s involvement in these discussions is depicted very well, as are his own evolving views. He started out as a proponent of the miasma theory of disease, because of the visibly positive effect that keeping a hospital clean had on morbidity and mortality. His experiments in keeping surgical wounds clean and protected were based on germ theory, and were among the many studies and trials that ultimately supported the adoption of that idea in both theory and practice.
The Butchering Art does have an omission that I found perplexing. Although it mentions Florence Nightingale once or twice early on, there is no discussion of her work. If you are writing about the campaign for cleanliness in Victorian healthcare settings, it seems bizarre not to include this statistician, public health campaigner, and nurse. Nightingale was involved in the contagion theory/miasma theory debate – like Lister she stayed with miasma theory until germ theory came around, because she had seen firsthand the importance of cleanliness in healthcare settings. She carried out an early epidemiological study on the patients in her Crimean war hospital (below) demonstrating the role that infection played in hospital deaths, campaigned successfully for better sanitation in Britain and India, and was a prominent figure in health, activism, and statistics at a time that directly overlapped with the period at which Lister was most active. It’s impossible to imagine that he hadn’t heard of her or read her work, especially given that – as established in this book – he was interested in the professionalisation of nursing to benefit patient care.
I’m not sure what caused this omission. I think I have a fairly good grasp of the people who were working on this and related issues at the time, and there were no other glaring gaps that I could see. Maybe simply the fact that Nightingale was a nurse, rather than a physician? Or maybe Fitzharris is going to write a book about Nightingale next and didn’t want to spoil too much? If so, that would make me very happy. Writing about Nightingale so often describes her as a “ministering angel” or “the lady of the lamp”, and ignores the fact that the bulk of her work was not bedside nursing but research, activism, education, and policy development. I’d love to read a decent biography that took her scientific work seriously. Also, it would be nice to have something to show the naysayers that these elements have been a key aspect of nursing for as long as it has been a profession and are by no means a recent innovation.
Anyway. Back to the book I am actually reviewing, and not the one that I want Fitzharris to write next. Those of a sensitive disposition – well, you probably aren’t going to pick up a Victorian medical history book in the first place, but just in case – be advised that vivisection was a common part of medical research during the era. As such there are descriptions of brutal experimentation on frogs and one particularly distressing scene with a dog. I am not especially an animal lover, but even I found the latter difficult to listen to. Fitzharris avoids passing judgement on Lister and others who carried out this type of research, and I’m glad, for it’s difficult to imagine how we would have developed out understanding of e.g. the nervous system’s role in circulation and blood pressure without it, given the technological limitations of the era. She doesn’t dwell on these experiments, but she covers them to a reasonable extent. There are also a lot of graphic descriptions of pre-anaesthesia surgery, which had to be carried out very rapidly (and thus not very accurately) because of the excruciating pain. It’s nothing worse than any other medical history book, but if you’re sensitive to blood, bowels, or anything of the kind, approach with caution. “Grisly” is in the subtitle for a reason.
There were all sorts of other interesting titbits in this book. Lister was English, but moved to Scotland for about six months and ended up staying for 24 years, moving between Edinburgh and Glasgow. Both cities had highly respected ancient universities, but Edinburgh was thought of as a much more avant-garde sort of place for medical treatment and teaching, in contrast with conservative Glasgow. When Lister tried to improve standards at Glasgow’s Royal Infirmary through clinical teaching on the wards – standard practice in large European cities by then – he was put firmly in his place: “that’s an Edinburgh idea”. The Glaswegian board in charge of medical services in the city was full of businessmen who’d bought their way in, rather than physicians, and this made it much harder for Lister to make changes than it had been at his previous workplace. In Edinburgh, he a) was surrounded by early adopters with an interest in scientific research, and b) had the patronage of his well-liked and respected father-in-law, James Syme, who’d been one of the early pioneers of ether in Britain and was generally open to new ideas.
At the same time, because of its rapidly growing population, heavy reliance on industry, and status as the “second city of the empire”, Glasgow was one of the best places in the world to improve surgical technique. People of all backgrounds were constantly admitted with wounds of every kind, especially workplace injuries, and it was while treating these that Lister was able to fully develop his antiseptic techniques. I was interested to read about how he did his best to conduct his trials ethically, long before such principles were broadly adopted: he developed his carbolic acid solution on people who would otherwise have needed amputations. If it failed and the wound developed an infection, he could still amputate and hopefully save the person’s life; if it succeeded, the injured person would keep their limb and therefore their livelihood. When he found a treatment that saved lives, but was uncomfortable or left a rash, he was dissatisfied and kept experimenting until he was able to find something with minimal side effects for the patient. Eventually, through this kind of meticulous and determined research, he dragged Glasgow Royal Infirmary – kicking and screaming the whole way – into the late 19th century. Lister’s wards went from having some of the highest surgical mortality in the country to some of the lowest during his tenure.
Overall, if medical history is something you’re interested in, I really recommend this, even if you know the era quite well already. Fitzharris is an excellent writer, able to make people and scenes come alive on the page, and she strikes a good balance between biographical material about Lister and the wider debates, discussions, and developments going on at the time. There is more as well that I didn’t have time to get to: unlike a lot of 21st century science historians, Fitzharris takes her subject’s devout faith very seriously, and examines the role it played in his career; she beautifully depicts the internecine squabbles of various medical schools, hospitals and universities, both within Scotland and within Britain more generally; she creates the world of 19th century hospital care with unsettling vividness. She also reports also a quite remarkable medical conference in the US, at which Lister was invited to speak (after germ theory and antiseptic principles had been widely and successfully adopted across Europe), specifically so that tonnes of eminent US surgeons could – one after the other – denounce him for being so stupid as to believe in “tiny living things”. The mind boggles. In case you’re curious, the first hospital in the US to adopt germ theory and antiseptic technique was Massachusetts General Hospital, which was also instrumental in the early use of ether. Anyway, the book is full of all sorts of stuff I didn’t get to write about in this review for space – well worth a listen (or read).
A note on format – the audiobook, narrated by Sam Woolf is very good indeed, though in hindsight I wish I’d had access to the references and footnotes that I presume are in the physical copy. Still, Woolf’s various Scottish and American accents all seemed okay to me, though I’m amused that he didn’t even attempt to give Louis Pasteur a French accent, and he gave the more dramatic scenes some verve without overegging it.