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the butchering art

11 april 2019

The Butchering Art is an entertaining look at medical innovation in the 19th century. Though you have to say it's a little bit histrionic. Lindsey Fitzharris goes in for pagelong compendia of every gruesome way that Victorians came up with to be medically mistreated, environmentally poisoned, and basically just die appallingly. It's a wonder anybody made it out of the 19th century so that we could hold a 20th.

Though perhaps the main flaw in this otherwise excellent book is simply a lack of context. We tend to think of the Victorian era as an age of progress that was also in many ways premodern. Fitzharris, breaking into the story in media res, gives us the 1840s as entirely premodern. The wonder is not so much how we could have gotten to the 1900s as how we made it to the 1800s.

Here and there, though, some background can be inferred. Victorian hospitals were lethal places, often worse than no hospitals at all. If we look much earlier, Fitzharris suggests, there were no hospitals at all. People died at great rates in the earlier-modern period before 1800, but they did not die in hospitals or of conditions peculiar to hospitals. Urbanization created new problems, among them a crush of patients who (because it was the age of progress) felt they had a shot at cures that a century earlier they would have left in the hands of God. The crowding-together of these patients created new problems, among them iatrogenic infections. The medical world of the Victorians was better than that of their forbears, but it was one where every two steps forward meant a step-and-a-half back.

Fitzharris begins with the introduction of anaesthesia into British surgical practice, in the 1840s. This was a big step forward. She presents it mainly as a blessing to patients who were saved the incredible pain of earlier operations; but of course it was a blessing to surgeons too. An etherized patient doesn't wriggle. Robert Liston, the dean of English surgery as the story opens, was famed for his great speed in whipping off limbs and such. When he adopted ether, he no longer had to work like quite such a madman. Surgery became a deliberate therapy as opposed to an athletic display.

But even though patients benefited from reduced trauma and more careful operations, they still dropped like flies on the recovery wards. Gangrene was rampant, also such lurid afflictions as sepsis and pyemia. Surgeons themselves had low life expectancies. They worked ungloved, unwashed, and (as Fitzharris is fond of relating) with filthy instruments, in gore-besmirched clothes. Early-Victorian medical science was clueless as to the cause of postoperative infections. And though The Butchering Art is Anglo- and Caledoni-centric, it's not like surgeons on the Continent or elsewhere were any better-informed. Fitzharris of course mentions Ignác Semmelweis, now a national hero in Hungary and the first to connect unsanitary conditions with puerperal fever; but Semmelweis was notoriously without honor in his own empire.

It took an English surgeon long active in Scotland, Joseph Lister, to connect the morbidity in British hospitals with the advances in germ theory that Louis Pasteur was pioneering in France. Lister was a gifted surgeon with a distinct family advantage: his father was an expert on microscopes, and raised young Joseph to look very, very closely at things. Yet while his work with microscopes convinced Lister that Pasteur was on to something, his development of antiseptic surgery was along a classic train of inference from things seen to those unseen.

Pre-Lister surgeons believed either that gangrene and similar infections arose by spontaneous generation, or via the "miasma" of unhealthy air. Spontaneous generation, disproven by Pasteur, lost adherents, but the miasma theory was plausible. Fitzharris says that some surgeons tried to seal wounds completely off from the surrounding air. This was both unhelpful and, ultimately, impossible.

Lister theorized that something in the air, not the air itself, was the culprit. He could see airborne organisms in his microscope, though he had no idea how they affected wounds. His best clue came from the distinction between simple fractures, with the skin unbroken, which usually healed on their own, and compound fractures, bone protruding through skin, which seemed an open door for gangrene. What if one simply washed the wound from a compound fracture, and kept it dressed with preparations soaked in carbolic acid? When such cases showed a great reduction in infection, Lister knew he was onto something.

Lister combined theory and empirical adjustment in an ever-perfecting cycle. But he was not a genius. Fitzharris describes a famous operation that Lister performed on Queen Victoria. He removed a growth from her arm and dressed the wound in his signature style; but to be extra-sure, he had assistants wander the operating room with an atomizer spraying carbolic-acid droplets everywhere. The idea was to kill the germs before they could settle on the Queen. The only effect was to make everybody a bit sick from inhaling all that antiseptic. But Victoria recovered and Lister was on his way to knighthood and the peerage – and immortality as a mouthwash.

Fitzharris, Lindsey. The Butchering Art: Joseph Lister's quest to transform the grisly world of Victorian medicine. New York: Scientific American / Farrar, 2017. RD 27.35 .L57F58