Hospitalism

In​ the small hours of a spring morning last year I asked for a hot-water bottle to be put on my calf: a ruptured disc was crushing my sciatic nerve, causing leg pain unappeased by opioids and benzodiazepines. I went back to sleep. When I woke up, I felt a damp substance on my leg, and when I wiped it off, I noticed a wet white rag was hanging from my fingertips. I thought little of it: pain was my sole preoccupation at the time, and there wasn’t any. Later that day, awaiting surgery, I was told the hot-water bottle had caused a burn clean through the epidermis, cauterising the nerves.

The burn became a black disc so tough you could rap it like the cover of a leather-bound book; I fretted about scarring, but what concerned the doctors was the possibility of my acquiring one of the antibiotic-resistant strains of bacteria that plague hospital wards. Two weeks later – the necrotic flesh had receded to reveal body fat resembling butter softened in the microwave – a GP peeled the dressing off, lifted it to her nose, and recoiled at the unmistakeable smell of infection. Swabs were taken, but it was merely the Staphylococcus aureus bacterium, its name deriving from the Greek for ‘grape-cluster berry’, which it resembles. A course of antibiotics, frequent sluicings with saline, and all would be well.

In the days of Lister, Liston and Pasteur, such infections were thought to be an example of what was known as ‘hospitalism’, for the better prevention of which it was even proposed that all hospitals should be razed by fire and rebuilt every ten years or so. Hospitalism comprised the ‘big four’ of infection: septicaemia, erysipelas, pyaemia and hospital gangrene. The last was most to be feared: to picture an afflicted limb, think of a gnawed chicken bone spat into a napkin. Surgeons would excise, amputate and re-embowel under anaesthesia, only to lose patients to infection in the aftermath.

Efforts to combat and contain hospitalism were as misguided as they were strenuous. All could agree on the urgent necessity of forestalling or treating infection, but not on the cause or the cure. The contagionist faction believed disease was communicated by some invisible agent, a chemical or an ‘animalcule’, and urged containment through quarantine and trade restrictions. This was all very well: but what of diseases like cholera, which couldn’t be explained by contact transmission?

The anti-contagionists theorised that a pythogenic process caused disease spontaneously to erupt from filth and decay, with pestilence travelling in an infectious miasma that seeped across windowsills. That the most disease-stricken populations lived in the most squalid conditions only bolstered the theory. Andrew Mearns’s survey of urban squalor from 1883, The Bitter Cry of Outcast London, describes rooms ‘black with the accretions of filth which have gathered upon them through long years of neglect. It is exuding through cracks in the boards overhead; it is running down the walls; it is everywhere.’ Any air that penetrated these rookeries had first passed over ‘the putrefying carcasses of dead cats or birds, or viler abominations still’. This was the model of a post hoc fallacy: surely a child breathing in air that had lingered over a rotting animal was inhaling a deadly pestilence?

Even the worst corner of the worst slum couldn’t compete with hospital wards and dissection rooms for filth. Berlioz trained as a doctor and recalled a visit to the ‘terrible charnel-house’ of a Paris dissecting room. ‘The fragments of limbs, the grinning heads and gaping skulls, the bloody quagmire underfoot and the atrocious smell it gave off’ made him feel ‘terrible revulsion’. Sparrows squabbled over morsels of lung; a rat gnawed at a vertebra. Berlioz jumped out of the window and ran home to take sanctuary in music. Surgeons took pride in aprons so dirty they could have stood up on their own; Robert Liston, who pioneered the use of anaesthesia, stored his instruments up his sleeve between surgeries to keep them warm. The mortality rate among medical students – who were liable to let the knife slip – was high: the surgeon John Abernethy concluded his lectures with a resigned ‘God help you all.’ When John Phillips Potter nicked his knuckle anatomising – at the dead man’s request – the circus performer the ‘Gnome Fly’, he swiftly succumbed to pyaemia, a kind of blood poisoning caused by the spread of pus-forming organisms which cause abscesses. The pus drained from his body could be measured by the pint. When Potter died, it was surmised that if he had eaten breakfast before picking up the scalpel, the food would have absorbed any poison attending the corpse, and he would have survived essentially unscathed.

This was the Grand Guignol stage on which Joseph Lister – the subject of Lindsey Fitzharris’s agreeably grisly and fastidiously detailed book The Butchering Art – took his place. Born into a Quaker family, Lister was tall, handsome and abstemious. He stammered and was prone to melancholy. Convinced, until he determined otherwise, that cold and wet feet could induce sickness, he wore thick-soled shoes. His father, Joseph Jackson Lister, an expert in microscopic lenses, solved the problem of image distortion. He passed on to his son a belief – not widely held – in the crucial importance of the microscope to medical science. Lister’s mother had suffered from erysipelas, an acute skin infection; his brother, having survived smallpox, was killed by a brain tumour.

Lister entered University College London in 1844, aged seventeen. London was a shock after the lawns and cedars of his Essex childhood, and his studies were attended by protracted periods of depression. Nonetheless it was exhilarating to be in the fray, and he proved his mettle early on when a woman called Julia Sullivan was admitted after being stabbed in the abdomen by her husband (looking down, she exclaimed: ‘Oh, my entrails are coming out!’). Lister had two lives in his hands: Sullivan’s and that of her husband, who would hang if a wounding became a murder. Fitzharris describes the incident with characteristic briskness, neither sparing the reader nor descending into prurience. Lister treated his patient with uncommon skill, suturing the gut in a procedure generally cautioned against because of the likelihood of infection (the application of a red hot poker, pressed on the entrails as slowly as possible, was the preferred method). She lived.

Lister’s first inkling that hospitalism was not inevitable came during an outbreak of hospital gangrene. Tasked with sloughing dead matter from infected wounds and applying a caustic solution, he observed that ulcers which had been debrided and cleaned were more likely to heal. The suggestion that the cause of infection lay inside the body was powerful. Examining pus from a gangrenous patient beneath the microscope he discovered ‘some bodies of pretty uniform size which might be the materies morbi [morbid substances]’. He had looked the enemy in the eye.

He pursued his prey down labyrinthine paths of theory, experiment and failure – periodically blocked by administrative obfuscation and opposition from his peers. Questions followed hard on the heels of answers (‘11 p.m. Query. How does the poisonous matter get from the wound into the veins?’). What was the purpose of inflammation? Was it beneficial or harmful; was it the cause of infection, or merely a signifier? What pus was dangerous, and what wasn’t? Why did a compound fracture often grow gangrenous, when fractures neatly contained beneath the skin didn’t? Frogs suffered for Lister’s ambition. ‘What new points render requisite still further experiments with the poor frogs?’ his father asked. Lister presented papers. He advocated cleanliness on the wards. He familiarised himself with the work of Louis Pasteur, whose investigations into spoiled wine had identified rod-like bacteria annexing the yeast. He concluded that ‘just as we can destroy lice on the nit-filled head of a child by applying a poison that causes no lesion to the scalp, so I believe that we can apply to a patient’s wounds toxic products that will destroy the bacteria without harming the soft parts of this tissue.’ Antiseptic irrigation was already in use, but only as a treatment, not as a prophylactic: Lister proposed that wounds should be cleaned before infection set in. He experimented with various preparations, pouring dilute potassium permanganate (used in powder form to produce a photographer’s flash) into the skin flaps of a recently amputated limb, but that test was a failure.

The most striking element of Fitzharris’s book is not its depiction of surgical daring (the legendary James Syme could take your leg off at the hip in less than a minute), or ghastly suffering (an unanaesthetised man with a facial tumour endured 24 minutes, watching slices of his jawbone drop ‘with a sickening rattle’ into a bucket), but the suggestion that the advance towards asepsis was driven as much by happenstance – and by adherence to the Holmesian principle that one must observe rather than merely see – as by hours in the laboratory. Lister’s lifelong fascination with the microscope, which prompted his examination of gangrenous pus as well as his use of antiseptics, can be traced back to his father, and to his own childhood realisation that a bubble trapped in a windowpane enlarges what lies beyond it. And one of the strongest challenges to the anti-contagionist theory came not from a paper in the Lancet, but from the Great Stink of 1858. The Thames, by this stage little more than a sewer conveying effluent to the North Sea, began to emit a stench which, according to Faraday, could be observed ‘rolled up in clouds so dense that they were visible at the surface’. Londoners fled; there was a proposal that the Houses of Parliament be evacuated. And yet there were no epidemics that year, contrary to the expectations of proponents of the miasma theory.

Lister’s greatest advance was prompted by a newspaper report. In Carlisle, sewage engineers gagging at the smell of liquid waste spread over nearby fields had addressed the problem by covering it with carbolic acid, a substance used with indiscriminate enthusiasm for tasks including preserving ships’ timbers and preventing body odour. But a curious side-effect was observed: an outbreak of cattle plague in the carbolic-soaked fields was halted, the plague-causing parasites having been eradicated. Lister, who had abandoned his trials with potassium permanganate, quickly obtained a sample of carbolic acid. Shortly afterwards, treating a child whose leg had been shattered by a cart, he faced a choice: whether to amputate to forestall the inevitable gangrene, or to test his theory that carbolic acid could prevent infection. With the arrogance necessary to the practice of medicine, Lister decided to put carbolic acid to the test. Some weeks later the boy walked out of the hospital.

Unfortunately, nobody – least of all a scientist – likes to be publicly corrected. Infection was still considered by many to be inevitable, and best left to play out as Providence determined – a version, in fact, of the ‘therapeutic nihilism’ to which most Quakers, Lister’s father included, adhered. To argue the contrary was tacitly to condemn surgical practices that had been in use for decades. In Vienna, the Hungarian physician Ignaz Semmelweis observed that, contrary to received wisdom, mothers were more likely to die of the postpartum infection ‘childbed fever’ when attended by a surgeon rather than a midwife. When a colleague cut himself performing an autopsy and died of an infection with symptoms identical to those of childbed fever, Semmelweis realised that the disease had been transmitted from corpse to surgeon and that it had been caused by the same agent that killed new mothers. A simple solution presented itself: surgeons should wash their hands with a preparation of chlorinated lime before administering to women in labour. Handwashing facilities were installed, deaths from childbed fever plummeted and Semmelweis briefly rejoiced in the title ‘Saviour of Mothers’. The triumph was short-lived: doctors demanded a full explanation of his theory, and not receiving one, refused to wash their hands. Semmelweis took to roaming around Vienna thrusting pamphlets into the hands of passers-by urging women to allow only midwives to attend their births. He was eventually sent to an asylum (where he sustained a wound in a scuffle with the guards and died, probably of an infection).

Lister wasn’t exempt from charges of quackery and folly, and Fitzharris – with an eye for the narrative arc – recounts the humbling of her hero. Anonymous letters to newspapers accused Lister of intellectual theft. His methods were denounced as ‘obsolete and inelegant’. In a broadside reminiscent of those levelled at Darwin, one opponent castigated Lister for portraying nature as ‘some murderous hag whose fiendish machinations must be counteracted’. Nonetheless, when Queen Victoria could no longer bear the pain caused by an abscess under her arm, it was Lister who was summoned to Balmoral, accompanied by a copper pumping mechanism known as a ‘donkey engine’, which sprayed a fine mist of carbolic acid (including, to the horror of onlookers, into the queen’s face). The abscess and the surgical instruments were soaked in antiseptic; the pus was drained; the wound healed well; and Lister – with what one imagines to have been a rare flash of humour – declared himself ‘the only man who has ever stuck a knife into the queen’.

Fitzharris does not do the longue durée, confining herself to Lister and his contemporaries. But efforts to tackle infection are almost as old as the human record. The Berlin Papyrus, an Egyptian medical document from at least as early as 1200 BCE, stresses the necessity of keeping wounds closed, to prevent malicious spirits from entering with disease in their wake – a notion that calls to mind the theory of the pestilential miasma. The topical application of honey was known to be beneficial: in the Greek physician Dioscorides’ De Materia Medica it is observed that honey is ‘good for all rotten and hollow ulcers’. Moses issued the Israelites with instructions to isolate those who had been in contact with the dead outside the camp (19th-century surgeons bustling from mortuary to operating table might have done well to recall this). The Butchering Art, with its attention to detail, its admiration for its subject and its unflinching sympathy for the suffering, proposes a causal chain – running through the history of human sickness and not yet at its end – in which Lister forms a strong and vital link.