Adapted from The Butchering Art: Joseph Lister's Quest to Transform the Grisly World of Victorian Medicine, by Lindsey Fitzharris, by Arrangement with Scientific American/Farrar, Straus and Giroux (US), Penguin Press (UK), Bompiani (Italy), Editora Intrinseca (Portugal), Editorial Debate (Spain), Ginkgo (Beijing) Book Co. (China), Het Spectrum (Netherlands), Lindhardt & Ringhof (Denmark), Locus Publishing Company (Taiwan), Suhrkamp Verlag (Germany), Znak (Poland). Copyright © 2017 by Lindsey Fitzharris. All Rights Reserved
As the veteran surgeon Robert Liston stood before those gathered in the new operating theater of University College London a few days before Christmas 1846, he held in his hands the jar of clear liquid ether that might do away with the need for speed in surgery. If it lived up to American claims, the nature of surgery might change forever. Still, Liston couldn't help wondering whether the ether was just another product of quackery that would have little or no useful application in surgery.
Tensions were high. Just 15 minutes before Liston entered the theater, his colleague William Squire had turned to the packed crowd of onlookers and asked for a volunteer to practice on. A nervous murmur filled the room. In Squire's hand was an apparatus that looked like an Arabian hookah made of glass with a rubber tube and bell-shaped mask. The device had been fashioned by Squire's uncle Peter, a pharmacist in London, and used by dental surgeon James Robinson to extract a tooth just two days prior. It looked foreign to those in the audience. None dared volunteer to have it tested on them.
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Exasperated, Squire finally ordered the theater's porter Shelldrake to submit to the trial. He wasn't a good choice, because, as retired surgeon Harold Ellis wrote, he was “fat, plethoric, and with a liver no doubt very used to strong liquor.” Squire gently placed the apparatus over the man's fleshy face. After a few deep breaths of ether, the porter reportedly leaped off the table and ran out of the room, cursing the surgeon and crowd at the top of his lungs.
There would be no more tests. The unavoidable moment had arrived.
End of Agony
At 25 minutes past two in the afternoon, Frederick Churchill—a 36-year-old butler from Harley Street—was brought in on a stretcher. The young man had been suffering from chronic osteomyelitis of the tibia, a bacterial bone infection, which had caused his right knee to swell and become violently bent. His first operation came three years earlier, when the inflamed area was opened up and, as a 1915 article in the American Journal of Surgery would describe, “a number of irregularly shaped laminated bodies” ranging from the size of a pea to that of a large bean were removed. On November 23, 1846, Churchill was once again back in the hospital. A few days later Liston made an incision and passed a probe into the knee. Using his unwashed hands, Liston felt for the bone to ensure it wasn't loose. He ordered that the opening be washed with warm water and dressed and that the patient be allowed to rest. Over the next few days, however, Churchill's condition deteriorated. He soon experienced sharp pain that radiated from his hip to his toes. This occurred again three weeks later, after which Liston decided the leg must come off.
Churchill was carried into the operating theater on a stretcher and laid out on the wooden table. Two assistants stood nearby in case the ether did not take effect and they had to resort to restraining the terrified patient while Liston removed the limb. At Liston's signal, Squire stepped forward and held the mask over Churchill's mouth. Within a few minutes the patient was unconscious. Squire then placed an ether-soaked handkerchief over Churchill's face to ensure he wouldn't wake during the operation. He nodded to Liston and said, “I think he will do, sir.”
Liston opened a long case and removed a straight amputation knife of his own invention. An observer in the audience that afternoon noted that the instrument must have been a favorite, for on the handle were little notches showing the number of times he had used it before. Liston grazed his thumbnail over the blade to test its sharpness. Satisfied that it would do the job, he instructed his assistant William Cadge to “take the artery” and then turned back to the crowd.
“Now, gentlemen, time me!” he yelled. A ripple of clicks rang out as pocket watches were pulled from waistcoats and flipped open.
Liston turned back to the patient and clamped his left hand around the man's thigh. In one rapid movement, he made a deep incision above the right knee. One of his assistants immediately tightened a tourniquet around the leg to halt the flow of blood, while Liston pushed his fingers up underneath the flap of skin to pull it back. The surgeon made another series of quick maneuvers with his knife, exposing the thighbone. He then paused.
Many surgeons, once confronted with exposed bone, felt daunted by the task of sawing through it. Earlier in the century Charles Bell cautioned students to saw slowly and deliberately. Even those who were adept at making incisions could lose their nerve when it came to cutting off the limb. In 1823 Thomas Alcock proclaimed that humanity “shudders at the thought, that men unskilled in any other tools than the daily use of a knife and fork, should with unhallowed hands presume to operate upon their suffering fellow-creatures.” He recalled a spine-chilling story about a surgeon whose saw became so tightly wedged in the bone that it wouldn't budge. His contemporary William Gibson advised that novices practice with a piece of wood to avoid such nightmarish scenarios.
Liston handed the knife to one of the surgical dressers, who, in return, handed him a saw. The same assistant drew up the muscles, which would later be used in forming an adequate stump for the amputee. The great surgeon made half a dozen strokes before the limb fell off, into the waiting hands of a second assistant, who promptly tossed it into a box full of sawdust just to the side of the operating table.
Meanwhile the first assistant momentarily released the tourniquet to reveal the severed arteries and veins that would need to be tied up. In a midthigh amputation, there are commonly 11 to secure by ligature. Liston closed off the main artery with a square knot and then turned his attention to the smaller blood vessels, which he drew up one by one using a sharp hook called a tenaculum. His assistant loosened the tourniquet once more while Liston stitched together the remaining flesh.
It took all of 28 seconds for Liston to remove Churchill's right leg, during which time the patient neither stirred nor cried out. When the man awoke a few minutes later, he reportedly asked when the surgery would begin and was answered by the sight of his elevated stump, much to the amusement of the spectators who sat astounded by what they had just witnessed. His face alight with the excitement of the moment, Liston announced, “This Yankee dodge, gentlemen, beats mesmerism hollow!”
The age of agony was nearing its end.
Two days later surgeon James Miller read a hastily penned letter from Liston to his medical students in Edinburgh, “announcing in enthusiastic terms, that a new light had burst on Surgery.” During the first few months of 1847 both surgeons and curious celebrities visited operating theaters to witness the miracle of ether. Everyone from Sir Charles Napier, colonial governor of what is now a province of Pakistan, to Prince Jérôme Bonaparte, the youngest brother of Napoleon I, came to see the effects of ether with their own eyes.
The term “etherization” was coined, and its use in surgery was celebrated in newspapers around the country. News of its powers spread. “The history of Medicine has presented no parallel to the perfect success that has attended the use of ether,” the Exeter Flying Post proclaimed. Liston's success was also trumpeted in the London People's Journal: “Oh, what delight for every feeling heart ... the announcement of this noble discovery of the power to still the sense of pain, and veil the eye and memory from all the horrors of an operation ... WE HAVE CONQUERED PAIN.”
Unseen Foe
Equally momentous to Liston's triumph with ether was the presence that day of a young man named Joseph Lister, who had seated himself quietly at the back of the operating theater. Dazzled and enthralled by the dramatic performance he had just witnessed, this aspiring medical student realized that the nature of his future profession would forever be changed as he walked out of the theater onto Gower Street. No longer would he and his classmates have to behold “so horrible and distressing a scene” as that observed by William Wilde, a surgical student who was reluctantly present at the excision of a patient's eyeball without anesthetic. Nor would they feel the need to escape, as surgeon John Flint South had done whenever the cries of those being butchered by a surgeon grew intolerable.
Nevertheless, as Lister made his way through the crowds of men shaking hands and congratulating themselves on their choice of profession and this notable victory, he was acutely aware that pain was only one impediment to successful surgery.
He knew that for thousands of years the ever looming threat of infection had restricted the extent of a surgeon's reach. Entering the abdomen, for instance, had proved almost uniformly fatal because of it. The chest was also off-limits. For the most part, whereas physicians treated internal conditions—hence the term “internal medicine,” which still persists today—surgeons dealt with peripheral ones: lacerations, fractures, skin ulcers, burns. Only with amputations did the surgeon's knife penetrate deep into the body. Surviving the operation was one thing. Making a full recovery without any complications was another.
As it turned out, the two decades immediately after the popularization of anesthesia saw surgical outcomes worsen. With their newfound confidence about operating without inflicting pain, surgeons became ever more willing to take up the knife, driving up the incidences of postoperative infection and shock. At Massachusetts General Hospital, for instance, mortality rates for amputations went from 19 percent before ether to 23 percent afterward. Operating theaters became filthier than ever as the number of surgeries rose. Surgeons still lacking understanding of the causes of infection would operate on multiple patients in succession using the same unwashed instruments. The more crowded the theater became, the less likely it was that even the most primitive sanitary precautions would be taken. Of those who went under the knife, many either died or never fully recovered and then spent their lives as cripples and invalids. This problem was universal. Patients worldwide came to further dread the word “hospital,” while the most skilled surgeons distrusted their own abilities.
With Robert Liston's ether triumph, Lister had just witnessed the elimination of the first of the two major obstacles to successful surgery—that it could now be performed without pain. Inspired by what he had seen on the afternoon of December 21—but mindful of the dangers still hindering his profession—the deeply perceptive Joseph Lister would soon embark on devoting the rest of his life to elucidating the causes and nature of postoperative infection and finding a solution for it. In the shadow of one of the profession's last great butchers, another surgical revolution was about to begin.