Kalyx Bowler

Prologue: The Age of Agony

When a distinguished but elderly scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is almost certainly wrong.
—Arthur C. Clarke

On the afternoon of December 21, 1846, hundreds of men crowded into the operating theater at London’s University College Hospital, where the city’s most renowned surgeon was preparing to enthrall them with a mid-thigh amputation. As the people filed in, they were entirely unaware that they were about to witness one of the most pivotal moments in the history of medicine.

The theater was filled to the rafters with medical students and curious spectators, many of whom had dragged in with them the dirt and grime of everyday life in Victorian London. The surgeon John Flint South remarked that the rush and scuffle to get a place in an operating theater was not unlike that for a seat in the pit or gallery of a playhouse. People were packed like herrings in a basket, with those in the back rows constantly jostling for a better view, shouting out “Heads, heads” whenever their line of sight was blocked. At times, the floor of a theater like this one could be so crowded that the surgeon couldn’t operate until it had been partially cleared. Even though it was December, the atmosphere inside the theater was stifling, verging on unbearable. The crush of bodies made the place feel plaguey hot.

The audience was made up of an eclectic group of men, some of whom were neither medical professionals nor students. The first two rows of an operating theater were typically occupied by “hospital dressers,” a term that referred to those who accompanied surgeons on their rounds, carrying boxes of supplies needed to dress wounds. Behind the dressers stood the pupils, who restlessly pushed and murmured to one another in the back rows, as well as honored guests and other members of the public.

Medical voyeurism was nothing new. It arose in the dimly lit anatomical amphitheaters of the Renaissance, where, in front of transfixed spectators, the bodies of executed criminals were dissected as an additional punishment for their crimes. Ticketed spectators watched anatomists slice into the distended bellies of decomposing corpses, parts gushing forth not only human blood but also fetid pus. The lilting but incongruous notes of a flute sometimes accompanied the macabre demonstration. Public dissections were theatrical performances, a form of entertainment as popular as cockfighting or bearbaiting. Not everyone had the stomach for it, though. The French philosopher Jean-Jacques Rousseau said of the experience, “What a terrible sight an anatomy theatre is! Stinking corpses, livid running flesh, blood, repellent intestines, horrible skeletons, pestilential vapors! Believe me, this is not the place where [I] will go looking for amusement.”

The operating theater at University College Hospital looked more or less the same as others in the city. It consisted of a stage partially enclosed by semicircular stands rising one above another toward a large skylight that illuminated the area below. On days when swollen clouds blotted out the sun, thick candles lit the scene. In the middle of the room was a wooden table stained with the telltale signs of past butcheries. Underneath it, the floor was strewn with sawdust to soak up the blood that would shortly issue from the severed limb. On most days, the screams of those struggling under the knife mingled discordantly with everyday noises drifting in from the street below: children laughing, people chatting, carriages rumbling by.

In the 1840s, operative surgery was a filthy business fraught with hidden dangers. It was to be avoided at all costs. Due to the risks, many surgeons refused to operate altogether, choosing instead to limit their scope to the treatment of external ailments like skin conditions and superficial wounds. Invasive procedures were few and far between, which was one of the reasons why so many spectators flocked to the operating theater on the day of a procedure. In 1840, for instance, only 120 operations were performed at Glasgow’s Royal Infirmary. Surgery was always a last resort and only done in matters of life and death.

The physician Thomas Percival advised surgeons to change their aprons and to clean the table and instruments between procedures, not for hygienic purposes, but to avoid “every thing that may incite terror.” Few heeded his advice. The surgeon, wearing a blood-encrusted apron, rarely washed his hands or his instruments and carried with him into the theater the unmistakable smell of rotting flesh, which those in the profession cheerfully referred to as “good old hospital stink.”

At a time when surgeons believed pus was a natural part of the healing process rather than a sinister sign of sepsis, most deaths were due to postoperative infections. Operating theaters were gateways to death. It was safer to have an operation at home than in a hospital, where mortality rates were three to five times higher than they were in domestic settings. As late as 1863, Florence Nightingale declared, “The actual mortality in hospitals, especially in those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of diseases amongst patients treated out of the hospital would lead us to expect.” Being treated at home, however, was expensive.

The infections and the filth weren’t the only problems. Surgery was painful. For centuries, people sought ways to make it less so. Although nitrous oxide had been recognized as a painkiller since the chemist Joseph Priestley first synthesized it in 1772, “laughing gas” was not normally used in surgery, because its results were unreliable. Mesmerism—named after the German physician Franz Anton Mesmer, who invented the hypnotic technique in the 1770s—had also failed to be accepted into mainstream medical practice in the eighteenth century. Mesmer and his followers thought that when they moved their hands in front of patients, a physical influence of some kind was generated over them. This influence created positive physiological changes that would help patients heal and could also imbue a person with psychic powers. Most doctors remained unconvinced.

Mesmerism enjoyed a brief revival in Britain in the 1830s, when the physician John Elliotson began holding public displays at University College Hospital during which two of his patients, Elizabeth and Jane O’Key, were able to predict the fate of other hospital patients. Under Elliotson’s hypnotic influence, they claimed to see “Big Jacky” (otherwise known as Death) hovering over the beds of those who later died. Any serious interest in Elliotson’s methods was short-lived, however. In 1838, the editor of The Lancet, the world’s leading medical journal, tricked the O’Key sisters into confessing their fraud, thus exposing Elliotson as a charlatan.

The scandal was still fresh in the minds of those attending University College Hospital on the afternoon of December 21, when the renowned surgeon Robert Liston announced he’d be testing the efficacy of ether on his patient. “We are going to try a Yankee dodge today, gentlemen, for making men insensible!” he declared as he made his way to the center of the stage. A hush fell over the theater as he began to speak. Like mesmerism, the use of ether was seen as a suspect foreign technique for putting people into a subdued state of consciousness. It was referred to as the Yankee dodge due to its being first used as a general anesthetic in America.

At six feet two, Liston was eight inches taller than the average British male. He had built his reputation on brute force and speed at a time when both were crucial to the survival of the patient. Those who came to witness an operation might miss it if they looked away even for a moment. It was said of Liston by his colleagues that when he amputated, “the gleam of his knife was followed so instantaneously by the sound of sawing as to make the two actions appear almost simultaneous.” His left arm was reportedly so strong that he could use it as a tourniquet, while he wielded the knife in his right hand. This was a feat that required immense strength and dexterity, given that patients often struggled against the fear and agony of the surgeon’s assault. Liston could remove a leg in less than thirty seconds, and in order to keep both hands free, he often clasped the bloody knife between his teeth while working.

Liston’s speed was both a gift and a curse. Once, he accidentally sliced off a patient’s testicle along with the leg he was amputating. His most famous (and possibly apocryphal) mishap involved an operation during which he worked so rapidly that he took off three of his assistant’s fingers and, while switching blades, slashed a spectator’s coat. Both the assistant and the patient died later of gangrene, and the unfortunate bystander expired on the spot from fright. It is the only surgery in history said to have had a 300 percent fatality rate.

Indeed, the perils of shock and pain limited surgical treatments before the dawn of anesthetics. One surgical text from the eighteenth century declared, “Painful methods are always the last remedies in the hands of a man that is truly able in his profession; and they are the first, or rather they are the only resource of him whose knowledge is confined to the art of operating.” Those desperate enough to go under the knife were subject to unimaginable agony.

The traumas of the operating theater could take a toll on student spectators too. The Scottish obstetrician James Y. Simpson fled an amputation of the breast when he was studying at the University of Edinburgh. The sight of the soft tissues being lifted with a hook-like instrument and the surgeon preparing to make two sweeping cuts around the breast proved too much for Simpson. He forced his way back through the crowd, exited the theater, hurried through the hospital gates, and made his way up to Parliament Square, where he declared breathlessly that he now wished to study law. Fortunately for posterity, Simpson—who would go on to discover chloroform—was dissuaded from pursuing a change of career.

Although Liston was all too aware of what awaited his patients on the operating table, he often downplayed the horrors for the sake of protecting their nerves. Just months before his experiment with ether, he removed the leg of a twelve-year-old child named Henry Pace, who had been suffering from a tubercular swelling of the right knee. The boy asked the surgeon whether the operation would hurt, and Liston responded, “No more than having a tooth out.” When the moment came to have his leg removed, Pace was brought into the theater blindfolded and pinned down by Liston’s assistants. The boy counted six strokes of the saw before his leg dropped off. Sixty years later, Pace would recount the story to medical students at University College London—the horror of the experience, no doubt, fresh in his mind as he sat in the very hospital in which he had lost his leg.

Like many surgeons operating in a pre-anesthetic era, Liston had learned to steel himself against the cries and protests of those strapped to the blood-spattered operating table. On one occasion, Liston’s patient, who had come in to have a bladder stone removed, ran from the room in terror and locked himself in the lavatory before the procedure could begin. Liston, hot on his heels, broke the door down and dragged the screaming patient back to the operating room. There, he bound the man fast before passing a curved metal tube up the patient’s penis and into the bladder. He then slid a finger into the man’s rectum, feeling for the stone. Once Liston had located it, his assistant removed the metal tube and replaced it with a wooden staff, which acted as a guide so the surgeon wouldn’t fatally rupture the patient’s rectum or intestines as he began cutting deep into the bladder. Once the staff was in place, Liston cut diagonally through the fibrous muscle of the scrotum until he reached the wooden staff. Next, he used the probe to widen the hole, ripping open the prostate gland in the process. At this point, he removed the wooden staff and used forceps to extract the stone from the bladder.

Liston—who reportedly had the fastest knife in the West End—achieved all this in just under sixty seconds.

Now, as Liston stood before those gathered in the new operating theater of University College London a few days before Christmas, the veteran surgeon 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 fifteen 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. None dared to have it tested on them.

Exasperated, Squire ordered the theater’s porter Shelldrake to submit to the trial. He wasn’t a good choice, because 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.

At twenty-five minutes past two in the afternoon, Frederick Churchill—a thirty-six-year-old butler from Harley Street—was brought in on a stretcher. 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.

“Now, gentlemen, time me!” he yelled. A ripple of clicks rang out as pocket watches were pulled from waistcoats and flipped open.

It took all of twenty-eight seconds for Liston to remove Churchill’s right leg, during which time the patient neither stirred nor cried out. When the young 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.

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, this aspiring medical student realized as he walked out of the theater onto Gower Street that the nature of his future profession would forever be changed.

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.

As it turned out, the two decades immediately following 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. Operating theaters became filthier than ever as the number of surgeries increased. Surgeons still lacking an understanding of the causes of infection would operate on multiple patients in succession using the same unwashed instruments on each occasion.

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 inflicting pain. Inspired by what he had seen on the afternoon of December 21, the deeply perceptive Joseph Lister would soon embark on devoting the rest of his life to elucidating the causes and nature of postoperative infections and finding a solution for them. In the shadow of one of the profession’s last great butchers, another surgical revolution was about to begin.

— From The Butchering Art by Lindsey Fitzharris