Kalyx Bowler

It was during this time that Lister attempted to improve hygiene at the Royal Infirmary in the hope that it would minimize incidences of hospitalism. “Cleanliness” in hospitals often meant no more than sweeping floors and opening windows in the operating theater, and the Royal Infirmary was no exception. Lister suspected that if he could make the wards cleaner, his patients might stop dying.

And so he began subscribing to what was known in the 1860s as the “cleanliness and cold water” school of thought, which drew analogies between the tarnishing of silver and the infections caused by bad air. Advocates of this philosophy knew that if a person dipped a spoon in cold water, it would delay the formation of a sulfide coating. Using that same logic, they thought that by boiling water and letting it cool before washing both the instruments and the wound site, a surgeon could prevent postoperative infections from developing.

Lister’s focus on cleanliness was still linked to his belief that outbreaks of hospitalism were due to the poisonous atmosphere on the wards. Others had already started to question this theory. Between 1795 and 1860, three doctors put forward the idea that puerperal (or childbed) fever—which, like sepsis, was accompanied by both localized and systemic inflammation—was caused not by miasma but by materies morbi (morbid substances) transmitted from doctor to patient. Each believed the disease could be prevented by following strict rules of cleanliness in the hospitals.

The first of these three doctors was a Scotsman named Alexander Gordon, who was working in Aberdeen when a prolonged outbreak began there in December 1789. Over the course of three years, Gordon treated seventy-seven women who had contracted puerperal fever, twenty-five of whom died in his care. In his report published in 1795, he argued that “the cause of the epidemic Puerperal Fever under consideration was not owing to a noxious constitution of the atmosphere” but rather to the medical staff itself, which spread the fever to new patients after attending those afflicted with it. Gordon was convinced that the cause of puerperal fever was something on the practitioners themselves. He claimed he could “foretell what women would be affected with the disease, upon hearing by what midwife they were to be delivered, or by what nurse they were to be attended during their lying-in.” In almost every instance, his prediction was correct.

The second person to make this connection was the American essayist Oliver Wendell Holmes, who was also a physician and later professor of anatomy at Harvard University. In 1843, he published a pamphlet titled The Contagiousness of Puerperal Fever. His work was based heavily on Gordon’s and laid the groundwork for a revival of the Scotsman’s ideas fifty years after they were first published. Unfortunately, Holmes failed to make an impression on his contemporaries and in the 1850s was attacked for his beliefs by two prominent obstetricians, who thought it was a personal insult to be accused of being the carrier of the very disease they were trying to combat.

And then there was Ignaz Semmelweis, who solved the problem of how to prevent childbed fever in Vienna at the same time Holmes was writing about it in America. Semmelweis, who was working as an assistant physician at the city’s General Hospital, noticed a discrepancy between the hospital’s two obstetric wards. One was attended by medical students, while the other was under the care of midwives and their pupils. Although each ward provided identical facilities for its patients, the one that was overseen by the medical students had a significantly higher mortality rate, by a factor of three.

In 1847, one of his colleagues died after cutting his hand during a postmortem examination. To his surprise, the Hungarian physician realized that the disease that had killed his friend was identical to puerperal fever. What if doctors working in the deadhouse were carrying “cadaverous particles” with them onto the wards when they assisted in the delivery of babies, and it was this that was causing infection rates to spike? After all, Semmelweis observed, many of these young men went directly from an autopsy to attend to the pregnant women at the hospital.

Believing that puerperal fever was caused not by miasma but by “infective material” from a dead body, Semmelweis set up a basin filled with chlorinated water in the hospital. Those passing from the dissection room to the wards were required to wash their hands before attending to living patients. Mortality rates on the medical students’ ward plummeted. In April 1847, the rate was 18.3 percent. After hand-washing was instituted the following month, rates in June were 2.2 percent, followed by 1.2 percent in July and 1.9 percent in August.

Semmelweis saved many lives; however, he was not able to convince many physicians of the merits of his belief that incidences of puerperal fever were related to contamination caused through contact with dead bodies. Even those willing to carry out trials of his methods often did so inadequately, producing discouraging results. After a number of negative reviews of a book he published on the subject, Semmelweis lashed out at his critics. His behavior became so erratic and embarrassing to his colleagues that he was eventually confined to a mental institute, where he spent his final days raging about childbed fever and the doctors who refused to wash their hands.

In fact, Semmelweis’s methods and theories had little impact on the medical community. Lister visited a clinic in Budapest where the beleaguered physician had recently worked, and he later reflected: “Semmelweis’s name was never mentioned to me having been, as it seems, entirely forgotten in his native city as in the world at large.”

Try as Lister might, none of the measures he instituted affected mortality rates, not even the improved hygiene on his wards. Patients continued to die, and there seemed to be little he could do to stop it. His house surgeon said of Lister that a divine discontent began to possess him. His mind, he said, “worked ceaselessly in an effort to see clearly the nature of the problem to be solved.” Lister’s exasperation spilled over into the classroom, where he turned to his students with the question that had been haunting him for some time: “It is a common observation that, when some injury is received without the skin being broken, the patient invariably recovers and that without any severe illness. On the other hand trouble of the gravest kind is always apt to follow, even in trivial injuries, when a wound of the skin is present. How is this? The man who is able to explain this problem will gain undying fame.”

Then, at the end of 1864, while Lister was struggling to prevent the deaths of his patients at the Royal Infirmary, a chemistry professor and colleague, Thomas Anderson, drew his attention to something that would help him tease out the solution to the medical riddle that consumed him. It was the latest research on fermentation and putrefaction by a French microbiologist and chemist by the name of Louis Pasteur.

— From The Butchering Art by Lindsey Fitzharris