Courtesy Lindsey Fitzharris.

Modern hospitals are supposed to be gleaming, scrubbed places, with hand sanitizer dispensers every few feet for maximum germ killing. But once upon a time, hospitals were filthy. Surgeons wore blood-encrusted aprons and didn’t even clean their operating tables between patients.

How did we get from the dirty days of the early 19th century to the modern era? A big part of the answer is a man named Joseph Lister, who helped sell the United Kingdom and eventually the wider world on the notion of germ theory and the importance of antiseptic practices, explains Lindsey Fitzharris in her new book, The Butchering Art. A Oxford-educated medical historian who blogs at The Chirurgeon’s Apprentice, Fitzharris traces surgery’s transition from a rough-and-tumble trade that really did bear more than a passing resemblance to the work of the neighborhood butcher to a respected specialty at the top of the medical field, over the course of the second half of the 1800s.

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Developing an awareness of germs and the importance of fighting them in the operating theory was a monumental step. While the quality of medical care still varies dramatically depending on the resources available, a whole range of injuries and illnesses have been made dramatically less dangerous for many, many people. The book is a particularly interesting if you’ve ever been close to anybody who’s gotten a c-section or a mastectomy, which Fitzharris covers in particular depth. (It was possible to remove a breast cancer in the time of Jane Austen, but your odds weren’t exactly heartening, either.)

I chatted with Fitzharris about the state of medicine before Lister—she’d just popped somewhere for a cup of coffee and presumably delighted her fellow patrons with tales of gore and germs—and her book. Our conversation has been lightly edited.

JEZEBEL: Today surgeons are the ultimate medical hotshots. But it seems like, as your story opens, they’re basically a bunch of disreputable guys with hacksaws and no professional respect.

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Lindsey Fitzharris: Like a gang of surgeons walking the streets looking for their victims, right?

I became interested in the history of surgery for that exact reason, that surgeons are the top of the hierarchy in the medical world and they’re seen as these meticulous, careful-thinking gods of the medical world, and there was a time when they were seen as craftsmen, people who worked with their hands. They certainly weren’t as respected as their counterparts, the physicians, who were university educated. A physician didn’t touch the patient. He used his mind, and so he was more respected, whereas the surgeon was seen basically in the same kind of way that any manual worker at this time would be seen.

So there’s a real transformation that happens in the 19th century as they become scientific surgeons, rather than just these manual craftsman or butchers that you see in the earlier part of the 19th century. I find that transformation absolutely fascinating, because as you say, they’re revered now. The surgeon’s opinion takes precedence over all other opinions.

Plate 30, Various techniques for the amputation at the knee and ankle. 1848. Via Wellcome Library, London.

“The butchering art” is actually a pretty literal description, it seems like—this was really a lot like the very hands-on work of butchering.

One of my favorite stories, which is in the book, is about a guy named Robert Liston. He’s the first surgeon to perform an operation under ether in Britain. He’s what I identify as the last butcher of his generation. I actually originally wanted the book to be about him, but I realized he doesn’t really drive the transformation of surgery. He’s just a part of it, a witness to it. But one of my favorite stories is, one of his patients is going to have a bladder stone removed. Now this is pre anesthetic, pre antiseptic. It was a horrific surgery. They would bring you into the operating theater, you were fully awake, they tied you up, and they would start to cut in to remove these bladder stones. It’s awful. And terrifying.

The patient was brought in and I guess he looked at Robert Liston, this 6’2” sort of monster—he was very tall for his generation, very strong, he could hold you down and remove your leg in under 30 seconds. He looked at Liston and he thought, no, I’m out. And he just jumps off the table, he runs, he locks himself in the closet, and Liston charges after him—just to make this even more of a nightmare scenario—and rips the door off the closet and drags him back to remove the bladder stone. And it’s kind of funny as all horrible things are funny if enough time passes. Today it’s so unbelievable to us that that could happen, but of course, these people were real and it happened and it was awful. I’m happy to report that the guy did survive, but a lot of patients didn’t.

I can’t believe how fast they had to work. Liston, there’s that story about him accidentally cutting off somebody’s testicle because he worked so fast.

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I know! And they had to be fast because, you know, blood loss, shock—all these kinds of things they’re working against. The patient struggling against them. So you had to be very fast. There’s this myth that people drank a lot beforehand. Well, that would thin your blood and that would make it worse. So the patient was very aware.

Not all surgeons were that fast. There’s one surgeon who’s performing a bladder stone removal—this should take about five minutes in a pre anesthetic era, and it ends up taking him over an hour. And there’s tons of spectators and what makes it even worse is that the surgeon starts cursing the patient for having abnormal anatomy. You’re sitting there, you’re struggling, you’re naked from the waist down, this is all awful, and the surgeon is basically telling you off for having strange anatomy. The patient pulled through, but he died 24 hours later and the autopsy report revealed that he actually didn’t have abnormal anatomy. It was unsurprisingly the surgeon’s fault.

When you think about a leg being removed in maybe a minute, it sounds really fast. But if you just sit there for 60 seconds in silence and think about your leg being sawn through—I just can’t even imagine. Nothing could be fast enough, right?

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It’s really hard for me to even begin to get into the headspace of these Victorian surgeons, because the importance of cleanliness now is so ingrained that the descriptions of operating rooms made my skin crawl. I had this very visceral reaction. Even if germ theory hadn’t taken hold yet and they didn’t understand the importance of sanitary conditions, I guess I just don’t understand why they didn’t clean? Even if just from an instinctive point of view?

It’s now so accepted and so engrained, as you say, that it seems so unbelievable to us that you could walk through these hospitals and that would acceptable. And I try to tell people that when Lister comes around, this young man, he’s got his microscope, which is seen as this suspicious instrument to begin with in medical community in the 19th century, and he’s telling people essentially that there’s these invisible creatures that you can’t see with your eye and they’re killing your patients. And he sounds crazy, because it just was so foreign to them. And I think the other reason why it was so difficult for these surgeons to accept germ theory at first was because they had to accept that they were actually inadvertently killing the people that they had been trying to save all along. That’s a hard pill to swallow.

But you know, you had patient after patient coming onto the operating table, and it’s fast, it’s furious, and a lot of the surgeons didn’t wash their hands or their instruments because they felt no concept of germs. They felt, why would I do that? Because my hands are just going to get dirty with the next patient. There just seems to be no point. It seems weird to us, because I’m washing my hands constantly. I carry sanitizer in my purse. But for them, it just seems illogical to constantly be washing their hands when they were just going to get dirty again.

The public perception of surgeons. Photo: Wellcome Library, London. Five surgeons participating in the amputation of a man’s leg while another oversees them. 1793.

And time they could spend doing more surgeries. Because these hospitals are all really crowded, and there are more people that need procedures than they had even remotely enough beds for, right?

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Absolutely. The hospitals were so overcrowded. These were not places that you went if you were wealthy or if you were middle class. You were treated at home. Your surgeon would come there and do the operation. In fact, there’s a story of a woman who undergoes a mastectomy without any anesthetic. And the surgeon comes to her house and he opens up his hand to show her the knife and he tells her to prepare her soul for death. Not confidence-inspiring at all. But that would have taken place in her bedroom, and the hospitals were really for people who were very poor. But they also weren’t for people who were very desperately poor, because in order to get into the hospital, you needed a ticket, and a lot of hospitals charged you extra for your inevitable burial. They so assumed you were going to die in these places that you had to prepay. Or you’d have to pay if you were considered to be extra foul, extra dirty. So it was people who had some kind of income to still pay for their room and board. If you were desperately poor you just had no medical options at that time.

I think the most quietly appalling thing of the book was the idea of “hospitalism.” There’s four separate germ-related conditions that pop up in hospitals that are so common in the 19th century that they just call them “hospitalism.”

That’s right. In the 18th century, the hospitals were smaller. In the 19th century, they start to become big urban hospitals because of the population growth, so they become very overcrowded. The fact that the bug catcher, the guy who’d go and rid the bed of lice, was better paid than the surgeons and the doctors kinda tells you all you need to know about these hospitals. As a result, infections broke out and they coined the term “hospitalism,” which refers to the fact that you were more likely to die because of being admitted into these hospitals. But the funny thing is, things like gangrene, some of the descriptions in my book, we would probably today call them necrotizing fasciitis, where it’s sort of a flesh eating infection. We still battle those things in hospitals. Septicemia is still a problem with patients and once that sets in, it’s very difficult to stop. So you can imagine that if it’s difficult today, and then you put the patient in a lice-infested bed, and there’s no concept of germs, they almost have no chance. But we can look at things like the superbugs in hospitals today, these kinds of infections that seem to exist in hospitals only because of the fact that there’s so many sick patients around. It was obviously a much bigger problem back then, but I think it would be wrong to say that hospitals don’t struggle with cross contamination and infection today, as a result of the fact that they’re so crowded.

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One of the things that was really interesting, as somebody who had a baby not all that long ago, I couldn’t stop thinking about c-sections and mastectomies. We consider those surgeries fairly routine at this point. To what extent were those surgeries even remotely possible with any hope of survival?

Mastectomies were certainly being done, pre-anesthetic as well, which is really awful. In my book, Joseph Lister’s sister gets breast cancer, and many of the surgeons around him refused to do mastectomies, because they felt like she was going to die either way, but they would accelerate the death, because when you take off the breast there’s this gaping wound that would then be susceptible to infection. Lister ends up doing the surgery on his dining room table in his house, which is mind-boggling when you consider how emotionally draining that also must have been for him. But she survived! Because he uses antisepsis and he controls the environment so that she doesn’t get any kind of post-operative infection.

But these operations were going on much longer than people realize. A lot of people think, for instance, breast cancer is only being diagnosed in more modern times. Surgeons understood what breast cancer was. It’s just that they couldn’t do that much for patients back then, and usually by the time you could feel it or there were signs that it was breast cancer, it was probably too late anyway if they went in and did a mastectomy. But yes, just as I told you, that one patient who was in her house and she was told to prepare her soul for death, she wrote to her daughter, she ended up pulling through. She wrote to her daughter and she talks about how she was underneath the surgeon’s hand for nearly an hour and a half and his hand was just covered in blood up to the wrist. At one point the blood flew into his eye and he couldn’t see. Just when you thought it couldn’t get any worse.

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It’s just amazing to think, as you say, how far we’ve come and how routine it is.

As far as c-sections go, that was really only done if there was the belief that the mother was going to die anyway. Because, again, you’re talking about a big gaping wound that would be susceptible to infection. The term “cesarean” comes from the belief that Julius Caesar was cut from the womb of his mother. We’re pretty sure that’s a myth, because his mother lived to old age, and it just seems impossible that she would survive something like that at that time. The first real written evidence we have of it, I think it’s 16th century, and it’s a pig farmer and he uses the instruments that he castrates the pig with to cut the baby out of his wife, and she reportedly survives. But again, it’s such an old document that you do question it. But these things were only done if there was this idea that the mother was going to die. It was done as a very last resort. It’s only in much more modern times, post anesthetic, post antiseptic, that we can perform c-sections without the concern that the mother is going to die because of that.

Germ theory, like you said, is a bonkers idea if you’re a working surgeon in the early 1800s. It sounds bananas. Why was Lister able to sell everybody on this idea?

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As a historian, it always comes back to that basic question. Is it the man? Is it the times? What makes the moment transformative? What makes the paradigm shift? And it’s obviously a bit of both. Lister’s coming at the right time, the crisis is growing, the hospitals are becoming more crowded, patients are dying at increasing rates. One of the things that I hope my readers will get is, actually, when anesthetics start being used in the operating theater, surgery becomes much more dangerous, because they don’t understand germs. So they no longer have the patients struggling against the knife, but they’re more willing to dig deeper into the body. They’re more willing to pick up the knife. And so there’s this conveyor belt in the operating room, patient after patient, and the tables aren’t being washed down, the instruments aren’t being washed down. Lister’s at the eye of this storm. The hospitals are these pest houses, and it became such a problem that it was even suggested in a completely serious way that the only solution would be to burn these places down from time to time and start anew. So he’s there at that critical moment, where nobody knows what to do and it is getting worse.

And then I think there is an element that it’s Lister. He’s a Quaker, he seems to believe that he has this purpose in life to do this, and he’s very persistent. And he’s very good creating almost a cult around him. He starts to convince the younger generation. He knows that the older generation is more difficult to convince, so he starts teaching his students about antisepsis and germs. And it’s those men ultimately who go out into the world and spread the gospel, so to speak, of Lister. They even become known as Listerians. And they go around and they start teaching this. So he’s a very effective PR manager when it comes to getting his message out. But he just really believes in this, and he’s a very compassionate person, to the point where he really annoyed other surgeons. He wouldn’t actually charge his patients—he would let them decide how much they should pay him.

I think was the right person at the right time. In so many historical instances you see this. We were ready for a different view of the body and the world and he was there. And obviously he’d come across Pasteur’s germ theory and it was just a marriage made in heaven between science and medicine.

Picture this, but caked in five other people’s blood. Photo: Science Museum, London, Wellcome Images. Amputation saw made 1823-1829.

It’s just so hard for me to imagine not knowing about germs, since we’re so germ phobic.

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I hope that people, especially in the medical and scientific community, pick this up and that kind of thing is underlined—the fact that what we know today might not be what we know tomorrow. And that science and medicine are not hard truths all the time. We are constantly doing research, we are constantly asking questions, finding different answers. And you see that even in modern times, in the last ten years, in how we understand, for instance, ulcers. And sometimes the people within the profession themselves are their own worst enemies and they fight it, because it’s so difficult to kind of shift out of that paradigm. It will be interesting to see how things change in the future and how we start to understand diseases slightly differently, as we dig deeper and deeper into that world of the infinitely small and start to understand the nuances of how diseases work.

The Butchering Art is very informative, but I also read it in two days and it’s very entertaining. I tore through all these grisly facts about the history of surgery. You have a YouTube series, Under the Knife. It would be so easy to get bogged down in fiddly details but it’s also easy to go too far to the other side and get too viral. How do you balance doing history in an entertaining way?

I did all of my degrees at once. I did my undergrad, my masters, my PhD at Oxford. Two weeks later, I started my postdoc at UCL. It was so intense and I got to a point where I burned out, and I sort of fell out of love with history. It was too much theorizing about the past. And academic history is so valuable, don’t get me wrong. But for me, the things that had always interested me as a little girl were the stories about the people who lived and died and what was it like, what did it smell like, what did it look like. And so I started the blog The Chirurgeon’s Apprentice a few years back to fall in love with history again. I wanted to tell the stories that excited me about the past. So I always kind of pivot to that, whether I’m writing or I’m doing the YouTube series. What story would people who have no real academic interest in the past would get them interested in the subject?

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But it’s always a fine line, because especially with medical history, you are dealing with something quite awful. I never want to come off flippant, to say, well, wasn’t it stupid that people believed X in the past. Because actually, it’s just their world view. To go back to what are people going to say about us in a hundred years—you have to really try to get into the mindset of those people. But for me, the greatest thing that I’ve ever really accomplished, hopefully, is making my subject accessible to people who aren’t doing a Phd in it. That’s what I love to do, and I’m hoping with The Butchering Art, that people will be able to pick it up with no background in medical history. Maybe they don’t even like history. And they’ll find it enjoyable. I think that’s really important, for people to connect with the past and to understand it and to have fun with it as well.