Victorian England was a dangerous place to live, especially in the bustling towns and cities. There was a potential accident around every corner, for instance, being run over by a cart or falling from a horse, or being burned or scalded at home when clothing caught fire or a pot of boiling water was knocked over.
In the 1840s, with the increasing amount of building work going on in urban areas, the number of accidents rose. Railways, docks and collieries were also extremely hazardous. In the mills and factories, workers could easily lose a limb or be killed if they became caught up in unfenced machinery. Injuries were also prevalent in manual occupations. A labourer could sustain a crushed hand or finger after carrying (and dropping) a heavy load; the same risk applied to a waggoner unloading goods from a cart.
Anyone injured in a serious accident would be taken to the nearest general hospital for surgical treatment, but that wasn’t necessarily a good thing before the 1880s. That’s because a 35% post-operative death rate was usual at this time. For an operation such as amputation at the thigh, this death rate was as high as 65%. ‘Hospital diseases’ such as hospital gangrene, erysipelas (also known as St Anthony’s Fire) and pyaemia were deadly killers.
In 1861, 42% of deaths after amputations at Guy’s Hospital in London were a direct result of pyaemia. The name of the disease literally means ‘pus in the blood’, it being a form of blood poisoning caused by the spread of pus-forming bacteria in the bloodstream. The infection could spread rapidly in a hospital ward as miasmatic material could infect one patient while their emanations could infect other patients in the ward. The disease had a very distinct ‘sweet’ smell.
Erysipelas, an infection that caused red patches on the skin, and hospital gangrene were an ever present threat to patients in the 1860s and 1870s. Nathaniel Paine Blaker, a surgeon at the Sussex County Hospital recalled that in the autumn of 1864,
“these diseases raged to such an extent that fourteen or fifteen patients, and also the head nurse, died in the male accident-ward in one week. The disease usually came on suddenly [in] …a patient with a wound…apparently going on well [who] was reported to have a rigor. This was followed by fever (there were no clinical thermo-meters in those days), restlessness, loss of appetite and perhaps vomiting. In a short time the parts round the wound became red, hot and swelled, and in a few hours gangrene commenced in a small spot and spread rapidly…”
A seemingly insignificant event could result in death from pyaemia. On a Saturday night in March 1864, George Milton, a fifty-two-year old domestic servant from Glasgow, ‘had his thumb seized by a drunken man who bent it back till it forced the lower end of the second phalanx through the skin & caused compound dislocation of it’. George was admitted to Glasgow’s Royal Infirmary and the House Surgeon ‘took off [the] lower end of bone of phalanx & replaced it’. By 14 March, erysipelas of the forearm had set in and two weeks later, the unit joint was affected with George’s general health suffering. The whole of his left forearm was put up in a poultice. On 30 March, it was decided to amputate the limb below the elbow joint under the influence of chloroform. Although George ‘appeared to rally a little after the operation [he] took rigor several times during the day and sank, complaining of stiffness & pain of his joints, his breath [had] a faint odour resembling that in pyaemia’. George died on 4 April, just over a month after his thumb had been injured.
Given the high death rates after operations (which through word of mouth and newspapers patients would have been aware of), it’s no wonder that hospital registers record a significant number of patients refusing treatment and leaving voluntarily. Frederick Treves, a surgeon at The London recalled the surgical wards in the 1870s:
“The poor had a terror of it, which was not unjustified, and many an hour I spent merely trying to persuade patients to come in for treatment. Operation results were not encouraging and the general public knew it. I remember the whole of Talbot [ward] being decimated by hospital gangrene. Every man died with the exception of two who fled the building. There was only one sponge in the ward and with that deadly instrument the nurse… washed every wound in the evening using, not only the same sponge, but the same basin and the same water!…Maggots in a wound were regarded as part of the normal fauna of a hospital ward and called for no particular comment.”
Hospitals tried a wide variety of methods to address the increasing mortality rates. They included white-washing walls, removing privies from wards, separating medical and surgical patients, building new wards to allow more cubic space per patient, instigating new ventilation systems, and trying to prevent contaminated air entering the wards. Beds and wards were also disinfected with chemicals such as carbolic acid.
Wounds had been treated with wine and vinegar acting as antiseptics for centuries and various post-operative and post-accident dressings were used to assist the healing process, including nitric acid, arsenic and tincture of iodine. Unfortunately, no-one yet understood the link between germs and infections, or that the surgical staff themselves could be the source. Surgeons and their assistants operated in blood-spattered street clothes with unsterile wooden-handled instruments, without changing between patients or using face masks or gloves.
Joseph Lister put forward his theory of antisepsis while working as a surgeon at the Glasgow Royal Infirmary. He concurred with Louis Pasteur’s argument that germs were airborne, carried on dust particles, and that they could be removed from the air by filtration, heat or other means. After hearing of the effectiveness of carbolic acid in disinfecting sewage in Carlisle, Lister decided to use the chemical as a filter between the air and open wounds.
On 12 August 1865, Lister undertook his first trial of carbolic acid on eleven-year-old James Greenlees, whose left leg had been run over by a cart. Lister dressed a compound fracture of the tibia with lint soaked in linseed oil and carbolic acid, and kept the dressing in place for four days. The wound healed perfectly and James walked out of the hospital six weeks later.
In 1867, Lister wrote about his antiseptic methods and the germ theory in the Lancet but most surgeons saw antisepsis simply as a new type of wound dressing which involved carbolic acid, and they only adopted parts of it. Other surgeons, such as George Callender at St Bartholomew’s Hospital, developed their own effective means of combating sepsis which were less time-consuming and cumbersome. Many still believed that infections occurred spontaneously in wounds, not through bacteria.
By 1871, Lister had introduced the carbolic acid spray and gauze elements to his method. However, it was not widely used until the late 1870s and it did not kill air-borne micro-organisms. Although Lister religiously used his antisepsis techniques, he did not scrub his hands, simply rinsing them in carbolic solution, and he operated in his street clothes.
Lister’s antiseptic theories were more widely accepted after 1877 when he became Professor of Clinical Surgery at King’s College, London. He continued to adapt his methods, abandoning the cumbersome spray in 1887, and by the 1890s, cleanliness and the germ theory became part and parcel of the practice of asepsis to exclude germs from wards and operating theatres.
The bacteria which caused surgical infections were identified by the 1880s and it was now known that they could be destroyed with antiseptics like carbolic. Hospitals strove for absolute cleanliness to prevent infections and crucially, this included medical and surgical instruments. As early as 1874, Louis Pasteur had suggested placing medical instruments in boiling water and passing them through a flame to sterilise them. In 1881, Robert Koch advocated the heat sterilisation of instruments but this method was not widely used until the 1890s.
Hugh Lett, a medical student at The London in 1896 described the procedures undertaken before surgery:
“Instruments and ligatures were boiled and placed in a tray of carbolic lotion, and before long on a sterile towel, and handed to the surgeon…Rubber gloves were still unknown, the preparation of the surgeon’s hands [were] therefore formidable; prolonged scrubbing with soap and Lysol, followed by soaking in carbolic lotion, and finally immersion for some minutes in a solution of biniodide of mercury in spirit. Further, during the operation the surgeon frequently dipped his hands into a solution of carbolic.”
By the 1890s, hospitals were no longer feared by the public. The new antiseptic and aseptic techniques, and a better understanding of how deadly hospital diseases were transmitted, led to a significant reduction in post-operative death rates.