In 1825, visitors to St George’s Hospital in London discovered mushrooms and maggots thriving in the damp, dirty sheets of a patient recovering from a compound fracture. The afflicted man, believing this to be the norm, had not complained about the conditions – and nor did any of his fellow bedmates think the squalor especially note-worthy. Those unlucky enough to be admitted to this and other hospitals of the era were inured to the horrors that resided within.
Today, we think of the hospital as an exemplar of sanitation. However, late Georgian and early Victorian hospitals were anything but hygienic. A hospital’s ‘Chief Bug-Catcher’ – whose job it was to rid the mattresses of lice – was paid more than its surgeons at this time. In fact, bed bugs were so common that the ‘Bug Destroyer’ Andrew Cooke claimed to have cleared upwards of 20,000 beds of insects during the course of his career. Hospitals were breeding grounds for infection and provided only the most primitive facilities for the sick and dying, many of whom were housed on wards with little ventilation or access to clean water. As a result of this squalor, these places became known as ‘Houses of Death’.
A number of London hospitals in the first half of the 19th century were rebuilt or extended in line with the demands placed upon them by the city’s growing population. For instance, St Thomas’s Hospital received a new anatomical theatre and museum of specimens in 1813; and St Bartholomew’s Hospital underwent several structural improvements between 1822 and 1854 that increased the number of patients it could receive. Three new teaching hospitals were built in the city, including University College Hospital in 1834.
Listen: Lindsey Fitzharris delves into the terrifying world of 19th-century hospitals and shows how scientific advances transformed the situation, on this episode of the HistoryExtra podcast:
However, most hospitals remained overcrowded, grimy and poorly managed. The assistant surgeon at St Thomas’s was expected to examine more than 200 patients in a single day. The sick often languished in filth for long periods before they received medical attention.
The unsanitary conditions created a dangerous environment for those trapped within a hospital’s walls. Pregnant women who suffered vaginal tears during delivery were especially at risk as these wounds provided welcome openings for the bacteria that doctors and surgeons carried on them wherever they went. In the 1840s, it was estimated that more than 1,000 mothers died each year from puerperal fever brought on by bacterial infections in England and Wales. Puerperal fever wasn’t the only culprit. Many women also died from pelvic abscesses, hemorrhaging or peritonitis – the latter being a terrible condition in which the tissues that lines the inner wall of the abdomen becomes inflamed.
Hospitals reeked of urine, vomit and other bodily fluids. The smell was so offensive that the staff sometimes walked around with handkerchiefs pressed to their noses. Surgeons didn’t exactly smell like rose beds, either. Berkeley Moynihan – one of the first surgeons in England to use rubber gloves – recalled how he and his colleagues used to throw off their own jackets when entering the operating theatre and don ancient frocks that were often stiff with dried blood and pus. They had belonged to retired members of staff and were worn as badges of honour by their proud successors, as were many other items of surgical clothing. As a result, surgeons carried with them the unmistakable smell of rotting flesh, which those in the profession cheerfully referred to as “good old hospital stink”.
As well as the foul smells, fear permeated the atmosphere. The surgeon John Bell wrote that it was easy to imagine the mental anguish of the hospital patient awaiting surgery. He would hear regularly “the cries of those under operation which he is preparing to undergo”, and see his “fellow-sufferer conveyed to that scene of trial”, only to be “carried back in solemnity and silence to his bed”.
In this period, it was safer to have surgery at home than it was in a hospital, where mortality rates were three to five times higher than they were in domestic settings. Those who went under the knife did so as a last resort, and so were usually mortally ill. Few surgical patients recovered without incident. Many either died or fought their way back to only partial health. Those unlucky enough to find themselves hospitalised would frequently fall prey to a host of infections, most of which were fatal in a pre-antibiotic era.
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Holes in the skull
To alleviate pressure in the head, a Victorian surgeon might perform a procedure known as trephination in which he drilled or scraped holes into the skull.
Even before the discovery of anaesthetics, surgeons frequently performed mastectomies on patients with breast cancer. They used a hook-like instrument to lift the soft tissue before making two sweeping cuts around the breast to remove it.
Specialists called ‘belly-rippers’ removed ovarian tumours in a procedure known as an ovariotomy. A long incision was made across the abdomen, which often became a source of sepsis. Sometimes normal ovaries were also removed to treat ‘menstrual madness’, masturbation, and cases of insanity.
Lithotomy was used to remove bladder stones, and was one of the most feared surgical procedures of its time. The condition was most common in male patients. The surgeon rammed a metal rod down the patient’s penis and cut through the fibrous muscle of the scrotum before sliding his fingers into the opening to remove the stone.
During an amputation, a surgeon would make a sweeping incision around the circumference of the limb, pulling away the skin and muscle, and sawing through the bone. A capable surgeon could do this and tie up the arteries in just under two minutes.
The operating theatre itself was just as dirty as the surgeons working in them. It was frequently 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. The surgeon John Flint South remarked that the rush and scuffle to get a place in an operating theatre was not unlike that for a seat in the pit or gallery of a playhouse. People were packed like herrings in a barrel, 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 theatre like this one could be so crowded that the surgeon couldn’t operate until it had been partially cleared.
Most operating theatres looked more or less the same in this era. They 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. Not all patients were laid flat. Before the dawn of anaesthetics in the 1840s, many were sat upright in an elevated chair. This prevented them from bracing when the surgeon’s knife began to dig into their flesh. Unsurprisingly, they were also restrained, sometimes with leather straps. Underneath their feet, the floor was strewn with sawdust to soak up the blood. 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.
Pain was not just an unavoidable side effect of surgery. Most surgeons operating in a pre-anaesthetic era believed it was a vital stimulant necessary for keeping the patient alive. This is why opiates and alcohol were used sparingly, and typically administered shortly before (not during) a procedure, as the loss of consciousness was considered to be extremely dangerous. As a result, surgeons had to be fast. Very fast. Take, for example, Robert Liston – a surgeon operating in the first half of the 19th century who was known as the “the fastest knife in the west end”.
Who was Robert Liston?
At 6ft 2ins, Liston was 8 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 30 seconds, and in order to keep both hands free, he often clasped the bloody knife between his teeth while working.
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. Once, he removed the leg of a 12-year-old child named Henry Pace, who had a tubercular swelling of the right knee. The boy asked the surgeon whether or not 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 theatre blindfolded and pinned down by Liston’s assistants. The boy counted six strokes of the saw before his leg dropped off. Sixty years later, he 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.
The patients weren’t the only ones who felt anxious before an operation. Surgeons, too, were apprehensive about cutting into living bodies. The Scottish surgeon Charles Bell was described by one colleague as having “the reluctance of one who has to face an unavoidable evil”. John Abernethy, a surgeon at St Bartholomew’s Hospital, confessed to shedding tears and being physically ill before or after a particularly terrible operation. He described the walk to the operating room as being like “going to a hanging”. Many surgeons, once confronted with exposed bone, felt daunted by the task of sawing through it. 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 the 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.
Yet as horrible as these hospitals were, it was not easy to gain entry to one. Throughout the 19th century, almost all the hospitals in London except the Royal Free controlled inpatient admission through a system of ticketing. One could obtain a ticket from one of the hospital’s ‘subscribers’, who had paid an annual fee in exchange for the right to recommend patients to the hospital and vote in elections of medical staff. Securing a ticket required tireless soliciting on the part of potential patients, who might spend days waiting and calling on the servants of subscribers and begging their way into the hospital. Some hospitals only admitted patients who brought with them money to cover their almost inevitable burial. Others, like St Thomas’s in London, charged double if the person in question was deemed ‘foul’ by the admissions officer.
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At a time before germs and antisepsis were fully understood, remedies for hospital squalor were hard to come by. The obstetrician James Y Simpson suggested an almost-fatalistic approach to the problem. If cross-contamination could not be controlled, he argued, then hospitals should be periodically destroyed and built anew. Another surgeon named John Eric Erichsen voiced a similar view. “Once a hospital has become incurably pyemia-stricken [a type of septicaemia], it is as impossible to disinfect it by any known hygienic means, as it would be to disinfect an old cheese of the maggots which have been generated in it,” he wrote. There was only one solution: the wholesale “demolition of the infected fabric”.
By the 1860s, the situation had reached critical mass. At a time when surgery couldn’t have been more dangerous, an unlikely figure stepped forward: Joseph Lister, a young, melancholy surgeon. By claiming that germs were the source of all infection – and could be treated with antiseptics – he changed the history of medicine forever. Towards the end of the 19th century, hospitals ceased to be houses of death and instead had become houses of healing.
Dr Lindsey Fitzharris is the host of the YouTube series entitled Under the Knife. Her debut book, The Butchering Art: Joseph Lister’s Quest to Transform the Grisly World of Victorian Medicine, was published by Allen Lane in October and shortlisted for the 2018 Wellcome Book Prize.