33 - Lister Introduces Antisepsis
SURGERY, at the beginning of the nineteenth century, had progressed scientifically little beyond the point at which Ambrose Pare had left it two centuries before. A good surgeon was he who could operate fast, could be oblivious to the patient’s agonized screams of pain, and could retain hope that the patient might survive inevitable post surgical “hospitals.” This term applied to a variety of septic infections virtually endemic in patients in hospital wards. “Hospital’s” was fatal to about one of three surgical patients. To commit surgical patients to hospitals came to be regarded as almost tantamount to signing their death certificates in advance.
Discovery of the principle of anesthesia in 1846 effected the first great change in surgical procedure. Anesthesia removed blind fear and invoked blessed insensibility for patients during operations. Anesthesia did away with the necessity for utmost speed, making possible more careful, finished surgical techniques; and making feasible surgical procedures that previously had been regarded as beyond physical endurance. Anesthesia quieted the unnerving, heartrending screams associated with the operating theatre, relieving surgical practice of one of its least attractive aspects.
As anesthesia encouraged surgeons to widen application of their ministrations to human ills, deaths from infectious diseases especially in crowded and none too clean hospital wards, increased apace. Suppuration in wounds was so common that it became accepted as normal: medical men discoursed learnedly about “laudable pus” and its absence was looked upon with alarm. Pyemia, septicemia, tetanus, Erysipelas, puerperal fever, and hospital gangrene were the great hazards faced by surgical and obstetric patients. The situation became so alarming that some hospitals were closed; some were torn down and rebuilt on the theory that these affections arose from something unknown that emanated from the physical structures. For surgeons to operate on the surface of the body, or to amputate through within range of surgical ability and of patients’ endurance, was to court great postoperative danger to life. To treat patients for compound fractures but methods other than amputation was negligence; to imputable was to take a fifty-fifty charge with patients’ lives. To open the abdomen, or the chest, or the skull, was unthinkable. Ovariotomy was the one exception.
Such was the course of surgical practice until Joseph Lister introduced antiseptics in treatment of wounds and in operations. Though Lister’s methods were slow to be accepted, surgery began to embrace this second great change in the final quarter of the nineteenth century. Risks to patients’ lives were reduced markedly. By combining advantages of anesthesia with antisepsis, and, later, with asepsis, surgeons were able to carry out operative procedures far beyond the realm of pre-Listerian imagination. That pioneering, that pushing into new areas of surgical practices for relief of human disorders has continued to accelerate during the decades that have elapsed.
To Joseph Lister, surgery and medicine owe a great debt of gratitude for having patiently and scientifically introduced the age of antisepsis. In turn, Lister freely acknowledged his indebtedness to earlier workers, and especially to Louis Pasteur. Douglas Guthrie summed it up well: “Standing on the shoulders of his predecessors, he beheld something that was invisible to them.”
Joseph Lister was born April 5, 1827, at Upton, Essex, England, the fourth child and second son of Joseph Jackson Lister. The family had a comfortable income from the wine business, and the elder Lister had time to pursue his favorite hobby, microscopy. His discoveries for improving the microscope gained for him a Fellowship in the Royal Society in 1832. Joseph Lister was raised in quiet Quaker family surroundings. Undoubtedly, his father’s scientific interests contributed to the boy’s early decision that surgery should be his life’s work. Joseph Lister received the degree of Bachelor of Arts from London’s University College in 1847, and continued his studies in medicine at the same institution. There, Lister, had opportunity to observe, on December 21, 1846, the first operation performed in Great Britain with the aid of ether anesthesia by the famous surgeon, Robert Liston.
In 1852, Lister obtained the Bachelor of Medicine degree from University College, and Fellowship in the Royal College of Surgeons of England. In this year, too, his first original work, “On the Contractile Tissue of the Iris,” appeared in the Quarterly journal of Microscopical Science, followed a few months later by another. “The Muscular Tissue of the Skin.” His familiarity with microscopes served him well.
In September, 1853, with a letter of introduction from a former teacher, Lister called upon James Syme, who was Professor of Clinical Surgery in the Medical School of the University of Edinburgh, Scotland. The visit to Edinburgh was to have been one of a series to medical centers, but Syme was immediately attracted to the enthusiastic young surgeon and persuaded Lister to stay on as clerk, and, shortly thereafter, as resident house surgeon in Syme’s wards in the Old Royal Infirmary of Edinburgh. Within a short time, Lister became affectionately known as “The Chief” among students; and Syme was known as “The Master.”
Within a year after Lister’s arrival in Edinburgh, a series of circumstances created vacancies, not only at the Infirmary, but on the teaching staff if the Royal College Surgeons of Edinburgh. Persuaded to take these appointments, Lister began his teaching career, and opened an office for consultation practice.
By 1856, Lister had been appointed Assistant Surgeon at the Royal Infirmary. In that year, too, he married Agnes Syme, the Professor’s daughter. She proved to be an ideal wife, helpmate, and companion for the busy teacher, researcher, and surgeon. Though the Listers had no children, theirs was a long, happy life of sharing work and leisure.
In his prime, Lister was described as nearly six feet in height, called “mutton-chops” sideburns, shaving his face and chin. His bearing was dignified and his manner always restrained; he was ever kindly and considerate; his voice was soft and musical. He wore a black frock coat with a waistcoat of the Victorian type, and a chimney-pot silk hat of the period. He was invariably courteous and polite; but when occasion demanded, he showed that his dexterity was equal to that of other surgeons.
At about this time, Lister is credited with having invented several ingenious surgical instruments, including: a needle for silver wire used as suture material; a hook for removing foreign bodies from the ear; forceps for use in sinuses; blunt-pointed bandage scissors; and a screw tourniquet for compressing the abdominal aorta. Some instruments associated with his name are used by surgeons even today.
Opportunity again knocked at Lister’s door when the Professorship in Surgery at Glasgow University was vacated. He was the successful one among seven applicants for the appointment. He took over his new post March 9, 1860. The teaching position did not include a hospital appointment, and another year elapsed before Lister was placed in charge of wards at the Glasgow Royal Infirmary.
It was at the Glasgow Royal Infirmary that Lister was to make his most important studies. Along with teaching and clinical duties, Lister, appalled by conditions and sufferings of patients in surgical wards, began studies on the cause of inflammation. The first changes he made- introduction of ordinary cleanliness and of liberal use of soap and water- met with resistance; but the quiet, mild Quaker got his way. Then, seeking to reduce suppuration, he began study of various methods of wound treatment. Certain questions kept recurring to him: Why does a simple fracture heal and a compound fracture prove almost always fatal? Why is mortality greater among patients in hospitals than among those in private homes? Why must there be suppuration?
Publication of Pasteur’s work on fermentation and on decomposition, demonstrating that these processes are due to living organisms, provided Lister with his essential clue. He repeated some of Pasteur’s experiments. He experimented further with prevention of putrefaction of blood. He satisfied himself that Pasteur was indeed right; it was not air, but something in the air, which produced fermentation. Was it not likely that these minute organisms cause suppuration, then a way must be found to kill them in the wound, or better still, to keep them out of it. Lister knew that heat would kill germs- and kill living cells, too; filtering could remove germs- but how could it be done practically? He knew, too, that some chemicals destroy germs. This approach seemed most logical. “It appears,” Lister wrote in the Lancet, “that all that is requisite is to dress the wound with some material capable of killing these septic germs, provided that any substance can be found reliable for the purpose, yet not too potent as a caustic.”
Lister had been intrigued by an account of effects produced by carbolic acid upon sewage from the town of Carlisle, and it occurred to him that his antiseptic might be used in treatment for compound fractures. First samples, in the form of crude creosotes, were unsatisfactory; but Lister was happy to find that purified crystalline phenol was miscible with water, and that addition of a small amount of water caused the substance to remain in liquid state. It proved to have local sedative qualities, and reacting with blood, formed a hard, tenacious. Protective crust. Leisters first trial was a failure, but he attributed that to improper management.
On August 12, 1865, James Greenness’, a boy aged eleven years, was admitted to one Lister’s wards in Glasgow Royal Infirmary, with a compound fracture of his left lower leg. The wound was about one and one- half inches long, and three quarters of an inch wide. Little bleeding had occurred.
Lister treated the wound first by through application of carbolic acid, then dressed it with lint and cloth soaked in the solution. The dressing was covered with tin foil to prevent evaporation, and the leg splinted. Dressings saturated with carbolic acid in water, or in oil, were continued. In six weeks, the bones had united, and two days there-modestly: “The remarkable retardation of suppuration, and the immediate conversion of the compound fracture into a simple fracture with a superficial sore, were most encouraging facts.’’
Ironically, Ignaz Semmelweis, who had blindly sought to apply antiseptic and to surgical procedures in hospitals in Venna and in Budapest, died of septicemia, August 13, 1865-the day after Lister began his first successful antiseptic treatment for a wound. At the time, Lister had not heard of Senseless. In later years, Lister’s writings generically accorded the Hungarian physician credit for his earlier work.
By 1867, Lister was able to report on a series of eleven patients treated for compound fractures, all but two of whom regained use of their limbs. One man, during Lister’s absence, had to have an amputation, after which he recovered. Another, though he progressed satisfactorily at first, died of hemorrhage caused by perforation of an artery by a fragment of bone.
Lister began to apply his antiseptic principle to treatment for ordinary wounds, and for carbuncles, for boils, for whitlows, and for acute abscesses. Results were equally remarkable. In 1867, Lister published a series of reports in the Lancet entitled, “Papers on a New Method of Treating Compound Fracture, Abscess, etc., With Observations on the Condition of Suppuration.” To the Surgical Section of the British Medical Association, meeting in Dublin the same year, Lister reported more fully “On the Antiseptic Principle of the Practice of Surgery.” In this he made the remarkable observation:
“Previous to its (the antiseptic method) introduction the two large wards in which most of my cases of accident and of operation are treated were among the unhealthiest in the whole surgical division of the Royal Glasgow Infirmary… But since the antiseptic treatment has been brought into full operation and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their character; so that during the last nine months not a single instance of pyemia, hospital gangrene, or erysipelas has occurred in them.”
Soon convinced that pure carbolic acid was too strong, lister experimented with dilutions. He found 1:20 to 1:40 solutions in water, and 1; 4 solutions in oil, satisfactory. He experimented also with various other formulations, such as paste, putty, and solid dressings; and with other antiseptics, rangings from bichloride of mercury (corrosive sublimate) to boric acid.
Lister, observing that suppuration took place around sutures in wounds despite antiseptic procedure, next turned his attention to suture material. Customarily, surgeons had carried silk suture threads in coat lapel buttonholes for convenience. Lister experimented on animals, and found silk sutures soaked in antiseptic could be left in wound without suppuration. Further, he experimented with suture material from animal sources, developing sterile “catgut’ sutures (made from sheep’s intestine). He proved that they are superior, in some respects, to silk, and that they are absorbed, in situ.
New events were to change the course of Lister’s life. His father-in-law, Professor Syme, became ill and the Chair of Clinical Surgery at the University of Edinburgh became vacant. Lister was elected to the post, and returned to Edinburgh in October, 1869. Professor Syme died the following June.
In Edinburgh, Lister had more free time, so his experiments continued. His microscope was an invaluable aid; and with it he learned many new things about germs. Although he never wrote a book, Lister continued to teach and to write about his findings for medical journals. Typically, his views were accepted more readily by Continental surgeons than by British. Though his students loved him and put his methods into practice, most British surgeons of Lister’s generation were apathetic, indifferent, or antagonistic toward his concept of antisepsis.
Undiscouraged, Lister calmly forged ahead. He began to apply the antiseptic technique to surgical wounds. Operators and assistants were directed to scrub their hands with soap and water, and then dip them frequently in carbolic acid solution. Instruments were immersed in carbolic acid solution for twenty minutes before use. The skin of the field of operation was scrubbed with soap and water and with carbolic acid solution, and towels wrung out in the solution were used to surround the operative site. In addition to thee precautions, Lister was concerned about germs floating in the air. Seeking a remedy, he developed the spray technique: carbolic acid 1:100 was placed in a sprayer and disseminated as vapor in the operating room. Early hand-operated sprays soon gave way to steam sprays. Needless to surgeons and for assistants; but operations could now be undertaken that previously had not been thought possible. Lister reported on use of this spray method to the British Medical Association in 1871, and continued the spray technique in his operating rooms until 1887, after which time he concluded that, with proper aseptic procedures, surgeons could dispense with the irritating cloud of phenolic vapor.
Lister’s star continued to rise. He was called to treat Queen Victoria for an abscess. He became a friend of Pasteur, and was instrumental in smoothing out differences that threatened to become acrimonious between Pasteur and the rapidly rising young German scientist, Robert Koch, who had proved that each infectious disease is the product of as particular microorganism; and whose work had given medicine the new science of bacteriology.
In 1877, Lister was invited to take the Chair of Surgery at King’s College Hospital, in London. While Lister was happy in Edinburgh, where his classes were large and well attended he decided to accept the London physicians had been particularly cold to his concept of antisepsis and he hoped to convince them by working among them. His was a hard task. He acquired only a small personal practice in London, though patients were sent to him form all over the world. His classes were small and poorly attended. Hospital staff members resented his procedures. He accepted patients given up by other surgeons, operated aseptically with success, and saw them restored to health. At the International Congress of Medical Science in Amsterdam in 1879, Lister was acclaimed with enthusiasm by brilliant work for Lister to win over his colleagues in London. Meanwhile, his antiseptic technique was developed into aseptic technique by surgeons in Germany and in France, during the 1880’s.
In his later years, Lister was showered with honors. His visits to Continental Europe were like triumphal marches. He received numerous degrees from universities and honors from nations. He was made surgeon-in-ordinary to Queen Victoria in 1878; made a baronet in 1883; elected Foreign Secretary to the Royal Society in 1893; and created a peer by Queen Victoria in 1897- the first medical man to have been thus honored in Britain. He participated actively in the celebration of Pasteur’s seventieth birthday at the Sorbonne in Paris in 1892. He visited the United States of America in 1876. As an indirect result of Americans’ acceptance of his doctrine, rubber gloves were first used as a requisite to asepsis in surgery by Professor William Stewart Halsted of Johns Hopkins University School of Medicine and Johns Hopkins in Baltimore, about 1890.
Lord Lister’s triumphs in his later years were clouded by the loss of Lady Lister, who died suddenly in 1893. Lister had held his teaching position at king’s College for fifteen years. The next twelve years were spent largely in traveling, in lecturing, and in writing. Then, in 1903, he saw the Lister Institute of Preventive Medicine open its doors.
Though physically frail, Lister’s mind continued active. His last publication, on improved catgut ligatures, was published in Lancet and in the British Medical Journal in 1909. Cared for by his wife’s sister, Lucy Syme, he lived out his last years at the seaside town of Walmer, in Kent. There he passed away quietly, February 10, 1912.