Eminent doctors: Their lives and their work; Vol. 2 of 2

by G. T. Bettany

FOOTNOTES:

[11] Obituary notice, May 3, 1879, p. 645.

[CHAPTER XVIII.]
SIR JOSEPH LISTER AND ANTISEPTIC SURGERY.

Again and again in these pages the hereditary succession of scientific powers has been illustrated. Not the least eminent example is to be found in the case of Sir Joseph Lister, who is the son of Mr. Joseph Jackson Lister, F.R.S., of Upton House, Essex, who in the words of the Rev. J. B. Reade, F.R.S., in his presidential address to the Royal Microscopical Society in 1870, “raised the compound microscope from its primitive and almost useless condition to that of being the most important instrument ever yet bestowed by art upon the investigator of nature.” Mr. J. J. Lister was born in London on January 11, 1786, his parents being members of the Society of Friends. At fourteen years of age he left school to assist his father in the wine trade: but though for many years closely occupied in business, he contrived by early rising and otherwise to supplement his plain school education, and to make himself accomplished in mathematics, as well as generally acquainted with most subjects in literature, science, and art. His predilection for optics was early shown. As a little child with shortsighted eyes, he enjoyed looking through air bubbles in the window-pane, enabling him to see distant objects more clearly. At school he was the only boy who possessed a telescope. He soon became addicted to microscopical study; but it was not till 1824, when he was 38 years old, that he thought of improving the object-glass of the compound microscope, and made suggestions to W. Tulley, the optician, which resulted in the production of a new object-glass much less thick and clumsy, which speedily became the favourite. On January 21st, 1830, he read a paper before the Royal Society “On the Improvement of Compound Microscopes,” announcing the remarkable discovery of the existence of two aplanatic foci in a double achromatic object-glass. This formed a basis for subsequent important improvements. In 1837 he gave to Andrew Ross the construction for a ⅛-inch objective of three compound lenses, by which that maker’s fame was largely increased, and it became the standard form for high power for many years. He also made some notable researches “On the Structure and Functions of Tubular Polypi and Ascidiæ” (Phil. Trans. 1834), and independently came to the same conclusions as Sir George Airy, the late Astronomer-Royal, on the limits of human vision as determined by the nature of light and of the eye; but his paper on this subject was never published, owing to the publication of Sir George Airy’s researches. He survived in vigorous health to see his son Joseph in secure possession of fame, dying on October 24, 1869. His son records[12] that “he was most unselfish, and scrupulously tender of hurting the feelings of others, and extremely generous in the pecuniary support of public philanthropic objects, as well as in secret acts of charity. Though warmly attached to the religious Society of Friends, to which he belonged, he was a man of very liberal views and catholic sympathies. But the crowning grace of this beautiful character, though it might veil his rich gifts from those not intimate with him, was a most rare modesty and Christian humility.”

Joseph Lister was born in 1828, and took the B.A. degree at London University in 1847. Pursuing a course of medical study at University College, London, he gained the M.B. degree in 1852, being awarded gold medals in anatomy and in botany at the first M.B. examination, and the scholarship and gold medal in surgery at the final examination. He became Fellow of the Royal College of Surgeons in 1852, and took a similar qualification at Edinburgh in 1855. He married a daughter of Mr. Syme, then Professor of Surgery in the University of Edinburgh.

Devoting himself to physiological research on matters having a wide bearing on practical medicine and surgery, Mr. Lister attained wide repute as an original investigator at a comparatively early age, and his position in physiology was assured by a series of papers which would suffice to make his career memorable, if he had never applied antiseptic measures to the treatment of disease. Beginning with some observations on the contractile tissue of the iris in 1853, he went on to study the muscular tissue of the skin, the flow of the lacteal fluid, and the minute structure of involuntary muscular fibre, on all of which subjects his papers are published in the “Journal of Microscopical Science.” In 1857 he commenced his series of contributions to the Royal Society, the first being on the functions of the visceral nerves, with special reference to the inhibitory system. This was further developed in “An Inquiry regarding the Parts of the Nervous System which regulate the Contractions of the Arteries” (Phil. Trans. 1858). But his two most important papers at this period are those on the Early Stages of Inflammation (1857), and on the Coagulation of the Blood, delivered as the Croonian Lecture for 1863.

For some years Mr. Lister was a lecturer on surgery in the Edinburgh Extra-Academical School. He was afterwards elected Professor of Surgery in Glasgow University, and Surgeon to the Glasgow Royal Infirmary.

While Mr. Lister held these appointments, circumstances occurred which were calculated to stimulate to the highest degree the effort to discover some method of dressing wounds which should obviate the dangers of putrefactive changes. About 1860 a new surgical hospital was erected as part of this infirmary, and although many of the most approved principles of hospital construction had been adopted, the building proved extremely unhealthy. Pyæmia, erysipelas, and hospital gangrene soon showed themselves, affecting on the average most severely those parts of the building nearest to the ground. For several years Mr. Lister found that in his male accident ward, which was on the ground-floor, when nearly all the beds contained patients with open sores, the diseases which result from hospital atmosphere were sure to be present in an aggravated form; whereas, when a large proportion of the cases had no external wound, these evils were greatly mitigated or entirely absent. At this period the managers were very desirous of introducing additional beds into the wards, to supply accommodation for the rapidly increasing population of Glasgow; and Mr. Lister strongly and firmly resisted such increase in his wards. Some of the wards indeed at times became subject to such severe mortality that they had to be closed for various periods. One particular visitation was so serious that it was resolved to make an investigation to discover if possible the cause of the evil, which might, one would think, have been done at an earlier period. Great was the shock of every one concerned to find that a few inches below the surface of the ground behind the two lowest male accident wards, with only the basement area, four feet wide, intervening, there was the uppermost tier of a multitude of coffins, which had been placed there at the time of the cholera epidemic of 1849. The corpses had undergone so little change in the interval that the clothes they had on at the time of their hurried burial were plainly distinguishable. The wonder was, not that these wards on the ground-floor had been unhealthy, but that they had not been absolutely pestilential. Yet at the very time when this shocking disclosure was made, Mr. Lister was able to state, in an address which he delivered to the British Medical Association at Dublin in 1867, that during the previous nine months, in which his new antiseptic plans of treatment had been in operation in his wards, not a single case of pyæmia, erysipelas, or hospital gangrene had occurred in them.

The managers of the infirmary of course did all in their power to remedy this insalubrious state of things. They poured large quantities of carbolic acid and quicklime upon the ground, considering this a less dangerous proceeding than to attempt the removal of the putrefying mass; they covered the ground with an additional thickness of earth, and adopted other measures. The hospital itself was far from being well situated in other respects. It abutted against the old Cathedral Churchyard, much used for the “pit burial” of paupers in a most deleterious state of aggregation. Yet during the two years and a quarter intervening between the Dublin address and Mr. Lister’s leaving Glasgow for Edinburgh, his new antiseptic system continued in the main as successful as before.

In the course of the year 1864 Professor Lister had been much struck with an account of the remarkable effects produced by carbolic acid upon the sewage of the town of Carlisle, the admixture of a very small proportion not only preventing all odour from the lands irrigated with the refuse material, but also destroying the entozoa which usually infest cattle fed upon such pastures. His attention having been for several years greatly directed, as we have seen above, to the subject of suppuration, especially in its relation to decomposition, he saw that such a powerful antiseptic was peculiarly adapted for experiments with a view to elucidating that subject, and thus the applicability of carbolic acid to the treatment of compound fractures occurred to him.

The antiseptic system was put into practice in the Glasgow Infirmary in March 1865, but at first applied almost exclusively in compound fractures (or those in which there is an external wound) and abscesses. From 1867 it was employed for almost all surgical cases. It arose out of Mr. Lister’s study of Schwann and Pasteur’s germ theory and the experiments connected with them. He repeated many of the experiments, and devised new methods calculated to test whether they were capable of explaining the phenomena of putrefaction. These sufficed to prove definitely that in putrefaction the development of such organisms as the microscope could detect, and the concomitant putrefactive changes, were occasioned by minute germs suspended in the atmosphere. Professor Tyndall’s beautiful experiments, by which he demonstrated the perfect manner in which cotton wool filters the air of its suspended particles, led to the idea (suggested by Dr. Meredith of the Indian service to Mr. Lister) that cotton wool might be used with advantage as an antiseptic dressing. The cotton wool must itself be rendered pure of germs by some antiseptic agency, for by the theory the air within it must contain germs. But the main feature upon which Mr. Lister for a long time relied was the copious use of carbolic acid in such a form as to prevent the occurrence of putrefaction in the part concerned.

Mr. Lister’s first paper on the subject, published in the Lancet for 1867, struck a chord which the editor of that journal emphasised as follows on August 24 of that year (p. 234): “If Professor Lister’s conclusions with regard to the power of carbolic acid in compound fractures should be confirmed by further experiment and observation, it will be difficult to overrate the importance of what we may really call his discovery. For although he bases his surgical use of carbolic acid upon the researches of M. Pasteur, the application of these researches to the case of compound fractures, opened abscesses, and other recent wounds, is all his own.” The risk of blood-poisoning after operations in themselves slight, was declared to be the one great opprobrium of surgery. There was no limit to the operative skill of surgeons, but a miserable and serious risk of fatal after-consequences against which the surgeon had no defence. Mr. (now Sir James) Paget had in 1862 given forth an idea of which we can now more clearly see the bearing, when he said that the best results he had seen in cases of pyæmia were with patients kept night and day in a current of wind. We now see that this in fact amounted to continually passing over the patient air less charged with germs than that of the room or ward in which he was placed. Mr. Lister contemplated the destruction of these germs at the seat of the wound, and the prevention of the access of fresh germs.

An example will perhaps illustrate the matter better than a theoretical account. An experiment was performed on the 31st December 1868 on a young calf a few days old, under chloroform, namely, the tying of the carotid artery on the antiseptic system, with threads composed of animal tissue. The threads employed had all been soaked for four hours in a saturated watery solution of carbolic acid, which swelled and softened them. The hair near the wound was cut short, and a solution of carbolic acid in linseed oil rubbed well into the skin to destroy any putrefactive organisms lying amongst the roots of the hair. The sponges employed in the operation were wrung out of a watery solution of the acid, and all the instruments introduced into the wound, together with the fingers of the operator’s left hand and the copper wire used for sutures, were treated with the same lotion, some of which was poured into the wound after the introduction of the last stitch, at one of the intervals left for the escape of discharge, to provide against the chance of any fresh blood which might have oozed out during the process of stitching having passed back and taken fresh germs in with it. The external dressing was a towel saturated with the oily solution of carbolic acid, folded as broad as the length of the neck, wrapped so as to extend freely beyond the wound, and prevented by several contrivances from slipping. A sheet of gutta-percha tissue was applied outside to prevent contamination of the antiseptic towel from without. A few ounces of the oily solution were poured daily over the towel for the first week, after which the dressings were left untouched for three days and then entirely removed. The wound was found quite dry, and free from tenderness. When the animal was subsequently killed, the ligatures were seen to be converted into living tissue; and such experiments proved how valuable animal fibres might be as ligatures under the antiseptic system.

Again, a portion of cotton wool was impregnated with about one two-hundredth part of its weight of carbolic-acid vapour, and the surface of a granulating sore and surrounding skin was washed with a dilute solution of the acid. A piece of oiled silk of the size of the sore was then applied, to prevent the dressings from sticking through becoming dry. Over this was placed a piece of folded linen rag of rather larger size, and similarly impregnated with carbolic acid vapour to the cotton wool; this being intended to absorb any discharge from the sore. Lastly, an overlapping mass of carbolised cotton wool was securely fixed over all. The result was that although all chemical antiseptic virtue left the dressing by evaporation of the volatile carbolic acid in a day or two, yet putrefaction was practically excluded by the cotton wool for any length of time.

Subsequently another variety of protective material was adopted, namely antiseptic gauze, a loose cotton fabric, the fibres of which were impregnated with carbolic acid lodged in insoluble resin. The interstices between the fibres were kept free from these ingredients, so that the porous fabric might readily absorb discharges. By arranging this in a sufficient number of layers and covering the whole with a layer of mackintosh, the discharge was compelled to pass through the whole length of the antiseptic dressing. Thus it was almost certain that if no putrefactive mischief were left in a wound or abscess, none would enter it, however profuse might be the discharge.

If a wound was presented for treatment, inflicted by some other than the surgeon, some dust was sure to have been introduced, which probably contained putrefactive germs. The energy of these had first to be destroyed by washing the raw surface with some strong antiseptic agent. But in operating upon a previously unbroken skin, Mr. Lister considered that he could prevent the septic particles from entering at all, by operating in an antiseptic atmosphere. This was provided by producing a shower of spray of carbolic acid of the finest character. This answered exceedingly well when the solution producing the spray consisted only of one part of carbolic acid to 100 parts of water.

Here we must limit our detailed account of the antiseptic system. Under it large abscesses are opened, the matter pressed out, and fresh matter does not form, and cures are effected in severe cases which scarcely ever used to be cured. Arteries are tied with a security before unknown. Amputations and excisions are effected with a safety and diminished mortality quite surprising. Even senile gangrene shows hopeful results which were previously quite out of question. Pyæmia, hospital gangrene, and erysipelas have been almost banished from wards where the system is properly carried out. Recently a modification has been introduced, in which there is employed, not a volatile material as in the case of carbolic acid, but a dilute solution of corrosive sublimate combined with albumen. Gauze is now prepared for Sir Joseph Lister steeped in this substance, and it may become generally adopted; but it does not appear likely to supersede carbolic acid for the purification of instruments, sponges, the skin, or as a substitute for the carbolic spray. The particular form of antiseptic is a matter of detail, on which improvement may long continue to be made; but the development of the essential idea of preventing the access of germs which can cause putrefactive changes by one method or another, and the destruction of them as far as possible when they have obtained access, will remain connected with Sir Joseph Lister as an achievement of the highest force; indeed his name seems likely to give a new word to our language, namely Listerism, by which the essential features of his system are understood.

Professor Lister was awarded a Royal Medal by the Royal Society of London in 1880, having previously received the high distinction of the MacDougall Brisbane Prize from the Royal Society of Edinburgh in 1875, for a remarkable paper on the Germ Theory of Fermentative Changes. He was created a baronet in December 1883. The universities of Cambridge, Edinburgh, and Glasgow had conferred upon him the honorary degree of LL.D., and Oxford that of D.C.L. He has been for some years Surgeon to King’s College Hospital, having succeeded Sir William Fergusson.