Nineteenth-century surgery is so inextricably associated with epidemic hospitalism that modern surgery seems to be a direct product of the introduction of Joseph Lister’s (1827–1912) antiseptic system. The factors involved in the evolution of modern surgery were certainly more complex, but the importance of Lister’s obsession with preventing infection by attention to both the surgical operation and the quality of post-surgical care should not be underestimated.
Lister’s father, Joseph Jackson Lister (1786–1869), was a wine merchant whose scientiﬁc interests included the development of the achromatic microscope. Joseph Lister attended Quaker schools in London and University College before going to Edinburgh to study surgery. As a prote´ge´ of the great Scottish surgeon James Syme (1799–1870), Lister learned to love the most ‘‘bloody and butcherly
department of the healing art.’’ Happily married to his mentor’s daugh- ter, Lister established his reputation as a surgeon, scientist, and teacher. In keeping with his father’s interests, Lister supplemented his clinical work with microscopic studies of inﬂammation, infection, and blood clotting. His success as a teacher and assistant surgeon at the Royal Inﬁrmary in Edinburgh led to an appointment in 1860 as Regius Professor of Surgery in Glasgow where Lister developed his antiseptic techniques. Lister’s ideas and methods continued to develop, especially when he returned to Edinburgh in 1869 to replace Syme as professor of clinical surgery. Lister returned to London in 1877 as professor of surgery at King’s College Hospital.
Unlike Ignaz Philipp Semmelweis (1818–1865), Lister was an
experimental scientist who shared Louis Pasteur’s (1822–1895) insights into the relationship between theory and practice. Like most of his con- temporaries, Lister initially believed that infection might be caused by the entry of noxious air into a wound. When his attention was drawn to Pasteur’s research on the diseases of wine and beer, however, Lister reached an understanding of the applicability of germ theory to surgical infection. Although few physicians were willing to believe that what occurred in the chemist’s laboratory was relevant to medicine, Lister began a study of inﬂammation in which he used various animal models. Insights gained through these experiments and in hospital wards provided the basis for the development of the antiseptic system.
In attacking the problem of hospital infections, Lister deliberately
chose compound fractures for his critical tests, because ‘‘disastrous con- sequences’’ were frequent with open or compound fracture (a fracture in which the broken ends of the bone protrude through the skin), in con- trast to the uncomplicated healing characteristic of simple fracture (a fracture in which the skin remains unbroken), although the trauma involved and the possibility of deformity were similar. Infection often claimed more than 60 percent of patients with compound fractures. Sur- geons traditionally probed and enlarged the opening of the wound, but the prognosis was so poor that immediate amputation was considered a reasonable course of treatment. Nevertheless, as Ambroise Pare´ (1510–
1590) demonstrated when he managed his own broken leg, amputation
and/or death were not inevitable consequences of compound fracture. According to experienced surgeons, any blockhead could perform an amputation, but great skill was needed to heal a compound fracture without primary amputation.
The search for antiseptics and disinfectants has been part of folk medicine and surgery throughout history. As Florence Nightingale (1820–1910), pioneer of modern nursing and sanitary reform, often said, most of these agents were useless, except when they overwhelmed the nose and forced people to open the windows. Carbolic acid (a solution of phenol) was one of many chemicals used in the nineteenth century as
Antiseptic surgery in 1882.
a general disinfectant for cesspools, outhouses, stables, and drains. After reading about the beneﬁcial effects the town of Carlisle enjoyed after adding carbolic acid to its sewage works, Lister tested it in animal and human experiments. Several cases ended in failure, but sug- gested ways in which Lister could improve his techniques. In 1865, an
11-year-old boy with a compound fracture of the leg was admitted to the Glasgow Royal Inﬁrmary. The limb was splinted and the wound was washed and dressed with carbolic acid. Within six weeks, the bones were well united and the wound had healed without suppuration. Between August 1865 and April 1867, Lister treated 11 patients with compound fractures using the antiseptic technique; nine survived. Further reﬁnements of the antiseptic system led to successful treatments for a variety of life-threatening conditions. Moreover, when the antiseptic sys- tem was fully incorporated into the hospital routine, the overall rate of hospitalism declined dramatically. Although Lister published an account of the antiseptic system in The Lancet in 1867, English surgeons generally ignored his work. In order to convert English surgeons to the antiseptic system, in 1877, Lister accepted the chair of clinical surgery at King’s College, London. His surgical demonstrations at King’s College Hospital eventually won over many skeptical surgeons, despite continu- ing resistance to germ theory in the English medical community.
Surgeons who worked with Lister brought his ideas and methods
back to their own medical communities where they were able to expand
their repertoire and range of operations. Rather than conﬁning them- selves to interventions deemed absolutely necessary to preserve life, they could perform operations previously considered unsafe or even impos- sible. By the time Lister retired in 1892, his methods were ﬁnally winning due recognition and many honors. Lister was the ﬁrst medical man ele- vated to the British peerage (he became Baron Lister of Lyme Regis in
1897). He was an ardent supporter of medical research at a time when antivivisectionists were very active. Theoretical reasons for resistance to the germ theory were emphasized in professional debates, but, as in the battle against puerperal fever, much of the opposition came from hospital managers who were reluctant to assume the costs of improving operating rooms and hospital wards.
Lister attributed his success to his appreciation of Pasteur’s
argument that the ‘‘septic property of the atmosphere’’ was due to germs suspended in the air and deposited on surfaces. To attack the germs in the air directly, Lister experimented with devices that sprayed carbolic acid into the air of the operating room. His favorite pump—known as the mule—dispensed a ﬁne mist that his patients and assistants found extremely irritating. Eventually, Lister acknowledged that he had over- emphasized the problem of airborne germs. Focusing his attention on improvements in the disinfection of hands, instruments, and wound dressings, he reluctantly abandoned the spray. Unfortunately, surgeons who thought that the ‘‘antiseptic system’’ was simply a matter of sloshing carbolic acid on wounds assumed that the system had failed if wounds became infected.
Although few Americans today are familiar with the work of
Joseph Lister, some vague memory of ‘‘Lister the germ killer’’ survived in advertisements for Listerine. The name of this product added the suggestive value of Lister’s name to the ancient tradition of strong- smelling wound disinfectants. Since the 1870s, when Listerine the ‘‘germ ﬁghter’’ was sold to doctors and dentists as a general antiseptic and mouthwash, the secret formula has retained its strong ﬂavor and odor. Since the 1920s, Listerine has been advertized to the public as a ‘‘germ killer’’ for the prevention of colds, sore throats, and bad breath.