12 May

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

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.

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