Date read: 23-04-2024

Author: Lindsey Fitzharris

How strongly I recommend it: 8/10

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Joseph Lister was a pioneer of antiseptic surgery. In doing so, he likely saved thousands, if not millions of lives during his time and in the future. We’re all beneficiaries.

I’m in awe of his work. He’s a personal inspiration, alongside Michael Faraday.

But I want to note that he wasn’t a lone ranger; he stood on the shoulders of giants too, notably Louis Pasteur, whose germ theory led to Lister’s breakthrough.

Lister wasn’t the first person to recognize the importance of hygiene either; Ignaz Semmelweis was a Hungarian doctor who first noticed the importance of disinfection before surgery. However, the medical community rejected his ideas because they went against the established opinions of that time. He eventually went crazy, got ostracised even further, and died after he was beaten by the guards in the asylum.

Fun fact: Lister’s work inspired the doctor Joseph Lawrence to develop an alcohol-based formula for a surgical antiseptic. In honour of Lister, he named it “Listerine”.

Fun fact #2: After attending one of Lister’s medical seminar and learning about antiseptic surgery, Robert Wood Johnson joined forces with his brothers to start a company to sell ready-to-use sterile surgical dressings. The company’s name? Johnson & Johnson.

My notes

The physician Thomas Percival advised surgeons to change their aprons and to clean the table and instruments between procedures, not for hygienic purposes, but to avoid “every thing that may incite terror.” Few heeded his advice.

It was not uncommon during this period for physicians to prescribe treatment without first performing a physical examination. Indeed, some dispensed medical advice through letters alone, never laying eyes on the patient in question.

The surgeon was very much viewed as a manual labourer who used his hands to make his living, much like a key cutter or plumber today. Nothing better demonstrated the inferiority of surgeons than their relative poverty. Before 1848, no major hospital had a salaried surgeon on its staff, and most surgeons (with the exception of a notable few) made very little money from their private practices.

Instruments like the amputation knife of Lister’s student days were havens for bacteria. Fashion often trumped function. Many had decorative etchings and were stored in velvet cases, which bore bloodstains from past operations.

Many of Lister’s instructors still believed the microscope was not only superfluous to a study of surgery but also a threat to the medical establishment itself. Even with improvements like Joseph Jackson’s achromatic lens, the instrument continued to be regarded with suspicion by those within the medical community, many of whom lacked the skill and training to operate one effectively. What revelations did the microscope offer? Surely all relevant signs and symptoms could be observed with the naked eye.

At the time of Lister’s appointment, nursing was not a calling that required skill or training, nor did it command much respect. Educated, well-to-do women didn’t dare enter a profession that would expose them to the intimate workings of the male body or leave them alone and unsupervised with men. Florence Nightingale—the woman who would later revolutionise nursing—had not yet fully developed the protocols of cleanliness for which she would become celebrated. Furthermore, it would be another nine years before the founding of the International Red Cross, which would be instrumental in training nurses in the latter half of the nineteenth century.

Like most hospitals in the 1860s, the Royal Infirmary attracted patients who were too poor to pay for private care. Some were uneducated and illiterate. Many doctors and surgeons viewed them as socially inferior and treated them with a clinical detachment that was often dehumanizing. Lister, true to his Quaker roots, exhibited an unusual level of compassion for those on his wards. He refused to use the word “case” when referring to specific patients, choosing instead to call them “this poor man” or “this good woman.” He also recommended to his students that they use “technical words” so that “nothing was said or suggested that could in any way cause them anxiety or alarm”—something that would undoubtedly be viewed as unethical today but was born purely of compassion when Lister suggested it.

Lister understood that being in a hospital could be a terrifying experience and followed his own golden rule: “Every patient, even the most degraded, should be treated with the same care and regard as though he were the Prince of Wales himself.” He went above and beyond the call of duty when it came to putting at ease the children who were admitted to his wards.

Even in his private practice, he exhibited an acute empathy with patients that extended to their pockets. Consequently, Lister objected to issuing bills to those whom he treated and lectured his students that they should “not charge for [their] services as a merchant does for his goods.” Reflecting the ideals of his faith, Lister believed that the greatest reward for a surgeon was the knowledge that he had performed an act of beneficence for the sick.

In an instant, Pasteur went from being a serious chemist held in esteem by most of the scientific community to being considered a maverick by his championing of what he called “the world of the infinitely small.” His research immediately fell under attack, threatening to topple long-established views of how the world worked. The scientific journal La Presse passed damning judgment on the French scientist: “I am afraid that the experiments you quote, M. Pasteur, will turn against you.… The world into which you wish to take us is really too fantastic.”

His articles were instructive rather than theoretical, though his commitment to Pasteur’s scientific tenets was clear. The majority of each paper laid out detailed case histories in which Lister spoke about his struggles to prevent or control putrefaction in the wounds of each patient. His intent was to show the readers, who were invited to feel that they were standing at Lister’s shoulder, how to replicate his methods. Throughout the series of articles, he also demonstrated how his system evolved by explaining why he rejected certain types of dressings and why he tried different approaches when others had failed. The unashamedly scientific method Lister had applied to his experiments was plain for all to see.

In his address to the British Medical Association in 1869, he (Thomas Nunneley) said that Lister’s antiseptic system was based on “unsupported fancies, which have little other existence than what is found in the imagination of those who believe in them.” He thought that Lister’s advocacy of the germ theory was preposterous: “This speculation of organic germs is, I fear, far more than an innocent fallacy,” he told conference attendees, among them James Y. Simpson. “It is a positive injury,” he continued, “for teaching … that those desperate consequences which so often follow wounds result from one cause alone, and are to be prevented by attending to it alone … leads to the ignoring of those many and often complicated causes.”

As one of Lister’s assistants astutely observed: “A new and great scientific discovery is always apt to leave in its trail many casualties among the reputations of those who have been champions of an older method. It is hard for them to forgive the man whose work has rendered their own of no account.”

If seeing was believing, Lister was creating a group of disciples: men who would graduate and spread his ideas beyond the narrow confines of the university. His followers, who later became known as the “Listerians,” soon came to dominate the institutions and ideology of British surgery, spreading the doctrine of antisepsis with a reverential devotion.

Indeed, Lister’s students—who might attend a demonstration with their minds settled on one technique, only to discover that their professor had already developed a new method since their last encounter—came to expect these changes. For them, it underlined the value of experimentation in medicine and illustrated that observational acuity and accuracy could lead to improvements in surgery.

As Lister’s methods evolved, skeptics characterized these constant modifications as admissions on his part that the original system did not work. They didn’t see these adjustments as part of the natural progression of a scientific process.

But for all the opposition Lister faced, he was fighting the battle with like-minded people who recognized the revolutionary nature of his work. Initially, his antiseptic system received more support on the Continent than it did in Britain, so much so that in 1870 Lister was asked by both the French and the Germans to furnish some guidelines for treating wounded soldiers fighting in the Franco-Prussian War. As a consequence, the German physician Richard von Volkmann became a spirited devotee after his hospital at Halle—overcrowded with wounded soldiers from the war and so dreadfully overcome with infection that its closure was imminent—achieved astonishing results by employing Lister’s methods. Following this, Lister’s system was taken up by other European surgeons, including a Dane named M. H. Saxtorph, who reported success in a letter to Lister.

On that trip, John Tyndall—who had recently visited Lister’s wards in Glasgow—casually mentioned to the French scientist that “a celebrated English surgeon” had made an important contribution toward understanding the causes of putrid and contagious diseases using Pasteur’s work as a guide. This was the first time Pasteur had ever heard of Lister. His interest was piqued.

The two men began a lengthy correspondence. In their letters, they discussed their experiments, theories, and discoveries and expressed mutual respect and esteem. Lister saw Pasteur as the man who had provided the means by which he could understand wound sepsis. In turn, Pasteur was in awe of Lister’s advancement of the subject. As Pasteur wrote, “I am extremely surprised at the precision of your manipulations, [and] at your perfect comprehension of the experimental method.” He was amazed that Lister could find the time to conduct such complex research while also attending to his patients. “It is a perfect enigma to me,” he wrote to Lister, “that you can devote yourself to researches which demand so much care, time and incessant painstaking, at the same time as you devote yourself to the profession of surgery and to that of chief surgeon to a great hospital. I do not think that another instance of such a prodigy could be found amongst us here.” To Lister— man who had always placed immense faith in the scientific method—this was as high a compliment as could be paid him, especially since it came from such a revered figure as Pasteur.

Although there had been a perceptible shift in opinion toward the acceptance of Lister’s methods in the capital, it took several more years before the wholesale adoption of antisepsis occurred in London. This was largely due to the fact that many surgeons in the city were unwilling to endorse Pasteur’s germ theory of putrefaction.

In a letter that appeared in The Lancet, a correspondent who signed his name “Flaneur” made a perceptive observation regarding the city’s slow adoption of antisepsis:

The truth is, that this is a question in science rather than in surgery, and hence, while eagerly adopted by the scientific Germans, and a little grudgingly by the semi-scientific Scotch, the antiseptic doctrine has never been in any degree appreciated or understood by the plodding and practical English surgeon. Happily for his patients, he has for a long time been to a considerable extent practising a partially antiseptic system, thanks to his cleanly English instincts; but it has been like the lady who talked prose without knowing it.

Still, one nation remained unconvinced of the merits of Lister’s methods: the United States. In fact, in several American hospitals, Lister’s techniques had been banned; many doctors saww them as unnecessary and overly complicated distractions because they had not yet accepted the germ theory of putrefaction. Even by the mid-1870s, understanding of wound care and infection had barely progressed, despite Lister’s theories and techniques appearing in American medical journals. The medical community had, for the most part, rejected his antiseptic methods as quackery.

If Lister had nursed any hope that his diligence and reasoned argument concerning his antiseptic system would convert the American audience, he would be sorely disappointed. One attendee accused him of being mentally unhinged and having a “grasshopper in the head.” Others berated him for speaking so long. “The hour being late,” one critic whined, “I merely desire to point out a few facts which … militate against the [germ] theory, as far as it claims that a certain class of minute living organisms … are essential to disease-processes.” But it was Samuel Gross—the man who had hoped to discredit Lister by inviting him to speak at the International Medical Congress—who would have the final word: “Little, if any faith, is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called treatment of Professor Lister.”

Before heading back to Britain, Lister moved on to Boston, and it would prove to be a serendipitous visit. There, he met Henry J. Bigelow, the man who had banned his antiseptic techniques at Massachusetts General Hospital. Bigelow hadn’t attended the medical conference in Philadelphia, but he had read reports about Lister’s lecture. Although he still wasn’t convinced about the existence of germs, he was impressed by Lister’s dedication to his system and the care and attention he paid his patients. Bigelow invited Lister to speak at Harvard University, where he was warmly received by the medical students in attendance. Not long afterward, the American surgeon delivered a lecture of his own. In it, he praised “the new doctrine” and confessed his conversion to Lister’s antiseptic system: “I have learned that the duty of the surgeon … should be to destroy the actual intruders [germs], and effectually to exclude their thronging companions.” With Bigelow’s endorsement, Massachusetts General became the first hospital in America to make institutional use of carbolic acid as a surgical antiseptic. It was an extraordinary volte-face of policy in a hospital that for years had banned Lister’s methods and even threatened to fire those who dared implement them.

Lister recognized the importance of the hospital, but only in relation to the care and treatment of the poor. His former student Guy Theodore Wrench later argued that had it not been for his mentor’s work, hospitals might have ceased to exist altogether. “Large hospitals were being abandoned and hut hospitals substituted,” Wrench wrote. “Lister’s work … came in the nick of time. It saved not only patients but hospitals. It prevented … an entire reversion of the method of dealing surgically with the poor.”

Joseph Jackson had once reminded his son that it was a blessing that he had been permitted to be the means by which the antiseptic system was introduced to “thy fellow mortals.” A life of self-sacrifice and singular determination had been fully vindicated. His pioneering work ensured that the results of surgery would no longer be left to chance. Henceforth, the ascendancy of knowledge over ignorance, and diligence over negligence, defined the profession’s future. Surgeons became proactive rather than reactive when it came to postoperative infection. No longer lauded for their quick hand with a knife, they were revered for being careful, methodical, and precise. Lister’s methods transformed surgery from a butchering art to a modern science, one where newly tried and tested methodologies trumped hackneyed practices. They opened up new frontiers in medicine—allowing us to delve further into the living body—and in the process they saved hundreds of thousands of lives. Hector Cameron, Lister’s former student and assistant, later said of him, “We knew we were in contact with Genius. We felt we were helping in the making of History and that all things were becoming new.” What was once impossible was now achievable. What was once inconceivable could now be imagined. The future of medicine suddenly seemed limitless.