Thursday, April 28, 2011

Joseph Lister: Father of Antiseptic Surgery

Great Advances in Science

The frequency of disastrous consequences in compound fracture, contrasted with the complete immunity from danger to life or limb in simple fracture, is one of the most striking as well as melancholy facts in surgical practice.
Lord Joseph Lister,
On a New Method of Treating Compound Fracture, Abscesses, etc:
With Observations on the Conditions of Supperation, Part I.
The Lancet
(1867): 326

Lister saw the vast importance of the discoveries of Pasteur. He saw it because he was watching on the heights, and he was watching there alone.
Sir Thomas Clifford Allbutt,
Baron Joseph Lister, The Encyclopædia Britannica (1911), 778.

Before Joseph Lister's discoveries and observations helped advance surgical practices one hundred fifty years ago, many persons would die from post-surgical complications, typically infections. Lister's recommendations to use the antiseptic carbolic acid, now known as phenol, in the surgical theatre in mid-Victorian England greatly increasing the survival of persons having what today would be considered routine surgeries, such as repairing a compound fracture.

In a compound fracture, for example, the bone breaks through the skin, exposing the wound. In such cases, although patients might have survived the surgery, they often died from gangrene. After his own research, and reading about the work of Louis Pasteur and Ignaz Semmelweis, he began to place dressings soaked with carbolic acid (phenol) to cover the wound and the rate of infection was vastly reduced.

Lister then experimented with hand-washing, sterilizing instruments and spraying carbolic in the theatre while operating in order to limit infection. The machine sprayed a fine mist of carbolic acid over the wound, thus keeping it free from infection. Although better methods were soon invented, this initial discovery greatly decreased the mortality rate after operations.

This was only the beginning in making the connection between a sterile operating theater and higher survival rates. We now take these things for granted, but it took years to convince the medical establishment of its validity, as is common with revolutionary ideas. Many were still mired in the theories of miasma, or poor air quality.

Operations were performed by doctors who didn't wash hands and worked under less-than-sterile conditions. While ward cleanliness was an important step, and we can thank Florence Nightingale for such improvements,  it was not as important as controlling and preventing infections caused by bacteria invading an open wound. Many physicians didn't understand or accept the ideas of microbes, or bacteria, that they couldn't see. Once again, a lot had to do with Lister's early years, what he viewed and what was deemed important.

Born to A Quaker Family

Joseph Lister was born to Isabelle Harris and Joseph Jackson Lister in Upton, Essex, England (now a suburb of London), on April 5, 1827. His father was a Fellow of the Royal Society and inventor of the achromatic lens for microscopes, leading to Lister's interest in microbiology. Joseph was born into a family of Quakers, and attended their schools in Hertfordshire and London.

He attended the University of London, and graduated with a bachelor of arts degree in 1847. He continued his studies, after surviving a case of smallpox, and entered the University of London's medical school. Lister graduated with degrees in medicine and surgery in 1850. He was an excellent student, winning two gold medals for his academic achievements. He continued on and became a Fellow of the Royal College of Surgeons (FRCS) in 1852.

While a surgeon on staff at the University of London's Hospital, he was in charge of some cases during an outbreak of gangrene at the hospital. Using the tools of his father's invention, the achromatic microscope, he was led to believe that the conventional wisdom, germs in the air, was wrong:
He was thus early led to suspect the parasitic nature of the disorder, and searched with the microscope the material of the spreading sore, in the hope of discovering in it some invading fungus; he soon convinced himself of the cardinal truth that its causes were purely local. He also minutely investigated cases of pyaemia, another terrible scourge of hospitals at that time, and made camera lucida sketches of the appearances revealed by the microscope.
The real culprit were germs on the clothes and hands of the surgeons and medical staff. But Lister did not yet have a scientific explanation. That would come years later. He then served as assistant to the leading Scottish surgeon James Syme at the Royal Infirmary, Edinburgh, Scotland, from 1854 until 1860. In 1856, Lister married Syme’s daughter Agnes, and joined her as a member of the Anglican Church, of which he remained a member until his death. The couple had no children.

It was said that Agnes was a great help her husband, "helping with experiments and writing up his notes," Ann Lamont writes in Joseph Lister: Father of Modern Surgery.

In 1860, Lister became a professor of surgery at University of Glasgow and its Royal Infirmary. Then and there a number of things came together. For one, he observed that between 45 and 50 percent of amputation patients died from sepsis (infection). After he had read about Louis Pasteur's ground-breaking work on the theory of germs in 1865, it gave him a scientific basis for his clinical studies that he started in earnest a year earlier, in 1864.

Surgeons Using Lister's Antiseptic Method: Joseph Lister, centre, guiding the use of the carbolic spray apparatus on the right.
Photo Credit & Source: Chemistry Explained.
In a now-famous paper, "On a New Method of Treating Compound Fracture, Abscesses, etc: With Observations on the Conditions of Supperation, Part 1,"  that Lister wrote when he was professor of surgery at the University of Glasgow, and published in the British medical journal, The Lancet (July 27, 1867), we can see the scientific lessons learned:
Bearing in mind that it is from the vitality of the atmospheric particles that all the mischief arises, it appears 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 this purpose, yet not too potent as a caustic.

In the course of the year 1864 I was 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, as it was stated, destroying the entozoa which usually infest cattle fed upon such pastures.
In 1869 Lister left Glasgow for the University Edinburgh where he was named professor of surgery. As time progressed, the new theory of germs gained greater acceptance. But it was not until Lister was appointed chair and professor of  clinical surgery at King’s College Hospital in London, in 1877, that he began to win over the English doctors.

By 1879, Lister’s principle of antiseptic surgery had gained almost universal acceptance. While his method, based on the use of antiseptics, is no longer used today in modern hospitals (asepsis), his principle—that bacteria must be prevented from entering a wound—remains the basis of surgery to this day.

After his wife died on a rare holiday, in Italy, in 1892, Lister retired from medicine in 1893. The loss of his wife sunk him into some despair, his routine disrupted. Writing and research became less important to him. 

Lister received many honours. In 1883, Queen Victoria knighted him as Sir Joseph Lister. In 1897, he was given the title Lord Lister of Lyme Regis. He was first to be made a British peer for services to medicine. In 1902, he was given the Order of Merit, and made a Privy Councillor. Also named in his honour is the bacterial genus Listeria. On the commercial level, in 1879, Listerine mouthwash was named after him for his work in antisepsis.

Joseph Lister died at Walmer, Kent, his country home on February 10, 1912. He was eighty-four. After a funeral service at Westminster Abbey, Lister was buried at Hampstead Cemetery, Fortune Green, London

The Sad Story of Ignaz Semmelweis

It's important to remember that achievement, discovery and advancement is rarely if ever done in isolation. It is usually built upon the findings of others who preceded you. In the case of Lister, his work was based on the work of Ignaz Semmelweis (1818-1865), a Hungarian physician who was unsuccessful in convincing the medical establishment of the need for hand washing to reduce the cases of puerperal fever among pregnant women. His temperament differed from Lister's no doubt.

After more than fifteen years trying to establish this antiseptic technique, he suffered a nervous breakdown and was forcefully committed to an insane asylum, where he was severely beaten. Semmelweis died of pyemia (blood poisoning) from a gangrenous wound two weeks later, possibly from the beatings, on August 13, 1865. In an article on Semmelweis, John H. Lienhard writes:
That same year Joseph Lister begins spraying a carbolic acid solution during surgery to kill germs. In the end, it's Lister who gives our unhappy hero his due. He says, "Without Semmelweis, my achievements would be nothing."
That says a lot about both Drs Lister and Semmelweis. Their work, done at different times and different nations, is a victory for humane medicine.