Joseph Lister

Dimitris Stamatios | July 3, 2023

Summary

Lord Joseph Lister, 1st Baron of Lister (Upton, April 5, 1827 – Walmer, February 10, 1912), was a British physician.

A professor of surgery, he was the inventor and proponent of the antisepsis method, revolutionizing, not without serious disagreements, the attitude and approach of surgeons to surgical practice.

Joseph Lister was born April 5, 1827, into a wealthy Quaker family in Upton, Essex, the son of Joseph Jackson Lister, a pioneer in the use of the compound microscope (he was the first to accurately measure the diameter of red blood cells). At Quaker schools he learned to speak fluent French and German, which were at that time the main languages of medical research.

He attended the University of London, one of the few allowed to Quakers at that time. He initially studied in the Faculty of Letters, but at the age of 25 he graduated with honors in medicine and entered the “Royal College of Surgeons.” In 1854 Lister became first assistant and friend of surgeon James Syme of Edinburgh, then considered the best surgeon in England. In Edinburgh, at the “Royal Infirmary,” equipped with 200 beds for surgical patients, Lister found the ideal environment to put his talents as a surgeon and researcher to good use. During those years he performed a series of experiments on inflammation and blood coagulation. In 1857 he presented to the Royal Society a paper entitled “The Early Stages of Inflammation” in which he described his observations on experimental wounds induced on bat wings and frog legs. These tissues were chosen because they were transparent, so blood clotting and other processes associated with inflammation and healing could be visualized with the microscope. In 1867 he discovered the use of carbolic acid, which became the world’s most widely used antiseptic for surgery. He later left the Quakers, joined the Scottish Episcopal Church and married Agnes, Syme’s daughter. During their honeymoon they spent three months visiting major medical centers in France and Germany; Agnes fell in love with medical research and lived beside him as a researcher for the rest of her life.

After a stint at the University of Glasgow, where he had won the chair of surgery, he returned to the University of Edinburgh (1869-1877) as Syme’s successor and continued to develop increasingly advanced methods of antisepsis. In 1877, he became professor of surgery at “King’s College Hospital” in London, where he went with four assistants, including William Cheyne, and successfully practiced nerve and brain surgery and improved the technique of mastectomy, i.e., the removal of the breast for cancer.

He retired from professional life when his wife died in 1893 in Italy during one of the few vacations they had taken. Despite the resulting depression and a stroke that seized him, he made public appearances from time to time.

He died on February 10, 1912, at his country home in Walmer, Kent, at the age of 84.

After the funeral in Westminster Abbey his remains were interred in Hampstead Cemetery, Fortune Green, London, in the southwest side of the central chapel.

When Lister entered the University in 1843, the studies of the medical faculty focused primarily on medicine and very little on surgery. This reflected an age-old divide between physicians, who were culturally trained and able to make diagnostic judgments and suggest therapeutic principals, and surgeons, who were manual executors of indications and considered “barbers.” Until 1743, surgeons were associated with barbers: in 1745 in London the “Company of Barber-Surgeons” was replaced by the “Association of Surgeons,” which in time acquired a similar physiognomy to the “Royal College” of physicians. Moreover, even today in England, at least at the level of title, there is a distinction: the English call the physician doctor (Doctor or Dr.) and the surgeon sir (Mister or Mr.).

A pioneer of true surgery was Ambroise Paré (1510-1590), anatomist and war surgeon, who also used to say, “I operate, but God heals.”

The 19th century was the time when surgical masters operated in amphitheaters filled with students and mere observers, in ordinary clothes, with instruments encrusted with filth mixed with residual biological fluids from previous surgeries. Men who were insensitive to the torment they caused their patients by operating on them without any anesthesia and whose fame and skill was tied exclusively to the speed with which they completed their operations: necessary to limit the dramatic consequences of the pain on the unfortunates who ended up in their hands but whose fate, however, was marked by the inevitable infection that accompanied every surgical practice.

This explains why in a major hospital of the time, Massachusetts Hospital in Boston, famous in the history of surgery because Professor John Collins Warren on October 16, 1846 operated on a patient under general anesthesia for the first time, only slightly more than 300 operations (an average of one operation per month) were performed in the period from 1821 to 1846.

The discovery of anesthesia, while extraordinary because it eliminated pain, would still have a negligible impact on postoperative mortality, which was extremely high due to the hygienic conditions under which surgeries were performed and fatally resulted in infection (conceptually unknown at the time) that was often fatal.

And surgeons always and for the most part were insensitive to this tragic fatality. Some, endowed with a different sensibility, were obsessed with this unknown and dreaded fatal complication whether they called it “puerperal fever” as Ignaz Philipp Semmelweis did, or “hospital gangrene” as per Lister.

John Bell left us in this regard an important and stark account of the conduct of surgical operations at the time. Instruments were often soiled with biological fluid from other patients or were cleaned with the simple aid of a cloth. The operating room was packed with students (at the time, there were not many operations, mainly because of the low probability of survival to the postoperative period, this was before Lister introduced antisepsis techniques).

In any case, the dominant principle governing the behavior of surgeons before Lister’s time was essentially summed up in avoiding exposure of the wound to air, which was considered the cause of all infection.

James Young Simpson, discoverer of the anesthetic uses of chloroform, based on the observation that cases of infection were far more numerous in the overcrowded hospitals of English cities than in the countryside, where the sick were usually treated in cottages (there the bacterial contagion was in fact less likely), loudly proposed instead the razing of hospitals in favor of smaller buildings. These buildings were to be made of iron, so that they could be destroyed and rebuilt over time. Clearly, such a strategy would have required extraordinary funding and was unlikely to be implemented.

Lister had noticed that gangrene, which was widespread in hospital settings, was rather rare outside. This had led him to believe that the disease, characterized by the putrefaction of tissues, was due not so much to hypothetical “venomous gases” contained in the air (miasm theory), but to the fact that “something transmitted it” from one patient to another. Something present in the air, in bandages that were used still dirty for multiple patients, in surgical irons summarily scraped of grime before use, in the surgeon’s hands or clothing?

A friend and university colleague of his, T. Anderson, advised him to read the work of a French chemist, Louis Pasteur, who in those years had shown how fermentation of certain liquids was related to bacteria in them and how boiling was able to stop it. Lister had the virtue of guessing that something similar to the fermentation studied by Pasteur was taking place in wounds, coming to the conclusion that ways should be sought to prevent putrefaction of wounds analogous to what heat did by preventing fermentation.

In 1860 two chemists, Lamaire and Calvert, separately had synthesized a substance, phenol for use as a deodorizer and disinfectant for sewers. In 1865 Lister decided to use phenol (then called carbolic acid and later phenolic acid) on an exposed fracture, a dramatic pathology because it inevitably ended in death by gangrene, or at least amputation of the affected limb. He went on to use carbolic acid in exposed bone fractures, a pathology then very common in Glasgow, a city undergoing rapid and chaotic industrial development. Fractures, essentially of the limbs, were occurring as a result of work or road accidents, and patients were arriving at the hospital in such a serious condition that the only life-saving attempt was amputation. Lister’s goal was to prevent suppuration and save the limb, while being vigilant to catch the early signs that the antiseptic treatment had failed. The various operative steps followed a set pattern. Initially, blood clots and any foreign bodies were removed, then the wound was cleansed with concentrated carbolic acid to destroy all germs (carbolic acid in fact causes its protein component to precipitate). Then gauze soaked in carbolic acid was applied over the wound to prevent subsequent contamination. This was then covered with a thin layer of tin or a lead disk, with the intention of preventing evaporation of the antiseptic. Finally, the dressing was secured by adhesive strips. A thick, adherent crust consisting of blood and carbolic acid formed over the wound and remained in place for many days; its protective properties were restored from time to time by pouring pure carbolic acid over it, after partially removing the metal coating. However, this dressing had limitations: in fact, pure carbolic acid was highly irritating to the healthy tissues surrounding the wound. Lister then tried to mitigate this side action by diluting the carbolic acid in both water and oil. The aqueous solution, which was weaker and more labile than the oily one, served for initial disinfection of wounds, while the oily one was applied later. Lister also experimented with a kind of poultice consisting of lime and a solution of carbolic acid in linseed oil.

Lister published the results on this new method of fracture care in the prestigious journal The Lancet. It was March 16, 1867, and in the title of the article, Antiseptic Principle of the Practice of Surgery the term “antisepsis” appeared for the first time.

The antiseptic method also gave brilliant results in the treatment of abscesses. In Lister’s time, most abscesses had a chronic course and were related mainly to diseases of the spine or other bones; the most common cause was tuberculosis. The outcome was always unsatisfactory and death was the most frequent development.

The operative model adopted by Lister was to incise abscesses and prevent the contents from rotting, despite contact with air. To achieve this he would pass gauze soaked in carbolic acid over and around the skin overlying the abscess, then make the incision with a scalpel previously dipped in an oily solution of the same acid. Germs that could airborne into the abscess cavity were destroyed by the antiseptic agent.

In any case, to avoid septic contamination of the open abscess as much as possible, he covered it with poulticles of carbolic acid. The goal was to “attack” atmospheric germs to keep the wound aseptic.

Prior to the application of Lister’s method, the opening of an abscess was invariably followed by suppuration, as the microorganisms promoted decomposition of the pus, which took on irritating properties and gave rise to suppuration.

In his many attempts to exploit the antiseptic action and limit the unfavorable effects of carbolic acid, Lister began around 1870 a new clinical experiment with a sprayer. With this instrument he initially sprinkled a solution of carbolic acid on wounds when he removed their dressing. Later he used the spray to purify the air in operating rooms and to destroy germs floating in it before they polluted the wound. In its final edition the sprayer consisted of a large copper atomizer operated by a foot pedal, an underlying container of the solution resting on a tripod about three feet high. An articulated blowpipe connected to the atomizer served to direct the spray. The entire apparatus weighed about 10 pounds and was carried into the operating room by an assistant and a nurse who operated it throughout the operation. As the years went by, Lister scaled down the use of this technique to the point of abandoning it.

The search for antiseptics was competitive with the identification of new types of wound protection and bandaging. Among other things, he used so-called “protective,” a mixture of inert, nonirritating materials impermeable to carbolic acid and other antiseptics.

As he asserted, “An antiseptic serves to prevent putrefaction, the protective to exclude that the antiseptic, by its collateral action, keeps the wound under an abnormal stimulus, that of irritation.” The ingredients of the protective were the most diverse: from rubber to tin, from gilded sheets to oiled silk covered with cup varnish, from eggshell mixed with gum arabic to kerosene and wax, from gutta-percha to dextrin and starch.

Phenic acid was henceforth applied by nebulization in the preparation of operating rooms to which more enclosed and isolated spaces would begin to be dedicated, but used particularly to wash instrumentation, surgical supplies, and the hands of surgeons, who would also begin to use more suitable and clean clothing.

Phenolic acid, formerly known as carbolic acid and now called phenol, is an aromatic compound derived from benzene. Pure, it occurs as white crystals that, due to oxidation by oxygen in the air, tend over time to take on a yellow or pink tint.

As Bernard Shaw pointed out, with Lister “the end of the century tastes like carbolic acid.”

It was many more years before William Stewart Halsted proposed that Goodyear manufacture latex gloves to be worn during surgeries (used in the operating room in 1890), and the use of headgear in the operating room was adopted.

Antisepsis took the first step. The next would be the transition from antisepsis to asepsis, to the discovery of “infection,” which would change the history of surgery and with it the fate of so many patients. It would be Robert Koch in 1872 with the discovery of the anthrax bacillus who would give content and meaning to this new and revolutionary concept.

Pasteur and Koch’s studies particularly attracted Lister, who delved into the relationship between bacteria and disease and broadened his interests in the field of immunology.

In those years the idea of aseptic surgery matured, not as an alternative but as an extension of antiseptic surgery as originally conceived by Lister. The antiseptic system tended to destroy germs with chemical agents both before and after wound invasion and to prevent any subsequent invasion by microorganisms of the wound. Asepsis, as Lister himself understood it, meant “the condition of a wound from which sepsis is absent.” This meant ensuring aseptic cleansing without antiseptic material coming into contact with the wound and instead using antiseptic media to prevent germs from polluting the surgical wound.

Lister’s discovery was not met everywhere with consensus and acclaim. In many circles, especially scientific ones, his theories were opposed and even derided. The practice of antisepsis was inconvenient and appeared only as a waste of time for old surgeons who made speed the pride of their art.

But Lister had the authority to impose and enforce, at least in the facilities he headed, strict regulations on antisepsis, and eventually results and time proved him right. And a well-deserved reputation he at least managed to enjoy during his lifetime.

Lister has gone down in history as the founder of the antiseptic method, but he probably would have remained in the shadows if he had not been a surgeon first. And his surgical practice would not have been enriched by new techniques if he had not had the antiseptic system to support it. He reintroduced into clinical practice lithotomy, i.e., removal of kidney stones, which was considered prohibitively expensive after initial failures because it presupposed opening the abdominal cavity resulting in fatal peritonitis. He improved the operation for varicose veins. He performed many operations to correct bone deformities resulting at that time from malnutrition, rickets and tuberculosis. Plastic surgery also got a major boost with Lister. He also perfected the steps and timing of limb amputation. He was an innovator in the field of wound suturing and blood vessel ligation: he was convinced that there could be no perfect ligation as long as the material used represented a foreign body capable of causing inflammatory reactions. A ligation of a vessel had to at least avoid the danger of hemorrhage secondary to suppuration that could occur around the thread used. And so to avoid suppuration he dipped the silk threads in carbolic acid before using them. Later he introduced the use of catgut, which, again treated with carbolic acid, proved to be without drawbacks.

Another area in which the antiseptic method yielded immediate and resounding results was in improving the sanitary conditions of the hospital environment. In an article published in 1870 in The Lancet entitled “Influence of antiseptic treatment on the hygienic conditions of a surgical ward,” Lister pointed out that mortality from amputation had decreased markedly, gangrene and pyaemia had disappeared, erysipelas almost completely eradicated, and tetanus almost nonexistent.

Lister became Britain’s most famous surgeon, and from all parts of the world flocked to study his disinfection systems. Among the very first was the French surgeon Just Lucas-Championnière, who in 1868, still a student, traveled to Glasgow to learn the new technique from Lister himself. Later, in 1876, he would be the first in the world to publish a monograph devoted to the antiseptic method, Chirurgie antiseptique. Principes modes d’application et résultats du pansement de Lister. This monograph was later translated into English.

The father of antisepsis will be honored by naming a germ, listeria, responsible for listeriosis (causes mainly high fever, endocarditis, osteomyelitis, cholecystitis, peritonitis, meningitis, cranial nerve paralysis, and motor loss).

In 1885 he obtained the greatest scientific recognition a surgeon could then desire: the presidency of the “Royal College of Surgeons.” In 1897 Queen Victoria bestowed on him the title of baronet.

He had the honor of being called to consult, as Britain’s foremost expert, when King Edward VII of England, in June 1902 just days before his coronation was stricken with appendicitis.

After his death, an award was established to honor his memory. The Lister Medal became the most prestigious award that could honor a surgeon.

Two stamps were printed in September 1965 to commemorate Lister’s contributions to antiseptic surgery, and a coin was minted in his honor.

He is one of only two English surgeons to whom a monument was erected (the other being John Hunter. There is a statue of Lister in Kelvingrove Park in Glasgow, celebrating his connection with the city. A marble bas-relief depicting Lister occupies the tympanum of one of the main facades of the Umberto I General Hospital in Rome: that of the Surgical Clinic. Lister, in the foreground, is standing beside a recently operated patient; he is presenting the case to the audience, while his assistants in the background are busy with various tasks. The tribute that the Italian people gave to Lister when he was now a celebrity is more than eloquent and more significant when one considers that the bas-relief was carved when he was still alive.

Lister’s main merit was that he applied a scientific approach, based on experimental evidence, to surgical problems.

He was one of the founders of the British Institute of Preventive Medicine, which in 1903 was renamed the Lister Institute in his honor.

Sources

1. Joseph Lister
2. Joseph Lister
3. ^ Fermentation was the word Lister used for the putrefactive process of sepsis that we might now describe as wound infection[6]
4. ^ Nervous breakdown is defined as a stressful situation where a person is generally unable to function normally in day-to-day life that becomes emotionally and physically overwhelming.[52] Lister’s nephew Godlee used it to describe the situation and is perhaps indicative that adolescence was just as difficult in 1847, as it is now.
5. a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap Fitzharris, Lindsay (2019). Medicina dos Horrores. Rio de Janeiro: Intrínseca. p. 320. ISBN 978-8551005224
6. Fitzharris 2018 ↓, s. 27–31, 175.
7. a b Fitzharris 2018 ↓, s. 28–31.
8. Fitzharris 2018 ↓, s. 31, 37.
9. Fitzharris 2018 ↓, s. 38–39.
10. Fitzharris 2018 ↓, s. 54.
11. 1,0 1,1 (Αγγλικά) SNAC. w6tq647k. Ανακτήθηκε στις 9  Οκτωβρίου 2017.
12. 3,0 3,1 «Encyclopædia Britannica» (Αγγλικά) biography/Joseph-Lister-Baron-Lister-of-Lyme-Regis. Ανακτήθηκε στις 9  Οκτωβρίου 2017.
13. «Gadsdens of Upton House West Ham». 27  Φεβρουαρίου 2014. Ανακτήθηκε στις 21  Ιουνίου 2018.
14. archiveshub.jisc.ac.uk/search/archives/e7a4a66e-de4a-3a3b-920b-0c065f4fd7b3. Ανακτήθηκε στις 21  Ιουνίου 2018.
15. http://lordlisterhotel.co.uk/history