On the centenary of the death of Joseph Lister, it is appropriate to remember and honor his remarkable achievements, which earned him the title “Father of Modern Surgery.”
lectures to commemorate “mankind’s greatest surgical benefactor”1 were held this year at king’s college london, england, and the royal college of surgeons edinburgh, where speakers covered a wide range of topics relevant, including the history, current research in surgical infection, and health policy in Britain. Many of the presentations included quotes from or about Lister of his day, and those quotes are still relevant to modern surgery.
It was Lister’s genius to take Pasteur’s work on the etiology of fermentation and imagine this process as the same one that was causing infection and gangrene. In the face of moves to abolish all surgery in hospitals due to the prohibitive mortality rate from infection,2 Lister changed the treatment of compound fractures from amputation to limb-sparing and led the way for abdominal and other intracavitary surgeries.
born in essex, england, into a quaker family, his father was elected to the royal society for his construction of the first achromatic lens and co-authored a paper with thomas hodgkin on red blood cells. His paternal guidance was a major influence throughout Lister’s career.3
lister was an excellent student at the university college of london and became an internal surgeon at the university college hospital, where he was awarded a fellowship to the royal college of surgeons. Following the advice of the keen professor of physiology, he went to study with the renowned surgeon james syme in edinburgh. Lister prospered in Edinburgh and married Syme’s eldest daughter, Agnes.
His main research interest was inflammation, a process then considered a specific disease and not a response of healthy tissues to infection. lister came to understand that inflammation caused loss of vitality, rendering tissues defenseless as if they were dead, 4 defenseless against the organisms he would eventually attribute as the cause of the devastating and feared surgical site infections. He published 15 articles on muscle action on the skin and eye, blood clotting, and changes in blood vessels with infection.
at 33 years of age, he was appointed regius professor of surgery at the university of glasgow, but it took another year for him to gain privileges at the glasgow royal infirmary. his initial application was turned down by the chairman of the royal nursing board, david smith, with the comment “but our institution is curative. It’s not educational.” 3 glasgow had twice the population of edinburgh and was known for its “affectionate, fickle and uncritical locals”, 2 an ideal setting for a young surgeon to embark on a new, unproven treatment regimen.
the world of surgery when lister began his practice was primitive by our standards. Although Fracastoro of Verona in 1546 theorized that small germs could cause contagious diseases,5 no one associated them with wound infections. bedding and lab coats were not laundered, and surgical instruments were only cleaned prior to storage. the same probe was used for all patients’ wounds during rounds to look for pockets of undrained pus. suppuration and laudable pus were considered part of normal healing. surgical procedures were only occasionally performed in the practice of the average surgeon,5 and there was talk of banning all surgeries in hospitals due to septic complications. sir j.e. Erichsen, future president of the royal college of surgeons, stated that “the abdomen, thorax, and brain will forever be closed to operations by a wise and humane surgeon.” Semmelweis’s work on puerperal fever was unknown.
lister’s interest in wound healing began when he was working as a dresser for sir erichsen. Erichsen believed that the wounds were infected by miasmas that arose from the wounds themselves and concentrated in the air. Erichsen had deduced that more than 7 patients with an infected wound in a 14-bed ward caused air saturation and the spread of dangerous gases that caused gangrene. Lister was not convinced, as when the wounds were debrided and cleaned, some wounds healed. this aroused his suspicion that something in the wound itself was to blame.4
lister’s intellectual breakthrough came when, on the advice of thomas anderson, a glasgow professor of chemistry, he read pasteur’s papers, recherches sur la putrefaction, and postulated that the same process that causes fermentation was involved in wound sepsis.4 Having heard of creosote being used to disinfect sewage, he applied carbolic compounds as an antiseptic to surgical wounds. having noted the marked difference in morbidity and mortality between simple and compound fractures, he postulated that infection arose from exposure to air in compound fractures without skin protection. he began his antiseptic method with compound fracture wounds because standard amputation treatment was always available in case his method failed.
The results of this new method of treating wounds soon became apparent, and so “it did not seem right to retain it any longer from the profession in general.” 4 His work was initially published in 2 articles in the Lancet; the first in March 1867, the second in July of the same year.4 At the Dublin meeting of the British Medical Association in August 1867, Lister stated: “before their presentation, the 2 great rooms in which most of the my accident and operation cases were among the most unsanitary in the whole surgical division of the glasgow royal infirmary (…) but since the antiseptic treatment went into full operation, (…) my wards (…) they have completely changed their character; Therefore, during the last 9 months they have not had a single case of pyaemia, hospital gangrene or erysipelas.”7
lister made many modifications to his method of wound care, and the iconic carbolic spray was just one part of the evolution of antisepsis. The skepticism and opposition of some of his colleagues 8 is legendary, as was the enthusiasm when the positive results in the patients were evidenced. Germany led the way in adopting Lister’s antiseptic technique, followed by the United States, France, and finally Great Britain.5 Some of this opposition was understandable, since the germs were too small to be seen under their microscopes. , and lister thought that the air was the only source of contamination. He received prestigious accolades and awards from many nations and was made a Peer of Great Britain.
lister was only human, and history has duly recorded some blemishes. Although he was held in the utmost respect and praise by his students, collegiality in Glasgow was an issue, and he neglected to share the credit for his success with other members of the Glasgow team, much to the chagrin of the Royal Infirmary administration. 8 Harsh criticism of London’s medical education system nearly cost her appointment to King’s College Hospital at the height of her career,1 and she did not support equality for women and men in medicine.9
Although asepsis and sterile technique have replaced antisepsis as the main principle of fighting infection, it was the application of Lister’s germ theory to the care of surgical patients that laid the foundation for what surgeons do now. directed the minds of physicians and surgeons to the vital need to keep wounds clean and free from contamination.
Joseph Lister continues to be an inspiration to surgeons today.