Celebrating a surgical legacy

"IN the field of observation, chance favours only the prepared mind," said microbiologist Louis Pasteur in a lecture in 1854. Eleven years later the surgeon Joseph Lister was to exemplify this observation perfectly when he undertook his early trials with antiseptic agents at Glasgow Royal Infirmary.

Lister, whose father was a microscope maker, had long been a keen experimenter, having carried out numerous studies on the eye, hair, the inflammatory process and coagulation, among others. It was to the attention of this 'prepared mind' that his colleague, Dr Thomas Anderson, a chemistry professor, brought the recent work of Pasteur, who had shown in experiments on wine that tiny living organisms could ruin the fermentation process.

Lister repeated some of Pasteur’s experiments and was soon convinced that the sepsis that so often wreaked havoc among surgical patients was not, in fact, due to an 'impure' state of the air, as was generally believed, but to the 'germs' in Pasteur’s theory. He thus set about preventing these germs from entering surgical wounds by erecting barriers composed of dressings saturated in carbolic acid – a compound then used in the treatment of sewage – and covered with a tin cap.

These initial trials, carried out on patients with compound fractures, which were often fatal traumatic injuries, yielded hugely successful results – to Lister’s surprise, of the first 11 cases, 10 survived, with only one requiring amputation. It was the start of a medical revolution that is still reverberating today – and which explains why, 100 years after his death, the surgical community will be marking the occasion with a series of centenary celebrations.

Learning from Lister

"The contribution of Joseph Lister to surgery is quite comparable in importance to the invention of radio or the internal combustion engine," says Dugald Gardner, a professor of histopathology and emeritus conservator of the Royal College of Surgeons of Edinburgh (RCSEd), who has written on Lister’s life and work.

As part of the celebrations, the RCSEd will be throwing their doors open for a conference celebrating the life and work of their illustrious former fellow as well as placing it in a contemporary context. King’s College hospital in London, where Lister was professor of clinical surgery from 1877 to 1893, has also teamed up with the Royal Society and the Royal College of Surgeons of England to host a conference entitled 'Learning from Lister'.

"Lister remains relevant today because his work helped to change the practices of surgery, making them safer and more effective," says Brian Hurwitz, professor of medicine and the arts at King’s.

"The conference will provide an opportunity for all those interested in the development of hospital healthcare policy and translational practices, to discuss their respective approaches to surgery today."

Lister was an important figure in the Royal Colleges not just by reputation but because over the course of his career he studied, practised and taught in the UK’s three great surgical centres. He trained at University College London before moving to Edinburgh in 1853 at the age of 26 to become dresser and later house surgeon to James Syme, professor of clinical surgery. He married Syme’s daughter Agnes and the pair moved to Glasgow in 1860, where he had been appointed chair of surgery and where his 'system' was conceived. Lister returned to Edinburgh in 1869 to be professor of clinical surgery and finally went back to London, to King’s, in 1877.

Answering his critics

Though Lister was celebrated in his lifetime – he was Britain’s first medical baronet and the Jenner Institute of Preventive Medicine, which he had helped to found, was renamed in his honour in 1898 – it was not so at first. There was a mixed reception to his first series of papers, varying from condemnation through tolerance to enthusiastic support. For some opponents, it was the radical nature of his proposals that was the problem. For others, it was sheer animus – in Edinburgh James Young Simpson, who had introduced chloroform in 1847, was no fan of Professor Syme, Lister’s mentor and father-in-law. "Simpson not only criticised Lister verbally, he published fairly abrasive notes in medical journals, saying you shouldn’t believe that chap," says Professor Gardner.

But Lister could give as good as he got and in 1870, after leaving Glasgow, he published a summary of the results of his antiseptic method in The Lancet, along with a stinging attack on the Glasgow Royal Infirmary, whose wards, he wrote, were converted “from some of the most unhealthy in the kingdom into models of healthiness” thanks to his techniques.

The directors there responded in kind, suggesting that much of the improvement documented by Lister had, in fact, to do with "better ventilation, the improved diet and the excellent nursing, to which the directors have given so much attention of late years".

Such arguments did not distract Lister from being a constant experimenter and innovator. As well as developing and adapting his system over the years with less irritative compounds, better dressings and his famous antiseptic spray, with which he attempted to create a protective field over the operative site, he went on to introduce absorbable ligatures and drainage tubes into surgery. In addition, Lister was a prodigious lecturer and writer of scientific papers. He was in touch with the leading scientists of the day, among them Pasteur and Robert Koch, who isolated the tubercle bacillus in 1882, and soon achieved international acclaim.

Paradigm change

With the long view of history it is possible to see Lister’s ideas on antisepsis as the beginning of a paradigmatic change, but it was really a generation before the whole surgical community were on board. And in fact what they were on board with was the post-Listerian idea of asepsis, which had surpassed his original theories, advocating not the direct application of disinfectant to wounds but the rigorous eradication of germs from the whole operating theatre. Indeed, by 1890, Lister himself had renounced the use of his carbolic spray.

But none of this diminishes Lister’s importance, argues Michael Worboys, professor of the history of medicine, who will be speaking at the King’s College conference. "He represented the modernisation of medicine, technical innovation. To be a London surgeon at that time, the most important thing was to be a gentleman. You could get your hands dirty in the surgery but not outside. So he came from a different ethos. In Glasgow and Edinburgh, the medical schools were closely tied to the universities so he would have hung out with scientists in a way that the clinicians in London, apart from at University College, didn’t.

"If you go back to the early 19th century, the cutting edge of medical knowledge was made in the clinic. By the end of the 19th century cutting-edge medicine came from the laboratory. Lister is a clinical figure who makes that transition."

Gus McGrouther, professor of plastic and reconstructive surgery, who will also be a speaker at the King’s College conference, agrees: "I think Lister’s major contribution was to change thinking rather than any specific one thing he did in terms of antisepsis."

There is an additional legacy, too, he adds, which has to do with the role model Lister offers to doctors everywhere. "He was learning from the microbiologists of his day. There wasn’t a eureka moment in the bath where he suddenly thought, 'There are bugs causing this.' He knew about Pasteur’s work. We need to have doctors who are scholars, not just technicians. There’s a great drive to make us all into technicians following guidelines, but if you want to actually move things forward, doctors have got to read, understand and innovate."

For more information on the celebrations go to the King’s website and that of the RCSEd.

Adam Campbell is a freelance journalist and regular contributor to MDDUS publications