Joseph Lister: Surgery Transformed

Joseph Lister published his first paper in the BMJ in 1867 and remarkably went on publishing in the journal for another 40 years. He is of course best known for his studies of antisepsis and the introduction of surgical techniques which transformed survival rates after surgery. About half of all patients who were subjected to surgery died as a consequence before Lister's work. We've chosen Lister as one of the few representatives of 160 years of publication in the BMJ. Is that justified? What's so special about him? Oh it's certainly justified. I mean the change, the benefit that he brought to generations of patients as a result of antiseptic and later aseptic technique. It enabled surgery of the abdomen, surgery of the chest, surgery of the joints, surgery of the head, none of which would have been possible without antiseptic techniques. Before that making an incision was almost a kind of death warrant and yet of course that's what surgeons do. Hospital gangrene. He was interested in wound healing and wound infection. How does a wound heal and why in those days did it almost invariably go purulent? Yes. People knew from the earliest days that if you break your arm eventually it'll stick together but if there's a simple fracture of the arm and a spicule of bone has gone through the skin that's terrible. In Glasgow when Lister got out his figures there was a 90% amputation rate for what we call compound fractures and there was a 50% mortality rate. I mean you break your leg you're going to have your leg chopped off almost certainly and you've got a 50-50 chance of dying. Before the introduction of antiseptic techniques I was shocked to hear about the extraordinarily poor survival rate after even quite modest surgery. Did Lister himself suffer the same kind of problems of survival in the early stages? He certainly did. I mean no surgeon in those days was immune from it. Syme had established what became known as the cleanliness and cold water school of surgery. He regarded wound cleanliness as important and cleanliness as practiced by Syme was also practiced by Lister. So I think in many ways he had less of a problem than many other surgeons but of course it was still an enormous problem. So what was the state of knowledge of the basis of infection at that stage? The generally accepted theory was the the miasma theory. They didn't have a concept of microorganisms at that time and that of course was the great contribution that Pasteur made. Here's this chap Pasteur who's shown that we all know that if you leave milk out on a saucer or urine or wine in two or three days it gets smelly and filthy and And of course he showed these little animalcules, these little organisms, these microbes floating in the contaminated milk. Now people knew about these organisms but they didn't bother about them at all. So as soon as Lister read Pasteur's paper the penny dropped. It wasn't the air getting into the wound it was the microbes getting there. It's just as simple as that. In preparing the object I by accident put a small drop of the pus on a glass plate. On more careful examination I saw numerous pellucid cells such as A, B, C. The nuclei of some of these resembling some cells such as would be called ordinary pus corpuscles. So how to kill the microbes? He experimented with a number of chemicals. Zinc chloride, one or two other things, didn't work. And then he heard that the drains in Durham were absolutely revolting and they poured carbolic acid down the drains and the smell went. And having visited Durham, Lister knew that the smell of the surgical ward at Glasgow Ward Infirmary was worse than the sewers of Durham. So he thought I'll kill these organisms with carbolic. And he owed an enormous debt to Pasteur and of course in later life they famously met at the Pasteur Jubilee in Paris in 1892 and the portrait here of these two distinguished old men hugging each other in public. The first occasion in which he used this with success was on a young lad of 14 who had been run over by a cart who had sustained a compound fracture of his tibia and fibula. So Lister very carefully mopped out the wound with carbolic, put a carbolic dressing all over the leg, put a splint on and left him for four days. Took the dressing off and the child walked out of hospital six weeks later on both legs. I feel sure that if I had resorted to ordinary dressing, the progress of the case would have been exceedingly different. His first paper in the BMJ, 1867 I think, what were the key features of that? Well he described the cases in which he had successfully used this technique. He used the word antiseptic and he used the phrase antiseptic surgery. And he described an outcome from these compound fractures without infection that was practically unknown in those days. You would think that as soon as this was reported, everybody said well thank God, thank God for Lister. There was a lot of opposition to him. For centuries people had described all sorts of unguents and mixtures and applicants to put on wounds which didn't work, you see. Some more revolting than others. So this is another piece of cracker you see. And Lister said success depends on meticulous attention to detail. You've got to do things exactly the way I tell you. Like any innovator, he had opponents because this was a fairly radical step for most surgeons. He had opponents in Glasgow, he had opponents in Edinburgh and his principal and most influential opponent in Edinburgh was James Young Simpson of chloroform fame, but also James Spence here, who was the Professor of Surgery in Edinburgh at this time, who publicly derided Lister and derided him in print as well. But he had his supporters and of number his opponents. The carbolic acid didn't just kill germs, it killed healthy cells as well and he tried various ways to make it less irritant. He said we'll kill the organisms in the atmosphere. Yes. And so he introduced the carbolic spray and there's Lister's car, one of his models you see, and the job of the assistant was to do an aerosol of carbolic. In the operating theatre? In the operating theatre, which of course you know and I know. And then produced this even worse instrument, Lister's donkey, and there's the handle, again this tremendous spray with everybody coughing and sputtering. As regards the spray, I feel ashamed that I should ever have recommended it. It turns out that it is physically impossible that the microbes can have been in any way whatever affected by their momentary presence in the spray. What's I think striking about Lister's presentation in even the early papers was how relatively rigorous it was. His attempts to control, to have sufficient numbers, not to do modern statistics but at least to draw reasonable conclusions. Well he was a scientist. Much of his success was due to his personality. He had a rigorous scientific background and when opposition to his work, and of course there was opposition, when that opposition arose he dealt with it in a very unemotional scientific way. 20 years you see, between patients screaming in agony being held down for their operation, no anaesthetic, dying of sepsis you see, to patients being operated on pain-free and there was healing. You know you think now, we think things are revolutionary, nothing compared with those 20, 25 years where the whole of modern surgery, the whole of modern medicine in inverted commas, was founded.