Lister & the development of antiseptic techniques in surgery at GRI.

Thank you to everyone for registering for Lister Week. This is the first event organised by Friends of GRI and we have an exciting lineup of presentations as well as an exhibition located in the David Livingstone Lecture Theatre in Ward 30. So what is the big deal about Joseph Lister? Well he was born in London in 1827, studied medicine at the University College of London and then moved to Edinburgh to study under the renowned surgeon James Syme. And at that time he met and married Syme's eldest daughter Agnes. He moved with Agnes to Glasgow in 1860 where he was appointed the Professor of Surgery at Glasgow University. Shortly after this appointment he started to work here in Glasgow Royal Infirmary and it was during this period that he discovered the benefits of carbolic acid in cases of compound fracture. He has been described as the father of modern surgery and the greatest surgical benefactor to mankind. He died in 1912 at the age of 75. You can read more about Lister by visiting our exhibition that will also be available on the Friends of GRI website. So I hope you enjoy Lister Week and I would now like to hand over to Friends of GRI Chairman Professor Ross Lorimer who will introduce our first speaker. Ladies and gentlemen it's a great pleasure to introduce first speaker Dr Alastair Chook who is a BELIT graduate of the University of Glasgow and who is also archivist to Greater Glasgow Health Board and the West of Scotland. Now the Glasgow Royal Infirmary has provided a service for the citizens of Glasgow for more than 200 years. Within its walls have also been developed many important advances and in terms of surgery we will hear more of this today. To learn about the past we have to stand on ladders and to get up ladders we need help and the help that we are having today from Alastair Chook will paint the picture of the development of surgery and associated specialties within the Royal. Those of us who have spent a lot of time in the Royal will recognise its place in the history of medicine and therefore what he has to say will be of great interest to all of us. Alastair I welcome you. People have been memorialising Joseph Lister for about a hundred years. By that I mean writing articles in journals, producing exhibitions in museums, making films, television programmes, whatever. So today I'm going to give a little bit of time and thought to the process of memorialisation. But first of course for the benefit of those who are not familiar with the backstory, who perhaps don't know very much about Lister, I'd better say a few words of introduction. So on the screen now we have an image of the original Glasgow Royal Infirmary. This building was designed by Robert Adam and completed in 1794. Now there are a few things about it which are worth saying just in passing. The main operating theatre used for teaching purposes for medical students was under the glazed dome at the top of the building. There was no hoist or lift connecting the operating theatre to other parts of the infirmary. So patients who had been through operations were carried down the stairs on something resembling a stretcher, sometimes conscious, sometimes very audibly in distress. So perhaps quite an intimidating place to be a patient and particularly a surgical patient. A fever hospital was added in 1829 and in the illustration that's on the screen now you can see the fever hospital on the right and as the title of the slide suggests you can see the new surgical block which was added in 1861 at the back of the picture. The other thing which I'd say as we look at this image is that beyond the surgical block there is an area which is not easy to make sense of but that's actually St Mungo's burial ground. So the surgical block was opened just a few months before Lister came to Glasgow. It offered a much better designed building, a building much better suited to its purpose than the late 18th century equivalent. It had a multiplicity of operating rooms, some of them quite small, certainly not intended for teaching purposes but just for the practical business of getting on with the job. And this is where Lister pioneered antiseptic surgery, the active use of antiseptic agents to prevent infection during and after operations. And it is worth thinking just for a second, you know, why did Lister make this breakthrough in this location and at that time? And I think part of the answer to that lies in the proximity of St Mungo's burial ground. St Mungo's was a sort of halfway house between the necropolis which faces the Royal Infirmary from a mound over Wishart Street where the very, very well-to-do and very well-known were buried and the much more humble sort of pauper arrangements elsewhere. So St Mungo's burial ground was for people who were not impoverished but certainly didn't have a lot of money and as a result some of the corpses, some of the coffins, were very close to the surface of the soil and of course a source of infection. Lister published a series of seminal articles in The Lancet and I'll just read out a few words from one of those. The two large wards in which most of my cases are treated were amongst the unhealthiest in the whole Glasgow Royal Infirmary in consequence of those wards being unfavourably placed with the reference to supply of fresh air. One of Lister's wards where he treated men was actually at ground level so it was very close to the burial ground. His women's ward was on the floor above. Here we have the new Glasgow Royal Infirmary, basically the building which is still standing today. Now then, a few things that should be said about that. It began because the old Royal Infirmary was simply no longer fit for purpose and in fact when it was being demolished the extent to which it was no longer fit for use became all too apparent. Bits of it simply crumbled and fell away. It was begun in the late 1890s as a project to celebrate the diamond jubilee of Queen Victoria, as many hospital buildings were, but it took a very, very long time to raise the sum of money required. So it was eventually opened by King George V in 1914 and he was in the royal carriage in the previous slide. The cost was raised with very generous donations from the owners of large businesses. The Templetons, famous carpet makers, were foremost amongst those. There were separate fundraising efforts amongst the workforces of the shipyards, marine engineering works etc etc. Churches, all sorts of organisations played a part. There were flag days when people were asked to put money in a collecting tin and in return given a to put in their lapel and a sort of upmarket equivalent of jumble sales. Finally, in order to make it possible to get on and do and complete the work, a quarter of a million pounds was transferred from the infirmary's endowment funds and I put on there for the sake of comparison that the cost of a brand new dreadnought battleship was about eight times greater than the sum that was needed from endowment funds. So this effectively made the 1860s surgical block redundant and that led to controversy. The old surgical block was left standing during the First World War and for the first couple of years of the war there were a limited number of wounded servicemen who'd been brought home from Flanders or from France who were treated there. The managers of the royal infirmary began to talk about demolishing the building after the war and that provoked all sorts of controversy. I have a quotation here from the Glasgow Herald. The preservation of the list award in the royal infirmary is a duty and a privilege which the managers of that institution cannot ignore without reproach to themselves and to the city. Nonetheless, despite all these protests and all the brouhaha, they decided to go ahead. So in the winter of 1923 into 1924 the building was knocked down, the furnishings, the interior woodwork and so forth from ward 24 where Lister was believed to have done the most important work on antisepsis were taken out and given to the Wellcome Institute to be put in their museum in London, and there was an extraordinary trade in bricks. Bricks that had been taken from the demolished building were sold. I have a quote here from Donald Hay who some people remember as curator of the Royal Infirmary's museum in the 1980s and Donald says, this takes me back to a man called Frank Chamberlain. Frank was a legend in his time. When they knocked down the list awards, Frank went and collected the stones. He used to box them up and send them. Eventually the demand was so great he had a cartload of bricks delivered to the Royal Infirmary and the Americans were tremendously pleased to have them. So what he was doing basically was selling things to medical schools, mainly in North America, for a substantial sum of money. Quite a nice little supplement to his income and this was confirmed by a consultant at the Royal Infirmary called Willie Reed when he visited the United States in the 1970s and was shown one of these bricks being displayed in the museum there. So here we have the Lister Ward reconstructed in the Wellcome Museum. This particular room in the museum opened in 1926. The one aspect of that display which I'm sure is inaccurate is the portrait of Lister himself. I'm sure he did not hang a portrait of himself on the wall of his ward. Now I want to think for a few minutes about the global significance, the worldwide significance of Lister and it seems to me that this represents a turning point, a kind of paradigm shift moment when Western scientifically based medicine became supremely confident in its own superiority. David Hamilton in his history of Scottish medicine has described it as the beginning of a new era. Now of course it was only possible because it had been preceded by the development of effective anaesthesia and this has created a mindset. Now in order to try and demonstrate this I've put on the slide a quotation which I found on the website of the Royal College of Anaesthetists. This is currently part of their website. Now I'm not meaning here to hold up the college to any sort of criticism or whatever. It's simply a way of illustrating the point that the way in which this is written suggests that the only way of making progress is the Western way and that I think is a significant development and one in which Lister's work plays a role. From the 1860s onwards most Western doctors regard any form of non-Western medicine as inferior, often simply as nonsense and there is a widespread assumption which persists for more than a century that nobody from the Western medical tradition can possibly learn anything at all from people who come from a different background and this worldview of course is underpinned by all sorts of other developments. It doesn't take place in isolation. There are tremendous advances in steam technology, in firearms, all sorts of things that give the Western world, basically Europe and North America, a tremendous technological advantage over everybody else and by way of contrast I think it's probably a good idea to refer to David Livingstone who is an eminent Scottish medical missionary of a slightly earlier generation and Livingstone's attitudes and approaches are quite at variance with those which come from a later generation. I have a quote here from Livingstone's famous book on his missionary travels and researches. Livingstone introduced the discussion with the witch doctor by writing, to understand we must place ourselves in their position and believe as they do that all medicines act by a mysterious charm and he then goes on to quote the African doctor as saying, we do not despise those things which you possess though we are ignorant of them. We don't understand your book, by which he means the bible, but we don't despise it. You ought not to despise our little knowledge although you are ignorant of it. An irony here is that Joseph Lister was actually a very modest man. He himself was not given to any kind of display of pride or any notion of his own importance. His kindness towards patients stood out because it was something of a contrast with some of his colleagues. He was a man brought up in the Quaker denomination and although he later transferred his allegiance to the Scottish Episcopal Church, his Christian faith remained one of the main driving forces of his life. I thought it would be a good idea here to draw attention to one of his students, one of his, one of the students of whom he thought most highly but who is not very often mentioned in the same breath as Joseph Lister. This is Sir John Kirk who having completed his medical degree accompanied Livingston on the expedition that was supposed to go up the Zambezi but actually went into modern-day Malawi because they discovered that they couldn't get past the Kibora-Bassa rapids. Kirk subsequently had a distinguished career. He became effectively a diplomat, was based for many years in Zanzibar. He was a great student of the natural world, birds, plants, all sorts of things and most importantly a very very active and effective anti-slavery campaigner. He was also for his time a noteworthy amateur photographer and so I popped in a photograph that he took of his home in Zanzibar. The lady walking away from the camera is Lady Kirk. So let me go on to think explicitly about memorialisation of Lister. The reconstructed ward opened at the Wellcome Institute in 1926. The lecture theatre which still stands, the Lister Memorial Lecture Theatre at the Royal Infirmary opened the following year. The statue of Lister in Kelvin Grove Park was unveiled in 1924 and also in the 1920s historical research began in relation to Lister's work on antiseptic surgery. The research of the 1920s started with Lister's seminal articles in The Lancet. He had explicitly referred to 11 patients who he anonymised and referred to as patients A, B, C, D and so forth. So the people carrying out the historical research started their work by looking for patient A and they identified him as being James Greenlees, a teenage boy who was admitted in August of 1865 and the idea that James Greenlees was the very first patient to be treated using an antiseptic technique is one which you will still find repeated in many many places. For the bicentenary of the Royal Infirmary a significant history was published, an official history of the Royal was published and as part of that Ian Russell went and re-examined the archives, looked with a fresh eye at the sources and he found a series of male patients who preceded Greenlees. These were people by and large for whom antisepsis had been used after rather than during the operations and he found that the first of these was a man called Charles Cobb who was operated on in March of 1865 and was the first in a series of compound fracture patients. Several of these patients were not successfully treated. The most noteworthy was a man called Neil Kelly who was in the infirmary for an extraordinary length of time and eventually had to have his leg amputated because the treatment clearly had not worked. Now Lister simply left these cases out when he was writing his Lancet articles. He knew perfectly well that there would be voices of a sceptical nature so he thought well I'll just put this to one side you know it'd be a matter for his own conscience as it were. Ian Russell I should say was working on the basis of Lister's own statements that he had liked to avoid subjecting women and girls to painful treatments which might be regarded as being of an experimental nature but the story does not end there because Ian Russell's version can be updated. Ian Russell does refer if you read his chapter in the book he does refer in passing to the use of antiseptic dressings on wrist or after I should say after wrist operations. The earliest antiseptic treatment of that nature which has been found so far is a young girl who was admitted in late November and treated through November and December of 1864. The research that revealed this was done by Pier Paolo Andriani and he deserves the credit for having identified Euphemia Perman as the first person to have been treated with the antiseptic treatment. The spelling of her surname is one which I have given some time and thought to. It would make much more sense if it was Pennan but in all the available written material it is very clearly written with an r not with an n so I think it really is Perman and she's recorded in the case notes as being 13 years old although later she said she was 12 at the time. So let's have a look at the case notes. A year ago her left wrist became sore by a squeeze from a boy and it has been a useless hand to her ever since. On the 27th of November Lister operated and the next day she could actually extend her fingers. By the 8th of December there was evidence of a post-operative infection and this was dressed with carbolic acid in a strength of one part acid to 16 parts water. By the 13th the healing process was already well advanced and before Christmas she was discharged with a fully functioning joint and hand and with all post-operative infection effectively dealt with. So in a very real sense I think Euphemia might be regarded as the first antiseptic patient that we know about. There is a postscript to the story. I mentioned that the statue to Lister was unveiled in Kelvin Grove Park in 1924. I have on the slide here a quotation from Sir Hector Clare Cameron who had been one of Lister's junior colleagues who was asked to unveil the statue. So he says that he was honoured to be asked to unveil the statue and he records that an old lady modestly requested that she be allowed to place a wreath. It showed, he thought, that this was a good deed. In other words Lister's good deed was capable of living on in the heart of an obscure and humble woman. Euphemia wrote to Cameron as an old lady offering reminiscences of her time as a patient. She wrote, it was my wrist. I was then a girl of 12 years and did not understand the good that was being done to me but I have realised it years ago. I'll just leave you with the thought that there might be more to find out. The statement in the case notes that a big boy did it and then vanished seems to me less than convincing and that's the classic makey-uppy story. I do wonder if in fact Euphemia was the victim of some kind of domestic abuse and that would certainly align with the fact that she remembered Lister for the rest of her life as being a kindly, thoughtful, helpful man which suggests of course that that was a characteristic or those were characteristics that she didn't very often meet with in adult men.