[BITList] Surgery and scientific naturalism

[John Feltham]

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Lister, Joseph, Baron Lister (1827–1912), surgeon and founder of a system of antiseptic surgery, the second son and fourth child of seven of Joseph Jackson Lister FRS (1786–1869), wine merchant and microscopist, and his wife, Isabella, née Harris (1794?–1864), daughter of Anthony Harris of Maryport, Cumberland, was born at Upton House, Upton, Essex, on 5 April 1827. His younger brother, Arthur Lister, became a botanist.

Early life and education

Lister's ancestors had been members of the Society of Friends since the early part of the eighteenth century. Great deference was paid to learning in the comfortably off Lister household, and several members of the family were talented artists. Joseph had a stammer and possibly for this reason he was educated at home until he was eleven, when he was sent to the local school at Hitchin. At the age of thirteen he was sent to Grove House School, Tottenham. At school he was apparently a precocious child and enjoyed natural history, collecting, dissecting, and preparing and drawing specimens of various kinds. In later life he frequently spoke of the great influence on him of his father (of whose life he wrote the account for the Dictionary of National Biography) and of how much he was indebted to him for encouraging him in scientific pursuits and especially the study of natural history. According to his nephew, Rickman John Godlee, in his biography of Lister, Joseph determined to be a surgeon while still at school (Godlee, 14). None of his near relatives was in the medical profession, and it seems that this desire was entirely spontaneous.

Lister entered University College, London, in 1844, aged seventeen. While a student in the faculty of arts he was present at the first operation under ether in Great Britain, performed by Robert Liston in the theatre of University College Hospital in December 1846. Lister took his BA degree at the University of London in 1847. There then followed an attack of smallpox and, more importantly, a religious crisis, in which he seems to have doubted whether medicine was his true vocation. Following this in 1848 he had some form of mental breakdown, and he spent time in Ireland recuperating. Lister, who all of his life was said to be aloof, reportedly had no close friends at University College (Fisher, 39). He did not resume his medical studies until the autumn of 1849.

University College, founded in 1828, had a small medical school at this time. It was unusual in London, however, for it was here, rather than at any other metropolitan school, that a student would come in contact with the view that the basic sciences, particularly the experimental sciences and especially physiology, should be the foundation of all medical education, practice, and progress. This was an opinion Lister adopted early in his career and it can be seen to have informed not only his reforms of surgical practice but his views of where and how medicine should be taught and practised, and of who should be the leaders of the medical profession. Two teachers at University College seem to have been particularly important to Lister in this respect. One was Wharton Jones, who had formerly been a lecturer in physiology at Charing Cross Hospital, and who was professor of ophthalmic medicine and surgery; he was keenly interested in microscopy and Lister's early microscopical investigations were very similar to work carried out by Jones. The other was William Sharpey, professor of physiology, who was a central figure in the creation of the British school of experimental physiology, which flourished from the early 1870s. Sharpey liked and admired Lister and directed his early researches. Lister won gold medals in comparative and pathological anatomy and silver medals in surgery and medicine. He was also an accomplished artist and many drawings of his dissections during this period survived. In 1852 he became president of the students' medical society of University College. During his student career Lister served as house physician to Dr Walter Hayle Walshe and as house surgeon to John Eric Erichsen. In 1852 he took his MB degree and became a fellow of the Royal College of Surgeons.
Edinburgh, 1853–1860

In September 1853 Lister visited Edinburgh to witness the surgical practice of James Syme, professor of clinical surgery. Syme was an old friend of Sharpey, who had advised Lister to make the journey and had given him a letter of introduction. Syme was at this time fifty-four years of age, a surgeon of acknowledged eminence, a bold, skilful operator, and an inspiring teacher. He was a man of decided views, who seems to have enjoyed controversy. Lister found Syme to have ‘a very original mind’ (Fisher, 60). He soon became Syme's dresser and familiarized himself with his methods, and he subsequently acted as his house surgeon for one year. Lister then decided to settle in Edinburgh. He took an active part in teaching in the extramural school, and in 1856 he became assistant surgeon to the Royal Infirmary.

During these years Lister was also pursuing microscopical and physiological researches in his spare time. In his first published work, on the structure of the iris, he endorsed and extended the view of the German physiologist R. A. von Kölliker that this structure was muscular. This paper and another on the involuntary muscular fibres of the skin were published in 1853 in the Quarterly Journal of Microscopical Science. During the same year he also carried out experimental work on the flow of chyle, and during the years 1853–8 he published a series of papers dealing with physiological problems. In 1857 he read before the Royal Society a paper published in the Transactions of 1858, ‘The early stages of inflammation’, in which he made detailed observations on blood clotting. For this paper Lister used a camera lucida to draw the microscopic changes he observed in the blood flow in the frog's web and the bat's wing. The coagulation of the blood was central to the physiological issues that preoccupied Lister throughout his scientific life. Various other papers on physiological and pathophysiological questions were published in these years, during which time he received a great deal of intellectual and financial support from his father.

On 23 April 1856 Lister married Agnes Syme (1834–1893), the eldest daughter of the surgeon. The Symes were Episcopalians and Lister, confessing a preference for Church of England services, left the Society of Friends. The wedding was followed by a three-month tour of the continent, including visits to the most celebrated medical schools. Throughout their married life Agnes Lister took a great part in assisting her husband in research work, the notebooks of his experiments being largely written by her. They had no children.

Antiseptic surgery

In 1860 Lister was appointed to the chair of surgery at Glasgow University. The same year he became a fellow of the Royal Society. A year later he became surgeon to the Glasgow Infirmary, at that time a hospital with 572 beds. From this time onward Lister's laboratory studies were mainly concerned with inflammation and suppuration, and his clinical research centred on the management of injuries and wounds. During his tenure of the chair of surgery at Glasgow, Lister was an unsuccessful candidate for the chair of surgery at Edinburgh in 1864, and for a similar chair at his old medical school at University College, London, in 1866. In 1869 he was appointed professor of clinical surgery at Edinburgh, and he remained there until 1877.

During the late 1860s and throughout the 1870s Lister published papers which brought him to prominence in the medical profession and also projected him to the centre of scientific and surgical controversy. Eighteenth-century voluntary hospitals were small institutions and their wards had not been noted as breeding grounds of septic diseases. However, the enlarged wards, particularly the surgical wards, of the great Victorian hospitals, often situated at the centre of vast insanitary cities, were a different matter. In these hospitals, perhaps encouraged by the availability of anaesthetics, surgery was performed that was much more ambitious than that of the previous century and it was widely recognized that septic febrile diseases, such as erysipelas and hospital gangrene, could break out and very rapidly wreak havoc in terms of morbidity and mortality among the surgical patients. Fever in a surgical ward often began with sepsis in a wound. These phenomena, christened ‘hospitalism’ by the Edinburgh obstetrician James Young Simpson in 1869, were addressed in various ways. Sanitary reformers such as Edwin Chadwick and Florence Nightingale proposed the redesigning and resiting of hospitals. Lister, whose Glasgow wards were subject to the menace of hospitalism, proposed a method of wound treatment, based, he said, on scientific principles, which would ensure uncomplicated healing and thus obviate fevers. At stake therefore were not only patients' lives but experimental science and the future of the urban hospital–university complex as the centre of medical practice and education—to all of which Lister was committed.

In 1867 Lister published a number of papers in The Lancet which announced his system of antiseptic surgery. These papers describe the management of various cases of compound fracture (in which the broken bone pierces the skin), a condition recognized as having great likelihood of becoming septic. Lister claimed a high degree of success in the healing of these wounds following the setting of the fractures. A key feature of these papers was Lister's claim that his antiseptic treatment was based upon scientific principles discovered by microscopy and experimental physiology, notably principles arrived at through his own work on inflammation.

Central to much thinking in the public health sphere and also to medical ideas about fever at this time was the issue of decomposition, decay, or putrefaction. Decaying organic materials in the wrong place (the street, for example) were implicated as the causes of the epidemic and endemic fever of towns, just as the putrefaction of dead blood and other tissue was seen as the source of mischief in wounds. The causal mechanisms by which this occurred, however, were subjects of much dispute. Many held that putrefaction was a fermentation caused by chemicals, oxygen being implicated by some. In 1865 Lister's attention had been directed by his colleague Thomas Anderson, professor of chemistry at the university, to the work of Louis Pasteur. On the basis of experimental work Pasteur claimed that fermentation and putrefaction were caused by minute living organisms, ‘germs’, suspended in the atmosphere.

In the light of this knowledge, Lister said, he devised the idea of a chemical barrier interposed between the wound and the air to prevent the ingress of germs. Within the protected wound, he predicted, healthy healing by what was known as granulation could occur in a blood clot. His choice of chemical barrier was carbolic acid, which was known to him as a disinfectant used at Carlisle for the treatment of sewage. He first used carbolic acid in the treatment of compound fracture in the spring of 1865 and in his earliest cases he used liquefied German creosote, an impure carbolic acid; this he introduced into the wound and then he covered the part with a layer of lint soaked in carbolic acid. He used a similar method in the treatment of abscesses. In the first series of Lancet papers Lister described eleven cases of compound fracture, of which nine recovered, an excellent result which has to some extent obscured the historical context in which it occurred.

Lister's views at this time about the causes of wound sepsis were very different from those which he was to hold twenty years later. In 1867 Lister did not regard pus formation in wounds as the central problem of healing; pus had appeared in eight of the cases of compound fracture described in The Lancet, and Lister took the common surgical view that pus was not ominous unless it were malodorous, signifying putrefaction. Similarly Lister's ‘germs’ of those years were not like the germs described in later germ theory. They were more like seeds of disease, highly plastic agents (not specific causal entities) whose pathogenic qualities depended on the local environment in which they developed. In this respect Lister shared the assumptions of many Victorian sanitary reformers who regarded fever as the product of local miasmata. In Lister's early theory germs were the intermediary through which miasmata acted. Indeed at one point Lister claimed his method had succeeded in spite of the fact that the Glasgow Infirmary had beneath it the coffins of the cholera victims of 1849 and was next to the cathedral churchyard where paupers were once buried in pits.

Lister's achievement is also complicated by the fact that many other surgeons of this period were experimenting with chemicals and with cleanliness and also claiming equivalent success. In 1868 the Birmingham surgeon Lawson Tait reported that of twelve cases of compound fracture he had managed, all healed without suppuration except the two he treated using Lister's methods. The next fifteen years saw intense debate over the method and the ‘principles’ of Lister's antiseptic surgery. Those surgeons not convinced by Lister complained that carbolic acid irritated the skin and that simple dressings and cleanliness produced equally good results. Time and again Lister's critics iterated the view that in many environments wounds exposed to the air healed by the most desirable of all mechanisms: first intention. One of Lister's most hostile opponents was the Birmingham surgeon Sampson Gamgee, a former old friend. No controlled trial, in a modern sense, of Lister's methods was possible and many surgeons produced retrospective statistics showing how morbidity and mortality had fallen on their wards using their own techniques. Surgical mortality undoubtedly did fall in this period, but other factors played a part in the decline too: for example, hospitals installed new sanitation systems, nursing and dressings improved, and the diet of patients got better. Lister, by contrast, at times seemed to revel in the ‘dirty’ conditions of his wards and the ‘cleanliness’ of his patients' wounds.

From 1867 Lister constantly revised his principles, which were always based on claims about experimental evidence. His practice was continually modified too, the published modifications nearly always being referred to new scientific evidence, usually the result of his own researches. In particular the irritation of crude carbolic acid was a problem he struggled to circumvent. Thus he introduced carbolic oil and carbolized putty, and later he employed carbolized shellac and watery solutions of carbolic acid. From the first he insisted on the necessity of immersing instruments and everything else that came into contact with the wound in carbolic acid, and he also carried out a thorough chemical cleansing of the patient's skin in the vicinity of the wound. Further, he devoted much time and thought to devising dressings, such as gauze impregnated with resin and paraffin and then dipped in a watery solution of carbolic acid. He also introduced the carbolic spray apparatus for disinfecting the air in the field of the operation, being at the time impressed with the belief that the air was the most important factor in the causation of sepsis, owing, he said, to the presence of germs in its dust. Later the spray was dispensed with, when Lister acknowledged that the air did not play as important a part in sepsis as infection derived from the skin, instruments, and dressings, for example. Nevertheless, the introduction of the spray showed his single-mindedness in devising means to counteract septic agencies where he considered them most malign: at the surface of the wound. He also experimented with other chemical antiseptics.

Besides his antiseptic work Lister modified the technique of many operations and invented new methods of treatment. He revived an earlier form of lithotomy, modified the operation for varicose veins, and increasingly chose to open elbow and knee joints to make repairs, though he was by no means the first to do the last. He introduced the use of absorbable ligatures and of drainage tubes in the treatment of wounds; surgeons opposing drainage tubes did so on the grounds that they were only necessary because it was the carbolic acid that produced the fluid which had to be drained off. Lister studied experimentally in animals the changes undergone by ligatures in wounds, and on this basis he introduced catgut for ligatures as it was ultimately absorbed. Raw catgut, however, proved unsuitable, and Lister devoted many years to experiments on catgut in order to prepare it in such a manner that it should retain its firmness and at the same time be aseptic. He also introduced many other techniques, such as the expedient of elevating a limb prior to an operation on it and so rendering it bloodless before the application of a tourniquet, thus saving the patient an unnecessary loss of blood.
London and the impact of germ theory

In 1877, before leaving Edinburgh to succeed Sir William Fergusson as professor of surgery at King's College, London, Lister antagonized many London surgeons, and those of King's College Hospital in particular, by criticizing the teaching of clinical surgery in London. Such antagonisms were grounded in the Listerian experimentalist approach to surgery versus the tradition of practical empirical innovation, which was favoured by some London surgeons. Lister withdrew his remarks eleven months later. On accepting the professorship at King's College he made it a condition that he should bring with him his house surgeon, William Watson Cheyne, a senior assistant, John Stewart, and two dressers, W. M. Dobie and James Altham, in order that his antiseptic methods might be carried out to his satisfaction. The Listers moved to a John Nash house at 12 Park Crescent, Portland Place. Little seems to have been known of Lister's methods at King's and there were conflicts, especially with the nursing staff. Cheyne reported that the nursing staff ‘hampered him as much as they could’ (Fisher, 238). Lister complained about the small number of students attending both his rounds and the operating theatre. The King's medical faculty were split in their views of Lister and his techniques. Lister gradually gained converts among surgeons, notably among younger men who, like him, were proponents of the cause of experimental science in medicine. The most significant of these was Cheyne, his house surgeon.

Lister also gained a considerable reputation in Germany. At the end of the 1870s and in the 1880s a new germ theory, mainly formulated by the German Robert Koch, began to be adopted in Britain. This theory was quite different from Lister's putrefaction theory: it posited specific disease-causing micro-organisms which invaded the body. The Listerians acknowledged this theory but still for a while adhered to their putrefaction theory of wound decay. Cheyne noted in his Antiseptic Surgery (1882) that ‘antiseptic surgery is simply a struggle with the causes of putrefaction. I have not mentioned the germ theory of infective disease at all. That has no essential bearing on the principles of antiseptic surgery’, and he chastised surgeons for ‘confusing together the two germ theories’ (Cheyne, 287–8). Gradually, however, Lister, Cheyne, and other disciples adopted Koch's views and as they did so they modified their practice and theories to take account of them, even though they maintained that their modifications were a development of Lister's earliest opinions. They also took the view that any surgeon achieving good results was practising Listerian antiseptic surgery whatever method was employed. By the late 1880s German germ theory and aseptic surgery (which placed much more stress on the sterility of the whole surgical environment rather than just the wound) were dominant. In 1882 Cheyne took the view that aseptic surgery was ‘introduced by Mr. Lister’ (Cheyne, 123).

Lister's achievement

Any assessment now of how much more successful Lister's antiseptic surgery was (if at all) than that of the practices of other surgeons who were endeavouring to reduce mortality seems impossible. Equally it is hard to assess how far aseptic surgery was the outcome of antiseptic practices or of the cleanliness tradition. Successful pioneers of abdominal surgery in women, Spencer Wells and Lawson Tait, either gave up Listerian methods or aggressively opposed them. But whatever the merits of the case, the revolution in surgery—for revolution there was—was perceived to be largely Lister's achievement. Lister was of that party which triumphed in late nineteenth-century medicine, indeed triumphed in late nineteenth-century society at large: the party of so-called scientific naturalism. Those identifying with this cause usually embraced Darwinism and campaigned for a greater place for science in education, policy, and industry. They called for the introduction of experimental scientific disciplines into the universities, and in medicine they advocated the large university hospital as the apex of patient treatment, medical education, and research. Lister was one of the heroes of the party. Soon after his move to London two of the foremost scientific naturalists, Thomas Huxley and John Tyndall, proposed Lister for membership of the Athenaeum. The Royal Society was the stronghold of the scientific naturalists and it is testimony to Lister's place within that circle that he was elected president in 1895.

Lister filled the chair of clinical surgery at King's College for fifteen years. During the whole of this time he was actively engaged in operating and teaching and in pursuing his researches in his laboratory at Park Crescent. He had a modest private practice but reportedly this never became extensive because of his unpunctuality. Convinced as he was of the necessity of experimental science for the progress of medicine he took a major part in promoting it. He testified in favour of animal experimentation to the royal commission which reported in 1876. He took an active part in the founding in 1891 of the British Institute of Preventive Medicine on the lines of the Pasteur Institute in Paris, and he became its first chairman. In 1897 its name was changed to the Jenner Institute and again in 1903 it was renamed the Lister Institute of Preventive Medicine. In 1880 he was elected to the council of the Royal College of Surgeons and he served for the usual period of eight years. He was unwilling to serve for a further period and thus was never president. In 1883 a baronetcy was conferred on him, and in 1897 he was raised to the peerage as Baron Lister of Lyme Regis. In 1899 the neurologist Henry Head recorded in a letter:
The Chinese minister paid Lister the most colossal compliment that it has ever been my lot to hear from any man's mouth—but this is the Chinese way. He stated that he was writing the lives of the hundred greatest men of the world for the perusal of my Imperial master. England furnished him with the names, William Shakespeare, William Harvey ‘and you, my Lord are the third’, bowing low to Lister in the President's chair. As we cheered I almost expected to see poor Lister fall together in internal agony like Herod the Tetrarch. (Wellcome L.)

Character and final years

Lister was regarded by his enemies as distant and even his friends agreed he was not greatly given to laughter. In Glasgow, Edinburgh, and then London, the Listers held dinner parties, of which there are conflicting accounts. John Dobie reported that his chief was full of fun at the dinners and that he had called wine ‘the milk of old age’ (Fisher, 241). But the surgeon John Leeson observed of one of these occasions that the ‘dinner was perfectly correct, verging a little on the side of plainness, as became a Puritan household. There was no smoking, and the wine was partaken sparingly’ (Fisher, 241). Politically Lister was a Conservative. In 1902 Lister was one of the twelve original members of the newly constituted Order of Merit. On the occasion of his eightieth birthday in 1907 he received the freedom of the City of London. He remained, however, more fond of Edinburgh. In 1908 Lister left 12 Park Crescent, Portland Place, where he had lived ever since he went to London in 1877, and moved to Park House, Walmer, Kent, where he died on 10 February 1912. Burial in Westminster Abbey was offered, but he had left instructions to be buried by the side of his wife. The funeral service was held in Westminster Abbey on 16 February 1912, and the burial took place at the Hampstead cemetery.

Christopher Lawrence 

Sources  

R. J. Godlee, Lord Lister (1917) · R. B. Fisher, Joseph Lister, 1827–1912 (1977) · C. Lawrence and R. Dixey, ‘Practising on principle: Joseph Lister and the germ theories of disease’, Medical theory, surgical practice, ed. C. Lawrence (1992), 153–215 · L. Granshaw, ‘“Upon this principle I have based a practice”: the development and reception of antisepsis in Britain, 1867–90’, Medical innovations in historical perspective, ed. J. V. Pickstone (1992), 17–46 · W. W. Cheyne, Antiseptic surgery: its principles, practice, history and results (1882) · DNB · WWW · G. T. Wrench, Lord Lister: his life and work (1913) · Wellcome L., PP HEA D4/5


Archives  

Commonwealth Mycological Institute, Kew, London, notebooks · Edinburgh Royal Infirmary, minute books · King's College Hospital, London, minute books · NRA, casebooks · Passmore Edwards Museum, London · RCP Lond., letters · RCS Eng., corresp. and papers · Royal College of Physicians and Surgeons of Glasgow, corresp. and papers · Royal Medical Society, Edinburgh, dissertation · Suffolk RO, Ipswich, corresp. and papers · U. Birm. L., letters · U. Glas. L. · Wellcome L., corresp., diary, notebooks, papers, and sketch book |  Bodl. Oxf., letters to Sir Henry Acland · Bodl. Oxf., corresp. with Sir Henry Burdett · RCP Lond., corresp. with Sir Thomas Barlow · RCS Eng., corresp. with John Chiene · U. Edin. L., letters to Albert Wilson · W. Sussex RO, letters to Sir Alfred Kempe · Wellcome L., letters to Sir Thomas Barlow · Wellcome L., letters to Lister Institute · Wellcome L., corresp. with Sir Edward Sharpey-Shafer





Likenesses  

photograph, 1850–59, NPG [see illus.] · E. B. Stephens, bust, 1873, St Thomas's Hospital, London · J. H. Lorimer, oils, 1895, U. Edin. · W. W. Ouless, oils, exh. RA 1897, RCS Eng. · M. M. Jenkin, wax medallion, 1898, NPG · C. E. Ritchie, portrait, 1908 · T. Brock, marble bust, 1913, RCS Eng.; related plaster cast in NPG · T. Brock, bronze bust, c.1922, Portland Place, London · Barraud, cabinet photograph, NPG · S. Begg, process print, NPG; repro. in ILN (9 Jan 1897) · T. Brock, marble medallion, Westminster Abbey, London · H. J. Brooks, group portrait, oils (Council of the Royal College of Surgeons of England of 1884–5), RCS Eng. · H. M. Paget, process print (after sketches by A. Cox), NPG; repro. in The Graphic (26 Sept 1896) · J. H. Thomas, memorial medallions, UCL; also University College Hospital, London · E. Walker, photogravure photograph (after Moffat), NPG · Walker & Boutall, photogravure photograph (after Barraud), NPG · glass positive photograph, NPG · photographs, Wellcome L.


Wealth at death  

£67,996 4s. 6d.: resworn probate, 1912, CGPLA Eng. & Wales 



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