Celebrating the sesquicentennial of Lord Joseph Lister

The sesquicentennial anniversary of the publication of Lord Joseph Lister’s (1827–1912) first paper on carbolic acid and antisepsis in The Lancet is March 16.¹ Even though physicians, including Lister himself, abandoned the use of carbolic acid only two decades later, he remained the leading advocate of the application of germ theory in the care of surgical patients in Great Britain.² Harold Ellis, CBE, FRCS, has called the achievement “the watershed between two eras of surgery, the primitive and the modern, since it was the first to be performed as an antiseptic procedure.”³

Controversial from the start

Lister, a Scottish surgeon, struggled with the one-in-two mortality rate from wound infection that surrounded surgery in the mid-19th century. Thomas Anderson—a Glasgow professor and an expert in agricultural chemistry—advised Lister to read Louis Pasteur’s papers, “Recherches sur la putrefaction,” which described the role of microbes in spoiled wine and milk. Lister reasoned that the same phenomenon could occur in decomposing flesh. Lister and Anderson discussed the latter’s work to deodorize sewage and render it suitable for agricultural manure. Carbolic acid was a favored compound, removing the unpleasant smells without apparent ill effects on grazing cattle.^4,5

Lister made the connection between the stench of human waste and gangrene and the potential of carbolic acid to function as a disinfectant, and so he began to use carbolic acid in dressings in patients with open fractures. Of his first 11 patients, only two died, which was a result he viewed as a stunning improvement.⁶ Many surgeons adopted Lister’s so-called antiseptic system, including spraying carbolic acid over the operative field, a practice he advocated a few years later, and which would eventually be known as “Listerism.”⁷

Other surgeons and scientists remained skeptical. Carbolic acid burned uninvolved skin and irritated the eyes, nose, and hands of anyone exposed to it. In 1886, Howard Atwood Kelly, MD, of the University of Pennsylvania, Philadelphia, said, “If used in strength sufficient to certainly prevent sepsis, the patient is very often killed along with the germs.”⁸ Furthermore, other surgeons reported rates of infection and death that were lower than Lister’s without using the chemical.⁹

In 1881, German physician and microbiologist Robert Koch found that bacilli thrived in wounds treated with carbolic acid. He advocated the use of pressurized steam to sterilize anything that came in contact with the patient, from instruments to the surgeon’s garb, an approach that proved effective in controlling surgical infection. Within a decade, asepsis supplanted Listerism.¹⁰

Lister’s legacy

Why is Lister celebrated in the history of surgery? He was not the first to use carbolic acid or to apply antisepsis. In 1901, Dr. Kelly wrote that Jules Lemaire, a Paris, France-based physician, was the first to use carbolic acid in surgery in 1864, three years before Lister’s papers were published.¹¹ In 1970, Owen H. Wangensteen, MD, FACS, opined that Ignaz Semmelweis’ use of hypochlorous acid in 1847 to prevent puerperal fever was rightly the first use of antiseptic in preventing surgical infection.¹²

Michael Worboys, former director of the Centre for the History of Science, Technology and Medicine, University of Manchester, U.K., argues that Lister’s contribution to the evolution of surgery is based on how he incorporated Pasteur’s findings into his practice of surgery.¹³ His exacting techniques of wound dressings and antiseptic mists, however ineffective, were based on his understanding of science. Lister’s work showed that surgery had evolved from the heroics of Scottish surgeon Robert Liston’s bravura 30-second amputations and its 300 percent mortality rate—the patient, the assistant who lost a finger, and a bystander who died from shock after nearly being sliced by Liston’s errant scalpel. Perhaps Lister’s contribution to modern medicine can best be summed up by Rev. Thomas Gariepy, CSC, professor and chair of healthcare administration, Stonehill College, Easton, MA: “Antiseptic surgery…fostered the alliance between science and medicine.”¹⁴

While carbolic acid vaporizers are now relics, Lister and Lemaire based their practices on Pasteur’s revolutionary discoveries. When Professor Koch, the next great figure in microbiology, determined that bacilli caused human disease, the field was thus prepared to accept asepsis as the next significant development in surgery.

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References

1. Lister J. On a new method of treating compound fracture, abscess, etc. With observations on the conditions of suppuration. The Lancet. 1867;89(2273):357-359.
2. Worboys M. Spreading Germs. Disease Theories and Medical Practice in Britain, 1865-1890. Cambridge, UK: Cambridge University Press; 2000.
3. Ellis H. The first “antiseptic” operation. J Perioper Pract. 2015;25(4):87-88.
4. Anderson T, Bateman JF. Report on the Means of Deodorizing the Sewage of Glasgow. Glasgow, Scotland: University Press, 1858. Available at: archive.org/details/b21467316. Accessed January 20, 2017.
5. Report from the Select Committee on Sewage of Towns; together with the Minutes of Evidence and Appendix. Ordered by the House of Commons to be printed, April and July, 1862. Br J Psychiatry. 1863;9(45):143-144. Available at: bjp.rcpsych.org/content/9/45/143. (Password protected). Accessed January 23, 2017.
6. Lister J. On the antiseptic principle in the practice of surgery. Br Med J. 1867;2(351):246-248.
7. Lister J. On a case illustrating the present aspect of the antiseptic treatment in surgery. Br Med J. 1871;1(524):30-35.
8. Kelly HA. Asepsis not antisepsis. A plea for principles, not paraphernalia, in laparotomy. Transactions of the Obstetrical Society of Philadelphia. Am J Obstet Dis Women Child. 1886;19(10):1076-1081.
9. Greenwood A. Lawson Tait and opposition to germ theory: Defining science in surgical practice. J Hist Med Allied Sci. 1998;53(2):99-131.
10. Schlich T. Asepsis and bacteriology: A realignment of surgery and laboratory science. Med Hist. 2012;56(3):308-334.
11. Kelly HA. Jules Lemaire: The first to recognize the true nature of wound infection and inflammation, and the first to use carbolic acid in medicine and surgery. JAMA. 1901;36(16):1083-1088.
12. Wangensteen OH. Nineteenth century wound management of the parturient uterus and compound fracture: The Semmelweis-Lister priority controversy. Bull NY Acad Sci. 1970;46(8):565-596.
13. Worboys M. Practice and science of medicine in the nineteenth century. Isis. 2011;102(1):109-115.
14. Gariepy TP. The introduction and acceptance of Listerian antisepsis in the United States. J Hist Med Allied Sci. 1994;49(2):167-206.