University life To be formally inducted into the academic staff, Lister had to deliver a
Latin oration before the
senatus academicus. In a letter to his father, he described how surprised he was when a letter arrived from
Allen Thomson informing him that the thesis had to be presented the next day on 9 March. Lister unable to start the paper until 2 am that night, had only prepared around two-thirds of it, when he arrived in Glasgow. The rest was written at Thomson's house. In the letter, he described the dread he felt being admitted into the room prior to presenting the oration. After the thesis was read and Lister was inducted to the senate, he signed a statement not to act contrary to the wishes of the
Church of Scotland. While the contents of his thesis have been lost, the title is known, "De Arte Chirurgica Recte Erudienda" ("On the proper way of teaching the art of surgery"). In early May 1860, the couple made the journey to Glasgow to move into their new house at 17 Woodside Place, at the time on the western edge of the city. In 1860, university life in Glasgow was lived in the grimy quadrangles of the small college on Glasgow
High Street, a mile east of the city centre next to
Glasgow Royal Infirmary (GRI) and the
Cathedral and surrounded by the most squalid part of the old medieval city. The Scottish poet and novelist
Andrew Lang wrote of his student days at the college, that while
Coleridge could smell 75 different stenches during his student days in Cologne, Lang counted more. The city was so polluted the grass did not grow. The position of Professor of Surgery at Glasgow was peculiar, as it did not carry with it an appointment as surgeon to the Royal Infirmary, as the university was separate from the hospital. The allotment of surgical wards to the care of the Professor of Surgery depended upon the goodwill of the directors of the infirmary. His predecessor Lawrie never held any hospital appointments at all. Having no patients to care for, Lister immediately began a summer lecture course. He discovered that college classrooms were considered too small and had low ceilings for the number of students, which made them unpleasant to be in when filled to overcrowding. Before his first lecture, the couple cleaned and painted the dingy lecture room assigned to them, at their own expense. He inherited a large class of students from his predecessor that grew rapidly. After his first session, he wrote favourably of Glasgow: In August 1860, Lister was visited by his parents, who took a "saloon" carriage on the
Great Northern Railway. In September 1860,
Marcus Beck came to live with the Listers and their two servants, while he studied medicine at the university. In the closing weeks of the summer, the Listers with Beck, Lucy Syme and Ramsay went on a short holiday to
Balloch,
Loch Lomond. While the group was visiting
Tarbet, Argyll, the men rowed across the loch and ascended
Ben Lomond.
Election to surgeoncy In August 1860, Lister had been rejected for a post at the Royal Infirmary by David Smith, a shoemaker who was the chairman of the hospital board. When Lister put his case to Smith explaining the need for anatomical demonstrations so the students could understand the practice of surgery, Smith stated his belief that "the infirmary was a curative institution, not an educational one". The rejection both annoyed and surprised Lister as he had been promised by Thomson that the position was assured. Indeed, he had informed his father of the fact that the post was guaranteed in his letter to his father. In November 1860, the winter lecture course began. In total 182 students registered for the lectures and according to Godlee it was likely the "largest class of systematic surgery in Great Britain, if not in Europe". The class consisting of mostly 4th year students with some 3rd and 2nd year students, was so enthused, that they decided to make Lister the Honorary President of their Medical Society. When the time approached for the election to the surgeoncy in 1861, 161 students signed a petition on parchment supporting his claim for election. Lister was not elected until 5 August 1861, in what was described by Beck as a "troublesome canvas". Lister was put in charge of wards XXIV (24) and XXV (25) in October 1861. It was not until November 1861 that he performed his first public operation. Soon after Lister arrived at the GRI, a new surgical block was built and it was here that he conducted many of his trials of antisepsis.
Holmes System of Surgery Between the end of his winter lecture course and his appointment, Lister's correspondence contained little of scientific interest. A letter to his father dated 2 August 1861 explained why. He had halted his experiments on coagulation to work on two chapters, "Amputation" and "On Æsthetics" (On anaesthetics) for the medical reference work
System of Surgery by
Timothy Holmes, published in four volumes in 1862.
Chloroform was Lister's preferred anaesthetic. He wrote three papers for Holmes in 1861, 1870 and 1882. The science of anaesthesia was in its infancy when Lister first recommended chloroform to Syme in 1855, and he continued to use it until the 1880s. His sister Isabella Sophie first described it to him in 1848 when she had a tooth pulled. He had also used it without complications on three patients with tumours of the jaw in 1854. He classed it along with alcohol and opium as a "specific irritant" in "On the early stages of imflammation". Lister preferred it to
ether, as it was safer to use in artificial light, protected the heart and blood vessels, and, Lister believed, gave the patient "mental tranquility" as it was the safest. In the 1871 edition, he reported that there had been no deaths in the Edinburgh or Glasgow infirmaries from chloroform, between 1861 and 1870. Lister described how his assistant applied the chloroform onto a simple handkerchief used as a mask and watched the patient's breathing. In 1870 however Lister updated the chapter to state that he felt apprehension about using chloroform on the "aged and infirm". In the same edition he recommended
nitrous oxide for tooth extraction and the use of ether to avoid vomiting after
abdominal surgery. In the winter of 1873, the English medical journals reported that
sulphuric ether should be used instead but Watson Cheyne stated there had been no deaths from chloroform during the winter of 1873. In 1880, the British Medical Association recommended the synthetic gas
ethidene dichloride for clinical trials. On 14 November 1881,
Paul Bert published the dose-response curve of chloroform but Lister believed that smaller doses were sufficient to anaesthetise the patient. Starting in April 1882, Lister first conducted clinical research using ether and from July to November, lab experiments on
chaffinches and then on himself and Agnes, to determine the correct dose. The 1882 chapter continued to recommend chloroform. The chapter on amputation was much more technical than the anaesthesia chapter, for example describing the ways of cutting the skin to produce flaps to close over the wound. In the first edition, Lister examined the history of amputation from
Hippocrates to
Thomas Pridgin Teale,
William Hey,
François Chopart,
Nikolay Pirogov and
Dominique Jean Larrey and the discovery of the tourniquet by
Etienne Morel. In the first edition, Lister devoted seven pages to
dressings, but by the third edition used only a single sentence to recommend a dry dressing as opposed to the more common water dressing. By the third edition, Lister focused on describing three innovative surgical techniques. The first was a method for amputation through the thigh that he developed between 1858 and 1860, a modification of
Henry Douglas Carden's technique for knee amputation. The thigh amputation went through the
femoral condyles in a circular fashion with a small posterior flap that enabled a neat scar. The second technique was an
aortic tourniquet for controlling blood flow in the
abdominal aorta. The vessels of the aorta were too tough to close properly and
ligatures either damaged the artery walls or caused premature death if left in too long. The third technique was a method of bloodless operation that he created in 1863–1864 by elevating a limb and quickly applying an
india rubber tourniquet to stop limb circulation. It became unnecessary with the use of the
Esmarch bandage. In 1859, he advocated for the use of silver wire sutures that had been invented by
J. Marion Sims, but their use fell out of favour with the introduction of antiseptics.
Croonian Lecture On 1 January 1863, Lister returned to the topic of coagulation with the
Croonian Lecture titled "On the coagulation of the blood", although it contained little that was new. The lecture, given in London at the invitation of the
Royal Society and the
Royal College of Physicians, began by reconfirming the fallacious nature of the ammonia theory, instead proposing that shed blood coagulates when the solid and fluid elements of the blood meet. His experiments had confirmed that blood plasma (liquor sanguinis) alone does not coagulate, but does when in contact with red blood cells. Lister suggested that living tissues possessed similar properties in relation to blood coagulation. He mentioned the presence of coagulable fluid in the interstices of cellular tissue and described instances of
oedema liquid coagulating after emission, possibly due to a slight admixture of red blood cells. Lister highlighted the tendency of inflamed tissues to induce coagulation in their vicinity, suggesting that inflamed tissues temporarily lose their vital properties and behave like ordinary solids, leading to coagulation. He provided examples of inflamed arteries and veins exhibiting coagulation on their interior, like artificially deprived vessels. Lister then noted that inflamed tissues induce coagulation and oedema effusions remain liquid. He hypothesised that the accumulated red blood cells increased pressure in inflamed
capillaries and contributed to the loss of healthy condition in capillary walls, leading to coagulation. In closing, Lister said his previous microscopic investigation published in the
Philosophical Transactions, supported the view that tissues could be temporarily deprived of vital power by irritants. He proposed that inflammatory congestion arose from the adhesiveness of red blood cells to irritated tissues, like their behaviour outside the body when encountering ordinary solids. In finishing the lecture, Lister said he was satisfied that his previous conclusions on the nature of inflammation were independently confirmed through his research into blood coagulation.
On excision of the wrist for caries Lister's most original work that he undertook during 1863 and the beginning of 1864 was the development of a surgical technique for the excision of caries from the wrist, i.e., the removal of diseased bone due to
tuberculosis. The procedure consisted of removing the ends of the bones entering into an articulation instead of amputating the whole limb, and was considered a recent development in "conservative surgery". Several surgeons had attempted the procedure. It was first performed by German surgeons Johann von Dietz in 1839 and in 1849, followed by British surgeon
William Fergusson in 1851. While the development of techniques for excision of the elbow was largely successful, similar success for the excision of the wrist was elusive, so amputation was still considered the most appropriate treatment even in 1860. Lister developed a complicated technique that removed the tissue where the disease was likely to occur but preserved the structures used to move the fingers and wrist. The technique was adopted by the profession and the only complaint from surgeons was the length of the operation at 90 minutes. Lister waited almost a year before publishing the paper in March 1865 in
The Lancet. The paper presented 15 case histories. In summary, ten people were cured, two had hopes of achieving a cure, two died of causes independent of the operation and Lister considered one operation unsatisfactory, a failure rate of 13%.
Edinburgh position Professor of Systematic Surgery in Edinburgh
James Miller died in June 1864. The Edinburgh chair, considered the most prestigious within the Scottish medical community, came with an annual stipend of £700-£800 per year. Syme and his friends suggested that Lister should apply as his candidature was all but assured. A number of reasons have been advanced for why Lister applied. In a letter to his father, he said that he saw Glasgow as a stepping stone. There were a multitude of reasons to either stay or go. He was drawn to research, his friends were there, and he found the routine tasks in Glasgow to be "working in a corner". There was also the fact that his tenure only lasted 10 years. Testimonials from Christison, Paget, Buchanan and Syme followed the application. By the end of June, Lister was convinced the position was his. However, the chair went with
James Spence instead. Lister was disappointed and in social settings tended to
solipsism in conversation, but by October his father, in a letter said that it was, "very gratifying to learn thy complete reconcilement to remaining at Glasgow". Before he received the disappointing news, Lister had been called back to Upton as his mother Isabella was on her deathbed. She died on 3 September 1864. His father now lived alone at Upton as the only daughter left at home had married in 1858. Communication with his children became of paramount importance to Joseph Jackson and he started to send Lister a letter every week, stating in October "The thought that thou wilt look for letters from thee weekly, and the letters when they come, are alike gratifying to thy poor father." ;Winter lecture course On 1 November, Lister began the winter lecture course, divided in two: common tissue and organ conditions, and conditions of physiology. His first lectures were on blood, then nerves, then detailed special nerves which explained the process of inflammation. In introducing the subject, he stated that any injury that did not cause death would result in inflammation with the familiar symptoms of redness, swelling and pain. These symptoms indicated "inflammatory congestion", the suspension of vital energy, beginning with red corpuscles adhering together, which was caused by fibrin, which itself was caused by two substances in the blood, one in the blood cells and one in liquor sanguis (plasma). He described two types of inflammation, direct and indirect. He saw direct inflammation as caused by a noxious agent and indirect by "sympathy", an indication that his frame of reference was wholly inadequate. He then provided various examples and examined various types of inflammation such as acute, latent and chronic. The following lectures explained how to alleviate the symptoms of inflammation, by for example elevating a limb to enable blood flow, or reducing tension by draining an abscess. The remarkable aspect of Lister's theory of inflammation was that while the details of his observations were correct, his theoretical structure to explain his observations was completely wrong. Lister's error lay in his belief that inflammation was a "unitary disease", a single underlying disease, when in effect it was a range of conditions. The second division of the lectures focused on the heart, blood vessels, lymphatic system, bones, joints and nerves. On 13 November 1864, Lister introduced a small instrument to remove foreign bodies from the ear, initially used to remove an iron bead from the ear of a little girl. In the same year, he improved on the technique for fixing
Urethral stricture, a surgical procedure last improved upon by Syme. This was the first of three procedures to the improvement of strictures. ;Christmas Lister and Agnes spent Christmas 1864 with Joseph Jackson at Upton. In January, Lister attended a quite unusual operation by Syme in Edinburgh in which a patient's tongue was removed. A month later, Lister received an interesting letter from Jackson on fees that indicated Lister's growing private practice that he began in 1861. His practice was unusual, as it was solely dedicated to surgery, during a period when operations either took place at the doctor's surgery or at the patient's home. In March 1865, Lister and his colleagues became involved in the case of the murderer
Edward William Pritchard who was employed as a doctor in Glasgow. Prichard had broken his oath. In a letter to his father, Lister expressed his sincere hope that he would be hung.
Pasteur in 1885 At the end of 1864 or during the spring of 1865 (sources vary) while walking home with
Thomas Anderson, the chemistry professor at Glasgow and discussing putrefaction, Anderson drew Lister's attention to the latest research of the French chemist
Louis Pasteur, who had discovered living things that caused
fermentation and
putrefaction. Lister had not been a wide reader of continental literature, but began reading the weekly journal
Comptes rendus hebdomadaires of the
French Academy of Sciences in the years 1860-1863 where Pasteur discussed fermentation and putrefaction. The two papers that Anderson recommended to Lister were ''Sur les corpuscules organisés qui existent dans l'atmosphère, examen de la doctrine des générations spontanées'' 1861 (On the organised particles that exist in the atmosphere, examination of the doctrine of spontaneous generations). In this paper, Pasteur disproved the theory of
spontaneous generation by proving the hypothesis that life in boiled infusions arose from
spores. He also proved that particles in the air could be cultivated; and that if they were introduced from the air into a sterile liquid, they would reappear and multiply in the liquid. The second paper was Pasteur's magnum opus, titled
Examen du rôle attribué au gaz oxygène atmosphérique dans la destruction des matières animales et végétales après la mort 1863 (Examination of the role attributed to atmospheric oxygen gas in the destruction of animal and plant matter after death), published 29 June 1863. The paper concluded that fermentation, putrefaction and slow combustion destroyed organic matter and these were necessary processes for life to exist. Pasteur learned that slow combustion was related to the
anaerobic conditions when
microorganisms were present. Several other papers would directly influence Lister's work on microorganisms. The third paper was the ''Mémoire sur la fermentation appelée lactique (Extrait par l'auteur)'' (Memoir on the so-called
lactic acid fermentation (Extracted by the author)), published in 1857, described the discovery of the microbe responsible for fermentation in beer yeast. The fourth paper was the
Memoire sur la Fermentation Alcoolique (Memoir on Alcoholic Fermentation), published in
Annales de chimie et de physique in 1860. Pasteur described living microorganisms in yeast,
Saccharomyces cerevisiae, that were responsible for the effervescent change that led to fermentation. The last paper by Pasteur was the
Animalcules infusoires vivant sans gaz oxygène libre et déterminant des fermentations, (Animal Infusoria Living in the Absence of Free Oxygen and their fermentations) That paper, presented in 1861, was seminal in enabling Lister to understand the nature of
sepsis, where the body's response to infections leads to injury of the tissue and organs. Pasteur's research led him to believe the ferment that produced
Butyric acid was a microbe that lived in the absence of oxygen. The last paper that Lister found important was "Recherches sur la putréfaction" (Research on putrefaction) that concluded that "...that putrefecation is determined by living ferments". Lister was not the only surgeon interested in Pasteur's research.
Thomas Spencer Wells, surgeon to
Queen Victoria, had emphasised the significance of Pasteur's work at a meeting of the British Medical Association in 1864, stating "[By] applying the knowledge for which we are indebted to Pasteur of the presence in the atmosphere of organic germs ... it is easy to understand that some germs find their most appropriate nutriment in the secretions from wounds, or in pus, and that they so modify it as to convert it into a poison when absorbed". However, Wells did not have an experiment to demonstrate germ theory and was unable to develop the techniques to put it into practice.
Discovery The
serendipitous discovery of Pasteur's work at a time when he was struggling to control post-surgical infections provided a simple explanation for a problem he had long experienced. He was now convinced that infection and suppuration of wounds must be due to entry into the wound of minute living airborne creatures. He recognised that contamination was the vector for infection, realising from the first that the surgeon's hands, dressings and instruments would also be contaminated. However, Pasteur's work confirmed the view Lister had always expressed that contamination came from the air. Lister did not realise the vast and diverse amount of microbial life. As Lister's work at that time derived directly from Pasteur's, Lister probably thought that wound infection was due to a single organism. He had no concept, nor indeed did anybody else, of the vast number of types of germs. Reading the papers did spur him to determine how the hands, dressings and instruments he used could be rid of these ubiquitous organisms and how the wound could be cleared of them. Pasteur suggested three methods to eliminate microorganisms: filtration, exposure to heat, or exposure to chemical solutions. Lister was particularly interested in the efficacy of filtration and repeated many of Pasteur's experiments in modified form for instruction in his class, but eventually excluded the first two techniques as not applicable for the treatment of wounds. Lister confirmed Pasteur's conclusions with his own experiments and decided to use his findings to develop antiseptic techniques for wounds. In the early months of 1865, he began looking for the most convenient form of antiseptics that could prevent germs from entering the wound. The first of these he tried was
Condy's Fluid, a common household disenfectant and a strong oxidising but the patient's limb began to suppurate. He went on to examine a huge range of compounds including
Zinc chloride,
Salicylic acid,
Thymol,
Iodine,
Mercury cyanide and
Zinc cyanide but none were suitable.
Carbolic acid In 1834,
Friedlieb Ferdinand Runge discovered the
germicide phenol, then known as carbolic acid, which he derived in an impure form from
coal tar. At that time, there was uncertainty as to the relationship of
creosote – a chemical that had been used as a preservative on the wood used for
railway sleeper and ships to protect the wood from rotting – and carbolic acid. Upon hearing that creosote had been used for treating sewage in Carlisle, Lister obtained a sample from Anderson. Known as "German creosote", it was a thick, smelly tarry substance.
Antiseptic system 1865–1867 in 1875. Gross rejected Lister's methodology when Lister visited the International Medical Congress in Philadelphia in 1876. Gross is quoted as saying: "Little if any faith is placed by any enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid treatment of Professor Lister". Examination of the portrait reveals that the assistant is holding the surgical instrument by the blade instead of the handle, delivering germs directly into the wound. The assistants have dirt on their hands, and a family member is present at the operation, bringing more germs into the operation. , professor of surgery who was on the point of retiring, to the students of University of Pennsylvania School of Medicine. Examination of the portrait shows that the surgeons are now wearing
surgical dress, the use of surgical drapes over the body is predominant and a nurse is present as it is an operation on a woman. Lister's work elicited a worldwide revolution in surgery in less than 25 years.
History Hospitalism The history of antiseptic surgery in the years before 1847, was preventing or treating infection in accidental wounds, often received in battle.
1860's surgery and pathological theory In the 1860s, Lister's assumptions about surgery and theory of pathology were similar to those of his contemporaries.
Early experiments In early March 1865, Lister conducted his first experiment using the acid on a patient whose wrist was being excised due to caries. Although he carefully washed the wound, it became infected and the experiment was a failure. On 21 March 1865, Lister began his second experiment with carbolic acid on a 22-year-old patient named Neil Kelly who had a severe compound fracture of the leg. His treatment consisted of cleaning the wound of all blood clots and then applying the undiluted carbolic acid by the use of forceps across the whole wound. A piece of lint impregnated in the acid was then laid on the leg, overlapping the wound and fixed by an adhesive plaster. A thin metal sheet made of tin or lead and sterilised by the acid was over the lint, to prevent the antiseptic from evaporating. This was fixed with adhesive plaster and packing was used between the limb and the splints to soak up blood or discharges. A crust formed that was not removed except to apply a new antiseptic. While the treatment possessed many of the essential characteristics of the antiseptic dressings that Lister would subsequently introduce, it failed and suppuration began to occur, leading to the death of the patient. Lister blamed himself and noted that the treatment "..proved unsuccessful, in consequence, as I now believe, of improper management".
Antiseptic treatment and dressings The essential part of the wound treatment was not the application of strong carbolic acid to the wound, although that required careful management to ensure the wound was sterilised, but designing the dressing in such a manner to stop the ingress of airborne infection. This was often misunderstood, even when he was explaining the procedure to fellow doctors at Glasgow who were celebrating him as humanity's benefactor, and it caused him considerable irritation and unhappiness later in life. They were confused by the initial application of the acid and this led to the claim that Lister was advocating for the use of carbolic acid to prevent suppuration. The disadvantages of the first primitive
dressings of lint soaked in carbolic acid were soon apparent. The German creosote was also far from ideal, as it irritated the skin, causing
ulceration and then suppuration that occasionally resulted in tissue
necrosis. It was also almost insoluble in water. Lister began to look for another source of phenol. Lister discovered that
Frederick Crace Calvert, an honorary chemistry professor from the
Royal Manchester Institution was manufacturing small quantities of phenol at a much finer purity and managed to obtain some. The phenol was in the form of small white crystals which liquified at and were readily soluble in a ratio of 1:20 parts of water and to any extent soluble in oil. The watery solution could be used in a
lotion of any strength and be used for disinfection of wounds while the solution in oil that served as a reservoir of antiseptic seemed likely to provide a suitable dressing. Lister began to experiment with the phenol and produced a new dressing made of a putty that consisted of
carbonate of lime mixed with phenol mixed with boiled
linseed oil in a ratio of 1:4 or 1:6. After two failures, Lister had no clear experimental design to test the efficacy of carbolic acid. At that point he decided to only experiment on patients with
compound fractures, i.e. open wounds where the fractured bone breaks through the skin, leading to extensive loss of blood. In 1865, industrial accidents often led to the patient being thrown to the ground, leading to dirt entering the wound and a risk of deep infection. By the time the patient saw a surgeon several hours later, suppuration had invariably set in. In 1865,
amputation was the standard treatment for compound fractures. Lister reasoned that he could experiment on the patient and if the treatment failed, perform the amputation to remove the limb and save the patient's life. He believed this experimental model was both ethically and medically ideal.
James Greenlees On 12 August 1865, Lister achieved success for the first time when he used the crude oily full-strength carbolic acid to disinfect a compound fracture. He applied a piece of lint dipped in carbolic acid solution onto the wound of an 11-year-old boy, James Greenlees, who sustained a compound fracture after a cart wheel passed over his left leg. After washing the wound with carbolic acid dissolved in
linseed oil, he applied a dressing of putty mixed with the acid widely over the wound and placed a sheet of tin to cover the wound and protect it. The putty ensured that the acid did not wash out of the wound in blood or lymph fluid. He
splinted the leg and bandaged it to hold the lot in place. After four days, he renewed the pad and discovered that no infection had developed. He again dressed it and left it for five days. When he removed the second dressing, he found the skin around the wound was burnt and applied a dressing of
gauze soaked in a combination of 5% to 10% acid and
olive oil for a further four days. He then applied a water dressing to the wound until it completely healed. After slightly over six weeks, Lister discovered that the boy's bones had fused back together without
suppuration. Confident that carbolic acid was the antiseptic that he had been looking for, Lister treated patient after patient at the Royal Infimary in the following months, improving both the wound dressing design and the operating treatment. During the summer, the Listers never strayed far from Glasgow as he was still monitoring Greenlees. In the same month, he treated two
ulcers. Both sores were washed with an acid in oil solution and one was covered with an oiled paper coated with
spirit varnish and the second with
gutta-percha covered with a water dressing. In both cases the dressing failed and he swapped them for a water dressing covered with cotton. On 11 September 1865, Lister treated the second patient with the acid, Patrick F., a labourer with a compound fracture of the thigh. After the thigh was splinted, the small wound was dressed using lint dipped in carbolic acid and covered in oil paper. After 16 days, the patient had an excellent
prognosis. On 22 September, the Listers decided to take a short holiday to Upton and the patient was left with his house surgeon, John Macfee. However, the treatment failed and the limb was amputated after gangrene developed in the wound. When he wrote up his seminal paper, Lister considered the wound size too small to have effectively tested the efficacy of the acid, but he was happy with the outcome. At Christmas 1865, the Lister joined the Symes in Edinburgh. It was eight months before Lister treated another compound fracture. On 22 January 1866 he treated John Austin, a shipwreck survivor with a wound in the leg that had developed into an ulcer. He washed the wound in 20:1 oil-to-acid solution and dressed it with a lint bandage dipped in the solution covered with
plaster of paris.
Improved dressing On 19 May 1866, the first patient to use the improved method presented at Lister's accident ward with a compound fracture with extensive swelling and bruising. The patient was John Hainy, a 21-year-old
casting moulder in an
iron foundry, who had been supervising a crane when a chain broke and a metal box, containing a sand mould weighing 12
hundredweight or , fell from a height of four feet and landed obliquely on his left leg. Both leg bones were broken and a wound measuring had bled profusely into the muscles and tissue of the leg. A secondary complication had occurred when air bubbles had mixed with the blood when the man was moved to the hospital. The normal treatment would have been amputation, but Lister decided to treat the wound with phenol. He squeezed the leg to remove as much air and blood as possible, then placed a piece of lint soaked in carbolic acid on the wound and covered it with
tin foil. A bloody crust formed over the wound, consisting of a scab free of bacteria. Lister saw for the first time how the scab was gradually converted into living tissue, even when new carbolic acid was being applied - something entirely new. Unfortunately Hainy developed
bed sores that became gangrenous. These were treated with
nitric acid to remove the necrotic flesh and carbolic acid to sterilise the wounds. Hainy survived the injury. On 27 May, Lister wrote to his father expressing intense satisfaction, stating "I tried the application of carbolic acid to the wound, to prevent decomposition of the blood and to prevent the fearful mischief of suppuration. It is now eight days since the accident and patient has been going exactly as though the fracture were a simple one." Two weeks later another letter followed, reporting "The great swelling has almost entirely subsided, and the limb is becoming firm". On 11 June, he wrote a further letter to his father where he describes compound fractures as "no longer a case of uncertainty" and his decision to publish the results. On 7 August 1866, Hainy was released from hospital.
Abscess treatment On 7 November 1866, Lister began using his technique on abscesses, when he successfully treated 12-year old millworker Mary Phillips. On 17 March 1867, he treated a 5-year-old boy who had a disease of the spine that had developed a large abscess between the umbilicus to the middle of the thigh. Known as
psoas abscesses, they were often as result of complication from tuberculosis, where pus collects in the muscles within the abdominable cavity. They tended to grow very large but the relationship between underlying infection in the bone caused by the tuberculosis and the abscess was not understood. The treatment he developed consisted of draining the abscess, placing a piece of lint soaked with carbolic acid in the incision and applying a dressing consisting of layer of the putty then covered with tinfoil. The dressing was changed daily with the lint left in place. Eventually the lint was removed after several days, leaving a scar. In a letter to his father he stated "...cases of abscess treated in this way is so beautifully in harmony with the theory of the whole subject of suppuration, and besides the treatment is now rendered so simple and easy for any one to put in practice, that it really charms me".
Medical discourse During his life, Lister never wrote any books and was exhausted by the process of writing. He considered the meaning of each individual word, which would have meant writing a book both extremely time-consuming and a burden. An example of Lister's poor communication was placing the reason for his antiseptic treatment at the end of the first antiseptic paper, instead of in the first paper. Foremost amongst his biographers to examine Lister's writing skills was Joseph Fisher, who pointed to his flatness of expression and his inability to state the obvious, i.e. that he was seeking to prevent putrefaction. Fisher wondered if it was simple "stylistic ham-handedness", a statement examined by Connor and Connor in 2008. Lister used the Greek word
antiseptic to describe his new technique. This 1752 term was widely known in the medical community and meant cleaning the wound of dead flesh with an antiseptic fluid. Lister's use resulted in confusion for his readers and slowed the adoption of the new technique. In 2000, medical historian
Michael Worboys stated that his surgical contemporaries reported that "translating his words into action" was difficult. Connor and Connor analysed Lister's public and private written and spoken communication to determine if this was true. They concluded that Lister was not bad at writing and this was seen in his private letters to his father, describing the textual content as "clear, concise, informative and concrete". Although Lister understood the need to remain neutral and objective in his public communication, he struggled to find a suitable
ethos that would clearly convey his ideas and that resulted in his writing sounding awkward and unnatural. Sir
Charles Scott Sherrington attributed Lister's "sobriety of expression" and "self-restrained statements" to his Quaker faith. Crowther and Dupree writing on Lister's student cohort in 2007 described some of his essays as "turgid".
Performance perspectives In 2013, Worboys revisited Lister's writing, by examing it from three different performance perspectives- antiseptic, surgery and professional. Lister published work in antiseptics was written in two ways. First, Lister used case histories to illustrate the principles and practice of his clinical studies. He published a total of 47 case histories between 1867 and 1877. Occasionally he would publish statistics in a before and after scenario to show how antiseptic treatment benefited a patient but believed that case histories were more instructive. Secondly, he used programmatic statements that described the evolution and benefits of his germ theory. These were plans that described how a particular antiseptic technique should be applied, for example the 1 in 20 carbolic solution, or how to prepare dressings.
Elaboration of the antiseptic treatment (1866-1869) In July 1866, while he continued to treat compound fracture cases, he applied for a vacant surgeoncy position at the
University College London. It was an attractive position as it came with guaranteed post at University College Hospital. He approached Lord
Henry Brougham to prepare a testimonial that included a short description of the antiseptic system, which was the first formal description of his work. However, he lost the election. Lister was confident in achieving the position. In a letter to his father on 6 August 1866 he described "The disappointment was at first extremely severe : more so than I had expected". The position went to
John Marshall who had been an assistant surgeon for some 18 years.
On a new method of treating compound fracture, abscess In early 1867, Lister began writing the compound fracture case histories of his experiments with carbolic acid in a series of papers, the first to describe his new technique of antiseptics. Titled
On a New Method of treating Compound Fracture, Abscess, Etc., with Observations on the Conditions of Suppuration. the paper was published in
The Lancet in five instalments with the first appearing on 10 March 1867. and the last part on abscesses added in July 1867. The paper was divided into a main section dealing with compound fractures, and a short note on the treatment of abscesses. Lister's theory of inflammation provided the conceptual structure of the article. He stated that the inflammation that appeared immediately after an injury was both necessary and dangerous. It was a precursor to healing, but the fluids which flowed into the wound were akin to dead tissue. Inflammation could trigger putrefaction. Lister described tissues healing by
granulation, which he believed was the likely outcome in wounds in compound fractures. Lister believed that cells of granulated tissue were remarkably active and that since they were alive, they were immune to putrefaction and also to secondary inflammation, as they lacked sensory nerves. Airborne putrefaction, "a danger that was underrated", was proven by the
scabs which appeared to protect small wounds as they
healed. Lister then explained how often it appeared in less than 24 hours and had an associated
smell. He described the source of putrefaction and how the "raw surface" of the wound could putrify before the granulations formed or the liquids on the surface of the granulations putrified. The liquids were extremely acrid and acted on the sensory nerves to initiate indirect inflammation and
fever. This led to increased cell turnover and cellular death, increasing the quantity of putrescent material in the wound. Sloughs were produced that resulted in
suppuration. In the next section, Lister made his most famous declaration, namely that the decomposition of organic tissue was not caused by the gaseous components in the atmosphere but "minute particles suspended in [the air], which are the germs of various low forms of life, long since revealed by the microscope, and regarded as merely accidental concomitants of putrescence" and had been identified by Pasteur as the "essential cause" of putrefaction. His idea of germs during this period were not the same as the germs described in later germ theory. This is clearly attributed by his use of the phrasing "..living organism's
developed from germs". He described germs as working in the same manner as yeast converts sugar to alcohol. They were scavengers who lived on dead tissue, not parasites on living tissue but as highly adaptable agents whose
pathogenic properties depended on where they came from. Like many surgeons of the age, Lister believed that fever was a product of local miasma. In that respect, Lister's paper is open to many interpretations, but in the context of wounds, he believed that living tissue could resist germs. He never made the distinction as to whether germs were living beings for example in
erysipelas, that entered the body or were a chemical agent. In the rest of the paper, Lister described using carbolic acid, and how the acid formed a dense crust protecting the wound from the ingress of germs. He then described the detailed case histories of 11 patients. Healing by granulation occurred in all cases except 7,10, and 11, which did not suppurate. Cases 1 and 9 did suppurate. Lister did not regard pus as significant, as it was not associated with inflammation or change in putrefaction. In essence, he had
attained healing by granulation without inflammation in compound fracture cases. He believed that the elimination of suppuration was not a desirable therapeutic outcome, as a small amount of suppuration on a healthy granulation was not a cause for alarm.
Carcinoma of the breast In July 1867, Lister discovered that his sister Isabella Pim had
breast cancer. Pim had visited Paget and Syme to seek treatment but had such an extensive carcinoma that both surgeons advised against operating. Lister made the difficult decision to perform a
radical mastectomy. He consulted Syme in Edinburgh and rehearsed the operation on a dead body. The recovery went smoothly and although there was some suppuration in the wound, Lister's use of antiseptics prevented putrefaction. The next day he wrote to his father, "I may say the operation was done at least as well as if she was not my sister. But I do not wish to do such a thing again." Pim lived for another three years before dying of
liver metastasis on 9 August 1870.
The Protective Lister continued to refine the dressing and perfect the antiseptic treatment on several other compound fracture and patients with abscesses. He would often spend long nights experimenting in his home laboratory. He searched for a germicidal material that could be placed on the wound, known as the protective, it would serve to protect the wound from the irritating effects of the acid and stop the ingress of microbes but enable bodily secretions to escape. He initially looked at using
caoutchouc but the material allowed the acid to pass right through. He found block tin to be too rigid and tinfoil soon wore away.
Gold leaf was found to be too fragile. Lister also looked at very thin
toughened glass but it could not be obtained.
Antiseptic principle of the practice of surgery methods followed the publishing of Lister's
Antiseptic Principle of the Practice of Surgery in 1867. Within a few days of the publishing of the last part of the previous paper, Syme asked Lister to attend the British Medical Association meeting in Dublin on 9 August 1867. Lister had some difficulty preparing a new paper, the seminal "On the Antiseptic Principle in the Practice of Surgery-*" Lister's second paper on antiseptic surgery. It was later published in the
British Medical Journal (BMJ) on 21 September 1867. Lister claimed that based on experiments on inflammation, the essential cause of suppuration in wounds was decomposition. Several aspects of this claim need to be examined. Firstly, it was specific to wounds, as Lister had other views about suppuration elsewhere on the body. Secondly, he stipulated that decomposition was the "essential" cause of suppuration, i.e. not the only cause. Thirdly, decomposition was the cause of pus in wounds. Lister's pronouncement is best described as that he had discovered that the only important cause of suppuration in inflamed wounds is decomposition. Lister was specifically referring to the pathology of pus formation in inflamed tissue, the essential cause of harm in the practice of surgery. His appeal to the reader, in essence, to surgical consensus, was: "To prevent the occurrence of suppuration, with all its attendant risks, was an object manifestly desirable", and refers to the surgeon's dread of pus appearing in an inflamed wound. Lister then made the wholly inaccurate statement that "...oxygen, which was universally regarded as the agent by which putrefaction was effected" compared to other sources. Lister introduced the work of Pasteur, claiming that decomposition might be avoided by using a dressing that could destroy the minute organisms in the wound. Lister decided to formulate his new surgical technique into a general principle. He termed it the "antiseptic principle", thus linking its nomenclature to carbolic acid. His principle was ''that all the local inflammatory mischief and general febrile disturbance which follow severe injuries are due to the irritation, and the reason for this was the carbolic acid induced suppuration but prevented decomposition, which was contrary to normal surgical treatment that saw suppuration as an indication that something was wrong, in Lister's case essentially that the antiseptic treatment had failed.[325] influence of decomposing blood or sloughs.'' He was stating a "great principle" – not that decomposition was the cause of disease in wounds, but that it was the only cause. The paper instructed surgeons to continue treatment even when suppuration appeared. The reason for this was the carbolic acid-induced suppuration but prevented decomposition, which was contrary to normal surgical treatment, which saw suppuration as an indication that something was wrong, in Lister's case essentially that the antiseptic treatment had failed. He noted that he felt it necessary to affirm on "pathological principles" that
granulation tissue had no inherent tendency to form pus but only did so when "subjected to a preternatural tendency". He explained that carbolic acid and decomposing substances were similar, i.e., both caused suppuration by a chemical process but carbolic acid only acted on the surface of the tissue to which it was applied, but decomposition is a "self-propagating and self-aggravating poison". Decomposing tissue was a breeding ground for more decomposition that led to putrefaction in the tissue surrounding it. Lister argued that the pus formed by carbolic acid was acceptable as long as it was not accompanied by inflammation. In this respect, Lister's approach to normal or abnormal healing by granulation was the same as the average surgeon of the period: that healthy healing did not occur when inflammation was present. Lister paid particular attention to putrefaction. The last part of the paper stating that decomposing wounds were the cause of disease in hospitals, which was not an uncommon belief amongst the surgical community. He described how the two large wards where he offered treatment were the unhealthiest in Glasgow and how since the application of antiseptics, "wounds and abscesses no longer poison the atmosphere with putrid exhalations" and the wards completely changed their character. Not a single instance of pyaemia, hospital gangrene, or erysipelas had occurred in them since the new regime of antiseptics had begun. However, Lister did not explain how the "putrid exhalations" led to fever.
Illustrations of the antiseptic system of treatment in surgery On 21 September 1867, Lister published a new paper, "Illustrations of the Antiseptic System of Treatment in Surgery", in
The Lancet, his third paper on antisepsis. This paper was supposed be the first in a new series with the next paper to be on wounds with simple incisions but it never appeared. The paper summarised his earlier claims and added further observations on the nature of putrefaction. He stated that the "character of the decomposition in a given fermentable substance is determined by the nature of the organism that develops in it". He suggested that the cause of fermentation in food was yeasts and putrefaction was possibly caused by
Vibrios (a type of bacteria). At the end of the paper, he stated that on the basis of his new antiseptic theory "a really trustworthy treatment for compound fractures and other severe contused wounds has been established for the first time, so far as I am aware, in the history of surgery".
First reception of antisepsis (1867-1868) Although Lister was honoured in later life, his ideas about the transmission of infection and the use of antiseptics were widely criticised in his early career. On 24 August 1867, within a month of Lister's publishing his first paper on antiseptics, the editor of
The Lancet, Lister's nemesis
James G. Wakley, wrote an editorial crediting Pasteur for Lister's research and invited physicians to investigate Lister's claims and report their findings to the journal.
Simpson's attack On 21 September 1867, Scottish
obstetrician James Young Simpson, professor of medicine and midwifery at Edinburgh University and discoverer of chloroform, published an editorial that attacked Lister in the
Edinburgh Daily Review, written under the pen name "Chirurgicus", a common practice to signal a personal attack. Simpson's motive was that he was trying to convince the medical community of the efficacy of his acupressure technique, which used needles to halt arterial haemorrhage, counter to Lister's use of ligatures. The editorial letter was the first of many and began a tit-for-tat argument in the press over months and eventually led to the acceptance of antisepsis. Simpson claimed that Lister's prior article had copied a continental practice and accused him of plagiarising the work of French doctor and pharmacist
Jules Lemaire. Lemaire had described carbolic acid as a constituent of coal tar in 1860 in "Saponinated coal tar" and after a long series of investigations had followed up with an 1863 book, "De l'acide phénique, de son action sur les végétaux, les animaux, les ferments, les venins, les virus, les miasmes et de ses applications à l'industrie, à l'hygiène, aux sciences anatomiques et à la thérapeutique" (Carbolic acid, its action on plants, animals, ferments, venoms, viruses, miasmas and its applications to industry, hygiene, anatomical sciences and therapy) with the second edition in 1865, where he described the antiseptic power of carbolic acid. While Lemaire believed in the germ theory and realised the causes of putrefaction, he made no attempt to develop a process to exclude them from the wound. On 5 October 1867, Lister gave a robust reply to Simpson in a letter "On the Use of Carbolic Acid" to
The Lancet, denying that he had heard of Lemaire's work and arguing that that work had made little impact on the medical profession. Lister went on to defend his work, stating: ::"For my own part, I may say that, of all the gentlemen from Great Britain and both continents who have recently visited Glasgow, not one has ever expressed the slightest doubt that the system in question was entirely new; the novelty, I may remark, being, not the surgical use of carbolic acid (which I never claimed), but the methods of its employment with the view of protecting the reparatory processes from disturbance by external agency." He unsuccessfully searched all the Glasgow libraries for Lemaires work before finally discovering a copy in the library of Edinburgh University. On 19 October, Lister wrote a follow-up letter to
The Lancet and stated he did not claim to be the first physician to use carbolic acid and that he chose the acid due to its strength as an antiseptic. He also included a letter of support from a Carlisle medical student, Phillip Hair, who had studied in Paris. Hair stated he had seen no treatments there that were as effective as Lister's. Lister's response angered Simpson and two weeks later on 2 November 1867 he published a bitter reply: "Carbolic acid and its compounds in surgery" in,
The Lancet under his own name. Simpson reiterated his previous claims about Lemaire's and others' prior use of the acid, mentioning
James Spence, who had used the acid to wash amputations, but had abandoned its use. He cited a report by
Sampson Gamgee who visited Paris and reported that surgeons were using a solution of 100:1 of water to acid, while Lister recommended 40:1. Simpson exposed his true motives when he compared his preferred technique of acupressure to Lister's use of ligatures. He used the work of
William Pirrie, professor of surgery at
Aberdeen University, who had used acupressure to stop pus formation during
breast cancer operations, to illustrate his point, that there had been no deaths from pyaemia at the hospital, compared to the many deaths in Glasgow and Edinburgh. Simpson was acutely embarrassed when Pirrie replied a week later in
The Lancet in a small article titled "On the Use of Carbolic Acid in Burns", recommending its use for burn injuries and believing it proved effective in other treatments. Lister replied with a short note on 9 November to ask the reader to: "to judge for themselves how far the present attack admits of justification, promising to publish additional articles on his antiseptic technique". In December, two further letters were published in
The Lancet, the first by a young physician Arthur Hensman who credited Lister with an original technique that he considered of a practical use. The second later was more assertive declaring that Lister's technique was not described by the use of that acid but by way it was applied, affirming that the technique was important.
First experimentalist The first experimentalist surgeon to question the validity of the airborne microorganisms hypothesis, i.e. the Lister germ theory, was professor of clinical medicine at Edinburgh University
John Hughes Bennett. In a 17 January 1868 lecture for the
Royal College of Surgeons of Edinburgh Bennett advanced
The Atmospheric Germ Theory, agreeing with the theories of
Félix Archimède Pouchet, professor of natural history at the
University of Rouen, who believed in
spontaneous generation of life. Bennett attacked Pasteur's experimental foundations of germ theory and called him a mere chemist. Bennett described his own theory of molecular degeneration to explain how microorganisms transformed old tissue into new tissue by the action of molecules. Bennett taught that
molecules rather than
cells were the foundational building blocks of tissue and that microorganisms could be spontaneously created from different combinations of molecules. In his view, each molecule had a specific function, i.e. certain molecules were destructive to tissue, while others constructed tissue. Bennett believed that diseases developed from the physical properties of the air, such as its density or changes in temperature. Bennett believed that the germs that Pasteur captured could not be identified as organic organisms. The components of this dust were also found in minerals and they were either lint, debris from clothing, vegetable matter or pieces of seeds. Bennett particularly disagreed about temperature. Pasteur stated that germs died when heated to 30 degrees above boiling, and also from extreme cold. In the lecture, he referred to Pouchet's experiments duplicating Pasteur's, and refuted Pasteur's conclusions. Bennett did not realise that Pasteur had proved his theory by both isolating the germs and stopping them from reappearing. In his experiments, Bennett reported that he "proved" that germs generate spontaneously, so therefore one could never create a germ-free environment. It was likely that Hughes Bennett never adequately sterilised his experimental apparatus correctly. Derby successfully treated a 9-year-old boy who had fallen from a tree, resulting in a compound fracture. Other North American surgeons began adopting the new technique including the Canadian surgeon
Archibald Edward Malloch who had studied at Glasgow medical school and became Lister's house surgeon when Lister began using carbolic acid. In February 1869, Malloch by then in private practice in
Hamilton, Ontario successfully treated a 7-month old baby that had developed an abscess due to
septic arthritis in the right hip. Malloch had collaborated with Lister and understood the germ theory. He had demonstrated a series of fractures cases to
Samuel D. Gross a prominent
Philadelphia surgeon, who rejected the new technique. Indeed, most North American surgeons were loath to accept the principle, vividly illustrated by
David Hayes Agnew who was still using outdated surgical techniques in 1881 when he treated President
James Garfield who had been shot. The widest acceptance of Lister's technique was in Germany.
Leipzig surgeon
Karl Thiersch of began practicing the technique in 1867 and taught it to his students. His house surgeon
Hermann Georg Joseph had visited Lister in Glasgow and then tested it on 16 patients with abscesses, with favourable results. Joseph wrote a report on his results, and presented it on 21 December 1867. Within five years, the antiseptic method was universally accepted in Germany. French surgeons were hestitant in accepting the theory, except for Paris surgeon
Just Lucas-Championnière of
Hôtel-Dieu who adopted the technique when he visited Lister in Glasgow as a medical student in 1868 and became the leading French pioneer of Listerism. In 1875, Lucas-Championnière visited Lister a second time and then wrote the first French reference on antiseptics in the "Journal de Médecine et de chirurgie pratiques" (Journal of Practical Medicine and Surgery).
Sterility experiment In October 1867, Lister repeated a modified form of Pasteur's experiment, originally devised by French chemist
Chevreul, to support his germ theory and disprove the theory of spontaneous generation. Lister poured urine into four glass flasks, then washed the necks to remove any urine and modified three of them, extending and drawing their necks into a narrow tube bent at an acute angle. The fourth's neck was cut short and left vertical, but with a reduced diameter, smaller than the others' necks. The flasks were then boiled and when the heat was withdrawn, air was allowed to rush into the flask to replace the condensed steam. The flasks were then left undisturbed in the same room, the necks open to the air. Within four days a vegetative mould appeared in the fourth flask while the other three flasks remained clear. In November, he began using the flasks in his class. His dresser John Rudd Leeson described how Lister took the three flasks to London on their laps in a specially reserved first-class cabin, to ensure they survived the journey.
The catgut ligature (1867-1869) A practical problem in general surgery that Lister researched and developed was absorbable
ligatures that were used to tie large
blood vessels during amputation. It had been known for years that gunshot bullets, i.e. smooth metallic objects, could remain inside the body without causing suppuration but suppuration would occur in silk or thread ligatures, which resulted in the ends being left outside the body to enable the ligatures' removal. However, that method left an open path for germs to enter the body alongside the ligating material, and presented a risk of secondary
hemorrhage when the ligatures were removed. By late 1867, he understood that ligatures were sources of irritation. Lister also noticed, while treating a patient with a compound fracture, how a piece of dead bone had become live bone again as new blood vessels suffused the fracture. He reasoned that it was possible to find a material that could be absorbed into the body, thereby reducing the ingress of germs. He initially took the standard silk thread and impregnated it with carbolic acid. On 12 December 1867, in the first of a series of experiments, Lister tested the new ligature by tying the carotid artery of a horse. When the horse died six weeks later (of natural causes) it was dissected, and he found dense fibrous tissue had grown over the ligature. But he noticed the silk was being absorbed rather slowly. On 2 February 1868, in a letter to his father he reported using the new ligature on a private patient with a leg
aneurysm. The patient recovered completely. On 5 February he expressed his profound excitement at the patient's recovery to his father. However, the lady died 10 months later of another aneurysm due to
vascular disease. During the dissection, Lister found that most of the ligature had been absorbed but found a tiny blob of thick pus on the remaining piece, that led him to think an abscess could have formed. He began looking for another material and settled on
catgut. On 31 December 1868, while staying at Upton for Christmas, Lister tested the new carbolised catgut on a calf, running the experiment in his father's museum. He again tied the carotid artery and after a month, the calf was dissected. Initially he thought the ligature was still in-situ, but on closer examination saw that living tissue was growing into the structure. In a letter to his father he described his findings : However, the catgut preparation still was not suitable as he found it too slippery to use. He accidentally discovered that when a small amount of water was added to the acid and oil mixture, he found the catgut became both stronger and less slippery, rendering it suitable for regular use. He called this process "Seasoning" Now proven to work, it was sold in bottles of carbolised oil, a product that was in production for ten years. It was also sold wound into an oil-tight silver box containing a winder that was kept alongside a bottle of the acid. He continued to refine his catgut ligatures his whole life. On 3 April 1869, he published the results of his catgut experiments, "Observations on Ligature of Arteries on the Antiseptic System" in The Lancet that reported the experiment on the calf. The Lancet gave a glowing review on the paper. The first person to use Lister's catgut was
Edward Robert Bickersteth of
Liverpool Royal Infirmary. A former student of Syme and follower of antiseptics, he wrote a letter to Syme on 20 April 1869, describing two successful operations, the first on the cartotid artery for aneurysm and the second on the
external iliac artery. However, there were failures. James Spence had used it to tie the
Common carotid artery on a patient who had died. The postmorten found the catgut had changed into a gelatinous state. The surgeon who supplied it admitted incorrectly preparing it properly and was summarily sacked. Bickersteth showed by a simple experiment in
The Lancet that the catgut should have retained its strength for much longer period. By 1870, Lister was using catgut in the
Brachiocephalic artery, the largest artery it could be used on.
Improved dressings and protective While working on ligatures, Lister was continuing the development of an improved dressings. His latest refinement was the "cerate dressing" consisted of 6 parts paraffin, 2 parts wax, 1 parts olive oil and 1/2 or 1/4 carbolic acid mixture on
Calico On 8 March 1868, in a letter to his father, he described how his goal of a lighter dressing has been achieved: "all the inconveniences of the putty are got rid of, along with superior efficiency for some situations, as the new paste can be applied to parts to which it was impossible to apply the putty satisfactorily". However, the new dressing was too brittle for use. The next dressing Lister created was the "lac-plaster" that consisted of 4-parts
shellac to 1-part acid coated onto calico. It was found to be too sticky, so Lister coated it with
gutta-percha. In a letter to Malloch on 10 September 1868, he had changed the coating to
red lead pigment (a poison) that was incorporated into the calico, which made it less sticky. When used, it could be washed in water to restore the original stickiness. By 1869, Lister had eventually settled on the use of oiled silk sold under the "Green oiled silk protective" brand for the protective. The silk surface was painted with one part
dextrin, two parts of powdered
starch and 16 parts of watery acid in a 20-1 water-acid solution, to ensure a thorough wetting. The sterile silk dressing was an effective barrier between the acid and the tissue. Lister formally described the new treatment on 14 February 1870, in a clinical lecture on a compound dislocation of the ankle, as "An antiseptic to exclude putrefaction with a protective to exclude the atmosphere will by their joint action, keep the wound from abnormal stimulus". On top of the protective was up to eight layers of
gauze.
Address to the Royal Medico-Chirurgical Society On 17 April 1868, Lister gave an address to the
University of Glasgow Medico-Chirurgical Society. He spoke at length about the atmospheric germ theory and used his flask experiment to illustrate the theory in an effort to disprove the spontaneous generation of life. He also introduced catgut ligature and described five case histories to support his theory. During the two hour talk he gave three prerequisites to ensure success. The first was a belief in the antispetic technique, the second was a belief in the germ theory of disease and the third was that the surgeon must have a dependable antiseptic on hand. The address was the first time that Lister used the phrase "The germ theory of putrefaction" that both Lister and Cheyne would frequently use over the next decade. The most significant aspect of the address was that healing by organisation in a blood clot was preferable in complex wounds to healing by first intention. Healing by organisation was not well understood during this period. Lister considered it similar to granulation healing that produced less scar tissue. For simple wounds he would bring the edges together and would seek first intention healing, in a manner similar to what other surgeons of the day would do. With complex wounds like compound fractures where the wound edges could not be brought together, he wanted a scab to form through healing by organisation. Treatment was simplified in that case and saved a
drain being inserted to remove discharges. He tried to avoid a granulating sore forming which put the patient at greater risk. As his theory evolved on how clots healed, he began to consider granulation tissue as a product of "abnormal stimulation". He described it thus: Lister believed that antiseptics enabled the wound to heal without granulation.
Visitors to Glasgow Beginning in the spring of 1868, Lister had several more visitors in Glasgow. These included
Joseph Bell, a former student of Lister and
William MacCormac. In June 1868
Marcus Beck visited Lister and was invited to attended lectures given by Lister on operative surgery. In a letter to his father on July 1868, he describes how Beck was horrified when Lister made a free incision into a patients knee joint to repair loose cartilage. During this period Lister read several reports in '
The Lancet on the successful use of his technique. One in July 1868 was from Pearson Robert Cresswell (1834–1905), chief surgeon to the
Dowlais Ironworks in
Merthyr Tydfil. Cresswell reported successfully treating a man who had been shot in the leg. He described the new technique as "quite a revolution". In August, the lecture series ended and the couple went on holiday to
Ventnor on the
Isle of Wight.
Reception at home On 5 September 1868, Wakley who was aware of the report, wondered why London hospitals had not adopted antiseptics and posted a sarcastic enquiry on : ""Are the conditions of suppuration different here from those in Glasgow or Dowlais? Or is it that the antiseptic treatment is not tried with that care without which Mr. Lister has always pointed out it does not succeed?". Over the next several months Wakley published a series of brief reports from London surgeons. The first to report were
St George's Hospital surgeons, who followed Lister's directions exactly on 26 cases of lacerations but only 7 healed correctly and none by first intention healing. They described how little they understood antiseptics. In November 1868,
Thomas William Nunn of
Middlesex Hospital had some initial success but other surgeons offered differing opinions to its efficacy of the technique and described the acid as one of several disenfectants that could be used to dress wounds. The surgeons at
Guys and
St Bartholomew's Hospital had a similar experience. On 5 December 1868, the prominent pathologist
James Paget of
St Bartholomew's Hospital reported that he found the acid "useless" but admitted he might have been applying the technique incorrectly.
Thomas Bryant, the chief surgeon at
Guy's Hospital felt the technique worked as had
John Wood at
King's College Hospital who experimented with many different antiseptic compounds. There was also positve news when the
The Prince of Wales's General Hospital in Tottenham reported that it was using the full antiseptic system and had no pyaemia or erysipelas cases but one surgeon
John Marshall refused the treatment due to a patients "green urine and other toxic symptoms".
Defence of tradition In July 1869, at the annual conference of the
British Medical Association (BMA) at
Leeds, attended by both Simpson and Bennett, the English surgeon
Thomas Nunneley mocked Lister's ideas on
antisepsis and expressed disbelief in the germ-theory of wound infections. Nunneley was a well respected researcher and expert on erysipelas who proudly boasted during the surgical address that he had not permitted a single patient to be treated by carbolic acid during the three years that his colleagues had used it and achieved no better results that him. He labeled antiseptic treatment as both "fashionable" and "in vogue", based on "unsupported fancies which have little other existence than what is found in the imagination of those who believe in them". However it was his attack on Lister central premise of the germ theory that was so useful to Lister's detractors; that first intention healing occurred in wounds that were exposed to the air. In his conclusion he stated: On 7 August 1869, Lister forwarded a letter to the British Medical Journal where he accused Nunneley of being dogmatic with an incomplete understanding of the antiseptic principle. On 14 August,
The Lancet editor published a letter to encourage Lister's supporters, "Only experience can determine the actual value of carbolic acid; but Mr. Nunneley has fairly thrown down the gauntlet to those who advocated its use, and we trust that his challenge will not remain unanswered." On 24 August, Lister forwarded a letter he had received from Leeds surgeon
Thomas Pridgin Teale, a colleague of Nunneley at Leeds, to correct him of a misassumption, by stating he was using antiseptic treatment. Lister added ""That he should dogmatically oppose a treatment which he so little understands; and which, by his own admission, he has never tried". The BMJ intervened to advocate for an end to the dispute and focus on the scientific case, but blamed Nunnely for what they considered a smear campaign. Nunnely then found support in
James Morton, a Glasgow surgeon and colleague of Lister's and Donald Campbell Black, Professor of Physiology at
Anderson College. Blacks letter to the BMJ on 4 September 1869 poured scorn on Lister's use of carbolic acid, stating it was.. "the latest toy of medical science so-called" and referring to the whole thing as "carbolic acid mania". Both surgeons drew on the results of the work of Edinburgh surgeon
Thomas Keith, an
ovariotomy specialist, long considered a dangerous operation who supposedly never used antiseptics. However Keith replied to the BMJ on 18 September that he had used some antiseptic dressings in his operations. On 9 October, Black repeated his views in
The Lancet by calling the practice of using carbolic acid to sterilise instruments and the surgeons hands as "...frivolous and unscientific". He used statistics to validate his claims, stating there was no change in death rates from compound fracture cases between 1860 and 1868. Between 1867 and 1868, 33% of amputees died, similar to the figures from 1860 to 1862. From then on, Lister was determined to use statistics to reveal the mortality rates associated with his treatment. Both Black and Morton failed to understand the principles underlying the antiseptic system.
Edinburgh appointment Lister left Glasgow University in October 1869 and was succeeded by
George Husband Baird MacLeod. Lister returned to Edinburgh as successor to Syme as professor of surgery at the University of Edinburgh and continued to develop improved methods of antisepsis and asepsis. Amongst those he worked with there, was the senior apothecary and later MD,
Alexander Gunn. ==Edinburgh 1869–1877==