Joseph Lister

• 1. Introduction

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  Joseph Lister was born on the 5th of April 1827, and he would later be called the father of modern surgery. Yet the surgeons of his youth spoke fondly of what they called the good old surgical stink. They wore operating gowns crusted with stains and treated those stains as proof of experience. Hospital wards were aired out at midday as a precaution, but no one provided a way to wash a patient's wounds. A surgeon did not even have to wash his hands before seeing a patient. Lister died on the 10th of February 1912. From a purely technical point of view, he was not an exceptional surgeon. So how did a man with ordinary skill in the operating theatre change surgery across the world? What kind of upbringing produced someone who would look at a festering wound and suspect a living cause? And what did he see in the wards, and under his microscope, that his teachers had missed?

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• 2. A Quaker Household

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  In 1826, a year before Lister was born, his family moved into Upton House, a long low mansion in the Queen Anne style that came with 69 acres of land. The house stood in a village then near London and now part of it. Lister was the fourth child and second son in a family of four sons and three daughters. His mother, Isabella, had been a school assistant. His father, Joseph Jackson Lister, was a wine merchant and a gentleman scientist, and the father shaped almost everything that followed. He spent 30 years perfecting the microscope. In the process he found the Law of Aplanatic Foci, which solved a distortion called coma that had plagued the strongest lenses. The advance helped turn the study of tissues into a science in its own right, and by 1832 it had won him election to the Royal Society. The household was Quaker, a faith that Lister's family had held for generations. As a child Lister had a stammer, and that may be why he was taught at home until he was eleven. Afterwards he attended a Quaker academy in Hitchin, and at thirteen he moved to Grove House School in Tottenham. There he studied mathematics, natural science and languages. His father insisted on a firm grounding in French and German. At home the boy collected small animals and fish, dissected them, and examined them with the family microscope. He drew what he saw using the camera lucida technique that his father had explained to him. None of his relatives worked in medicine, and his nephew Rickman Godlee later described the choice of a medical career as entirely spontaneous. In 1843 his father decided he should go to university, and a religious barrier then stood in the way.

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• 3. Student Years in London

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  Oxford and Cambridge effectively shut out Quakers through their religious tests, so Lister applied to University College London. It was one of only a few institutions in Great Britain that accepted Quakers at that time. He left school in the spring of 1844, just short of his seventeenth birthday, and took rooms at 28 London Road with a fellow Quaker, Edward Palmer. The university had required every medical student to hold a Bachelor of Arts degree since 1837. So Lister matriculated in August 1845 to study classics first. On the 21st of December 1846 he and Palmer watched Robert Liston operate while a classmate, William Squire, administered ether. It was the first time the gas had been used to anaesthetise a patient there. Lister took his arts degree in December 1847, with distinction in classics and botany. Trouble followed quickly. He caught a mild case of smallpox, a year after his elder brother had died of the same disease. Grief and the strain of his classes brought on a nervous breakdown in March 1848. He recovered by travelling, first to the Isle of Man with his school friend John Hodgkin, and then across Ireland from the Dublin home of a Quaker host. His father wrote to him that his last meeting with his son had been like "sunshine after a refreshing shower, following a time of cloud". From the 22nd of July 1848, the record of his life goes blank for more than a year. He registered as a medical student in the winter of 1849 and returned that autumn carrying a microscope from his father. Two teachers marked him most. William Sharpey, professor of physiology, gave him a love of experiment and the microscope that never left him. Wharton Jones, who taught ophthalmic surgery, had studied the circulation of blood and inflammation in the frog's web and the bat's wing. Lister would soon use the same living specimens.

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• 4. The Ward Before Germs

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  In January 1851 Lister became a dresser to the surgeon John Eric Erichsen at University College Hospital. Within days an epidemic of erysipelas broke out in the male ward. A patient from an Islington workhouse had been left in the ward for two hours. The hospital had been free of infection, but soon there were twelve cases and four deaths. Lister noted in his notebook that recent surgical patients suffered worst, while those with older, suppurating wounds mostly escaped. Erichsen believed in miasma. In his view, wounds gave off noxious air that spread disease from bed to bed. Lister watched wounds that were cleaned and debrided sometimes heal, and he concluded that something in the wound itself was at fault. That May he became house surgeon, and for the first time he faced blood poisoning and hospital gangrene face to face. At an autopsy on a little boy who had died of pyaemia, he found thick yellow pus around the upper arm bone. The pus had crept backwards along the veins, and the boy's lungs held multiple abscesses. Lister could not explain it. Decades later, in the Huxley Lecture of the 2nd of October 1900, he traced his interest in germs and surgery to this single case. The treatment for gangrene was harsh. Surgeons chloroformed the patient, scraped away the soft slough and burned the dead flesh with mercury pernitrate. A grey film at the edge of a wound meant death was coming. Under the microscope, Lister saw odd objects he could not name, and he wrote that he imagined they might be the "materies morbi in the form of some kind of fungus". His supervisor Henry Thompson remembered him as "a shy Quaker" with a better microscope than anyone in the college. Lister wrote two papers on these epidemics, and both were lost after being read to the Student Medical Society.

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• 5. The Forgotten First Operation

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  At 1 pm on the 27th of June 1851, Lister performed his first operation in a casualty ward in Gower Street. His patient was Julia Sullivan, a mother of eight grown children, whose drunken husband had stabbed her in the abdomen. About a yard of small intestine hung out through three open wounds, and it was damaged in two places. Lister washed the bowel in blood-warm water but could not push it back inside. So he lengthened the cut, returned the intestine to the abdomen, and stitched the wounds shut. He gave her opium to keep her bowels still while they healed. She recovered. On the 15th of September 1851 he testified at the husband's trial at the Old Bailey. The husband was transported to Australia for 20 years. This operation came a full decade before Lister's first public operation at the Glasgow Infirmary, and for a long time nobody knew about it. Medical historian Ruth Richardson and orthopaedic surgeon Bryan Rhodes published their discovery of it on the 26th of June 2013, after both had been researching his career. A 1968 essay on Lister and abdominal surgery by the Liverpool surgeon John Shepherd never mentioned it. Shepherd began his account in the 1860s.

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• 6. Papers Under the Microscope

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  On the 11th of August 1852, Wharton Jones handed Lister a fresh slice of human iris after an operation at University College Hospital. Lister compared it with iris tissue from a horse, a cat, a rabbit and a guinea pig, and from six surgical specimens. His final examinations forced him to stop early, and his paper apologised for an incomplete investigation. Even so, it showed that the iris holds two separate muscles, the dilator and the sphincter. Earlier researchers had denied that a dilator existed. His next paper, published on the 1st of June 1853, took up goose bumps. It confirmed that in humans, smooth muscle fibres raise the hair, and it introduced a new way to cut sections of scalp tissue. It also corrected the German histologist Friedrich Gustav Henle, who had mistaken tiny blood vessels for muscle. Lister's camera lucida drawings were so exact that they could be used to scale and measure the observations. The naturalist Richard Owen, an old friend of Lister's father, was impressed enough to consider recruiting him. The Swiss physiologist Albert von Kölliker, whose work the papers advanced, became a lifelong friend. In 1897 Kölliker wrote to Lister at the age of 80, and Godlee later chose that letter to show how close the two men were. Lister graduated in medicine with honours in the autumn of 1852. He won the Longridge Prize, which carried a stipend of £40, and he passed the examination for the fellowship of the Royal College of Surgeons. Nine years of education had ended. Sharpey now advised him to spend a month with his lifelong friend, the Edinburgh surgeon James Syme.

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• 7. Edinburgh and Agnes

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  In 1823, at the age of 24, James Syme had performed the first amputation at the hip-joint in Scotland, and he finished it in under a minute. Speed mattered because anaesthesia did not yet exist. By the time Lister arrived in September 1853 with letters of introduction from Sharpey, Syme was widely seen as the boldest and most original surgeon in Britain. Scotland attracted ambitious young surgeons for reasons Lister knew well. Its universities were inexpensive, asked for no religious tests, and had grown from a scholarly tradition. Southern medical schools relied on hospitals and practice, and many looked down on surgery as manual labour. Lister wrote home that Edinburgh's infirmary had 200 surgical beds, against about 60 at University College Hospital. Within a month he was Syme's supernumerary house surgeon, taking notes at every operation. In October 1854 he took over the lectureship of the late Richard James Mackenzie, who had died of cholera after serving as a volunteer field surgeon in the Crimean War. Lister gave his first lecture on the 7th of November 1855 in a theatre known as Old Jerusalem, reading from 21 pages. Twenty-three students had signed up within a week. By the summer of 1858 he was reading his lecture to a single student who arrived ten minutes late. Seven more trickled in afterwards. At Syme's house, Millbank, he had met Syme's daughter Agnes, and he admired her quick mind and warmth. His Quaker parents worried, because marrying outside the Society of Friends meant leaving it. His father still promised financial support and even suggested Lister resign voluntarily. Lister left the Quakers and later joined the congregation of Saint Paul's Episcopal Church in Jeffrey Street. He married Agnes on the 23rd of April 1856 in the drawing room at Millbank, with only the Syme family present. She became his laboratory partner and only secretary. She took his dictation for hours, and left blank spaces in her handwriting for the small drawings he made and she pasted in.

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• 8. Frogs, Bats and Inflammation

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  Once Lister returned from his honeymoon, he gathered frogs from Duddingston Loch. The frogs he had caught earlier at his uncle's house in Kinross had escaped. Between 1853 and 1859 the microscope and the frog were the centre of his research. He also used bats, sheep, cats, rabbits, oxen and horses, working in his laboratory and at the veterinary college abattoir. His assistant Thomas Annandale recalled dinner hours long overdue, but wrote that "no one could work with Mr. Lister without imbibing some of his enthusiasm". In September 1855 Lister dripped water onto a frog's artery at temperatures rising from 80 to 200 degrees Fahrenheit. The artery first contracted and then dilated, and at the highest heat the blood slowed and clotted. He repeated the work on the wing of a chloroformed bat. His conclusion was that contracting vessels shut blood cells out of the capillaries, rather than trapping them. It was his first independent discovery. Later he came to regard this inflammation work as an essential preliminary to his antiseptic idea. In 1905, aged 78, he wrote, "If my works are read when I am gone, these will be the ones most highly thought of." In December 1856 he pricked his own finger to watch blood clot, and that began five papers on coagulation. Experiments on sheep legs showed that blood could stay liquid inside vessels for up to six days. On the 18th of March 1858 he dictated one coagulation paper to Agnes at 7 pm in about 50 minutes, and read it to a Edinburgh medical society at 8 pm. That summer he turned to the gut, using rabbits left un-anaesthetised so their reflexes would not be dulled. He found a plexus of nerves in the bowel wall and argued that the intestines have their own ganglionic apparatus. Another researcher confirmed his view of how outside nerves control the gut only in 1964. His experiments produced eleven papers between 1857 and 1859. They continued for three years, until a post at the University of Glasgow took him away from Edinburgh.

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