JOSEPH LISTER AND ASEPTIC SURGERY

THE DOCTOR'S BAG

- the blog about 19th century medicine and surgery

Keith Souter  aka Clay More

Post-operative infection was the most formidable obstacle to the advance of surgery right up to the mid-nineteenth century. Almost every wound, whether the result of accident or surgery would suppurate. That means it would become inflamed and produce pus. It was pretty well accepted as being inevitable.

The Romans and medicine
The Romans are renowned for their organisation and their documentation. The great Claudius Galenus of Pergamum ( AD 131 -201), better known as Galen, was a Greek physician whose views and teachings dominated European medicine for over a thousand years.

The Doctrine of Humors
At the very core of his teaching was the Doctrine of Humors, which had first been established by Hippocrates.

Essentially, it was believed that there were four fundamental humors or body fluids which determined the state of health of the individual.

These humors were blood, yellow and black bile and phlegm. Aristotle had taught that the humors were associated with the four elements of air, fire, earth and water, which in turn were associated to paired qualities of hot, cold, dry and moist. Thus, earth would be dry and cold, water would be wet and cold, fire would be hot and dry, and air would be wet and hot. 

The fluids were each seen to have main organs of the body that they governed. Thus, blood flowed through the heart and imbalance could cause heart troubles, water flowed through the brain and imbalance could similarly cause brain conditions. Yellow bile flowed through the gall bladder and black bile was thought to flow through the spleen. 

Galen developed the Doctrine of Humors further and taught that a proper balance of them was necessary for health. An excess of any humor could be treated by reducing a quality, or by reducing a humor, eg bleeding the patient or giving enemas, or treating with various Galenical drugs. An example of a Galenical would contain cucumber, which has cooling properties, because it naturally contains salicylates.

The four temperaments, according to the dominant humour

The individual’s temperament could also be discerned according to their balance of humors. Thus, sanguine individuals were perceived to have excess blood, choleric individuals had excess yellow bile, melancholics had too much black bile and phlegmatics had excess phlegm. As a philosophical system it had much to commend it and seemed perfectly plausible.

People prone to diseases like the plague were thought to be those of hot temperaments, that is, the sanguine and the choleric. They swede believed to have larger pores which allowed whatever caused plague to enter their system. 

The four cardinal signs of inflammation

Aulus Cornelius Celsus (25 BC - AD 50) was a Roman encyclopedist and patrician, but it not thought to have been a doctor. Nonetheless, his only extant work, the De Medicina, is the only surviving section of a much larger encyclopaedia. It is a primary source on diet, pharmacy and surgery and related fields. Like Galen's work it was influential for many centuries. 

His description of the four cardinal signs of inflammation are still taught today.

They are:

calor - warmth

dolor - pain

tumor - swelling

rubor - redness

When any part of the body becomes inflamed it will exhibit these four features. 

Celsus's work was rediscovered by Pope Nicholas V and in 1478 became the first medical author to be printed in movable type after Gutenburg's invention.

The pattern of wound infection

It did not matter how carefully a surgeon performed an operation or how many times a wound was changed, the pattern of infection was almost always the same. It would go through the four cardinal signs as described by Celsus. First to develop would be the redness and swelling. Pain would come as the tissues swelled and the part became warm.

Then the patient's temperature would rise and the pulse rate would increase. Then pus would develop and would often seep between the stitches of the wound. 

About a week later, in a relatively uncomplicated case, the pus would clear up, the redness would subside as the temperature and swelling started to reduce. That is what the doctor would tell the patient was likely to happen. Now this is the interesting thing, a patient treated for such a problem at home was likely to follow this pattern, whereas a patient treated in a hospital was far more likely to develop a complication. 

Those awful complications

There are all sorts of potential complications after any operation, but complications of an infected wound could depend upon what organism was causing it. although people were aware that there were such things as micro-organisms, as I discussed in the chapter on The Fight Against Infection, they did not recognise that micro-organisms actually caused the problem.

The following problems could occur:

dehiscence - effectively, the wound bursts open

haemorrhage - from rupture of blood vessels or from interference with blood clotting

thrombosis - blood clots forming in leg veins, with a risk of spread to the lungs as a pulmonary embolism.

lockjaw - this is the old name for tetanus, which we know to be caused by the bacterium Clostridium tetani. Painful spasms occur. This usually starts in the jaw muscles, but spreads to the whole body. Opisthotonus is the name given to painful spasm of the spinal  muscles, resulting in arching of the body.

Opisthotonus in a patient with tetanus, by Sir Charles Bell, 1809

erysipelas - this used to be called St Anthony's Fire, because of the burning intensity of the skin rash that it produces. it is caused by a Group A Streptococcus. It could occur on the face or anywhere that the infection gets into the body. The rash is large, has a raised edge and spreads rapidly. It made the person feel extremely unwell, with fever, intense pain and drowsiness. Septicaemia could occur resulting in death. Lord Carnarvon, the joint discoverer (with Howard Carter) of the tomb of Tutankhamen died from it after nicking an infected insect bite on his cheek.  The outlaw Doc Middleton also died from this after being arrested in his own saloon after a knife fight. He contracted erysipelas in jail and died.

Erysipelas or St Anthony's Fire

Septicaemia - spread of infection to the blood. In pre-antibiotic days this was a common cause of death.

'Laudable pus - the surgeon's changing attitude to pus
Pus is the name of white or yellow inflammatory fluid. It can be very thick depending upon what is in it. It is found inside abscesses and boils.  It is a Latin word. It is made up of tissue fluid, white blood cells, living and dead bacteria and tissue debris.

Before the Germ Theory surgeons regarded pus as a manifestation of the body's healing process and they thought it was a necessary nuisance. They referred to it as laudable pus.' After the Germ Theory they realised that it was a sign of infection.

One of the oldest surgical maxims is 'Ubi pus , ibi evacua.' It is Latin and it means, 'where there is pus, let it out.' In other words if pus is collecting as an abscess you incise and make an opening for it to lave the body rather than working its way inside to produce sepsis or septicaemia.

Surgery during the Civil War
As indicated earlier, surgery was fraught with danger before aseptic surgery. William Williams Keen (1837-1932), the first neurosurgeon in the USA (he was an innovator and performed the first successful brain tumour removal), served in the Union as a surgeon. He described the standard of surgical hygiene:

'We operated in old blood-stained and often pus-stained coats, the veterans of a hundred fights. WE operated with clean hands in the social sense, but they were undisinfected hands. We used undisinfected instruments from undisinfected plush-lined cases, and still worse used marine sponges which had been used in prior pus cases and had been washed only washed in tap water. If a sponge or an instrument fell on the floor it was washed and squeezed in a basin of tap water and used as if it were clean.'

Keen was, however, quick to adopt the aseptic techniques of Lister and he went on to become one of the foremost surgeons in the USA, with an international reputation.

Dressings were made of gauze or lint during this period.Lint was made by scraping clean cloth. During the war raw cotton was also used.

Disinfectants were also used when they were available. They were not used as a preventive measure though, but applied to clean up afterwards. The American Medical Association had a meeting in 1864 at which they discussed the Ventilation Theory. They proposed the notion that ventilation had been the great lesson of the war. Essentially, if the operation was performed with adequate ventilation, even being conducted in the open air there was less risk of infection because the 'noxious effluvia' that caused disease was dispersed. They advocate using disinfectants.

Among the disinfectants listed by the sanitary Commission were chlorine and charcoal, potassium permanganate and Labbaraque's  solution of sodium hypochlorite. The latter was used on leg ulcers, suppurating sores and gangrenous wounds.

Lord Lister and the development of aseptic surgery
Joseph Lister (1827-1912) was a talented surgeon who was deeply concerned about the infections that seemed so common after surgery and which were merely written off as 'ward fever.'

In 1854 he became a dresser (a junior assistant) to Professor James Syme at Edinburgh University in Scotland. He subsequently became his assistant and his son-in-law.

Joseph Lister, 1855

When he became the professor of surgery at Glasgow University he set his mind to addressing the problem of post-operative infections. He was aware of the work of both Ignaz Semmelweiss and Louis Pasteur and began exploring ways of adapting their findings to surgery.

Carbolic acid had been used to reduce the stench of fields that had been irrigated with sewage. Since livestock that grazed on the fields showed no ill-effects he deduced that it could be used as a disinfectant. He therefore started to experiment by spraying surgical instruments, the incision site and the surgical dressings with carbolic acid. He also insisted that doctors should wash their hands before and after in a 5 per cent solution of carbolic acid. His infection rate dropped dramatically.  Then in 1865 he applied carbolic acid dressings directly to the wound of an 11 year old boy who had been run over by a cart and sustained a compound fracture of his leg. The dressing was changed after two days without signs of suppuration. Six weeks later the leg as completely healed.

British stamp issued in 1965 showing a Lister carbolic spray

Lister wrote  a series of articles which were published in The Lancet and the medical profession took up his lead and the era of aseptic surgery began. He invented a carbolic acid steam spray for the purpose, which emitted a yellow, sweet, tar-like smelling mist into their around the operation. These sprays were fairly cumbersome, weighing around 4.5 kg.

Soon surgeons all over the world were using them.