[Headband and Initial from Crooke: A Description of the Body of Man. London, 1631.]

ANNALS OF MEDICAL HISTORY Volume IX Fall, 1927 Number 3

THE CENTENARY OF LISTER (1827-1927): A TALE OF SEPSIS AND ANTISEPSIS*

By ASTLEY PASTON COOPER ASHHURST, M.D.

PHILADELPHIA

URGERY holds of surgery, and to observe and note what three fundamen­ were the conditions under which surgeons tal problems: worked and patients suffered before the the control of dawn of antisepsis. It is a long journey, over hemorrhage, the rough roads: over roads obstructed by prevention of quagmires of putrefaction and morasses of pain, and the phlegmon; over roads which lead through care of wounds. the stench of hospital gangrene, the miasms France, by the of septicemia, the fires of erysipelas, and the intrepidity of chills of pyemia; into the by-paths and Pare, has con­ impasses of angioleucitis; and across deserts tributed most to the problem of the control where the shifting sands of empiricism often of hemorrhage; America, by the introduc­ covered the main route, and caused sur­ tion of surgical anesthesia, by Morton and geons to lose their way. It is a sad journey; by Long, has done more for the prevention and if there were no other prospect at its of pain than any nation before or since; end, it were best forgotten. and Britain, in the person of Joseph Lister, There were great surgeons before Lister, has shown the way along which surgeons just as there were brave men before Aga­ must travel to ensure for their wounds an memnon. The best of these surgeons pos­ uninterrupted course of healing. sessed a reasonable understanding of the I ask you to journey with me backwards, normal processes of healing. They recognized into the mists and uncertainties of the past that there was no dressing so suitable to be *Read April 6, 1927, on the occasion of the Lister applied to a fresh wound as the opposite Centenary Celebration of the College of Physicians side of the wound from which it had just of Philadelphia. been severed. They found that in the major- ity of cleanly cut wounds, union “by contused or lacerated; so that all hope of adhesion,” as it came to be known, could securing union in them seems to have been be thus secured if the wound was accurately very quickly abandoned. Thus it was that but not too tightly sutured, after checking many surgeons brought back with them all bleeding from its surfaces, so as to into civil life a doctrine of despair; a doc­ prevent the collection of blood clots between trine to the effect that wounds, especially its lips; for the presence of bloodclots or any gunshot wounds, were poisoned, and on that other foreign substance in the depths of a ' account alone could never be expected to wound not only prevented union by adhe­ heal unless treated by some method to sion, but actually caused suppuration. They overcome the poison. As a consequence, in had learned that in deep wounds involving the words of the eloquent John Bell, writing muscle it was difficult to secure union by one hundred years ago: adhesion, even though the wound had been They never allowed the lips of a wound to fall closed promptly by sutures; because these together: they filled it with dressings and acrid sutures had a tendency to unite the super­ balsams, or distended it with tents and leaden ficial parts of the wound, but to allow its tubes. They were ingenious in every invention to interior to gape, and in this gaping interior prevent its sudden healing. . . . Every wound blood would collect, putrefaction would was forced into a painful suppuration, which occur, suppuration would supervene, and the surgeons of those days were careful to en­ courage in proportion as the wound seemed the wound would break down and leave a more inflamed. The quantity of matter was again stinking and a painful sore. It is true that an argument that the wound needed to be some surgeons, very careful and neat in their thoroughly purged of its foul humours. The dressings, were able to apply compresses pain of a wound and the waste of substance was so skillfully and to use the roller bandage very great, under their management: the cure so intelligently, that they could frequently was proportionably slow, the scar was broad succeed in keeping the deeper parts of these and unsightly; but they comforted themselves large wounds in contact, and that in many by saying, that this method alone was sure, and instances they were able to make such consistent with the rules of art. Those few sur­ wounds unite by adhesion, where their less geons who ventured upon the cure by direct skillful or less painstaking and attentive and immediate adhesion, went fearfully and contemporaries never could get such wounds timidly to work. They were in a continual apprehension of ill accidents; and having failed to heal unless left wide open from the to comply with the canonical or regular method, first. having neglected to purge the wound, the Though this doctrine of adhesion of patient never suffered the slightest alteration wounds appears to have been known in the of his health, even at the distance of years, very earliest days of surgery, the medieval which was not imputed, either from malice or surgeons (if surgeons they could be called) ignorance, to this sudden and improvident cure. seem to have forgotten it, or to have mis­ This was the real origin of the secret dressings; trusted it. In the almost unending wars by and nothing can be more singular than the which Europe was rent for hundreds of various inventions which surgeons, in those years after the introduction of gunpowder, days, fell upon, to persuade their patients to let the great majority of wounds seen by their wounds be easily healed, and, at the same surgeons were frightful in extent, badly time, protect themselves from blame. lacerated and contused; such, in truth, as As Bell points out, the continual protes­ could not be made to heal by adhesion tations by LaMotte (1722) and other good even if promptly reunited by sutures. Even surgeons, of their never having, for the sake sabre wounds, which were frequent in those of gain, used any tents or injections to pro­ days of hand-to-hand fighting, were usually tract a cure, suggest to our minds some very extensive, and always more or less very unpleasant reflections. For while these authors enter their protest wounds, of which, if they had understood the against the general conduct of other surgeons, nature, they could have been under no appre­ and show their anxiety to proclaim their own hension of their healing suddenly, since the innocence, we cannot but see that they point whole course of a gunshot wound is mortified, at some practices and motives of conduct which and the parts through which the ball has passed, we fain would not believe. In those days, every being effectually killed, must be thrown in flap of skin, instead of being reunited, was cut sloughs. away; every open wound was dressed as a sore, They thrust their long tents into the neck, or and every deep one was plugged with a tent, even into wounds of the cheek, till the neck or lest it should heal. Tents, syndons, setons, head swelled monstrously. Even in compound leaden cannulas, and strong injections, were fractures, they thrust them deep betwixt the among the chief violences of ancient surgery. ends of the broken bones, as if they had been And no man . . . who regarded his own char­ afraid lest a callus should form. They introduced acter went without this cruel apparatus of tents their tents even into the cavities of the belly and and syndons when he was to dress even a slight breast. They never trepanned the skull where wound. The old surgeons never put the lips of there was inward suppuration, without thrust­ any wound together: if it was not large arid free, ing a tent into the substance of the brain itself, their rule wTas to dilate it, but never with the though sometimes they were content with lay­ knife; with a sort of forceps they tore it open; ing in a syndon, or slip of linen. “Often, I am they seldom made counter-openings to let out sure,” says LaMotte, “I have seen those who the matter; they never sought to put an end to would have been very willing to have taken the the formation of pus and the waste of the help of a mallet to drive their tents into the fleshy parts, but encouraged the suppurations. thorax. It was from shame only that they They plugged up the orifice, in order to dilate refrained.” it. They made their tents long, that they might convey acrid medicines to the very bottom of There arose, then, as intimated above, a the w7ound. They forced the suppuration, in school of secret healers, who attributed order to prepare it for the second stage of their powers of curing wounds, almost or their process, namely, incarnation. They pre­ entirely without suppuration, to knowledge vented the natural and easy flow of the matter, gained “from some eastern sage, or to have that they might have the satisfaction of seeing found out by deep studies in philosophy it spout out in great profusion when they with­ and alchemy, a sympathetic, or, as they drew their tent. They opposed their own ways to those of nature, and liked nothing which often called it, a philosophical cure of was not done by main force of surgery. . . . wounds.” By dint of leaving the wound No wound escaped this violence; and the prac­ alone, they let it heal naturally, while they tice of an ancient surgeon was exactly the amazed the patient and his friends by same with that by which beggars counterfeit applying their magic powders and sym­ sores, or rather convert accidental wounds into pathetic solutions to the bloody weapon perpetual ulcers. The most simple wounds of which had caused the wound; or, if the the limbs were frequently tortured by the original weapon could not be found, then old surgeons into the form of malignant sores, to a similar weapon, or even to a stick running for many months; wounds of the drawn across the wound, or to a bloody great cavities were always distended with tents towel which had been in contact with it. to the imminent danger of the patient: if he sur­ But it is to be noted well that these quacks vived, there remained fistulas which would refused to use their magical cures in the never heal; the sores ran more or less according to his state of health, or the season of the year; case of any wound where they could foresee and a man wounded in the chest wore his leaden suppuration; and they absolutely refused to cannula for life .... The old surgeons thrust treat gunshot wounds. their tents into all wounds, both those which Because gunshot wounds were poisoned, were in danger of healing and those also which it was necessary to kill the poison by pouring could not heal. They thrust them into gunshot over them “oil of elders, scalding hot”; and the story is well known of Pare, who, in But it was not until the great reforms in 1536, finding after a famous battle that his surgery inaugurated by the teachings of burning oil was used up before he had John Hunter, in the latter part of the poured it into the wounds of all the patients eighteenth century, that surgeons in general under his care, made bold to use instead “a returned to simple dressings, and allowed digestive of yolkes of egges, oyle of roses, nature to bring about healing in her own and turpentine.” way: healing “by the first intention” of In the night I could not sleepe in quiet, fear­ nature being rarely obtained except in ing some default in not cauterizing, that I small wounds, especially of the face, most should find those to whom I had not used the clean wounds united by adhesion; while burning oyle, dead impoysoned; which made those in which adhesion could not be me rise very early to visit them, where beyond expected, and those in which this method my expectation I found those to whom I had failed, united by granulation and suppura­ applyed my digestive medicine, to feele little tion, called “the second intention.” paine, and their wounds without inflammation After this happy and peaceful period of or tumor, having rested reasonable well in the surgery, when Alanson, Hey, the Bells, and night: the other to whom was used the sayd John Hunter, were the main advocates and burning oyle, I found them feverish, with great exponents, in Great Britain, of union of paine and tumour about the edges of their wounds by adhesion, and when their teach­ wounds. And then I resolved with myselfe never ings were being spread in this country by so cruelly to burne poore men wounded with gunshot. our own Physick, the Father of American Surgery; came the period of the Napoleonic This same Pare it was, who about twenty wars, with its disruption of civil surgery, years later had the courage also to abandon and the invasion of metropolitan hospitals the use of the actual cautery in favor of the by soldiers with gunshot wounds—large, ligature for the arrest of hemorrhage in ragged, and suppurating; and again there amputations. But the majority of surgeons came an era of civil surgery when the looked upon him as an obnoxious reformer, experiences and teachings of military life and continued to use their burnings, their prevailed. No surgeon dared to close his scalding oil, and their tents, syndons, setons, wounds or to make any attempt at union by leaden cannulas and strong injections, lest adhesion. The patients’ wounds stank and their patients’ wounds should heal too were corrupt; hospital gangrene, erysipelas, quickly. The names of certain surgeons, pyemia and tetanus again became domi­ however, stand out conspicuous above the nant in every surgeon’s mind, and in many a herd, because of their more intelligent patient’s wounds; scarcely any operation treatment of wounds.1 could be done with safety in these septic 1 Fioravanti, in the early seventeenth century, surroundings; and lying-in hospitals became possessed the knowledge of secret lotions; and veritable pest-holes, to enter which was after the wounds had been washed with these, almost equivalent to certain death. Seven and their edges apposed, he left them to heal in times as many women died after confine­ peace. Caesare Magati, of Ferrara, in 1616, though he followed the popular prejudice in attributing a ment in hospitals as out of them; ovariot­ poisonous influence to the action of the atmosphere omy was from three to four times as fatal in on wound surfaces, yet wrote against tents, and general hospitals (60 to 80 per cent mortal­ opposed dressing wounds with undue frequency. ity) as in small institutions or in the BcIIoste, surgeon-major of the Hospital at Brian^on, patient’s home (18 to 24 per cent mortality). in the Alps, about 1700 published an excellent little Erichsen’s figures (1874) show a fright­ book on wounds and wound treatment; and about this same time Dionis and other Paris surgeons ful mortality from sepsis after ampu­ began to take a more rational view of the care of tation in all the larger British and wounds. continental hospitals: the general mortality after major amputations in civil hospitals to the conclusion in my own mind that pyemia, varied from 26 to 60 per cent, while in if it does not find its birthplace, does find its military surgery it rose to 65 and even to 90 natural home and resting place in hospitals; per cent (in the Crimean War). Of these and although a hospital may not be the mother of pyemia it is its nurse. deaths, to be sure, many were due to the shock of the original injury or to that of the But what was it that made these “hos­ operation which had not taken, but merely pital diseases” develop? All was shrouded in had failed to save the patient’s life. But with mystery, and most surgeons clung to the all due allowance for such cases, pyemia theory that the diseases were borne by the alone was responsible for the death of from atmosphere from one patient to another: 12 to 30 per cent of patients counting only epithelial cells, dried pus, and other matters those who lived long enough after opera­ floated off in the air as a “miasm” from tion to have a chance to develop this dread these infected wounds, and the impurity disease, and without counting those addi­ of the air caused the wounds of other tional deaths due to erysipelas, secondary patients to become similarly diseased hemorrhage, gangrene of the stump, because this impure air, when inhaled by “exhaustion,” or “sudden sinking”—the the neighboring patients, thoroughly under­ latter terms probably indicating sepsis of mined their constitutions. some form as the cause of death. Erichsen, who published in 1874, an inter­ The cause of this prevalence of hospital esting series of lectures on “Hospitalism diseases was thought to be overcrowding, or and the Causes of Death after Opera­ ineradicable infection entrenched in hos­ tions,” founded his argument on the fol­ pital buildings. Erichsen recommended that, lowing premises: in his male accident ward in every hospital, each ward should be in University College Hospital, London, entirely vacated for one month every year, there were 14 beds; sepsis scarcely ever to permit of its cleansing and purification. occurred if no more than 7 patients in Sir James Y. Simpson, of Edinburgh, this ward had large accidental wounds or became so ardently convinced of the nefar­ had had major amputations; but as surely ious atmosphere and hopelessly infected as the number of such patients exceeded buildings of all large and well established 9, so certainly did hospital gangrene and hospitals, that he advocated tearing them pyemia appear, even if one or two beds all down and erecting in their stead cot­ in the ward remained unoccupied. It was tages, widely separated from one another, clear, he concluded, that the atmosphere for use as small hospitals; and he pro­ could normally absorb, and dispose of, posed that these cottage hospitals should only a certain quantity of miasm arising be of cheap construction, so that it would from wounds; and that, when its point of be perfectly feasible to tear them all down saturation was reached, the wounds became or burn them all up every few years. infected. Erichsen wrote: Simpson found that out of 2089 amputa­ About the contagion of erysipelas, there can tions in hospital practice 855 died; out of be no question. . . . On Jan. 17, i85i,acase 2098 amputations in country practice 226 of phlegmonous erysipelas of the leg was acci­ died. dentally brought into No. 1 Ward. As soon as Cadge, a well-known surgeon of Norwich, the nature of the disease was discovered, the wrote as follows, as late as 1874: patient was removed to the erysipelas ward,2 I have unwillingly and almost tremblingly at the top of the building, having only remained proceeded to operate in the hospital, but I have in No. 1 for about two hours. At this time No. 1 had a happy confidence and a perfect assurance Ward was perfectly healthy; but a few days that in all private cases I should avoid any of 2 Every hospital had to maintain a special ward for these disastrous consequences. ... I come erysipelas. afterwards a patient lying in the next bed to radius was turned out at the wound, though that into which the erysipelatous patient had the wound was chiefly on the opposite edge of been taken, and who had been operated upon for the forearm, namely, that next the little finger; necrosis of the ilium, was seized with erysipelas. along with the radius, one of the carpal bones On the 22nd, I performed five operations on projected through the wound, quite separated. patients who were in this ward. Of these cases I cut off the end of the radius with the cutting three were attacked by erysipelas on the 24th, pincers of an amputation case; I dilated the namely, a case of necrosis of the tibia, of partial wound with the knife, and I took up one of amputation of the foot, and of encysted tumour the arteries with the needle; I snipped away the of the scalp. All these patients died. On the 24th carpal bone with scissors, for it hung only by a a patient was operated on for strangulated rag of tendon and skin. I turned the hand right femoral hernia. He was seized with symptoms of upon the remaining part of the fractured radius, low peritonitis, doubtless of erysipelatous char­ laid the palm of the hand and the flat inside acter, on the 31st, and also died. of the forearm upon a firm splint, made a stitch in the lacerated skin of the wrist, to hold it It is a frightful picture; and it seemed a together, and finished by laying a large flat state of affairs from which there was no sponge upon the open part of the wound, just a ready escape except to stop doing any little moistened in spirits, so as to make it operations. In our own city, about this date, spongy, soft, and pliant. This closed the Prof. William Gibson was in the habit of laceration so smoothly, that almost the whole announcing every year to his classes at the of the integument adhered; the part which Philadelphia General Hospital (“Block- failed to adhere was of no great extent. The ley”) : “This is the season of the year when matter from it was in small quantity and good. erysipelas prevails in the wards; we will do In three days it was plain the hand was safe, no more operations until the first of March!”3 and that there would be no gangrene. In about But how was it to be explained that trivial fifteen days the swelling had subsided, the operations might lead to death from ery­ suppuration had become very good, and the parts so close it was likely the callus was begin­ sipelas, while severe compound fractures or ning to form. This man was about three months dislocations might sometimes escape? Con­ under my care . . . and now he finds his sider the two following case histories, one hand perfectly useful and strong for work. from Bell, the other from Abernethy, both dated about one hundred years ago. Compare with this admirable result of a John Bell narrates that a slater, having very severe injury, the following note from fallen from the top of a house, fortunately Abernethy who operated successfully on a lighted upon his right hand, thereby saving gentleman of stout make, removing from his life, but producing a severe compound the surface of the pectoral muscle a tumor dislocation at the wrist: about four inches in length, and three in breadth and depth. The wrist joint was entirely torn; the radius . . . was terribly shattered; the joint [The tumorl was found to be composed of a was burst up with such violence, that the hand steatomatous substance, contained in a thin cap­ hung quite on one side towards the radius, and sule. ... It was firm, and resembled cheese turned as it were upon a point; the small end in its yellow colour and unctuous appearance, of the ulna, with its styloid process, projected but it was not unctuous to the touch. The through the wound, and the hand looked as if wound made in the operation soon healed, and spitted upon this bone . . . and so violently the patient’s health was restored to as good, or was the hand distorted that the head of the seemingly a better state than before the for­ mation of this disease. He also regained his 3 This story I have from Dr. George W. Norris, on the authority of the late Dr. Andrew H. Halber­ usual athletic form. But in less than three stadt, of Pottsville, Pa., a graduate of the Medical months of his recovery, two new tumors formed, Department of the University of Pennsylvania in one above, and the other below the cicatrix 1853. of the wound. The patient did not particularly attend to them till they had attained a size Jackson Lister was in many respects a equal to that of a large walnut. To dissect out remarkable man: though largely self taught, both these tumours, and make so free a removal he found time, while actively engaged in of parts as to render it probable that no new business, to indulge, as an avocation, his growth would ensue, seemed to be a very formid­ love of mathematics, gaining “a’world able operation; and, as the nature of the former wide reputation for his discoveries" in the tumour was known, and it was supposed that field of optics, which led to the production these were of the same kind, it was agreed to of the ‘achromatic lens’ and the perfection puncture the upper one, to express the contents, and await the event. This was done by a punc­ of the modern microscope. . . . This work ture of half an inch in length, made by an gained for him the Fellowship of the Royal abscess lancet. The contents were exactly like Society in 1832.” (Godlee.) those of the original tumor. Vehement erysipe­ Joseph Lister had been carefully edu­ latous or irritative inflammation took place, and cated under his father’s supervision, though sloughing about the diseased part: the inflam­ his early determination to become a surgeon mation rapidly extended to the opposite side was not entirely approved. He secured the of the thorax, and then down the integuments of degree of b.a. from University College, the abdomen to the groin. The derangement of London, before beginning his medical studies, the constitution was as violent as the local which he pursued in the medical school disease, and in about a week the patient died. and hospital of his Alma Mater. In Uni­ This case, concluded Abernethy, showed versity College Hospital he became house the danger of irritating wens. Erysipelas, he surgeon under Erichsen, whose studies of held, was a disease dependent upon con­ hospitalism I have already quoted, and stitutional causes, especially a deranged who was at that time one of the leading condition of the gastrointestinal tract. He surgeons in London. Though the use of never even had an idea that the use of an anesthetics in surgical operations was well “abscess lancet” had anything to do with established at this time, Lister, in December, the development of erysipelas. 1846, had been present at the first operation Whether the wound should become in­ performed in London under ether, by fected or not, seemed all a matter of chance. Robert Liston, at University College Hos­ According to Godlee:4 pital. The older surgeons continued their A surgeon had to recognize that there was no habit of rapid operating, displaying great security against the simplest and most success­ manual dexterity and phenomenal strength, ful operations being followed by dangerous or but without the niceties and neatness which even fatal results. When he had closed the were to characterize the technique of the wounds, “he was,” as Volkmann said, “like rising generation of surgeons, for whom a husbandman, who, having sowed his field, absence of pain on the part of their patients waits with resignation for what the harvest may made hurry unnecessary. The contempo­ bring, and reaps it, fully conscious of his own raries and immediate pupils of John Hunter impotence against the elemental powers, which had passed with the last generation—Home may pour down on him rain, hurricane, and and Cline, Astley Cooper and Abernethy, hailstorm.” . . . Blizard and Wardrop. Charles Bell and Into this welter of wounds and sepsis Robert Liston, two of those Scottish sur­ came Joseph Lister, as a London medical geons, who, as Godice says, had migrated student, in 1848. He was the fourth child, to London as to a happy hunting ground, and second son of Joseph Jackson Lister, had but recently died;- but Sir Benjamin who, like his father before him, was a Brodie, Sir James Paget, and Sir William successful wine merchant, and a member Fergusson (also a recent arrival from Scot­ of the Society of Friends (Quakers). Joseph land) were at the height of their fame; while 4 Godlee, R. J. Lord Lister. Lond., 1917. James Syme (who had once established himself in London but shook its dust from establishing himself in practice in London. off his feet and retired again to Scotland Little did any of them think that his because he found the professional atmos­ month of observation was to be lengthened phere in London distasteful) had already to a residence of seven years in Edinburgh, made Edinburgh famous throughout the followed by a period of nine years in Glas­ world: brilliant as operator, inspiring as gow, and a second residence of eight years teacher, beloved as Chief, he dominated by in Edinburgh, before he returned to settle in his forceful personality the entire field of London in 1877, after an absence of twenty British surgery; while his colleague, Sir five years. James Y. Simpson, the patron saint of When Lister reached Edinburgh, he found chloroform as an anesthetic, was scarcely much to surprise and to captivate him: he less brilliant as a teacher and contro­ found 200 surgical beds in the Infirmary, versialist, invading all fields of medicine, while at University College Hospital there but practising obstetrics and gynecology. had been no more than 60; but more charm­ In Paris, Dupuytren, Larrey and Lisfranc ing, surprising, fascinating, and incom­ had gone, but Civiale, Maisonneuve, Vel­ parable yet, was Syme then in the zenith peau, Malgaigne, and Nelaton, greatest of his career as operator and teacher— of them all, were at the height of their Syme, with a hot head but a warmer heart; reputation; while in Germany, though von who loved controversy but hated a sham; Grafe and Dieffenbach were no more, Bruns, who was persevering and obstinate, but Chelius, and Langenbeck were their worthy tenderhearted and compassionate; who was successors. willing to rouse opposition, for he snuffed Young Lister, trained by his father in the battle from afar, and loved a fight— the use of the microscope, showed special Syme, inspiring enthusiasm, admiration, and interest in physiology, histology, and path­ love! ology. Those of his teachers who impressed Syme learned to love and to trust Lister, him most were Wharton Jones, Professor and soon the latter was appointed house of Ophthalmic Medicine and Surgery, but surgeon to Syme. “It might have been as much interested in physiology as in thought,” says Godlee, “beneath the dig­ ophthalmology; and William Sharpey, the nity of a Fellow of the Royal College of Professor of Physiology, who had been Surgeons of England to take such an trained as a surgeon under Dupuytren, appointment; but Lister was amply Lisfranc, and Syme, and had settled in rewarded.” Indeed Syme left the conduct of Edinburgh where he had taught anatomy the wards pretty much in Lister’s hands, until 1836; truly a splendid training for his acting himself rather in the capacity of subsequent career in physiology. Sharpey consulting surgeon; while Lister had, to kept in close touch with his Edinburgh assist him, twelve dressers, who called friends, spending part of every summer with him “the Chief.” He also busied himself in Syme. When Lister, who from the very first reporting Syme’s lectures for the Lancet. In had determined to be a surgeon, had com­ a year’s time Lister became Assistant Sur­ pleted his studies at University College, geon to the Infirmary; and, after a year and had received in 1852 his degree as longer spent in courtship, he became Syme’s Bachelor of Medicine from the University son-in-law. But his microscopical and phys­ of London, and had been made a Fellow iological investigations were not neglected: of the Royal College of Surgeons; it was he found it would be his duty to lecture on but natural that he should adopt Sharpey’s the pathology of inflammation, and, decid­ suggestion of spending a month in Edin­ ing he did not know enough of the subject burgh to observe Syme’s practice, before himself, he set to work to study it under the making a tour of the continent and finally microscope in the web of a frog’s foot. He was led on from this to a study of the posed to introduce additional beds beyond coagulation of the blood. those contemplated in the original construction. While these peaceful years slipped by in It is, I believe, fairly attributable to the firm­ Edinburgh, all England was sick at heart ness of my resistance in this matter that, though with the news constantly coming from the my patients suffered from the ills alluded to in a way that was sickening and often heart-rending, Crimean War of the dreadful condition of so as to make me sometimes feel it a questionable the wounded soldiers, and the pestilential privilege to be connected with the institution, conditions in the military hospitals, where yet none of my wards ever assumed the fright­ those old, old enemies, whose attenuated ful condition which sometimes showed itself forms, as Beclard expressed it, are known as in other parts of the building, making it neces­ angioleucitis, erysipelas and phlegmon, were sary to shut them up entirely for a time. rampant; and where thousands were dying of hospital diseases—hospital gangrene, Syme’s wards at Edinburgh were com­ secondary hemorrhages, and pyemia—where paratively healthy; and he had the proud only tens and hundreds had been killed in record of twenty amputations of the thigh battle. for disease, without a death; and of only one But at Edinburgh things went peacefully death (and that from pyemia) among forty on, Lister’s time being spent in investiga­ cases of ligation of the femoral artery for tion, teaching, operating, and practice, popliteal aneurysm. But he had once said to until i860, the post of Regius Professor of Lister that he thought perhaps it would be Surgery in the University of Glasgow well if immediate amputation were done in becoming vacant, he received the appoint­ every case of compound fracture, since on ment, at the early age of thirty-three years, the whole the mortality would be less than after endorsements had been given by many if an effort were made to save some of the influential friends. limbs. And in Lister’s own wards at Glas­ Now Glasgow was a city twice the size of gow, compound fractures did so badly, that, Edinburgh, and the classes in the Medical as noted above, he was often sick at heart. School of its University were very much He became convinced that it was not the air larger. He took the medical students by alone that was poisonous to these wounds, or storm; they became enthusiastic; they made rather, as others before him also had sug­ him Honorary President of their Medical gested, that it was not at any rate the oxygen Society. Indeed, as Mumford pointed out, in the air that caused the wounds to become Lister won through life golden opinions from infected. He remembered the teaching of those with whom he came in contact. John Hunter, that if a compound fracture But the Glasgow Infirmary, to which he could be made to heal under a scab it would became surgeon, was notorious for its do as well as a simple fracture: and yet the unhealthiness; it contained about 400 beds only obvious difference between the two was in all, and one operating theatre, in which that a compound fracture was open to the about 300 operations were performed annu­ air, while a simple fracture was not. ally. The wards were overcrowded, and had Semmelweis, the Hungarian obstetrician often to be closed on account of the frightful practising in Vienna before the middle of mortality. Lister after his return to Edin­ the last century, had made an important burgh wrote of his early experiences observation, and had acted upon it with at Glasgow: heaven-inspired empiricism: in one division At this period I was engaged in a perpetual of the lying-in hospital, where he was assist­ contest with the managing body, who, anxious ant, male students attended; in the other to provide hospital accomodation for the division, only midwives. In the division increasing population of Glasgow, for which the visited by the male students the mortality Infirmary was by no means adequate, were dis­ from “puerperal fever” was about three times higher than in the other division. chow sneered at him as “dcr Kerl der Scmmclweis, as ardent in pathology as in speculiert. ” Finally his mind gave way, and practice, observed in the post-mortem exam­ in 1865 he was brought back to Vienna to ination of the body of one of his colleagues, be put in restraint. By the irony of fate he who had died of septicemia following a died a few days later “of blood poisoning wound acquired at autopsy, that the lesions following a wound in his finger inflicted in were precisely those which he had been in the course of his professional work.” the habit of finding in the cases of puerperal (Godlee.) fever. The truth flashed across him that the Lister, who was not a great reader, and medical students, coming from post-mortem who was unfamiliar with the continental examinations, were infecting the patients in literature, had never heard of Scmmclweis

the wards by their examinations. He then at this period when he was worrying about insisted that the students purify their hands his compound fractures in the Glasgow in solutions of chloride of lime. The result Infirmary. Lister’s colleague, however, Dr. was an immediate drop in the mortality, Thomas Anderson, the Professor of Chemis­ much below that of the other division. But try, called his attention in 1865 to the work Semmelweis was as the voice of one crying of Pasteur, who had shown that “the air was in the wilderness: he was ridiculed, perse­ full of living germs, and that these are cuted, even driven out of Vienna. Returning carried on particles of dust floating in the to Buda-Pesth in 1850, with his sensitive atmosphere; that the activity of these nature crushed by this contumely, he could particles of dust can be destroyed by heat, not be induced to publish his views in book that they can be filtered off by cotton wool, form until 1861, after repeated solicitation or intercepted in the finely drawn-out, or by a few firm friends and believers—notably tortuous necks of flasks, through which free Rokitanski, Skoda, and Hcbra. But he was ingress and egress of air take place owing to attacked afresh by his opponents: he was the diurnal variations in temperature.” called “der Pesther Narr,” and even Vir- (Godlee.) Pasteur further had shown that fermentation was caused by certain minute treatment, were not entirely immune to the germs, that putrefaction was a species of development of hospital gangrene, he soon fermentation, and that both might be continued his antiseptic dressings until the prevented from occurring in fermentable or wounds were almost or entirely healed. putrescible substances if the latter were kept Within a year he was using a lotion of car­ free from these impurities of the atmosphere. bolic acid (1 to 40 of water) to wash the At once it occurred to Lister that decompo­ skin preparatory to operations, soaking his sition in wounds could be prevented, with­ instruments in carbolic solution (1 to 20), out excluding the air, “by applying as a and cutting his ligatures short, leaving them dressing some material capable of destroying to be dissolved by the tissues and absorbed the life of the floating particles.” Looking or discharged as the case might be; and he around for such an agent, his attention was drawn to the means of disinfecting by means of carbolic acid (recently introduced into commerce) the sewage of the town of Carlisle, which had proved singularly suc­ cessful. So Lister applied lint soaked in carbolic acid to some cases of compound fracture: in the cases with only a small external wound healing was usually uneventful; but in those with larger wounds, where more carbolic acid was used, though few of the phenomena of inflammation developed, yet a discharge of pus occurred. This pus, he soon realized, was a new kind of pus, being the effect of the tissue dis­ solution caused by the carbolic acid; it was not even the “laudable pus” which surgeons had been so pleased to see as an evidence that the patient’s tissues were reacting well to the injury, knowing as they did that when the stage of suppuration had been reached the patient had passed the dangers of early death from fulminating sepsis. This new kind of pus was an aseptic pus, but it was undesirable, as interfering with healing, could record that during the last nine when collecting beneath the carbolic scab; months not a single case of pyemia, hospital moreover, the carbolic acid burned the gangrene, or erysipelas had occurred in his surrounding skin surfaces. So the first wards. improvement was to reduce the strength by But most of Lister’s contemporaries did diluting the carbolic acid with oil; the next not recognize the fact that he was contend­ step was to use a putty, impregnated with ing for a principle in surgery; they looked carbolic acid, as an external dressing. At upon his innovations as nothing more than first he continued these antiseptic applica­ the introduction of some new form of wound tions only until granulations commenced, dressing—and the number and variety of returning then to the water dressings which wound dressings already in use was legion. were in common use by other surgeons. But The “open treatment,” which consisted in having learned that granulating wounds, applying no dressings at all, leaving the even when secured by the antiseptic early wound wide open so that its discharges might have ready exit, had its partisans in Meanwhile, in 1870, Lister returned to Britain, as well as in America, in Germany Edinburgh, to succeed Syme in the chair of and elsewhere; while a number of French Clinical Surgery. There it was that he surgeons believed in the total exclusion added fuel to the fire of discontent by of the air, Jules Guerin and Maisonneuve introducing the use of the carbolic spray adopting aspiration of the air from beneath both during operations and whenever a the dressings after they had been applied, wound was to be dressed. His theory was and Alphonse Guerin employing a huge that the spray—so fine that it barely thickness of cotton wadding totally imper­ moistened a piece of slate held in its path—■ meable to the air. The “simple dressing” would kill the germs floating on the dust employed by my father, than whom no one in the air before they had a chance to alight secured better wound healing in these on the wound. The facts that the patients, preantiseptic days, consisted in lint satu­ and often the assistants and sometimes rated and kept moist with pure laudanum, the surgeon, developed mild grades of the use of which he had learned from “that carbolic acid poisoning, and passed smoky excellent surgeon Dr. Joseph Pancoast”; urine; that their hands became numb and after forty-eight hours diluted alcohol was chapped from working in the carbolized substituted and continued until the wound atmosphere; and that occasionally the spray was nearly healed. was misdirected by the inadvertence of the Their objections to Lister’s methods were, assistant who manipulated it, and that it above all, that they were always being squirted carbolic acid into the eyes of the changed: first it was carbolic acid; then patient even when she was Queen Victoria; carbolized oil; then the carbolic putty; then —these no doubt were objections, but were watery solutions; then a carbolized cerate entirely out-weighed in Lister’s mind by plaster; then a “lac plaster”; then oil of the supposed advantages. And the strange eucalyptus; was there to be no end of thing is that there were so many surgeons innovations? Moreover, he never published the world over who came to agree with statistics of his cases; it is true he pub­ him, and, blindly adopting the spray as a lished, at rather tedious length, individual necessary part of the “antiseptic system,” case histories with wordy comments; but looked upon their colleagues who would let him come out and report a series of not use it as hopeless old fogies. In after amputations at least as good as Syme’s years Lister himself wrote as follows: “As series of twenty thigh amputations for regards the spray, I feel ashamed that I disease without a death, a series secured should have ever recommended it for the without any antiseptic trouble or carbolic purpose of destroying the microbes of the acid. What is more, they would contend, air. If we watch the formation of the spray this man Lister really does no better than and observe how its narrow initial cone we do ourselves: we have all of us cured expands as it advances, with fresh portions cases of compound fracture; we have all of of air continually drawn into its vortex, us had periods of nine months or more we see that many of the microbes in it, without a death in our wards from pyemia. having only just come under its influence, Why should we change our methods of cannot possibly have been deprived of their dressing wounds merely because he tells vitality.” Yet he continued to use the spray us to? Such, I imagine, were the thoughts in all operations and dressings from its that ran through the minds of many sur­ introduction in 1870 until the year 1887. geons when their attention was called to But some surgeons were curious enough Lister and to his work; and many of them to journey to Scotland in order to see for spoke their thoughts aloud, and published themselves what he was doing. Among them their opposing views in the journals. was Lucas-Championniere, a young Paris surgeon, who came, who saw, and who was surgery had made little impression on conquered, in 1868. He returned to France, American surgeons. Nor can it be sur­ and with clarion voice and trenchant pen prizing that to many it did not appeal: gave to the world the first systematic they were not entirely convinced of the account of antiseptic surgery.5 germ theory of disease, and except in the The German surgeons, especially Thiersch military hospitals during the War of the at Leipzig, Volkmann at Halle, and Nuss­ Rebellion they had not had much experience baum at Munich, eagerly took up the with these dread hospital diseases. There antiseptic system, as did the best of the were theoretical objections of another kind, Scandinavian surgeons; and everywhere it also: even granting that microbes were was the same story of wards reeking with the cause of suppuration, it had been sepsis soon converted into models of health­ proved that microbes could and did exist fulness: where no one had dared touch a in wounds, treated by most rigorous anti­ scalpel to a patient, perhaps for months at septic methods, without producing sup­ a time, almost at once pyemia, erysipelas, puration and without interfering with the and hospital gangrene became things of clean healing of the wound. It must be the past; secondary hemorrhages ceased to remembered that the science of bacteri­ occur, and patients no longer died of ology was at this time not only in its exhaustion or sudden sinkings! Ernst von infancy, it might be considered as being only Bergmann, succeeding Langenbeck at in a fetal or embryonal stage of develop­ Berlin, in 1882, had the acuteness of vision to ment. The existence of non-pathogenic perceive that antiseptic surgery was only a bacteria was scarcely recognized, nor had transition stage; and that what Lister Metchnikoff yet demonstrated (1883, 1893) really had in mind, as an ideal, was aseptic the existence of “phagocytosis.” Moreover, technique. With characteristic German thor­ it was asserted that microbes could be oughness he set himself to develop means carried by the blood; and if this were so, for securing this end; and with palatial what was the use of applying antiseptics operating amphitheatres, limitless supplies externally to protect the wound from of sterile gowns and dressings, and just microbes in the air, while nothing could enough antiseptics to sterilize the skin of be done about those brought to the wound patient and of surgeons, he showed that in by the blood? There were also those who most operations healing of wounds can be based their scepticism on more practical secured without infection, and without the grounds: they pointed to long series of contact of antiseptics with the open wound. major operations which they had done with About the same period Terrier was creat­ their own hands, with a mortality which ing a revolution in hospitalization in France, was lower by far than most of their con­ and was teaching by precept and example temporaries, and which was as low as or even the highest type of aseptic surgery. lower than that secured by the devotees of In 1875-76 Lister made a tour of inspec­ antiseptic surgery in their first essays.6 tion on the continent, to see for himself the 6 Thus my father, who was slower almost than workings of antiseptic surgery in the hands anyone else in adopting antiseptic principles, of others; and in 1876 he came to this pointed in 1881 to the fact that for the past ten country in order to attend the meeting in years he had not had a death from pyemia following Philadelphia of the International Medical a major amputation; and that in his first 100 major Congress of whose Surgical Section he was amputations there had been only 4 deaths from elected President. Up to this time antiseptic pyemia, none from erysipelas and none from hospital gangrene. When he compared his mortality of 4 5 Chirurgie Antiseptique. Principes, modes d’ap­ per cent due to pyemia with Erichsen’s tables, he plication et resultats du pansement de Lister. found in the latter nearly 14 per cent of patients Paris, 1880. dying from pyemia after major amputations, or These objections, both theoretical and to go to London, to succeed Sir William practical, were hard to answer. Lister was Fergusson as Professor of Surgery in King’s like the man who had escaped out of Plato’s College. The temptation was not as great as cave, and had made his way up to the light: it would have been some years earlier. He when he had seen a vision of his ideal, he was now fifty years of age; he was comfor­ came stumbling back again into the cave tably and contentedly established in Edin­ to tell his former fellow prisoners of the burgh, with a large circle of friends and wonderful things to be seen in the land of acquaintances. He was at the top of the promise. Is it any wonder, as he came back world in surgery. Students thronged to his with his eyes half blinded by the light of day, classes; visitors from all parts of the world that he looked to them clumsy, and awk­ came to see his clinic and observe his ward, and ridiculous; and that his first practice. Why should he give all this up? attempts to show others what could be done But, up yonder was London, the world in the land of vision sometimes turned out metropolis, still unbelieving in antiseptic to be failures? Lister could himself operate surgery; surely he must have much to on seven recent cases of fracture of the answer for, to his conscience, if he let slip patella, without a death; he could resect a this opportunity of carrying the war into femur for malunion; such operations no the enemy’s country. For Lister was deeply one could have done successfully without religious, and with a simplicity of character antiseptic surgery. But even while at Edin­ that made him particularly rigorous in burgh, Lister found that such cases proved regard to what he considered his duty: here, successful only when he did all the dressings in Edinburgh, was comfort and content; with his own hands. there, in London, was the unregenerate race There came, finally, in 1877, a call for him of surgeons. Was it not his duty to go? Can nearly 4 deaths from pyemia to every 1 due to the father wrote: “I feel compelled to say that while I shock of the injury or the operation. cannot subscribe to the extravagant laudations He could point also to a series of 46 cases of which this plan receives at the hands of its more excision of the knee, done without antiseptic pre­ enthusiastic advocates, I believe that, when used cautions, with only 4 deaths (2 from pneumonia, with judgment, and, if I may be pardoned the 1 from bed sores, and 1 from secondary hemorrhage); expression, when diluted with common sense, it is a death rate of 8.6 per cent; compared to a death capable of affording very valuable aid to the surgeon. rate of from 24 to 30 per cent from the same opera­ I have not, indeed, found any marked diminution in tion in collective statistics, which always show too the mortality after operations by its employment, favorable results. He noted that Ollier, the great but I find that the average period of con­ bone surgeon of France, having secured only one valescence is shortened; that the violence of the operative recovery among seven cases of excision traumatic fever and the frequency of secondary of the knee (a mortality of 85 per cent), had aban­ fever are both lessened; that upon the whole the doned the operation until the advent of antiseptic comfort of the patient is promoted; and that the surgery encouraged him to adopt it once more: labor and anxiety of the surgeon are very materially even then Ollier found his mortality (up to 1883) diminished. For all of which I am duly thankful.” was 33 per cent; while with continued and prob­ That the antiseptic treatment of wounds was ably more rigorous antisepsis Ollier reported that not always successful in these early days is evi­ among 41 patients whose knees he excised between denced by a story well known in the University 1885 and 1891 his mortality was 7.5 per cent—or Hospital at that time. A colleague asked my father’s only 1 per cent less than my father’s death rate ward surgeon, “How many infected wounds have without antiseptic methods. It is true that my you on your side of the ward this morning?” And father was extremely cleanly and neat in his work, received the unexpected reply, “Just thirteen less and that he used laudanum, alcohol, potassium than there are on your side the ward!” permanganate and other antiseptics long before Halsted, at the Johns Hopkins Hospital, had, finally adopting the “antiseptic system” as it had about this period, suppuration in from 7 to 10 come to be modified by all sensible surgeons (Lister per cent of his hernia operations, in spite of careful included) in the late eighties. Six years later my aseptic precautions. we not hear the still, small voice of con­ tion, with its parade of sterile gowns and science asking him, time and again, linen, its autoclaves, its steam sterilizers, “Watchman, what of the night? Watchman, and its marble operating rooms, yet it has what of the night?” Was it not his duty to proved its right to an honored place in carry antiseptic surgery into that night of modern surgical technique. indifference and too willing ignorance? Must When Lister was about to operate, he not his conscience have asked: first placed the marine sponges and the instruments in carbolic solutions, took off Watchman, shall its beams alone Gild the land that gave it birth? his coat, rolled up his shirt sleeves, pinned an unsterilized towel over his waistcoat, to and can we not hear the answer: keep it clean, and dipped his fingers in carbolic lotion. Then, while the patient was Ah, no! Ages are its own— Lo it bursts o’er all the earth! being put under the influence of chloroform, he swabbed the part to be operated on with And so Lister went up to London, back carbolic lotion, turned on the spray, and was into that welter of wounds and sepsis, ready to begin. After abandoning the spray, determined to show the London surgeons he always surrounded the operative area what a thing this antiseptic surgery was. with towels wrung out of carbolic solution. Whether they should hear, or whether they During the operation, which was seldom should forbear, he was determined. “For,” short, for Lister was a slow operator, the hands he must have said, “Woe unto me, if I of everyone concerned were frequently dipped preach not the Gospel.” in 1 to 40 lotion. The sponges, when soiled, were And yet, his arrival in London created washed in cold and hot water and replaced in the scarcely a ripple in the stagnant pool of 1 to 40 lotion. Thus, although they were forcibly professional self-esteem in which the Lon­ wrung out before being used again, a small don surgeons were steeped. He found King’s amount of carbolic acid was constantly con­ College Hospital small, compared to the veyed to the wound; and, as a safeguard against Royal Infirmary at Edinburgh; the students any gross contamination owing to the careless­ were not the same enthusiastic young men ness of assistants or nurses, he used to wash the wound with 1 to 40 lotion before sewing it up. who had crowded his courses in Scotland; (Godlee.) they rather looked askance at his teaching and practice, which they knew were not in For ligatures he used specially prepared favor at the Royal College of Surgeons. But catgut, brought dry to the operation, and amidst all these discouragements he kept simply soaked for about half an hour in 1 to resolutely at work, and his contemporaries 20 lotion. The sutures (silver wire, silkworm finally grew used to him. With Watson gut, or sometimes fine silk or catgut) were Cheyne as his able lieutenant, he slowly, but prepared only by means of carbolic acid. surely and progressively won over the The dressing in later years was a thick pad rising generation. His own contemporaries of gauze prepared with the double cyanide were courteous and friendly, but their of mercury and zinc: the incision itself was surgical habits were fixed; and it remained protected from this irritating chemical by for the next generation to carry the leaven the “green protective” (oiled silk covered of antisepsis with them into other metro­ with copal varnish) which was dipped in car­ politan hospitals, and down into the bolic lotion just before its application; the provinces. deeper layers of cyanide gauze were freshly From about the year 1890 onward, wrung out of 1 to 40 lotion, “in order to aseptic, as distinguished from antiseptic prevent the discharge from soaking straight surgery came to the fore; and though it is through opposite the wound, and in order to said Lister looked with regret on this innova­ force it to travel to the edge of the dressing before it could be contaminated by germs, a geons seem incapable of practising it thor­ layer of thin mackintosh cloth was placed” oughly. The antiseptic method is applicable between the outer layers of the gauze to all primarily septic conditions (many dressing. All his wounds were drained, as compound fractures, necrosis, abscesses, the use of strong antiseptic solutions pro­ malignant tumors, amputations, etc.); and voked considerable discharge. is valuable in a somewhat modified form in As late as 1905 I saw precisely this method all operations where the tissues are much of operating (with the exception of the bruised or long exposed to the atmosphere spray) still in use by two of Lister’s most during the course of the operation (some earnest admirers: Annandale in Edinburgh, excisions, ununited fractures, tedious dis­ and Lucas-Championniere in Paris. sections, etc.). When, however, the opera­ What a contrast to the modern aseptic tion is of short duration (under half an methods of operating: here the instruments, hour), or when the tissues, even during a dressings, etc., are sterilized,7 the former by longer operation, are not bruised or other­ boiling, the latter by dry heat, and the wise unduly injured, and especially in instruments are laid on a table covered with visceral surgery, the aseptic method is sterile sheets. The surgeon and his assistants, superior. in white operating suits, and with cap and When either method is properly em­ mask, scrub their hands in soap and water ployed, the wound heals without noticeable for ten minutes by the clock; they then inflammatory reaction, no stitch abscesses rinse them well in alcohol, -and don sterile form, no discharging sinuses remain, no gowns and gloves. The patient’s skin, ligatures are slowly eliminated from its similarly prepared twenty-four hours in depths, no granulations persist at one end advance, and kept covered with sterile of the incision, the comfort of the patient dressings, is painted early on the morning is enhanced, and the after-treatment much of operation, and again on the operating simplified. table, with iodine or picric acid in alcohol; Time would fail to tell of the many and the part to be operated on is suitably departments of operative surgery which draped in sterile sheets and towels, only have been developed only because Lister the immediate operative area being left paved the way by his teaching of the exposed. As soon as the skin incision is proper care of wounds. Other surgeons made, the skin edges are clipped to sterile since his time have made perhaps temporary towels, and all skin is thus excluded from name and fame for themselves by introduc­ the wound. With a fresh sterile knife the ing one or other new antiseptic. During surgeon proceeds, using instrumental tech­ the great German War, Menciere of Rheims, nique as much as he can. No antiseptics introduced, much as had Lister, various whatever are used during the course of the lotions, and an antiseptic putty; Rutherford operation: everything coming into contact Morrison originated a whole system of anti­ with the wound is sterile, and it depends on septic treatment with his bismuth, iodoform, the unceasing and seemingly pedantic pre­ paraffine paste (Bipp); Dakin’s solution cautions of the surgeon to keep the wound and Eusol (Edinburgh University Solution) aseptic. If one mis-step is made, the aseptic have each their advocates still. Lemaitre has to be abandoned for the antiseptic showed that early debridement, excision, method; and it cannot be denied that and epluchage, followed by the free appli­ adherence to a strictly aseptic technique is cation of iodine and provision for dependent much more difficult, and that many sur- drainage, permitted most war wounds to 7 Proper bacteriologic examinations are requisite be sutured, and that, if the patients were for control of the sterilization of dressings, linen, not transported, about 85 per cent of these etc. wounds would heal promptly; and it was further found, if wounds so treated were Out of the morass of phlegmon, out of the left unsutured at the front in the case of quagmire of putrefaction, back from the patients who had to be transported, that devious paths of angioleucitis, safely through when all wounds not involving bone were the fires of erysipelas, up from the shifting sutured promptly on arrival at the base sands of therapeutic empiricism, on to the about 85 per cent would heal without broad firm plateau of antiseptic surgery, this further difficulty. But all these methods are great man has led the nations of the world. merely modifications or applications of the Let us honor forever the memory of Joseph Antiseptic Principle in Surgery, which we Lister, who made straight in the desert of owe to Joseph Lister. sepsis a highway for those who come after.

LIST OF EXHIBITS DURING THE CELEBRATION OF THE LISTER CENTENARY BY THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, APRIL 4-10, 1927 Manuscripts 3. Sharpey, William. Wharton Jones, James 1. Letter to W. W. Keen, m.d., on vivisection Syme, and Louis Pasteur, the four men dated, April 4, 1898. (Bound.) Also framed having the greatest influence on Lister’s photostat reproduction. career. 2. Letter of thanks to W. W. Keen, m.d., dated 4. Lister, Joseph. Metal plaque, original in 3 April, 1907. University of Rochester, Medical School. 3. Note to W. W. Keen, m.d. Presented by L. R. Stagg, June, 1926. 4. Letter to Samuel Lewis, m.d., dated 30 Dec., Instruments 1874. 5. Post card to De Forest Willard, m.d. 1. Case of surgical instruments used during his 6. Receipt for “Transactions American Surgical life by Joseph Lister. Presented to the Association” dated, 13 Mar., 1897. College of Physicians by Sir Rickman 7. Receipt for “Transactions American Surgical Godlee. July, 1920. Association” dated, 4 Feb., 1898. 2. Apparatus made by and used by Lord Lister for experiments on the lactic acid and other Portraits fermentations. See Lister’s Collected 1. Photograph by Elliott & Fry, 55, Baker papers. 1907. v. i. p. 362. Street W. 3. Lister type steam vaporizer for producing 2. Cabinet photograph by Barraud. 263 Oxford carbolic spray. Presented by W. W. Keen, Street, London, W. m.d. (Mutter museum 2894.97.)