Victorian Worthies

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As yet, to a superficial observer, there were not many signs of a
brilliant career ahead of him. His private practice was small and did
not grow extensively for many years. The attendance at his earlier
course of lectures was discouragingly meagre. This would have been more
discouraging still, had not his dressers, from personal affection for
him, made a point of attending regularly to swell the number of the
class. Indeed, in view of the exacting demands made on him by the
hospital, Lister might have been content to follow the ordinary routine
of his profession. With his wife at his side and friends close at hand,
he had every chance of living a useful and happy life. But he still
found time to conduct experiments and to think for himself. His
researches were continued along the line which he had opened up in 1855,
and in 1858 he appeared before an Edinburgh Surgical Society to read a
paper on Spontaneous Gangrene.

This gave Mrs. Lister an opportunity to show her value. All his life
Lister was prone to unpunctuality and to being late with preparations
for his addresses, not because he was indifferent to the convenience of
others or careless about the quality of his teaching, but because he
became so engrossed in the work of the moment that he could not tear
himself away from it so long as any improvement seemed possible. This
same quality made him slow over his hospital rounds and often over
operations, with the result that his own meal-times were most irregular
and his assistants often had trouble to stay the pangs of hunger. This
handicapped him in private practice and in some measure as a lecturer.
He gave plenty of thought to his subjects, but rarely began to put
thoughts in writing sufficiently in advance of his engagement. When he
was in time with his written matter the credit was chiefly due to his
wife. On the occasion of this paper she wrote for seven hours one day
and eight hours the next, and her heroic industry saved the situation.

Towards the end of 1859 Lister decided to be a candidate for the
Surgical Professorship at Glasgow, which appointment was in the gift of
the Crown; and in spite of some intrigues to secure the patronage for a
local man, the post was offered by the Home Secretary, Sir George Lewis,
to the young Edinburgh surgeon. Syme's opinion and influence no doubt
counted for much. Lister's appointment dated from January 1860, but it
was not till a year and a half later that his position in Glasgow was
assured by his being elected Surgeon to the Royal Infirmary. Before this
he could preach his principles in the lecture-room, but he had little
influence on the practice of his students and colleagues. Thanks to the
reputation which he brought from Edinburgh, his first lecture drew a
full room, and his class grew year by year till it reached the
unprecedented figure of 182, and each year the enthusiasm seemed to
rise. But in the hospital he had an uphill task, as any one will know
who has studied the history of these institutions in the first half of
the century.

To-day the modern hospital is an object of general admiration, with its
high standard of cleanliness and efficiency; and few of us would have
any hesitation if a doctor advised us to go into hospital for an
operation. Seventy or a hundred years ago the case was very different;
and when we read the statistics of the early nineteenth century,
gathered by the surgeons who had known its horrors, it is hard to
believe that we are not back among the worst abuses of the Middle Ages.
Such terrible scourges as pyaemia and hospital gangrene were rife in all
of them. In the chief hospital of Paris, which for centuries claimed
pre-eminence for its medical faculty, the latter disease raged for 200
years without intermission: 25 per cent. of those entering its doors
were found to have died, and the mortality after certain operations was
more than double this figure. Erichsen, who published in 1874 the
statistics of deaths after operations, quoted 25 per cent. in London as
satisfactory, and referred to the 60 per cent. of Paris as not
surprising. In military practice the number of deaths might reach the
appalling figure of 80 or 90 per cent. What was so tragic about this
situation was that it was precisely hospitals, built to be the safeguard
of the community, which were the most dangerous places in the case of
wounds and amputations. In 1869 Sir James Simpson, the famous discoverer
of chloroform, collected statistics of amputations. He took over 2,000
cases treated in hospitals, and the same number treated outside. In the
former 855 patients (nearly 43 per cent.) died, as it seemed, from the
effects of the operation; in the latter only 266 cases (over 13 per
cent.) ended fatally. He went so far as to condemn altogether the system
of big hospitals; and under his influence a movement began for breaking
them up and substituting a system of small huts, which, whether tending
to security or not, was in other ways inconvenient and very expensive.
About the same time certain other reforms, obvious as they seem to us
since the days of Florence Nightingale, were tried in various places,
tending to more careful organization and to greater cleanliness; but
till the cause of the mischief could be discovered, only varying results
could be obtained, and no real victory could be won. Hence a radical
policy like Simpson's met with considerable support. In days when many
surgeons submitted despairingly to what they regarded as inevitable, it
was an advantage to have any one boldly advocating a big measure; and
Simpson had sufficient prestige in Edinburgh and outside to carry many
along with him. But before 1869 another line of attack had been
initiated from Glasgow, and Lister was already applying principles which
were to win the battle with more certainty of permanent success.

Glasgow was no more free from these troubles than other great towns; in
fact it suffered more than most of them. With its rapid industrial
development it had already in 1860 a population of 390,000. Its streets
were narrow, its houses often insanitary. In the haste to make money its
citizens had little time to think of air and open spaces. The science of
town-planning was unborn. Its hospital, far from having any special
advantage of position, was exposed to peculiar dangers. It lay on the
edge of the old cathedral graveyard, where the victims of cholera had
received promiscuous pit-burial only ten years before. The uppermost
tier of a multitude of coffins reached to within a few inches of the
surface. These horrors have long been swept away; but, when Lister took
charge of his wards in the Infirmary, they were infected by the
poisonous air generated so close at hand, and in consequence they
presented a gruesome appearance. The patients came from streets which
often were foul with dirt, smoke, and disease, and were admitted to
gloomy airless wards, where pyaemia or gangrene were firmly established.
In such an environment certain death seemed to await them.

Though his heart must have sunk within him, Lister set himself bravely
to the task of fighting these grim adversaries. For two years, indeed,
he was chiefly occupied with routine work and practical improvements;
but he continued his speculations, and in 1861 an article on amputations
which he contributed to the _System of Surgery_, a large work in four
volumes published in London, showed that he had not lost his power of
surveying questions broadly and examining them with a fresh and original
insight. He was not in danger of letting his mind be swamped with
details, but could put them in their place and subordinate them to
principles; and his article is chiefly directed to a philosophical
survey which would enable his readers to go through the same process of
education which he had followed out for himself. Sir Hector Cameron, the
most constant of his Glasgow disciples, once illustrated this
philosophic spirit from a passage in Cicero contrasting the many
scientists who 'render themselves familiar with the strange' (not
realizing that it is strange or needs explanation) with the few who
'render themselves strange to the familiar'--who stand away from the
phenomena to which every one has become too accustomed and examine them
afresh for themselves. In Lister he recognized the peculiar gift which
enabled him to rise superior to his subject, and to interpret what was
to his colleagues a sealed book. In these days, among the too familiar
scourges of the hospital, his work was perpetually putting questions to
him; to a man whose mind was open the answer might come at any moment
and from any quarter.

As a fact, already, far from his own circle and for a long while out of
his ken, there was working in France the most remarkable scientist of
the century, Louis Pasteur, who more than once put his scientific
ability at the disposal of a stricken industry, and in his quiet
laboratory revived the industrial life of a teeming population. A
manufacturer who was confronted with difficulties in making
beetroot-alcohol and was threatened with financial ruin, appealed for
his help in 1856; and Pasteur spent years on the study of fermentation,
making countless experiments to test the action of the air in the
processes of putrefaction, and coming to the conclusion that the oxygen
of the air was not responsible for them, as was widely believed. He went
further and reached a positive result. He satisfied himself that
putrefaction was set up by tiny living organisms carried in the dust of
the air, and that the process was due to what we now familiarly term
'germs' or 'microbes'. The existence of these infinitesimal creatures
was known already to scientists, but their importance was not grasped
till Pasteur, in the years 1862 to 1864, expounded the results of his
long course of studies. He himself was no expert in medicine, but his
discovery was to bear wonderful fruit when it was properly applied to
the science of health and disease. Lister's study of open wounds, his
observation of the harm done to the tissues in them when vitality was
impaired, and of the value of protective scabs when they formed, enabled
him to see the way and to point it out to others. When in 1865 he first
read the papers which Pasteur had been publishing, he found the
principle for which he had so long been searching. With what excitement
he read them, with what suddenness of conviction he accepted the
message, we do not know; he has left no record of his feelings at the
time: but it was the most important moment in his career, and the rest
of his life was spent in applying these principles to his professional
work.

With his mind thus fortified by the knowledge of the true source of the
mischief, realizing that he had to assist in a battle between the deadly
germs carried in the air and the living tissues trying to defend
themselves, Lister returned afresh to the study of methods. He knew that
he had to reckon with germs in the wound itself, if the skin was broken,
with germs on the hands and instruments of the operator, and with germs
on the dust in the air. He must find some defensive power which was able
to kill the germs, at least in the first two instances, without
exercising an irritating effect on the tissues and weakening their
vitality. The relative importance of these various factors in the
problem only time and experience could tell him. Carbolic acid had been
discovered in 1834 and had already been tried by surgeons with varying
results. At Carlisle it had been used by the town authorities to cope
with the foul odour of sewage, and Lister visited the town to study its
operation. In its cruder form carbolic proved only too liable to
irritate a wound and was difficult to dissolve in water. Lister tried
solutions of different strengths, and finally arrived at a form of
carbolic acid which proved to be soluble in oil and to have the
'antiseptic' force which he desired--that is, to check the process of
sepsis or putrefaction inside the wound. He also set himself to devise
some 'protective' which would enable Nature to do her healing work
without further interference from without. Animals have the power to
form quickly a natural scab over a wound, which is impermeable and at
the same time elastic. The human skin, after a slight wound, in a pure
atmosphere, may heal quickly; but a serious wound may continue open for
a long time, discharging 'pus' at intervals, while decomposition is
slowly lowering the vitality of the patient. Lister made numerous
experiments with layers of chalk and carbolic oil, with a combination of
shellac and gutta-percha, with everything of which he could think, to
imitate the work of nature. His inexhaustible patience stood him in good
stead in all these practical details. Rivals might speak contemptuously
of the 'carbolic treatment' and the 'putty method' as if he were the
vender of a new quack medicine; but at the back of these details was a
scientific principle, firmly grasped by one man, while all others were
groping in the dark.

[Illustration: LORD LISTER

From a photograph by Messrs. Barraud]

During 1866 and 1867 we see from his letters how he set himself to apply
the new principle first to cases of compound fracture and then to
abscesses, how closely and anxiously he watched the progress of his
patients, and how slow he was to claim a victory before his confidence
was assured. In July 1867, when he was just forty years old, he felt it
to be his duty to communicate what he had learnt and to put his
experience at the disposal of his fellow workers. He wrote then to _The
Lancet_ describing in detail eleven cases of compound fracture under his
care, in which one patient had died, one had lost a limb, and the other
nine had been successfully cured. This ratio of success to failure was
far in advance of the average practice of the time; but, for all that,
it is not surprising that he met with the common fate which rewards
pioneers in new fields of study. It is true that other reforms were
helping to reduce the number of fatal cases. Florence Nightingale had
led the way, and much had been learnt about hospital management. It was
possible to maintain that good results had been achieved by other
methods, and that Lister's proofs were in no way decisive. But there was
no need for critics to misapprehend the nature of his claims or to
introduce the personal element and accuse him of plagiarism. Sir James
Simpson revived the memory of a Frenchman, Lemaire, who had used
carbolic acid and written about it in 1860, and refused to give Lister
any credit for his discoveries. As a fact Lister had never heard of
Lemaire or his work; and, besides, the Frenchman had never known the
principles on which Lister based his work, nor did he succeed in
converting others to his practice. How little the personal question need
be raised between men of the highest character is shown by the relations
of Darwin and Wallace, who arrived independently and almost
simultaneously at their theory of the origin of species, Wallace put his
notes, the fruit of many years of work, at the disposal of Darwin; and
both continued to labour at the establishment of truth, each giving
generous recognition to the other's part in the work.

Unmoved then by this and other attacks, Lister continued his experiments
and spent the greatest pains, for years in succession, in improving the
details of his treatment. It would take too long to narrate his
struggles with carbolized silk and catgut in the search for the perfect
ligature, which should be absorbed by the living tissues without setting
up putrefaction in the wound; or his countless experiments to find a
dressing which should be antiseptic without bringing any irritating
substance near the vital spot. These latter finally resulted in the
choice of the cyanide gauze, which with its delicate shade of heliotrope
is now a familiar object in hospital and surgery. But one story is of
special interest because it shows us clearly how Lister, while clinging
to a principle, was ready to modify the details of treatment by the
lessons which experience taught him. It was on the advice of others that
he first introduced a carbolic spray in order to purify the air in the
neighbourhood of an operation. At first he used a small spray worked by
hand, but this was, for practical reasons, changed into a foot-spray and
afterwards into one worked by steam. One objection to this was that the
steam-engine was a cumbrous bit of apparatus to carry about with him to
operations; and Lister all his life loved simplicity in his methods.
Another was that the carbolic solution, falling on the hands of the
operator, might chill them and impair his skill in handling his
instruments. Lister himself suffered less in this way than most other
surgeons; with some men it was a grave handicap. The spectators at a
demonstration found it inconvenient, and in one instance at least we
know that the patient was upset by the carbolic vapour reaching her
eyes. This was no less a person than Queen Victoria, upon whom Lister
was called to operate at Balmoral in 1870. About the use of this
apparatus, which was an easy mark for ridicule, Lister had doubts for
some time; but it was not the ridicule which killed it, but his growing
conviction that it did not afford the security which was claimed for it.
He was hesitating in 1881; in 1887 he abandoned the use of the spray
entirely; in 1890 he expressed publicly at Berlin his regret for having
advocated what had proved to be a needless complication and even a
source of trouble in conducting operations. In adopting it he had for
once been ready to listen to the advice of others without his usual
precaution of first-hand experiments; in abandoning it he showed his
contempt for merely outward consistency in practice and his willingness
to admit his own mistakes.

It was at Glasgow that Lister made his initial discoveries and conducted
his first operations under the new system. It was in the Glasgow
Infirmary that he worked cures which roused the astonishment of his
students, however incredulous the older generation might be. He had
formed a school and was happy in the loyal service and in the enthusiasm
of those who worked under him, and he had no desire to leave such a
fruitful field of work. But when in 1869 his father-in-law, owing to
ill-health, resigned his professorship, and a number of Edinburgh
students addressed an appeal to Lister to become a candidate for the
post, he was strongly drawn towards the city where he had married and
spent such happy years. No doubt too he and his wife wished to be near
Syme, who lived for fourteen months after his stroke, and to cheer his
declining days. Lister was elected in August 1869 and moved to Edinburgh
two months later. For a while he took a furnished house, but early in
1870 he made his home in Charlotte Square, from which he had easy access
to the gardens between Princes Street and the Castle, 'a grand place'
for his daily meditations, as he had it all to himself before breakfast.
Altogether, Edinburgh was a pleasant change to him, and refreshing; and
the one man who was likely to stir controversy, Sir James Simpson, died
six months after Lister's arrival. Among his fellow professors were men
eminent in many lines, perhaps the most striking figures being old Sir
Robert Christison of the medical faculty, Geikie the geologist, and
Blackie the classical scholar. The hospital was still run on
old-fashioned lines; but the staff were devoted to their work, from the
head nurse, Mrs. Porter, a great 'character' whose portrait has been
sketched in verse by Henley,[47] to the youngest student; and they were
ready to co-operate heartily with the new chief. The hours of work
suited Lister better than those at Glasgow, where he had begun with an
early morning visit to the Infirmary and had to find time for a daily
lecture. Here he limited himself to two lectures a week, visited the
hospital at midday, and was able to devote a large amount of time to
bacteriological study, which was his chief interest at this time.

[Note 47: W. E. Henley, poet and critic, 1849-1903. His poems, 'In
Hospital' include also a very beautiful sonnet on 'The Chief'--Lister
himself, which almost calls up his portrait to one who has once seen it:
'His brow spreads large and placid.... Soft lines of tranquil
thought.... His face at once benign and proud and shy.... His wise rare
smile.']

He stayed in Edinburgh eight years, and it was during his time here that
he saw the interest of all Europe in surgical questions quickened by the
Franco-German war, and had to realize how incomplete as yet was his
victory over the forces of destruction. Some enterprising British and
American doctors, who volunteered for field-service, came to him for
advice, and he wrote a series of short instructions for their guidance;
but he soon learnt how difficult it was to carry out his methods in the
field, where appliances were inadequate and where wounds often got a
long start before treatment could be applied. The French statistics,
compiled after the war, are appalling to read: 90 out of 100 amputations
proved fatal, and the total number of deaths in hospital worked out at
over 10,000. The Germans were in advance of the French in the
cleanliness of their methods, and some of their doctors were already
beginning to accept the antiseptic theory; but it was not till 1872 that
this principle can be said to have won the day. The hospitals on both
sides were left with a ghastly heritage of pyaemia and other diseases,
raging almost unchecked in their wards; but, in the two years after the
war, two of the most famous professors in German Universities[48] had by
antiseptic methods obtained such striking results among their patients
that the superiority of the treatment was evident; and both of them
generously gave full credit to Lister as their teacher. When he made a
long tour on the Continent in 1875, finishing up with visits to the
chief medical schools in Germany, these men were foremost in greeting
him, and he enjoyed a conspicuous triumph also at Leipzig. Sir Rickman
Godlee, commenting on the indifference of his countrymen, says that
Lister's teaching was by them 'accepted as a novelty, when it came back
to England, refurbished from Germany'. But this was not till after he
had left Edinburgh, to carry the torch of learning to the south.

[Note 48: Professor Volkmann of Halle and Professor von Nussbaum of
Munich.]

In Edinburgh his colleagues, with all their opportunities for learning
at first hand, seemed strangely indifferent to Lister's presence in
their midst, even when foreigners began to make pilgrimages to the
central shrine of antiseptics. The real encouragement which he got came,
as before, from his pupils, who thronged his lecture-room to the number
of three or four hundred, with sustained enthusiasm. In some ways it is
difficult to account for the popularity of his lectures. He made no
elaborate preparations, but was content to devote a quiet half-hour to
thinking out the subject in his arm-chair. After this he needed no
notes, having his ideas and the development of his thought so firmly in
his grasp that he could follow it out clearly and could hold the
attention of his audience. His voice, though musical, was not of great
power. He was often impeded by a slight stammer, especially at the end
of a session. He was not naturally an eloquent man, and attempted no
flights of rhetoric. But it seems impossible to deny the possession of
special ability to a man who consistently drew such large audiences
throughout a long career; and if it was the matter rather than the
manner which wove the spell, surely that is just the kind of good
speaking which Scotsmen and Englishmen have always preferred.

And so it needed an even greater effort than at Glasgow for Lister to
strike his tent and adventure himself on new ground. It is true that
London was his early home; London could give him wider fame and enable
him to make a larger income by private practice; yet it is very doubtful
whether these motives combined could have induced him to migrate again,
now that he had reached the age of fifty. But he was a man with a
mission. Some of his few converts in London held that only his presence
there could shake the prevailing apathy, and he himself felt that he
must make the effort in the interests of science.

The professorial chair to which he was invited in 1877 was at King's
College, which was relatively a small institution; its hospital was not
up to the Edinburgh standard; the classes which attended his lectures
were small. Owing to an unfortunate incident he was handicapped at the
start. When receiving a parting address from 700 of his Edinburgh
students he made an informal speech in the course of which he compared
the conditions of surgical teaching then prevailing at Edinburgh and
London, in terms which were not flattering to the southern metropolis.
Some comparison was natural in the circumstances; Lister was not
speaking for publication and had no idea that a reporter was present.
But his remarks appeared in print, with the result that might be
expected. The sting of the criticism lay in its truth, and many London
surgeons were only too ready to resent anything which might be said by
the new professor. When he had been living some time in London, Lister
succeeded in allaying the ill feeling which resulted; but at first, even
in his own hospital, he was met by coldness and opposition in his
attempt to introduce new methods. In fact, had he not laid down definite
conditions in accepting the post, he could never have made his way; but
he had stipulated for bringing with him some of the men whom he had
trained, and he was accompanied by four Edinburgh surgeons, the foremost
of whom were John Stewart, a Canadian, and Watson Cheyne, the famous
operator of the next generation. Even so he found his orders set at
naught and his work hampered by a temper which he had never known
elsewhere. In some cases the sisters entrenched themselves behind the
Secretary's rules and refused to comply, not only with the requests of
the new staff, but even with the dictates of common sense and humanity.
Another trouble arose over the system of London examinations which
tempted the students to reproduce faithfully the views of others and
discouraged men from giving time to independent research. Lister's
method of lecturing was designed to foster the spirit of inquiry, and he
would not deign to fill his lecture-room by any species of 'cramming'.
Never did his patience, his hopefulness, and his interest in the cause
have to submit to greater trials; but the day of victory was at hand.

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