Try as he might, though, Lister could not push Agnes from his mind. But the hard fact remained: if he was going to marry an Episcopalian, he’d have to relinquish his membership in the Quaker community. For a man who had just seven years earlier seriously contemplated giving up his medical studies to become a minister, it was a vexing decision. There weren’t just religious consequences to consider; there were financial risks as well. Joseph Jackson continued to support Lister for the time being, granting him £300 per year for expenses, plus an additional £150 annual interest from his own property. However, there was no guarantee that his father would continue to pay him an allowance if he decided to stray from the flock.
Eventually, Lister asked his father outright whether he could continue to count on his financial support should he ask Agnes for her hand in marriage. Joseph Jackson put his religious concerns aside and pledged his love to his son: “I would not allow the circumstances of her not being within our society to affect my pecuniary arrangements for thee—or alter the expectations given thee some time ago.” He offered his son money to buy furniture should Lister’s proposal be accepted and told his son that he expected Syme would “make a settlement” on his daughter (in essence, offer a dowry) and that he would negotiate this with Syme directly.
His father assured him that neither he nor his mother wished Lister to “attend the worship of ‘Friends’ for the sake of our feelings.” He suggested that his son voluntarily resign his membership in the Society of Friends, rather than be formally disowned as the Rules of Discipline would demand if he married someone of a different faith. Joseph Jackson felt this was best all around and would leave the door open if Lister ever decided to return to the Quaker community.
With his mind at rest, Lister proposed to Agnes and was accepted. Agnes and her mother set the wedding date for the following spring. Lister, eager to begin his life with his new bride, complained to his father about the delay. If it were up to him, the two would be married at once. Joseph Jackson—no doubt amused by his son’s eagerness to begin enjoying the benefits of domesticity—assured him: “My preference like thine would be for the earlier, but thou wilt see that there are reasons why the fixing it should be left to the ladies [sic] discretion.”
The wedding gifts began rolling in: a black marble clock from the Pims in Ireland; a beautiful dessert service from his brother Arthur. Lister, who had only just moved, now had to find a home that was more suited for married life. With Agnes’s considerable dowry, along with money from Joseph Jackson given to them as a wedding gift, the couple could afford a more stately residence. Lister settled on 11 Rutland Street, just a few doors down from his old lodgings. This granite-faced Georgian house had nine rooms spread out over three floors, including a study just off the entrance hall, which Lister intended to convert into a consulting room for his future patients. In a letter to his mother, he also described a room on the second floor that had once been a nursery as it was “well provided with a sink with taps for hot & cold water.”
On April 23, 1856, the couple were married in Syme’s drawing room at Millbank House. Agnes’s sister Lucy later recalled that this was done “out of consideration for any Quaker relation” who would have been uncomfortable attending a church service. The Scottish physician and essayist John Brown toasted the happy couple after the reception. Their future was bright, not least because Lister’s star was rising within Edinburgh. During his speech, Brown made a prescient assertion: “Lister is one who, I believe, will go to the very top of his profession.”
* * *
When Lister returned to work at the Royal Infirmary, he continued to face the same problems that had presented themselves at University College Hospital in London. Patients were dying from gangrene, erysipelas, septicemia, and pyemia. Frustrated by what most hospital surgeons accepted as an inevitability, Lister began taking samples of tissue from his patients to study under the lens of his microscope so he could better understand what was happening at a cellular level.
Like many of his colleagues, Lister recognized that excessive inflammation often preceded the onset of a septic condition. Once this occurred, a patient would develop a fever. The underlying factor linking the two seemed to be heat. Inflammation was localized heat, whereas the fever was systemic heat. In the 1850s, however, preventing either was difficult because wounds rarely healed cleanly, to the extent that many doctors considered “laudable pus” essential to the healing process. Moreover, there was a debate within the medical community as to whether inflammation was in fact “normal” or a pathogenic process that needed to be countered.
Lister was determined to better understand the mechanisms behind inflammation. What was the connection between inflammation and hospital gangrene? Why did some inflamed wounds become septic while others didn’t? In a letter to his father, he wrote that he “felt that the early stages of [inflammation] had not been traced as they might be, so as to see the transition from the state of healthy increased redness to inflammation.”
Controlling inflammation was a daily struggle for the hospital surgeon. Contemporaries believed that a wound could heal in one of two ways. The ideal situation was if a wound healed by “first intention,” a term used by surgeons to denote the reuniting of the two sides with minimal inflammation and suppuration (formation of pus). Put simply, the wound healed cleanly, or “sweetly,” to use a term of the period. Alternatively, a wound might heal by “second intention” through the development of new granulations or scar tissue—a prolonged process that was frequently accompanied by both inflammation and suppuration. Wounds that healed by second intention were more likely to become infected, or “sour.”
The ways in which surgeons managed wounds were numerous and demonstrate just how much they struggled to understand and control inflammation, suppuration, and fever. Complicating matters was the fact that the development of septic infections seemed arbitrary and unpredictable at times. Some wounds healed beautifully with little medical assistance, while others proved fatal despite being carefully managed through frequent dressing changes and debridement (the removal of dead tissue). One phenomenon many surgeons noticed was that simple fractures resulting in no break of the skin often healed without incident. This reinforced the idea that something had entered the wound from outside, which in turn gave rise to the popular “occlusion method” that sought to exclude air from a wound.
The occlusion method could be achieved in multiple ways according to the preference of the surgeon handling the case. The first was to cover the wound entirely with a dry dressing, such as goldbeater’s skin made from the outer membrane of a calf’s intestine, or an adhesive plaster. If the wound healed by first intention, this method was successful. But if suppuration occurred, the putrefactive poison (or bacteria, as we know it today)—unable to escape from underneath the dressing’s constraints—would be redirected into the patient’s bloodstream, and septicemia would occur. To counter this effect, some surgeons continually reopened the dressing to clean out the discharge in a method called “occlusion with repeated opening.” Robert Liston, in fact, denounced this practice in the 1840s, noting that “the patient is kept in a state of constant excitement, and often, worn out by suffering, discharge, and hectic fever, falls a victim to the practice.”
Many surgeons were against the occlusion method because it trapped heat inside the wound, which was counterintuitive when it came to controlling inflammation. They also believed that the injured site should not be covered up entirely, because the bandages would become “loaded with putrid exhalations, and a profusion of bloody, ill-digested, foetid matter,” and this, in turn, would make the wound go sour. Syme preferred to stitch up the wound, leaving a small opening for drainage. Afterward, he wrapped everything but the portal with a broad piece of dry lint. This was left undisturbed for about four days, at which time the lint was removed and changed every second day until the wound had healed.
Some surgeons preferred “water dressings,” or wet bandages, which they believed c
ounteracted the heat of inflammation by keeping the wound cool. Others tried irrigating the wound directly, and even immersed the whole patient in water that constantly had to be changed. Although this method proved the most successful because it inadvertently removed discharge as soon as it was formed, it was expensive and awkward to enact, and there was much disagreement as to whether the water should be hot, tepid, or cold.
The biggest problem was that while a majority of surgeons tried to prevent wound infections, there was no consensus as to why they happened in the first place. Some believed that the cause was some kind of poison in the air, but it was anybody’s guess what the nature of that poison actually was. Others thought that wound infection could arise de novo through the process of spontaneous generation, especially if a patient was already in a weakened state.
Nearly everyone in the medical community recognized that hospital settings were a contributing factor to the rise of infection rates in recent years. More and different types of patients were admitted to hospitals as they grew in size during the nineteenth century. This was especially true after the advent of anesthesia in 1846, which gave surgeons more confidence to take on operations that they would not necessarily have dared undertake before that innovation. With so many patients on the wards, keeping the hospitals clean became increasingly difficult. The author of an important textbook, Year-Book of Medicine, Surgery, and Their Allied Sciences, felt the need to advise readers, “The bandages and instruments which have been employed for gangrenous wounds ought not, if possible, to be employed a second time; nor should bandages, linen, or clothing, be prepared or kept in rooms where infected patients are lying. Frequent change of the bedding, blankets, and linen, is also of the greatest utility where these diseases have already broken out.”
The level of hygiene that we expect in hospitals today simply did not exist, and certainly was not present at the Royal Infirmary when Lister began his work there. Finding some route to an understanding of the nature of inflammation and infection had become more critical than ever.
* * *
DURING THE FIRST YEAR of their marriage, Agnes grew accustomed to the sight of frogs in the marital home. Her husband’s obsession with the amphibians began on their honeymoon. Before heading off on a four-month tour of Europe, the newlyweds had stopped at an uncle’s house in Kinross, just a day’s travel from Edinburgh by horse and carriage. Lister brought his microscope with him and, having caught some frogs just outside the uncle’s property, rigged up a laboratory in order to begin a series of experiments that he hoped would help him better understand the process of inflammation—a subject that would consume him for the rest of his life. Unfortunately for Lister (though happily for the frogs), they managed to escape on this occasion, causing uproar in the house as the servants scurried around trying to catch them. After the couple returned from their travels, Lister resumed his experiments, this time in his own laboratory on the ground floor of his Rutland Street home. He worked tirelessly with his diligent wife by his side. Agnes often took dictation, recording his notes in meticulous handwriting in his casebooks. Indeed, there seemed to be little time for anything but study.
Until this time, Lister had mostly examined dead tissue under the microscope. These samples were often taken from patients he cared for at the Royal Infirmary or, in some cases, even sourced from his own body. But what he really needed was living tissue in order to understand exactly how blood vessels reacted under different circumstances. This was a crucial step in his understanding of wound care and the causes of postoperative infections. Once more, he turned his attention to live frogs, this time visiting Duddingston Loch to the east of the city center to procure a batch for research into the subject. It was then that he began to unravel the mystery that had troubled his profession for centuries.
Lister’s investigations into inflammation were a continuation of earlier work conducted by his UCL professor Wharton Jones, who made some microscopic observations on peripheral blood vessels by using the translucent tissues of bat wings and webs from the feet of frogs. Like his old professor, Lister recognized that the slowing of blood through the capillaries seemed to precede the onset of infection. What he wanted to understand was how inflammation affected blood vessels and blood flow in healthy limbs. In his home lab, he devised a series of experiments in which he inflicted controlled and graduated injuries on a frog’s webs, measuring the diameter of blood vessels with an ocular micrometer on each occasion. To do this, he placed various irritants on the webs, beginning with warm water made incrementally hotter with each application until it finally reached the boiling point. Next, Lister tested the effects of chloroform, mustard, croton oil, and acetic acid on the webs.
Crucial to his experiments was pinpointing the role that the central nervous system played in inflammation. To understand this better, Lister vivisected a large frog and proceeded to remove its entire brain without injuring the spinal cord. (The act of cutting into live animals for the purposes of scientific investigation had a long history in Britain. In 1664, Robert Hooke—a founding member of the Royal Society and pioneer of the microscope—strapped a stray dog to his laboratory table and proceeded to slice the terrified animal’s chest away so he could peer inside the thoracic cavity and better understand the mechanisms involved in breathing. What Hooke hadn’t realized before he began his experiment was that lungs were not muscles, and that by removing the animal’s chest and disabling the diaphragm, he had destroyed the dog’s ability to breathe on its own. To keep the animal alive, Hooke pushed a hollow cane down the dog’s throat and into its windpipe. He then pumped air into the animal’s lungs with bellows for over an hour, carefully studying the way in which the organs expanded and contracted with each artificial breath. All the while, the dog stared at him in horror, unable to whimper or howl in agony. Like Hooke, Lister saw vivisection as a necessary evil of his profession, one invaluable to his own research and to saving the lives of his patients.)
After he had removed the frog’s brain, he observed that “the arteries, which had previously been pretty full size and transmitting rapid streams of blood, were found completely contracted, so that the webs appeared bloodless except in the veins.” Over the next several hours, Lister continued to manipulate the spinal cord, even at times removing bits of it, until the frog died: “The blood had ceased to move in consequence of the feebleness of the heart.” He deduced that arteries in frogs without brains or spinal cords did not dilate.
Lister decided to present his findings to the Royal College of Surgeons in Edinburgh. When the time came to deliver his speech, however, he still hadn’t concluded his experiments to his own satisfaction. With the clock ticking, his father—who was visiting the young couple in Scotland—noted that his son had only completed half of his speech by the night before and that “one third had to be spoken extempore” on the day of delivery. But for all his unpreparedness, the paper was given without a hitch, and a version of it was published in the Philosophical Transactions of the Royal Society.
In the paper, Lister contended that “a certain amount of inflammation as caused by direct irritation is essential to primary union.” In other words, inflammation resulting from an incision or a fracture was to be expected when a wound was sustained and was indeed very much a part of the body’s natural healing process. Inflammation of a wound did not necessarily presage sepsis. In opposition to Wharton Jones, Lister argued that the vascular tone of a frog’s leg was under the control of the spinal cord and medulla oblongata, and thus inflammation could be directly affected by the central nervous system. Put plainly, Lister believed that there were two kinds of inflammations: local and nervous.
In his concluding remarks, Lister chronicled his experimental observations of the frogs, relating them to clinical situations such as trauma caused to skin by boiling water or surgical incisions. These early studies were crucial to Lister’s future clinical work on the healing of wounds and the effects of infection on tissues. He was ultimately incorrect in believing
that there were two types of inflammations, but through his groundbreaking work he secured a better grasp of the effects that inflammation had on the loss of vitality in tissues. This was of paramount importance in helping him understand why sepsis conditions were likely to develop in damaged tissue.
Even after his lecture at the Royal College of Surgeons, and when he wasn’t lecturing or treating patients at the Royal Infirmary, he continued his intensive experimentation on frogs, with Agnes’s help. This prompted Joseph Jackson to write to him: “I am ready to ask what new points … render requisite still further experiments with the poor frogs.” It would not be the last time Lister’s thoroughness and attention to detail would be a hindrance to the timely publication of important research. Nevertheless, during the first three years of his marriage, he managed to publish fifteen papers, nine of which appeared in 1858 alone. All of them were based on his original findings, and many of them detailed the results of his physiological investigations into the origin and mechanism of inflammation, which gave him a solid foundation on which to build his seminal work.
7.
CLEANLINESS AND COLD WATER
The surgeon is like the husbandman, who having sown his field, waits with resignation for what the harvest may bring, and reaps it, fully conscious of his own impotence against the elemental powers, which may pour down on him rain, hurricane and hail storm.
—RICHARD VON VOLKMANN
IN JULY 1859, JAMES LAWRIE—the fifty-nine-year-old Regius Professor of Clinical Surgery at the University of Glasgow—suffered a paralytic stroke that robbed him of the ability to move or speak. He was well known at the university and had even taught the famous medical missionary and explorer David Livingstone. Lawrie’s position, coveted by many within the surgical community, was suddenly in play.
The Butchering Art Page 12
