Chapter 24

For their honeymoon they took a long journey on the Continent in the summer of 1856; but half, even of this rare holiday, was given to science, and, after some weeks' enjoyment of the beauties of Italy, husband and wife made the tour of German universities, as he was desirous to see something, if possible, of the leading surgeons and the newest methods. Vienna, Dresden, Berlin, Munich, Frankfort, Heidelberg, and Stuttgart were all included in the tour. They were well received, and at Vienna the most eminent professor of Pathology in the University gave more than three hours of his time to showing his museum to Lister, and also invited the young couple to dine at his house. Though he had not yet made a name for himself, Lister's earnestness and intelligence always made a favourable impression; and as he had taken pains with foreign languages in his youth, he was able, now and later in life, to address French and German friends, and even public meetings, in their native tongue. He came back to find work waiting for him which would tax his energies to the full. In October 1856 he was elected Assistant Surgeon to the Infirmary, and now, in addition to lecturing, he had to conduct public operations himself, whereas he had hitherto only acted as Syme's assistant. This was at first a severe trial for his nerves. That it affected him differently from most experienced surgeons is shown by the fact that he used always, all his life, to perspire freely when starting to operate; but he learnt to overcome this nervousness by concentrating his attention on his work. He was not a man who had religious phrases on his lips; but in letters to his family, quoted by Sir Rickman Godlee, he gives us the secret of his confidence and his power. 'Yesterday', he says in a letter written to his father on February 26, 'I made my début at the hospital in operating before the students. I felt very nervous before beginning; but when I had got fairly to work, this feeling went off entirely, and I performed both operations with entire comfort.' A week later, in a letter to his sister, he returns to the subject. 'The theatre was again well filled; and though I again felt a good deal before the operation, yet I lost all consciousness of the presence of the spectators during its performance, and did it exactly as if no one had been looking on. Just before the operation began I recollected that there was only one Spectator whom it was important to consider, one present alike in the operating theatre and in the private room; and this consideration gave me increased firmness.' Interest in the work for its own sake, forgetfulness of himself, these were to be the key-notes of his life-work.

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.

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.']