From Sherwin B. Nuland's Doctors: The Biography of Medicine

 When George IV of England decided in 1821 that an unsightly cyst must be surgically excised from his scalp, he did not stop to consider that he would be risking his life by undergoing the simple operation. In George's time, a procedure of the type he proposed was accompanied by a mortality rate considerably higher than that of modern-day open-heart surgery. The great killer was postoperative infection. Its ever-looming specter haunted the conscience and walked the dreams of every surgeon each time he picked up his scalpel in an attempt to heal. To be a surgeon in those days was to have become inured not only to the shrieking struggles taking place in the operating theater but also to the nauseous stench of putrefying flesh that fouled the air of the postsurgical wards.

The king's chosen surgeon, Astley Cooper, was terrified by the prospect of making an incision on his sovereign's head. Of the various forms of infection he feared, it was the dreaded erysipelas that most worried him. "I was very averse from doing it," he later wrote. "I had always been successful, and I saw that the operation, if it were followed by erysipelas, would destroy all of my happiness, and blast my reputation.... I was thunderstruck, and felt giddy at the idea of my fate hanging upon such an event."

Nowadays it is known that the rapidly infiltrating inflammation of erysipelas is caused by the toxic effects of chains of ball-shaped bacteria we call streptococci. In Cooper's time, only one thing about the disease was certain: it spread a furious redness through its victim's incised tissues with enormous rapidity, killing more often than not. Once the process got under way, nothing except an incomprehensible change of mind by Nature herself could make it cease from expanding. No one knew what initiated erysipelas in surgical wounds, no one knew how to prevent it, and no one knew how to throw up an effective roadblock against its breakneck progression.

Somehow, Cooper collected his courage, removed the cyst, and saw his patient through a providentially uneventful healing process. George expressed his gratitude in the time-honored way of royalty he knighted his deliverer. A monarch's wen had been removed on a monarch's whim, fortune had smiled, and the sun shone on a new British knight.

From the safety of historical distance, it is perhaps too easy to underestimate what was a matter of frightening magnitude until scarcely a hundred years ago. The problem of postsurgical infections became increasingly troublesome with each passing decade of the nineteenth century. As the professional and economic opportunities for surgeons improved, more of them were trained, and more new techniques were developed, so that the numbers of operations began to multiply. The numbers of complications multiplied along with them. Wound infections were so common that patients and their doctors came to expect pus after every operation. An occasional wound would surprise its observers by healing cleanly without a bit of inflammation, but this was unusual and quite unexplainable. If a patient was lucky, his infection would localize itself to the immediate area of the incision. In such cases, a thick cream-colored odorless fluid would appear within five or six days, and then erupt through the incision to flow freely through its gaping edges, which then gradually filled in behind it with healthy young scar tissue. The appearance of this welcome effluvium was hailed as a sure sign that the wound would heal. The much-desired drainage was understandably called "laudable pus."

In later years, it would be discovered that laudable pus was produced by the action of staphylococci, spherical bacteria which group themselves in clumps and tend to go about their purulent business in a relatively localized fashion. When compared to some of the other microbial invaders that frequently lurked in the depths of wounds, the staphylococci were friends of the nineteenth-century surgeon. The streptococcus, on the other hand, was not content to languish in walled-off pools of purulence; there was no way to drain its noxiousness into a bowl. It was a malign microbe that burned its way centrifugally like an uncontrolled brushfire, sending a toxic poison ahead of it into the bloodstream. Like a harbinger of death, the toxin made itself known by high fevers and teeth-rattling chills. Though the syndrome was known as erysipelas by the doctors, its victims had a better name for it-they called it St. Anthony's Fire.

Still, from the mischief of the streptococcus there was at least some hope that a patient might survive. But there was another form of infection that doomed every one of its victims to a horrible death. This was a foul-smelling disgusting mess of putridity that went by the name of hospital gangrene. The infection was the result of a mix of microbes, some of which we now call anaerobes, because they grow best in the absence of oxygen and therefore invade deeply into the tissues of their powerless host. Its loathsome progression took place at a rate far less rapid than did the hot blush of erysipelas, but there was a relentless deliberateness to its plodding drift, enabling it to digest every bit of involved tissue into a gray slough of oozing necrosis. It killed everything in its path, and did so in a ghastly nightmare of wet stench that choked the nostrils and permeated the clothes of European and American surgeons for generations. Every postoperative hospital ward stank with it.

To compound the problems of some patients, a cluster of any of the responsible organisms, or clots containing them, could enter the veins from an infected wound at any time, resulting in the types of blood poisoning called septicemia and pyemia. When either of these dreaded complications occurred, the blood vessels became highways of death, transporting the migrant bacteria to various parts of the body where they might settle, multiply, and destroy organs by creating abscesses within them. Erysipelas, septicemia, and pyemia arising from the infected postpartum uterus are said to have been the pestilences whereby childbed-fever patients fell victim to the ministrations of their unwashed accoucheurs. And as if all of this were not enough, there was also the ever-present danger of tetanus. Although more common in battle injuries and farm accidents, tetanus claimed many a patient whose only wound had been made within the walls of a big-city hospital.

Every form of bacterium could be introduced into lacerated protoplasm by any of several mechanisms, and not a single one of them was so much as guessed at by other than a handful of seers whose preachings went unheeded. Semmelweis, Holmes, and the others used logic to inform their clinical observations, but no one had yet shown that germs cause disease. Their precepts and those of the few other visionaries who wrote in the first half of the nineteenth century had been untimely ripped from the gestating womb of scientific investigation. Their theories came before they were ready to be born. What was required was a normal full-term pregnancy of research in which an idea could develop to a sufficient state of maturity that it was ready to be received by a welcoming world. That this delivery could take place was assured by a pregnancy of quite a different sort, which would begin within a year of King George's operation-on December 27, 1822,in the small eastern French town of Dole, Louis Pasteur was born.

The discoveries of Pasteur were to change medical science in many ways, but it was in the understanding of surgical wound infections that they had their most immediate impact. The first patients to benefit were those undergoing major amputations, the most common operation of the time. In an 1867 article titled Hospitalism, Sir James Simpson of Edinburgh, the inventor of chloroform anesthesia, provided some disheartening statistics for these procedures. He studied the results of more than two thousand in-hospital extremity amputations in Britain, and found that 41 percent of patients died if their operations were done in hospitals with more than three hundred beds; infection was by far the greatest cause of death. In another two hundred patients whose amputations ware done out-of-hospital in country practice, only 11 percent died. Postoperative mortality figures were high in all of the hospitals of Europe, Paris reporting 60 percent, Zurich 46 percent, and Glasgow 34 percent, with equivalent figures coming from Berlin, Munich, Copenhagen, and other continental cities. America was not doing much better. The Massachusetts General Hospital had a mortality rate of 26 percent for amputations, and the Pennsylvania Hospital reported 24 percent. Simpson correctly warned, "The man laid on the operating table in one of our surgical hospitals, is exposed to more chances of death than the English soldier on the field of Waterloo." One result of the septic carnage was a movement in several European cities to raze the most disreputable of the offending institutions, and a few of them were torn down.

Because of the danger of sepsis, the discovery of anesthesia was prevented from having its anticipated effect upon the volume or nature of surgery that could be performed. The threat of infection made it impossible to operate within the body cavities except under the most unusual circumstances. Operations remained of necessity restricted to the amputation of extremities and the removal of tumors of the breast and body wall. Of 1,924 surgical procedures done at the Massachusetts General Hospital between 1847 and 1870, 1, 098 were amputations, 237 were for breast cancer, and almost all the rest involved relatively superficial structures. The infection rate was high in every category, and so was the death rate.

Sir Frederick Treves, who was to become one of England's leading surgeons around the turn of the twentieth century, was training in London in the early 1870s. When he reached his mid-fifties, Treves retired from practice to devote himself to a pursuit in which his skills were as great as they were in the operating theater-he became a writer of books and essays, many of which dealt with his life as a surgeon and a world traveler. "The Elephant Man" is the product of his talented pen. The very next essay in the series of which that classic tale is a part is titled "The Old Receiving Room," in which we may read the words of this gifted writer describing the operating theater of the London Hospital as it was in the period just before Pasteur's teachings were accepted:

Treatment was very rough. The surgeon was rough. He had inherited that attitude from the days when operations were carried through without anaesthetics, and when he had need to be rough, strong and quick, as well as very indifferent to pain. Pain was with him a thing that had to be. It was a regrettable feature of disease. It had to be submitted to....

In the [operating) theatre was a stove which was always kept alight, winter and summer, night and day. The object was to have a fire at all times ready whereat to heat the irons used for the arrest of bleeding as had been the practice since the days of Elizabeth. Antiseptics were not yet in use. Sepsis was the prevailing condition in the wards. Practically all major wounds suppurated. Pus was the most common subject of converse, because it was the most prominent feature in the surgeon's work. It was classified according to degrees of vileness. "Laudable" pus was considered rather a fine thing, something to be proud of. "Sanious" pus was not only nasty in appearance but regrettable, while "ichorous" pus represented the most malignant depths to which matter could attain.

There was no object in being clean. Indeed, cleanliness was out of place. It was considered to be finicking and affected. An executioner might as well manicure his nails before chopping off a head. The surgeon operated in a slaughterhouse-suggesting frock coat of black cloth. It was stiff with the blood and the filth of years. The more sodden it was the more forcibly did it bear evidence to the surgeon's prowess. I, of course, commenced my surgical career in such a coat, of which I was quite proud.

Wounds were dressed with "charpie" soaked in oil. Both oil and dressing were frankly and exultingly septic. Charpie was a species of cotton waste obtained from cast linen. It would probably now be discarded by a motor mechanic as being too dirty for use on a car.

Owing to the suppurating wounds the stench in the wards was of a kind not easily forgotten. I can recall it to this day with unappreciated ease. There was one sponge to a ward. With this putrid article and a basin of once-clear water all the wounds in the ward were washed in turn twice a day. By this ritual any chance that a patient had of recovery was eliminated. I remember a whole ward being decimated by hospital gangrene. The modern student has no knowledge of this disease. He has never seen it and, thank heaven, he never will. People often say how wonderful it was that surgical patients lived in these days. As a matter of fact they did not live, or at least only a few of them did.

The attitude that the public assumed towards hospitals and their works at the time of which I write may be illustrated by the following incident. I was instructed by my surgeon to obtain a woman's permission for an operation on her daughter. The operation was one of no great magnitude. I interviewed the mother in the Receiving Room. I discussed the procedure with her in great detail and, I trust, in a sympathetic and hopeful manner. After I had finished my discourse I asked her if she would consent to the performance of the operation. She replied: "Oh! it is all very well to talk about consenting, but who is to pay for the funeral?"

That the world was delivered from all of this festering horror and its surgeons' machismo insouciance was the work of Joseph Lister who accomplished it by bringing the fruits of Pasteur's pure science to the operating theaters and surgical wards of the hospitals of Europe. Like so many of the medical discoverers whose stories are told in this book, he was at first disbelieved by more than a few of his colleagues, who ridiculed and rejected his precepts. It took decades for his work to be so completely accepted that science, in a final fulfillment of John Hunter's example, could be brought as a full partner into the specialty of surgery. Ironically, the correctness of his views was finally recognized only after his methods were no longer needed to achieve the objective of preventing surgical infection. By then, better techniques had been found, all based on Lister's original insight that Louis Pasteur's discovery of germs in souring alcohol might be applied to identifying the cause of wound infections.

Pasteur found his putrefying bacteria in fermenting beer and wine; Lister found them in septic wounds. Thirty-five years later, America's ambassador to England, whose country had been among the last to embrace Lister's triumphant contribution, paid him a long-overdue honor on behalf of all mankind, when he greeted him with the words: "My lord, it is not a Profession, it is not a Nation, it is Humanity itself which, with uncovered head, salutes you."

The literary gifts of the surgeon who was also a sensitive writer must here again be called upon. Frederick Treves, who lived through the pre- and post-Listerian eras, called by some the B.C. and A.D. of surgery, one day wrote an assessment that epitomizes every critical analysis that has ever been made of Lister's work:

Lister created anew the ancient art of healing; he made a reality of the hope which had for all time sustained the surgeon's endeavors; he removed the impenetrable cloud which had stood for centuries between great principles and successful practice; and he rendered possible a treatment which had hitherto been but the vision of the dreamer. The nature of his discovery - like that of most great movements-was splendid in its simplicity and magnificent in its littleness. To the surgeon's craft it was but the 'one thing needful.' With it came the promise of a wondrous future; without it was the hopelessness of an impotent past.

Giovanni Morgagni had taught physicians to seek out the seats of their patients' symptoms within their organs. Lister, using the science of microscopy, now taught them to seek the primary causes of many of those organ derangements by looking into Pasteur's world of the infinitely small." He was that great scientist's leading apostle in the English-speaking world, indeed in the non-French-speaking world.

A student of the life of Joseph Lister may spend months or years researching all that has been written about him by those with whom he worked, and find not a single word of anything but praise for his character. When so much has been recorded about an individual and every bit of it provides only further evidence of a kind of earthbound saintliness, biographers, especially those of the modern debunking kind, always assume that a great deal has gone unrecorded. They look at the available facts, at decisions made, at the possibility of motivations perhaps impure, and seem always to be able to come up with something that is at least raffish, a few shady involvements or questionable patterns of behavior. If nothing else, there should be a detectable touch of smugness about being so good.

Not so with Lister. There seems to have been a quality about him that was so warmly, serenely, gently strong that words like "dignity," "forbearance ... .. integrity ... .. sweetness," and "honor" only leave his biographers as beggared for description as they did his contemporaries. His opponents admired him, and even his most relentless antagonists, fulminate against his theories though they might, spoke not a harsh word about the man himself There was a flavor of simple goodness in his life, flowing evenly from the philosophical spring of a distinctive faith that has nourished the spirit of more than a few of the moral leaders of the past three hundred years. The source of that spring is to be found in the ethical principles of the Religious Society of Friends.

The early Friends, who first began to organize themselves in Oliver Cromwell's mid-seventeenth-century Puritan England, were so filled with a sense of spiritual power that they were said to fairly quake with the fervor of their belief. Though the word "Quaker" was at first thrown at them in derision, they soon began to use it themselves, as something by which their commitment to a specific mission might be emphasized. The mission of the Quakers was simply stated by their founder, George Fox-it was "to wait upon the Lord," a concept derived from Isaiah 40:31: "But they that wait upon the Lord shall renew their strength; they shall mount up with wings as eagles; they shall run and not be weary; and they shall walk and not faint."

If waiting upon the Lord was their mission, the generative force that enabled Quakers to carry it out was the element they call the Inner Light, "that of God in every one." It is the essence of God within that makes a Friend rise to speak in a meeting for worship, and it is the essence of God within that leads him to do God's work on earth. No man is better than any other and no man is better than any woman. There is no hierarchy, no ritual. For Friends, there is no need for pride or pomp, there is only the need to do the kindnesses of friends. God's work on earth is to be done on earth-the world was not created to be set aside, it was created to be lived in. Worldly goods and worldly power are not to be renounced, for they provide the means to serve. A Friend in Lister's day was recognized by his plain Quaker-gray, almost black, clothes, by his earnest humility, and by a philanthropy whose charity was as quiet when giving money as it was when giving love.

In order to give, one had first to have. Nineteenth-century Quakers were hardworking in business and adept at investing. Consequently, many members of the Society became wealthy, and among them were the forebears of Joseph Lister. His father, Joseph Jackson Lister, was a wine merchant whose business had prospered so well that he was able to buy a beautiful Queen Anne house in Upton, at that time a country village far to the east of central London. Surrounded by its gardens and fields, Upton House was a mansion, no matter the plain way of life of its inhabitants. It was here that Joseph Lister was born on April 5, 1827, the family's fourth child and second son.

In those days, membership in the Society of Friends affected every aspect of life. Since Quakers would neither take an oath nor subscribe to the Thirty-nine Articles of the Episcopal faith, the great universities were closed to them, as were many of the better secondary schools. They did not dance, they did not hunt, and they had no music in their homes. They had no interest in sports or frolicsome diversions. Their worldly concerns were confined to business, education, and the life of the mind. It will not seem surprising, considering the directness and honesty of their world-view, that the Quaker intellect was often attracted to science. Self-taught in hours stolen from business, Quaker scientists in that era of the enlightened amateur made some important practical contributions. In the words of Rickman Godlee, Lister's nephew, "Even amongst those of moderate circumstances, it was common to find an intellectual man of high scientific attainments serving behind his own counter."

Among the most outstanding of the intellectual men of high scientific attainments was Lister pere, Joseph Jackson. In spite of having left school at the age of fourteen to enter his father's wine-importing firm, he taught himself enough mathematics and optics to become a skilled microscopist. One of his closest friends was a shy young Guy's Hospital doctor named Thomas Hodgkin, destined for posthumous renown for having described the disease that is called by his name. The two Friends undertook a study of the microscopic characteristics of the blood, with the result that they published observations demonstrating that red corpuscles are biconcave in shape. They showed also that under certain circumstances these disk-shaped structures tend to line up against each other like stacks of coins, formations called rouleaux.

The discovery of the true shape of red cells and their tendency to rouleaux formation was a significant contribution, but Joseph Jackson Lister later solved another problem, this one in optics, that was of even greater import to science. He discovered what optic physicists call the law of aplanatic foci, enabling him to devise a lens combination that overcame the technical difficulty called chromatic aberration that had plagued microscopists for a hundred and fifty years. For this he was elected a Fellow of the Royal Society.

Up until this time, the microscope had never been as useful to science as might have been hoped. Galileo's earl Y-seventeenth-century account of using his microscope to see "flies which look as big as a lamb, covered all over with hair and very pointed nails" had impressed virtually no one. The great astronomer was himself too occupied with looking up to look down, and seems to have thought of microscopes as a source of amusement. Later in the century, Anton van Leeuwenhoek, using superior lenses of his own design and grinding, was able to see what he called animalcules and we now call bacteria, and a brief flurry of microscopic discovery followed, including Marcello Malpighi's description of the capillaries in x66o. But throughout the eighteenth century, there were investigators, John Hunter among them, who considered the microscope to be a tool of dangerous deception. The reason for this skepticism was the distorted image produced by the relatively primitive magnification systems of the time. Visual aberrations resulted from the spherical shape of the lenses and their tendency to disperse ordinary light into the various colors of its spectrum-aberrations that were greatly increased by increasing the magnifying power of the microscopes. The practice of making observations with such distorting lenses, and using the full glare of the sun as the source of light, resulted in images in which could be seen all sorts of objects that were not really there. Astute observers recognized this, and stayed away from any but simple hand-held glasses.

Once the importance of pathological anatomy was established following the work of Giovanni Battista Morgagni and his successors, however, efforts were undertaken by several investigators to find a method of reducing aberration so that useful methods of high magnification might be made available. The result was that after 150 years of inactivity, the major problems were solved in the short span of four years. The first step was the invention in 1826 by the Italian Giovanni Battista Amici of the water-immersion lens, which made use of the principle that passing light through media of different refracting powers reduces aberration in the same way as does the human eye. The second, building on Amici's contribution, was Joseph Jackson Lister's.

In his 1900 Huxley Lecture, Joseph Lister spoke of "my father, whose labours had raised the compound microscope from little better than a scientific toy to the powerful engine for investigation." A contemporary referred to the elder Lister as "the pillar and source of all the microscopy of the age." In the next generation, the instrument would reach its ultimate usefulness in the hands of Louis Pasteur, whose studies led in turn to those of Joseph Jackson's own son, a young man whose scientific teeth were figuratively cut on the barrels of his father's finest microscopes.

Young Joseph Lister thus grew up in a home devoted to God and to science. His mother, prior to her marriage, was the director of reading and writing for girls at the Ackworth Friends School, and a devoted teacher of her children during their early years. Young Joseph proved from the very beginning of his education to be an excellent scholar. He seems to have become fascinated with nature at an early age, and particularly with medicine. Even before his teens, he announced his intention to become a surgeon, a decision greeted with some surprise by a family none of whose members had ever chosen a Professional career.

Having excelled at the Quaker schools to which he was sent, Joseph enrolled at the age of sixteen at University College in London. Founded eighteen years earlier, "the godless college," as it was called by friends and detractors alike, was intended to be an Oxbridge for everyone, regardless of social rank or religious belief. Joseph Jackson counseled his son about the importance of a general education prior to embarking on a career in medicine, advice even more important today than it was in x844. The boy enrolled in the B.A. program, a course of study requiring three years.

In 1847, young Lister began his matriculation at the medical school of University College. After such long anticipation, his first year was a grave disappointment. He made the mistake of taking lodgings with an elderly Quaker whose rigidly conducted household was far more gloomy than his own home, and he applied himself so diligently to his studies that he took little time to rest, and soon lost his usual air of optimistic cheerfulness. In his first year also he had an attack of a mild form of smallpox and attempted to return to classes before he had fully recovered. The result was an episode that was diagnosed as a nervous breakdown.

After trying to fight off depression and a state of uncontrollable introspection for some months, in early 1848 he was finally prevailed upon to drop out of school and take a long holiday; after some rest, followed by a bit of traveling in Ireland, he was ready to resume his studies. At the time, his father wrote him a letter to which he may have had many an occasion to refer during the difficult later years when he was trying to convince his surgical brethren about the validity of the germ theory of disease:

Believe us, my tenderly beloved son, that thy proper part now is to cherish a Pious cheerful spirit, open to see and to enjoy the bounties and the beauties spread around us:-not to give way to turning thy thoughts upon thyself nor even at present to dwell long on serious things. Thou wilt remember how strongly Dr. Hodgkin cautioned thee on these points, as dangerous to thy mental as well as bodily health.

With purpose renewed, in late 1848 Joseph returned to the University College medical school for the winter session, determined to live by his father's counsel. The fortitude of his Quaker upbringing had returned to him. He knew what had to be done.

Joseph Jackson's counsel and his example were not the only gifts he gave to his son. One of his best microscopes accompanied the boy to the medical school, and it was put to good use. Already an accomplished aficionado of the instrument, Joseph spent a great deal of his free time continuing his observations and sharing his knowledge. He presented two papers on his own work before the Hospital Medical Society, which proved to be strikingly predictable of the course he would take in his professional career. One was titled "Gangrene," and the other was "Use of the Microscope in Medicine," a subject of particular interest to his fellows because the school provided no formal teaching in the subject. He also did some original research on certain microscopic muscles, those of the iris and those that erect the tiny hair shafts in the skin to make goose bumps. Even with all of this extra work, he found time to apply himself so effectively to his studies that he received his degree with Honors in 1852.

Lister served a term as house physician, and then spent nine months as a house surgeon, forms of indenture roughly equivalent to the modern American internship. By the end of this time, he was twenty-seven years old and he had completed his formal training. There was no need, thanks to his family's comfortable circumstances, to rush out into practice. During his school years he had been particularly close to the Professor of Physiology, William Sharpey, who now suggested that he spend some time visiting other clinics, in order to broaden his view of surgery. Sharpey was a friend of James Syme, the Professor of Clinical Surgery at Edinburgh, and it was to that institution that the physiologist recommended his young prot6g6 travel prior to a tour of the European hospitals.

Within days of his arrival in Edinburgh in September 1853, the young surgeon realized that he had found a second father in his new mentor, though their natures, even their appearances, could not have been more at variance. Lister, just under six feet in height, gave the impression, with his powerful chest and handsome head, of being a much larger man than he actually was. He was reserved and modest, with a friendly eye and a quietly twinkling sense of generous humor that seemed to betoken a total lack of competitiveness. In spite of his unostentatious Quaker ways, he possessed a cultured mind and could speak fluent French and German. Altogether, he conveyed an air of urbanity completely lacking in the outspoken, combative little professor with whom he had come to study. Syme's face was plain-some called him homely and even a little sour-looking. Fifty-four years old at the time, he was generally considered to be the best technical surgeon in the British Isles, and his razor-sharp mind and his obstinate self-assurance made him a formidable opponent in medical disputation. It was as though each of the men saw a submerged part of his own personality in the other, and allowed a secret admiration for his unconscious alter ego to forge a deep friendship.

An enthusiast, Syme inspired Lister with an excitement that made him decide to remain in Edinburgh after his month's visit was over. Lawson Tait, the prominent Birmingham surgeon of a generation later, was a student at the time, and has left a graphic description of the type of operating extravaganza that was to be witnessed when the professor took up his scalpel to carry out one of the procedures that even he rarely dared in the I850s. Reading Tait's account of one such display, one does not find it difficult to understand why a young man in training would unhesitatingly give up any other plan in order to throw in his lot with the colorful performer:

The operating theatre of the old infirmary was crowded; every seat, even of the top gallery, was occupied. There were probably seven or eight hundred spectators, for Syme was to operate on a gluteal aneurysm. He was then in the zenith of his fame and in the very best of his powers, his hand as steady and his eye as true as it had ever been-incomparably the greatest surgeon I have ever seen. He entered the theatre with the recognized procession of assistants, house surgeon, and dressers, and was greeted with a subdued murmur of applause. The spectators included men of all ages and ranks in the profession, very many who had come from great distances to see the great feat-like Bickersteth, of Liverpool, who came specially to assist, if I remember rightly, and of course there were many boys like myself from fifteen upward. The patient was put to sleep, Syme buttoned up his dress-coat, turned up his sleeve, I saw a rush of blood, and in a few minutes the placing of the patient in the carrying-basket, and a round of applause, announced the end of the operation.

When the professor offered him an official post as his house surgeon, young Lister fairly leaped at the opportunity. If he had ever had any doubts about his suitability for a surgical career, the period spent with Syme surely dispelled them. Though there were horrible sights to be seen in the operating theater and frightful tragedies unfolded before his eyes each day, Lister had fallen in thrall to that peculiar form of enchantment that comes to embrace every surgeon who is any good at his work. It enveloped me when I was a twenty-two-year old student in New Haven, as it has enveloped other thousands of young men and now young women too, in different times and different places. It is independent of those other forces by which so many doctors are gripped-the sense of mission or obligation, the driving need to be of service to one's fellow creatures. It is even independent of the intense intellectual satisfaction of the specialty. Although each of these factors must coexist with it, what I refer to here is the sheer enjoyment of being a surgeon, an enjoyment made all the more seductive by an awareness that there is a touch of aberrance in it. In a letter to his father, Lister wrote of that feeling of exhilaration:

If the love of surgery is a proof of a person's being adapted for it, then certainly I am fitted to be a surgeon: for thou canst hardly conceive what a high degree of enjoyment I am from day to day experiencing in this bloody and butcherly department of the healing art. I am more and more delighted with my profession, and sometimes almost question whether it is possible such a delightful pursuit can continue. My only wonder is that persons who really love Surgery for its own sake are rare.

Lister planned to return to London when his training appointment ended in February 1855, but a few months before he was due to leave, news came of the death in the Crimean War of one of the Edinburgh staff surgeons. He hastened to apply for the vacant post, and by April of 1855 he was installed as Assistant Surgeon to the Edinburgh Royal Infirmary and Lecture in Surgery to the Royal Colleges of Surgeons of Edinburgh.

Surgery had not been the only object of Lister's fascination during his almost two years in Scotland. A frequent visitor to Syme's hospitable home, he had early begun to spend increasing amounts of time in the company of his chief's eldest daughter, Agnes. Syme, undoubtedly of the opinion that his young assistant was tailor-made for his daughter, approved; Joseph Lister pere, though much impressed with everything he heard about Agnes, was less sanguine, for it was in those days the rule that a Quaker who married out of the faith must either resign from the Society of Friends or be disowned. Eventually, though, he came to terms with his son's inevitable decision. Perhaps he took comfort in an epistle published by the Society of Friends only a year before: "True religion stands neither in forms nor in the formal absence of forms." And although Agnes Syme Lister's new husband now became a member of the Church of England, his outlook remained that of a Friend. Neither better nor worse than his fellows, he chose to be just a little different; neither remoteness nor aloofness set him apart from other men, just the fact of remaining as singular as his now discontinued thee-thou form of address. Though he stopped wearing the somber outward adornments of a Quaker, he never changed the inner adornments of his character.

The young Listers took a working honeymoon. After four weeks in the English Lake Country, they began a three-month tour of the continent. Except in Paris, whose hospitals Joseph had seen the previous year, they visited the clinics of almost all of the cities to which they traveled. They went to Padua and Bologna, and then on to the Allgerneines Krankenhaus in Vienna, considered to be the most important of the hospitals on their itinerary. Karl von Rokitansky had been a dinner guest at Upton House fourteen years earlier, and the renowned pathologist now spent a good deal of time entertaining his former host's son. For obvious reasons, this 1856 visit has been the cause of much speculation among scholars concerning possible conversations that might have taken place on the subject of Semmelweis. There are two reasons to doubt that such communications occurred. First, Lister later wrote that he had never known the work of the tortured Hungarian until long after his own discovery that germs cause infections. Second, even if there were reason to doubt the word of a man whose every other statement has proved to be unimpeachable, there is the well-known fact that the genius of puerperal fever was not often spoken about in Vienna after his flight to Budapest in 185o. There is no evidence of a Semmelweis influence at work in Lister's development of antisepsis.

After stopping at hospitals in Prague, Berlin, Wurzburg, and other German cities, the newlyweds returned home via Paris, moving into a house on Rutland Street only a few doors from Syme's consulting rooms and a fifteen-minute walk from the University and the Edinburgh Royal Infirmary. With home, hospital, and school all within a comfortably small venue, Joseph Lister now set out in earnest on his life's work.

It was a hectic life of clinical surgery and research upon which he was embarking. As a surgical consultant and as Syme's first assistant he was subject to urgent calls at any time of day or night. Though he had only a small private practice of his own, there was a busy schedule of rounds and clinics at the infirmary and the constant attention to his teaching obligations, which included the preparation of lectures. There was no such thing as a biological supply company in those days; he had to gather organs from the slaughterhouse and small animals from the streams and fields. He read constantly in the French and German literature of physiology and surgery.

From the very first, Agnes was Joseph's research assistant, amanuensis, and the most critical reader of his manuscripts. They converted the back kitchen of their new home into a laboratory where Lister, with his wife's help, began a wide-ranging series of investigations. His skill at microscopy soon enabled him to make contributions to the understanding of the structure and functioning of nerve and muscle fibers, blood coagulation, lymph flow, and that most persistently fascinating topic, inflammation. Experiment after experiment was carried out in the kitchen laboratory. Every investigation was recorded, as were his lecture notes and his later manuscripts, in the easily legible script of his associate, Agnes.

A letter Lister wrote to his father sometime before his marriage illustrates the zeal with which he went about his experiments:

I have long wished to see the process of inflammation in the frog's foot, and, as I think I once told thee, felt that the early stages of that process had not been traced as they might be. ... Accordingly ... having gotten a frog from Duddington Loch ... I proceeded last evening to the investigation . . . and a most glorious night I had of it.

Of Lister's early Experiments, those that were to have most influence on his thinking were the studies of blood clotting and inflammation. The final result of researches was to convince him that in order for coagulation to take place, the blood must be put into contact with some type of extraneous foreign material. In other words, something active must be done to it in order to make it clot. Accepted nowadays as axiomatic, Lister's observations solved one of the mysteries of the time - why blood remain in a fluid state in the arteries and veins? As long as flow continues in an intact vessel, coagulation can occur in normal blood. If the lining of the vessel is injured or disrupted, or if the blood comes into contact with something other than the inner coat of its vessels, it promptly clots. This observation put Lister in a frame of mind to consider that other alterations of physiology must also require some foreign intervention. He could easily prove this to be true in the case of inflammation. Studies of the inflammatory process served also to acquaint him with the microscopic changes exhibited by putrefying infected tissues.

Lister's reputation as a researcher and teacher grew rapidly. When the Professor of Surgery at the University of Glasgow announced his retirement in 1859, Syme was contacted to determine whether he would use his influence to convince his son-in-law to accept the chair and to consider an appointment as Surgeon to the Glasgow Infirmary. Not much convincing was needed. By March of 186o, Joseph and Agnes had settled in that city, which, with a population of slightly less than 400,000, was twice the size of Edinburgh.

After a preliminary summer session, the real business of the school year began in the fall. In those days, an Inaugural Lecture was an event of momentous significance; this one in Glasgow was to set the tone not only for Lister's tenure, but for his entire career as well. As he went off to the lecture hall with an entourage of his new colleagues just before noon on the appointed day, his anxious young wife, so much a participant in his career's success, tried to calm her nervousness by writing a letter to her mother-in-law in Upton. She began by describing the appearance of the amphitheater, whose refurbishing she and Joseph had supervised for the new term. She went on to set the scene as she visualized it in her mind's eye, and then heightened the drama even as her own feelings of worried suspense were increasing:

Now it is just about 12. Oh! I trust he may be blessed, and believe he will be. His gown will be going on for the first time except when I saw it tried on here. About 5 minutes past! he will be beginning! and how is he getting on?

She need not have worried. Blessed he had always been, and blessed he would be on this day as well. His warm good nature made itself immediately apparent to the students, who took to his lecturing style as though they had been waiting for it all their lives. He made a few witty quips to lighten their mood, and then said some very serious things which, although meant to be about surgery, declared the ethos of his own professional life. Among them was the aphorism of Ambroise Pare: "I dressed him, God healed him." He told them of his belief that there are two great requisites for a healer: "First, a warm, loving heart; and secondly, truth in an earnest spirit." There is no full record of his remarks that afternoon, but he must have conveyed his view of medicine in similar terms to those he used in a graduation address almost two decades later:

If we had nothing but pecuniary rewards and worldly honors to look to, our profession would not be one to be desired. But in its practice you will find it to be attended with peculiar privileges, second to none in intense interest and pure pleasure. It is our proud office to tend the fleshly tabernacle of the immortal spirit, and our path, if rightly followed, will be guided by unfettered truth and love unfeigned. In pursuit of this noble and holy calling I wish you all God-speed.

To tend the fleshly tabernacle of the immortal spirit was all the work of all the days of Joseph Lister's time on earth. Everything he did became part of that obligation. It was not in a spirit of sacrifice that he and his wife renounced worldly pleasures-it was rather in a spirit of exaltation that they had been given the talents and the opportunity to serve their Lord by serving mankind. It was, of course, not a privilege reserved to Quakers or even to the devout of any stripe. Many an atheist has borne it with nobility.

From the moment of that Inaugural Lecture, Lister became a favorite with the students. They made him Honorary President of their Medical Society, and 161 of them joined together at the end of his first academic year to address a petition to him in which they proclaimed "your eminent ability as a teacher of Surgery."

So new was the academic discipline of surgery that Lister was only the third occupant of the chair at Glasgow since its founding in 1815, and he was the first to devote full time to his specialty rather than to carry out its duties as part of a general practice. His research during the first years was a continuation of the earlier studies on inflammation and clotting. So well did these progress that he was invited to give the 1863 Croonian Lecture of the Royal Society of London. He chose as his topic "The Coagulation of the Blood."

Like all surgeons, Lister was distressed by the fact that virtually every surgical incision became infected. So universal was the presence of purulent drainage from wounds that most surgeons considered it an inevitable, natural course of events, as long as the pus was laudable. Lister refused to accept that point of view. His studies of inflammation had convinced him that normal healing should take place without tissue destruction and without infection, yet the specialty of surgery remained enmired in a sea of pus. It was not as though no one had thought up a theory, or even several, to explain putrefaction. The predominant theory was simple to understand, and

made still simpler by the fact that there was no possibility, given the technology of the time, either to prove it or to disprove it. The cause of putrefaction was said to be the oxygen in the air. On entering the surgical wound, it was thought to oxidize or break down the molecules of unstable organic material, thus destroying the tissues and turning them into pus. There being no way to prevent oxygen from entering a wound, there was no way to prevent infection. It was an explanation as laudable as the pus it was meant to justify, because it got everyone off the hook: if the omnipresent villain was oxygen - no surgeon could blame himself for being the cause of sepsis. That some infectious agent could be introduced into a wound by the operating team seems not to have been considered by anyone, except the scorned and now forgotten Semmelweis and the few others who had written of its role in the etiology of childbed fever.

The concept of oxygen-induced putrefaction made no sense to Lister, however. If it were tenable, healthy flesh should become infected spontaneously, since the normal blood flow carries oxygen to the tissues constantly. Moreover, it was rare in his experience to encounter a chest infection when a fractured rib released air into a bruised wound by puncturing a lung. No -- there had to be some other explanation, and, Lister believed, it had to come from some foreign substance entering the incision.

His supposition that the cause of putrefaction was an as yet undiscovered foreign substance was based on his studies of coagulation and inflammation. In each case, the presence of some irritative or injuring agent was required to set the process going. Arguing by analogy, he found himself, although he would not know it until many years later, thinking along the same lines as had Semmelweis: there must be some thing that enters a wound to cause infection. Semmelweis imagined it to be carried in on the hands of the doctors. Lister imagined it to fall in from that air in which it lived. All that remained was to identify that invisible thing, and then to figure out a way to destroy it.

With this point, the scene must shift southward to the French city of Lille, and the laboratory of the thirty-four-year-old Professor of Chemistry who was also the Dean of the Faculty of Sciences, Louis Pasteur. We will have to go just a bit backward in time as well, to 1856, when a local manufacturer of beet-root alcohol had come to the professor to tell him of a mysterious catastrophe that was destroying his business and that of his colleagues in the local beer and wine industries: without any visible cause, a great deal of each batch of fermenting alcohol was spontaneously spoiling into a slimy juice of useless sour ooze. At that time, fermentation was thought by everyone to be a chemical process (this was why the distraught manufacturer had brought his problem to a chemist), but a few experiments with his microscope convinced Pasteur that sugar is fermented into alcohol not by some lifeless compound but by the yeasts which he found to be growing in it. In that portion of the manufacturer's batch which was spoiled, he identified not only the yeasts, but also great numbers of rod-shaped microbes. With this one series of observations he had discovered that the cause of normal fermentation is the action of yeasts, and that the cause of souring is the action of bacteria. He had entered what he later came to call "the world of the infinitely small."

Of course, Pasteur was not the first explorer of that world. Since ancient times, there had been occasional writers who theorized that some day a contagium animatum would be found, which would explain disease. One Girolamo Fracastoro had gone so far as to write about it in 1546, predicting the discovery of what he called seminaria, the still-unseen germs by which he thought some diseases were spread. Then, over one hundred years later, in a series of letters written to the Royal Society of London beginning in 1676, Anton van Leeuwenhoek described the microscopic "animalcules" which he found in water, water-soaked organic materials, and finally in scrapings from his own back teeth, and identified the bacteria we know today as streptococci, bacilli, and spirilla. However, somehow in all the years that came after that no one took the trouble to seek such bacteria in the effluvia of disease; no one related Leeuwenhoek's animalcules to Fracastoro's seminaria.

Then, in the span of a few years, Louis Pasteur not only made the correlation but proved by experiment that these germs do not arise de novo by a process of spontaneous generation as so many had believed; instead they are present because they have reproduced themselves from the original organisms that intruded into the material being studied. And he demonstrated that a liquid rendered germfree by boiling would stay unputrefied so long as no new germs were allowed to enter the flask in which it was kept.

At its inaugural assembly on December 7, 1854, Pasteur had addressed the Lille Faculty of Science. One of the sentences he uttered on that day has since become a maxim well known to all researchers: Dans les champs de l'observation, le hasard ne favorise que les esprits prepares, "Where observation is concerned, chance favors only the prepared mind." Certainly true of the career of its originator, that statement has no better example than the way in which Joseph Lister would use Pasteur's discovery of bacterial putrefaction to explain wound infection.

Pasteur published the results of his fermentation experiments in 1857 and 1859, with follow-up studies later, in the French scientific journal Compte Rendu de l'Academie des Sciences. They were read in 1865 by Glasgow's Professor of Chemistry, Thomas Anderson, who, knowing of Lister's determination to solve the problem of surgical sepsis, called them to his colleague's attention. Lister's "prepared mind" recognized immediately that the French chemist had demonstrated the thing he was seeking, the cause of decomposition of organic matter, the perfect explanation for the occurrence of wound infections.

Lister read Pasteur's articles over and over, and he and Agnes repeated every one of the experiments in their home laboratory. He came to the same conclusions as had the Frenchman: fermentation and putrefaction in previously sterilized solutions of sugar or protein are always caused by the introduction of microscopic organisms from outside. Like Pasteur, he considered the primary source of contamination to be invisible germ-laden dust particles falling from the air. Since air could not be kept from a wound, to prevent infection, a way must be found to destroy the bacteria that were constantly dropping onto the open cut surface of an operative incision. In his words, "If the wound could be treated with some substance which without doing serious mischief to the human tissues, would kill the microbes already contained in it, and prevent the further access of others in the living state, putrefaction might be prevented however freely the air with its oxygen should enter." He later put the problem in even simpler terms: "When I read Pasteur's original paper I said to myself, 'just as we may destroy lice on the head of a child who has pediculi, by poisonous applications which will not injure the scalp, so, I believe, we can use poisons on wounds to destroy bacteria without injuring the soft tissues of the patient.'"

The next step would obviously be to find the proper poison to disinfect wounds without causing irreversible damage. Lister decided upon carbolic acid, again because of his prepared mind. The elders of the nearby community of Carlisle had successfully used small quantities of that chemical to destroy the foul odors of their urban refuse; in the process, they had also rendered odorless the nearby pastures that were irrigated with the waste's liquid content. A secondary unanticipated gain had been the destruction of the protozoan parasites with which the local cattle had been becoming infected when they grazed on these lands. It seemed obvious to Lister that the carbolic acid was killing the organisms that decomposed the refuse and gave it its characteristic odor of putrefaction. The proper disinfectant poison was thus at hand.

Lister decided to try the carbolic-acid method first in the treatment of compound fractures, injuries in which the sharp edge of the splintered bone could be seen through the crushed skin laceration. Such wounds had a high rate of infection, often requiring amputations, which in turn became filled with pus within days. On August 12, 1865, ironically one day following the obscure death of Ignac Semmelweis in a Vienna madhouse, an eleven-year-old boy named James Greenlees was run over by the wheel of a horse-drawn cart. On being brought to the Glasgow Royal Infirmary he was found to have a fractured tibia exposed through a wound an inch and a half long and three quarters of an inch wide. It was the ideal injury, not too dirty and not too extensive, upon which to use the new technique. Lister dressed the area with a lint bandage dipped in carbolic acid. The leg was then splinted, and allowed to remain untouched for four days. Afterward, the dressing was changed periodically until complete healing was found to have taken place. The process took six weeks. Lister's first clinical experiment was a success.

In the succeeding months, one patient after another was treated in much the same way. Ten more cases of compound fracture were seen, of whom eight recovered without untoward event. One of the remaining two developed hospital gangrene and required amputation while Lister was away for a few weeks; the other bled to death when a sharp bone fragment pierced a major artery after several weeks of good recovery. Carbolic-acid antisepsis, as the new concept of disinfecting a wound was to be called, was obviously worth further study.

Lister next turned his attention to a condition called psoas abscess. This fearsome complication of spinal tuberculosis took the form of a large collection of pus lying on one of the long muscles in the back of the abdominal cavity. Such abscesses grew very large, eventually coming to protrude into the groin. When they were incised for the necessary drainage, the resulting open wound often became invaded by the organisms of hospital gangrene, erysipelas, or the others, with death as the usual consequence. Lister developed a technique of disinfecting the skin around the incision with carbolic acid and then dressing the drained cavity with a puttylike substance of which the disinfectant solution was a major constituent. Again, results were excellent, compared to what had been before.

When he was sufficiently encouraged by his treatment of psoas abscess, Lister felt justified in applying his new method to amputations. The results were so gratifying that in 1867 he published a series of five papers in the Lancet, announcing the invention of antisepsis. The title was a long one, because it was meant to convey the importance of the text: The Antiseptic System: On a New Method of Treating Compound Fracture, Abscess, etc.; with Observations on the Conditions of Suppuration.

As Lister's experience grew, he modified his techniques to take advantage of his increasing store of knowledge. Every innovation was carried out with meticulous care; it seemed to some onlookers as though the ritual were as important as the theory behind it. Not only were the wounds exposed to carbolic acid during the operation, but also all instruments as well as the hands of the surgical team. And yet, Lister's operating-theater attire was not different from that in which his nonantiseptic colleagues customarily worked. He rarely removed his coat, preferring to roll his sleeves back in the manner of the day, and then to turn up the collar of his frock coat to protect the white starched shirt collar he always wore, so that it would not become sodden from the cloud of antiseptic spray which he later introduced. He dipped his hands in carbolic, applied soaked towels to the skin around the planned incision, and went to work, stopping frequently to rerinse wound, hands, and instruments with the disinfectant.

Postoperative management consisted of periodic dressing changes during which everything touching the incision was again disinfected, in an atmosphere heavy with spray-filled air. By late r869, a large enough experience with amputations had been accumulated that the results could be submitted to the Lancet for publication. Although Lister acknowledged that the numbers were still too small for proper statistical analysis, he correctly pointed out that when "the details are considered, they are highly valuable with reference to the question we are considering." The summary figures follow, exactly as they appeared in the issue of the Lancet for January 8, 1870. They speak for themselves:

Before the antiseptic period, 16 deaths in 35 cases; or 1 death in every 2 1/2 cases.

During the antiseptic period, 6 deaths in 40 cases; or 1 death in every 6 2/3 cases.

Not included in the statistics were the many wounds treated antiseptically which were thereby made to heal so well that amputation was avoided. Without carbolic acid, many of them would have resulted in infection and death. The paper stated, "If the history of all the contused wounds of the hands and feet that have been treated in my wards during the last three years were recorded, including many compound fractures not reckoned as such in our classification and several compound dislocations, it would be enough to convince the most sceptical of the advantages of the antiseptic system."

The publication of his results on amputation was the culmination of Lister's work in Glasgow. The term of office of the Surgeon to the Glasgow infirmary, limited to ten years and non-renewable, came to an end in 1870, and Lister had no wish to stay on at the university once his clinical appointment was ended. For several years he had been seeking a longer-lasting post elsewhere, applying for those that held any interest for him as they came up. He was not successful when a professorship became vacant at Edinburgh in 1864, or at his alma mater, University College, in 1866. He had begun to despair as his Glasgow term drew to a close, when a cerebral thrombosis suffered by his father-in-law proved, quite literally, to be a stroke of good fortune for him. When the partially paralyzed Syme resigned his Chair of Clinical Surgery, a group Of 127 Edinburgh students wrote to Lister begging him to become a candidate. Their letter stated, in part, "We feel sure that if you are appointed to this Chair, the benevolence of your character and the urbanity of your manners, will speedily draw around you a large band of attached and devoted followers." He was appointed to the post in August of 1869, and by October he and Agnes were once again settled in Edinburgh. He was forty-two years old. The happiest years of his life were about to begin.

Although Lister's benevolence and urbanity may have been well known to the Edinburgh student body, the news of his introduction of antiseptic surgery does not seem to have thus far reached them. His methods were receiving a warm reception at some of the continental hospitals, but no British surgeons outside of Glasgow had yet been converted either to antisepsis or to the principle upon which it was based, the theory that microbes can be the cause of certain diseases and of decomposition in tissues. Even at this early stage, debates were beginning to be heard about the significance of finding bacteria in infected wounds. There were those who believed that they were secondary invaders that entered after putrefaction had begun, rather than being the source of the infection. There were other skeptics who considered the germs to be harmless contaminants, refusing to believe that they played any role in the process of infection and unconvinced by Lister's improved results in the treatment of compound fractures and abscesses, or by his still-small series of amputations. In addition, there were several alternate theories, now best consigned to the abstruse researches of medical historians (oxidation of tissues, mentioned above, was the least speculative), which purported to explain suppuration and contagion by mechanisms other than marauding microbes.

Such was the state of affairs when the Listers moved into their large new home at 9 Charlotte Square in Edinburgh. During the next eight years, as heated discussions raged in every major center of' medical thought about what was coming to be called the germ theory of disease, Lister became one of the best known and most controversial scientists in the world. His practice and his clinic population grew large enough to enable him to test his techniques in a wide variety of operations, and his spreading fame brought increasing numbers of foreign visitors who wished to learn them. Once again, he and Agnes put together a kitchen laboratory and set to work on a series of investigations of wound infection.

To his students, it seemed puzzling that a surgeon would interest himself in such things as test tubes and microscopes. They flocked to him because of his quiet goodness and because he could teach them how to avoid infection; the theory behind it was of little interest to them. Here is the description written by one of them, J. R. Leeson, who came to visit his professor at home soon after his arrival in Edinburgh:

I felt instinctively that I was in the presence of a very unusual personality: such a combination of refinement, ability, benevolence, and sweetness of disposition as I had never before met; he seemed the embodiment of high purpose; an emanation of goodness radiated from him....

He led me to the windows before which on a long table were several rows of test-tubes covered with glass shades, half full of various liquids, and in the mouth of each was a plug of cotton wool.

It was a curious assemblage such as I had never seen, nor could I form the least conjecture as to what they were or why they should be plugged with cotton wool; my experience of test tubes was an open mouth, and I never remember having seen them closed.

With the greatest care and pride he picked out one here and there, held it up to the light and seemed inexplicably pleased at its condition: this was clear, this was turbid, and this was mouldy. Of course I tried to show an intelligent interest, but had not the faintest idea as to what it was all about and wondered what connection they could have with my visit or with any branch of surgery; and I remember thinking it strange that so eminent a surgeon should be interested in such an unusual subject and could find time to study such irrelevant and out-of-the-way matters.

At Edinburgh, the new Professor of Clinical Surgery lectured twice a week in that large amphitheater described by Lawson Tait. He discoursed on the physiology and bacteriology upon which his practical teachings were based, and he demonstrated the increasingly more complex methodology of his carbolic-acid technique. He had discovered the nature of sepsis, and his mission was to explain its prevention. He imagined the air to be swarming with microscopic organisms and every wound therefore to be by its very nature already contaminated from the instant of incision. His aim was to decontaminate everything that came into contact with exposed flesh, and he used carbolic solutions of varying strengths to do it, even going so far as to design a machine that sprayed a fine mist of the material, through which he operated heedless of its effect on his own lungs and those of his assistants.

Although Lister successively decreased the concentration of the carbolic in order to lessen skin irritation, everything else about Listerism, as the antiseptic technique became known, gradually grew more complicated. In its final form, it required that an inner crust of blood and carbolic be covered with a layer of waterproof silk upon which were wrapped exactly eight layers of carbolized muslin between the outer two of which was a sheet of gutta percha. The whole pungent mass was drenched with liquid resin and paraffin; it was then covered over with waxed taffeta soaked in more carbolic. Lister believed that any variation in the method might lead to failure.

And the results of compulsive adherence to Listerism were impressive. In his last three years in Glasgow, its inventor had had only one case of wound erysipelas. Hospital gangrene, on those few occasions when it occurred, did so in a mild form. Such improvements continued in Edinburgh. The number of wound infections remained low, Lister's mortality figures allowed him to dare more complicated operations, and the periods of recuperation of his patients were significantly shorter than those of his colleagues' patients in the same hospital. Needless to say, so were the lists of his dead patients.

Nevertheless, he continued to have few converts among the local surgeons. Books have been written about why it was that the entire surgical world did not immediately embrace Lister's teachings. One of the reasons is obvious: it was a great deal easier not to believe in them. Imagine a fifty-year-old surgeon at the height of his career, accustomed to striding into his amphitheater, changing into his old frock coat stained with the dried pus and blood of many a gory encounter, and then commencing to operate without the inconvenience of so much as a preliminary hand-wash; with his patient hastily etherized, he slam-bangs his way through the usual ten-minute operation and prepares for the next. Not since medical school, and even then only a few times if at all, has he looked down the barrel of a microscope. One day, he attends a lecture delivered by a professor who is surrounded by a distinctly nonsurgical array of flasks, lenses, and small glass-covered dishes, during which he is told that little invisible creatures are his real enemy, and that in order to defeat them he must soak to the wrist in a corrosive solution, operate through a spray of acrid vapor, interrupt the blinding speed of his procedure numerous times to irrigate the wound and all of his instruments with a chemical disinfectant, laboriously apply a complicated sharp-smelling dressing in a meticulously ritualistic way, and then follow very specific rules about dressing changes in the postoperative period. Then imagine that same surgeon at his club in the evening, lifting a glass of port to his lips with red, puffy hands chapped by the corrosive fluid in which they have soaked during the day.

And finally, imagine the worst thing of all. Imagine what it must have felt like for such a surgeon to accept a theory that confronts him with the intolerable fact that for the previous fifteen years of his career he has been killing his patients by allowing into their wounds microbes which he should have been destroying.

For such reasons, many a surgeon at the height of his career found the premises of Listerism unacceptable. Some few tried just enough elements of the ritual to feel themselves encumbered by it but not enough to make it work-their breaks in technique prevented success, and so they abandoned its directives all too willingly as being worthless. Lister himself did not expect early universal acceptance of his principles. He predicted that it would take a generation for them and for the germ theory to become part of medical practice. There are theologians who believe that the ancient Israelites were made to wander forty years in the wilderness in order that the slave mentality should die out and a new liberated post-Egypt generation be born. Perhaps it was similar reasoning that made Lister realize that the promised land of safe surgery would be vouchsafed only unto a newly born tribe of believers.

In 1874, Lister wrote the first in a series of letters exchanged with Louis Pasteur, to thank him for furnishing the key with which the secrets of wound sepsis had been unlocked. It was the British professor's use of that key that gave the clue to the French chemist that his own discovery of the alcohol-souring microbes could be applied to seeking the causes of disease. In later years his studies along this Listerian line of thinking would result, as noted earlier, in the identification of the specific bacterial agents of certain infections and, through use of an attenuated strain of the anthrax bacillus, in the innoculation of patients to produce immunity. Thus it was by a process that went from Pasteur to Lister and back again to Pasteur that the so-called germ theory of disease was eventually to be proved in practice.

But not yet. Even in the late 188os there continued to be debates published in our own American surgical literature concerning the validity of the germ theory. J. Collins Warren, the grandson of the first American to operate under ether anesthesia, visited Lister in Glasgow in 1869, He later wrote that when he returned to Boston and tried to be an evangelist of antisepsis at the Massachusetts General Hospital, he was "coldly informed that the carbolic acid treatment had been discarded." An imperfect trial had failed, and no more were to be attempted.

Articles on the germ theory appeared only infrequently in the American medical journals of the time. According to this country's physicians, the question of whether bacteria cause disease still awaited a definitive answer. Science was not yet a significant factor in medical thinking on this side of the Atlantic-anything that came out of a laboratory smacked of dubious foreign influences. Among those who opposed antisepsis and refused to accept the germ theory were some of the leaders of American surgery. Dr. Samuel Gross of Philadelphia, whose surgical textbook was the most popular in the country, was unconvinced that antisepsis did any good. He refused to use it. In 1876, as part of a review of the development of medicine on the hundredth anniversary of the independence of the United States, he noted that the surgeons of his native land did not believe in Listerism. He has been immortalized by Thomas Eakins in the famous painting called The Gross Clinic, in which he is shown operating in the traditional frock coat without an iota of antisepsis in sight. The patient's mother is depicted cringing a few feet behind his bare and bloody scalpel-wielding hand. The canvas was painted in 1875, nine long years after Joseph Lister had first described his doctrine in the most widely read medical journal in the English language.

In the same year during which Gross wrote his article, Joseph Lister was invited by the Centennial Medical Commission of Philadelphia to attend the congress which was part of America's hundredth-anniversary celebration. The president of the Commission was the nonbelieving Philadelphia professor, who nevertheless graciously asked his English colleague to be the chairman of the Section of Surgery, an honor eagerly accepted as an opportunity to preach the antisepsis doctrine to the as yet unaccepting Americans.

The reception that greeted Lister himself was far more enthusiastic, however, than the one accorded the three-hour oration in which he attempted to convert his audience. His convictions, as eloquently expressed as they were, did hot suffice to accomplish any major changes in attitude, especially when he demonstrated the complicated nature of his dressings. His personality and determination were admired much more than his antimicrobial technique. An observer for the Boston Medical and Surgical Journal caught the Americans' reaction: "He has a laughing face, but his firm mouth and bright eye give it character. Modesty is stamped upon his every act and word, but he does believe in antiseptic surgery."

Things were different, however, on the continent of Europe. For reasons that will be discussed more fully a few pages onward, continental and particularly German-speaking surgeons were far more prepared than the Americans to believe in the concept that infection is caused by microbes. Once the germ theory was accepted, the use of antisepsis or an equivalent technique was a natural consequence. Among the pioneers was Ritter von Nussbaum of Munich, who wrote Lister describing the way in which "We experienced one surprise after another.... Not another case of hospital gangrene appeared. ... Our results became better and better, the time of healing shorter, and the pyemia and erysipelas completely disappeared." Nussbaum expressed the feelings of many of Lister's continental disciples when he added, "I hold that next to that of chloroform-narcosis your discovery is the greatest and most blessed in our Science. God reward you for it, and grant you a long and happy life."

As has so often happened in the history of science, it had taken the tragedy of war to provide a setting in which innovation could emerge. In the brief but ferocious Franco-Prussian War of 1870-1871, the few surgeons who used Lister's methods had been able to demonstrate mortality statistics that were much better than those of the great majority of their colleagues. The postoperative carnage among the patients of Georg Friedrich Louis Stromeyer, surgeon general successively of the Schleswig-Holstein and Hanoverian armies, was thirty-six deaths following thirty-six amputations through the knee joint. What made this statistic all the more depressing was that Stromeyer was no incompetent-Fielding Garrison has called him "the father of modern military surgery in Germany." Neither were the French statistics any cause for acclaim; Of 13,173 amputations of all sorts done in the military hospitals of France, including fingers and toes, io,oo6 ended in death.

After the war, German surgeons, prepared by the growing scientific spirit at home, began to travel to Edinburgh to learn about antisepsis. Close on their heels came the French, and then representatives of other continental countries as well. By the time of the 1875 German Surgical Congress, many enthusiastic disciples had been won over. One of the most outspoken was Ritter von Nussbaum, who exhorted his audience, "Look at my sick wards recently ravaged by death. I can only say that my assistants and my nurses and I are overwhelmed with joy. It is with the greatest zeal that we undergo all the extra pains required by the treatment." Nussbaum also wrote a short book on antisepsis. Translated into French, Italian, and Greek, it led to the rapid continental spread of Listerism.

Among the most beholden of the Germans was Stromeyer, who went so far as to write a laudatory poem titled "Lister." He undertook the translation himself, and it should be read mindful of the caveat that his good intentions are somewhat marred by the fractured quality of his Teutonized English. Here is the first stanza, sounding as though it were written as a send-up for a senior-class show at some modern American medical school. No significance should be attached to the fact that the personal pronoun referring to the author of antisepsis is capitalized as though he were also the Author of us all. Although this does give the poem somewhat the quality of a paean to God, it should be remembered that the Germans treat their nouns and pronouns this way as a matter of course:

Some weeks after the German Surgical Congress, Joseph and Agnes Lister, with his brother's family of four, went on a tour of the continent, part of which was planned as a visit to the German hospitals to evaluate the success of antisepsis. After traveling through France and Italy, they journeyed to Munich, Leipzig, Berlin, Halle, and several other cities. Having been embraced by Nussbaum in Munich, they were treated to what their hosts called a "Lister-Banquet" in Leipzig, attended by some 350 professors, physicians, and students. There were many light, bright moments that evening. The guest of honor was entertained by humorous songs written for him, among which was one titled "The Carbolic Acid Tingle-Tangle." Unfortunately for posterity, its lyrics seem not to have been preserved. Professor Karl Thiersch proposed the honoree's health, and pointed out that antisepsis, like so many other great inventions, was in the midst of passing through what he called the three usual stages of discovery: "The first, when the world smiles and shakes its head and says, 'It's all nonsense'; the second with a shrug of the shoulders and a look of contempt, 'It's the merest humbug'; and finally, 'Oh, that's an old story, we knew that long ago."'

The Lancet of June 19, 1875, described the German visit in a way that was incomprehensible to the still-skeptical surgeons of the English-speaking countries: "The progress of Professor Lister through the University towns of Germany, which he is visiting chiefly, we believe, with a view to inquire into the mode in which the antiseptic treatment is carried out in the Continent, has assumed the character of a triumphal march." A similar reception awaited him four years later when he attended the International Congress of Medicine in Amsterdam. He was greeted, according to the British Medical Journal, with "an enthusiasm that knew no bounds," a prolonged standing ovation, and the encomium of the president, Professor Donders: "It is not only our admiration that we offer you, it is our gratitude, and that of the nations to which we belong."

Nevertheless, Lister's own countrymen remained fixated, like most Americans, at Thiersch's second stage. Although increasing numbers of younger British surgeons were beginning to accept antisepsis, most of the senior professors at the great London teaching hospitals stood stolidly opposed. As long as they remained so, Lister felt that he had not been successful with the group whose endorsement he valued most highly. And then, in 1877, an opportunity presented itself by which the situation might be turned around. Upon the death of its incumbent, Joseph Lister was offered the Chair of Surgery at the Medical School of King's College, London.

At first, it seemed inconceivable to his colleagues that he would leave one of the most prestigious schools in the world, as Edinburgh then was, to go to an institution of a decidedly lower caliber. Not only would he be taking a backward step academically, but he would have to give up a thriving private practice, the ample clinical opportunities for patient study at the Royal Infirmary, and his scores of devoted students. In return, he would enter an environment hostile to his teachings and resentful of his ever-growing international fame. When his students learned that their beloved teacher was giving serious consideration to the offer, they presented him with a petition of seven hundred signatures, begging him to remain.

There was a lot to leave behind in Edinburgh that was the stuff of happiness and the reward of the appreciative love in which Joseph Lister was enveloped wherever he went in that city. A student, John Stewart, has left us with one of the many moving descriptions that were in later years written by his pupils to portray their mentor as he was seen by them and by his patients. The quotes within the text are taken from a poem by William Ernest Henley, who is best known as the author of "Invictus," written while he was Lister's surgical patient at the Edinburgh Royal Infirmary:

Among the happiest recollections of those Edinburgh days are those of the Sunday afternoon hospital visits. This was one of Lister's ways of keeping the Sabbath Day. The coachman and the horses had a rest. Lister came to the Infirmary on foot. The picture is plain before me now.... Someone suddenly says, "Here comes the Chief!" and we see our hero enter through the little side-gate, pass down the slope, with his easy rapid stride, a light cane in his hand, and on his handsome face a look of happy meditation. The house-surgeon meets him at the main door, and in a few minutes they enter the ward. Students come to attention, patients' faces beam. I wonder if there were anywhere else in the world a surgeon whose pupils held him in more reverent admiration, whose patients so trusted him, loved and positively adored him. He cannot be unconscious of this feeling, the "soft lines of tranquil thought" grow softer, that "face at once benign and proud and shy" is suffused with the unaffected pleasure of this modest and simple-minded great man as he begins his tour of the ward.

But his friends and his students reckoned without the deeply ingrained Quaker sense of mission. As there is a fundamental strain of mysticism in the Inner Light concept of the Society of Friends, there is also a deep commitment to evangelicism.

For Lister, transfer to King's College was an inevitable part of his mission to carry the message of the germ theory to every doubting doctor who still disbelieved it. There was never any question in his mind but that he must accept the London offer. By October of 1877, Agnes and he had moved into a spacious house at 12 Park Crescent, near enough to Regent's Park so that they could stroll through its beautiful gardens. The professor brought four skilled assistants to London, to help him set up his new teaching program and to be his fellow missionaries. To the childless Listers, they were like surrogate sons. Among them was John Stewart.

Lister's Inaugural Lecture at King's was as well attended as had been its counterpart at Glasgow. The members of his audience, having come prepared to listen to a description of surgical operations, were chagrined to hear their new Professor launch into a learned scientific disquisition. Standing behind a laboratory table covered with tubes, flasks, and various other of the paraphernalia of bacteriology, he spoke about things of which they knew nothing and cared nothing. The polite applause at the lecture's end lulled Lister and his four disciples into thinking that they had made a good beginning. They soon learned otherwise. As Stewart described it, "The next few weeks were to us of his staff the abomination of desolation. There seemed to be a colossal apathy, an inconceivable indifference to the light which, to our minds, shone so brightly, a monstrous inertia to the force of new ideas."

Lister did not make much progress with his campaign during those early years at King's College. The attendance at his lectures dwindled down to ten or twenty semi-interested souls, in contrast to the three or four hundred enthusiasts who had crowded the hall each time he spoke in Edinburgh. The students soon learned that he taught nothing that was of use in the examinations of the Royal College of Surgeons, since those inquisitions were conducted by clinicians to whom the germ theory, and anything to do with science, was anathema.

Distressed and disappointed though he certainly was, Lister never betrayed a whit of antagonism or impatience with those who ignored him or those who maligned his doctrine. His assistants became accustomed to the quiet sigh of resignation with which he responded to the criticisms of lesser men. Sometimes a transient look of sadness could be seen crossing his face, but nothing beyond that momentary alteration ever revealed his pain. Long used to having their own occasional lapses treated by the Chief with merely a gentle word of admonition, his Edinburgh lads now saw more clearly than ever the majesty of which some are capable even when their greatest work is mocked. They strengthened themselves with the words from the Book of Proverbs which their professor so often used as the final sentences in a lecture, both in Scotland and here in England: "Let not mercy and truth forsake thee; bind them about thy neck."

If only a few English converts appeared among Lister's sparse audiences, continental visitors again began to fill many of the empty seats in the lecture hall and to appear on the wards, as they had done in Edinburgh. Leading European surgeons sent their prot6g6s to learn his methods. In the memoirs of Sir St. Clair Thomson, one of the house surgeons at the time, is recorded that it was necessary to post the hospital's no-smoking sign in French and German for the benefit of the foreigners. On some days, the scene in the auditorium epitomized the scene in the greater medical world: as many as sixty continental surgeons occupied the front seats, intermingling with no more than ten English students. Not infrequently, the professor delivered half his lecture in one of the languages of the no-smoking sign.

Lister was thus a prophet not without honor save in his own country among his own countrymen, especially if those countrymen were surgeons. (Many pathologists, being trained to understand the ways of science, quickly accepted the germ theory and Listerism, as did other physicians who had some experience with research in physiology.) Still, he was confident the truth would win out, one way or another. Thomson describes standing beside his Chief on the steps of the hospital one day, after a particularly vigorous sally had been directed against his doctrine by a stubborn colleague. The year was 1883, and the fifty-six-year-old professor had heard just about every argument that could possibly be thrown at him, and each of them many times. Wearily and with a quiet certitude, he predicted to his young pupil that the day must surely come when his principles would be universally utilized. Then, casting off his usual soft tone of serenity, he raised his voice just a bit to declare with a barely perceptible trace of sternness, "If the profession does not recognize them, the public will learn of them and the law will insist on them."

There were several reasons why the English were so slow to accept, or even to understand, antisepsis. Among them, of course, was the fact that Lister had made his techniques so complicated that they taxed the patience of those who would try them. But the overriding problem had to do with science, or rather its generally low condition of advancement in England even three quarters of a century after the death of John Hunter. Hunter's legacy had become a bit like Galen's, its most important principles being honored only in the breach. The state of affairs is explicated by a perceptive editor who made the following observation in an issue of the Lancet in early 1878:

The truth is, that this is a question in science rather than in surgery, and hence, while eagerly adopted by the scientific Germans, and a little grudgingly by the semi-scientific Scotch, the antiseptic doctrine has never been in any degree appreciated or understood by the plodding and practical English surgeon. Happily for his patients, he has for a long time been to a considerable extent practising a partially antiseptic system, thanks to his cleanly English instincts; but it has been like the lady who talked prose without knowing it.

The situation described by the Lancet editor is illustrated by the example of the aforementioned Lawson Tait, who had an enviably low rate of infections in his own series of gynecological operations, none of which had been done using the lessons of the germ theory, or so he thought. In his 1887 presidential address to the Birmingham and Midland Counties Branch of the British Medical Association he denied the validity of the germ theory of disease with the memorable words "To apply the conclusions derived from beef-tea in the flasks of the chemist's laboratory to the phenomena of living tissue is nonsense," and "I care not a fig for the germs." He scoffed at Listerism, and had only contempt for the principles of bacterial putrefaction upon which it was based: "It is when Lister comes in with his royal road to surgical success, still more when his German disciples, full of enthusiasm and quite empty of discrimination, appear on the scene, that I am in doubt, and equally in fear." On more than one occasion he offered to pack his wounds with dry germs, just to give the lie to Lister. He attributed his own salutary statistics to the liberal use of drainage tubes and absorbent dressings, as well as to his own "cleanly English instincts." The latter were in fact far more important than the former-Tait was known for his careful preoperative hand-washing and for his advocacy of plenty of soap and hot water on equipment and instruments. Though he may not have believed that germs cause putrefaction, he was nevertheless willy-nilly killing them before they got into his surgical wounds. He was unwittingly practicing a form of prophylaxis that would later become known as asepsis. He would one day be chagrined to discover that his results gave strong support for the very theory he sought to deride.

There was one other major factor in the foot-dragging of the English and of the Americans as well: they were resisting a powerful and ultimately overwhelming movement which was already beginning to permeate the atmosphere of German surgery. By this I mean the new order of things, in which the careful, meticulously executed operations permitted by antisepsis and anesthesia were replacing the old emphasis on speed and dazzling dexterity. The judiciously painstaking operative technique of Lister himself was an example of what was on the horizon. The day of the spectacular tour de force was drawing to a close. No longer would it be necessary to amputate a leg in thirty seconds, as did Robert Liston, before oxygen could enter the wound to putrefy it, and before the struggling patient could break free of the staunch grip in which he was being held by muscular assistants.

A new type of man was entering the specialty of surgery, a prudent scientific technician who treated human tissues with delicacy and thoughtfulness rather than brute force and blinding speed. lie was exemplified in England by Frederick Treves, and in America by William Stewart Halsted. As their teachings became more and more a part of daily medical practice, so did the germ theory and so did science. The old surgeon was more a theatrical performer than a student of disordered physiology. Certainly he was no man of science. The Listerian methods made many a senior operator an anachronism, superannuated by young men with a totally different set of talents from those by which their own teachers had achieved their success. The old surgeon's hour upon the stage was ending, but he was determined to delay his departure as long as he could.

Nevertheless, even at King's College Hospital, by the end of the I870's there were a few signs that the resistance to antisepsis, although still formidable, was beginning to crumble in the face of Lister's scientific truth. The senior professor John Wood visited the Chief's wards and was so impressed with what he saw that in November j878 he asked Lister to help him use the antiseptic technique in operations on two cases, one a goiter and the other an ovarian tumor. Both patients recovered without complication. Although Wood was three years older than Lister and too fixed in his operating habits to change them, he became a convert, at least in theory. This was all the more remarkable because he was the man who had been generally expected to be appointed to the chair now occupied by his rival, and he had been one of Lister's most ardent opponents. In the circumstances, one might, perhaps, forgive his grudging disclaimer, namely that the Germans needed antisepsis because "the Germans are dirty people ... it is not really necessary in England."

Like Wood, however, other leading London surgeons finally began to see the merit not only in the practical application of Listerism, but in the entire set of principles that followed from the germ theory. At a meeting held at St. Thomas' Hospital in December 1879, Lister was hailed by some of the very men who had once been his adversaries. In 1883, Alexander Ogston, an early disciple from Aberdeen, wrote him a letter that might well have been composed by any of the increasing number of his followers: "You have changed Surgery, especially operative Surgery, from being a hazardous lottery into a safe and soundly-based science; you are the leader of the modern generation of scientific surgeons, and every wise and good man in our profession--especially in Scotland-looks up to you with respect and attachment as few men receive." Soon after this, Lister was knighted by Queen Victoria. Ironically, it was the same year in which he stood on the steps of King's College with Thomson, and came close to losing his patience at the world's slowness to comprehend his message.

From that point on, the tide turned inexorably in his favor, o rather in favor of science. Tributes were showered on the newly dubbed Sir Joseph from all directions. He was made a Knight of the Prussian Order, and a Knight Commander of the Order of Denmark; he received medals and honorary degrees. Among them were doctorates from both Oxford and Cambridge, schools which his Quaker faith had made him ineligible to attend forty years earlier. He was awarded France's Boudet Prize for his application of Pasteur's discoveries to medicine, and he received Prussia's Order of Merit. Medical societies all over the world rushed to make him an honorary member.

As Lister's precepts became more and more a part of daily medical practice, so did the germ theory. Not only was Pasteur's continuing research providing ever more convincing evidence that microbes are the inciting cause of infectious disorders, but in 1876 a thirty-four-year-old German bacteriologist named Robert Koch had identified for the first time a specific bacterium as the cause of a specific disease, demonstrating in a simple, clear set of experiments that the bacillus found in the blood of animals suffering from anthrax was the direct agent that produced the pathological changes of that sickness when it was introduced in pure culture into other animals. The results of Koch's investigations were soon confirmed by Pasteur, who, as noted earlier, was able to develop a method to immunize against anthrax by using a bacillus of weakened virulence. In 1878, the final missing piece of evidence was supplied to Lister's original Pasteur inspired thesis when Koch produced his monumental paper "Investigations Concerning the Etiology of Wound Infections," in which he was able to link six different kinds of surgical infections to six distinct bacteria. The scientific basis for the germ theory had been proved beyond question. It remained only for the nonscientists and the Lawson Taits to come to grips with it.

A medical paradox was making its presence felt during this time. it began to be realized, and Lister himself was one of the realizers, that air swarms with far fewer microbes than had been thought. This affected Sir Joseph only insofar as he decided that it was safe to abandon his pungent carbolic spray. But some of the younger Students of the germ theory interpreted this perception in a much more far-reaching way. To them it meant that the organisms that contaminate surgical wounds must of necessity be carried into them by means other than particles failing from the atmosphere; the body seems to have defenses that make it immune to the small doses of bacteria that reach it from the air. The obvious sources of major contamination were thus the hands and the instruments of medical personnel-the doctors and nurses. Wound infection was another of those "we have met the enemy and it is us" phenomena that have sojourned on this earth since long before Walt Kelly and Pogo.

It follows from the preceding that it is not the wound that requires disinfecting as Lister had thought, but rather every foreign germ-laden object with which it comes into contact. The doctrine of asepsis was born.

Antisepsis aimed to disinfect the wound itself, since it was considered to be already contaminated from the air. Asepsis requires the scrupulous sterilizing of everything that will touch the area of operation. Its proponents declared, quite correctly, that an incision made through uninfected tissues remains uninfected unless germ-carrying objects enter it. The surgeon's hands must be scrubbed, his instruments must be boiled, and the wound drapes must be rendered germ free. The sterile incision can be made by the sterile knife held in the sterile hand only after the patient's skin has been made sterile by a disinfectant, whether carbolic acid or some equally effective agent. The disease-stained old frock coat must give way to the freshly laundered sterile gown. Thus was the insight of Ignac Semmelweis the Hungarian reborn, in an era which, thanks to the work of Pasteur the Frenchman, Lister the Englishman, and Koch the German, was ready to receive it and bid it warm welcome.

It now became Joseph Lister's turn to be superannuated. The very germ theory upon which Listerism was founded demanded that aseptic methods should replace antisepsis. In effect, asepsis is prophylaxis, while antisepsis is therapy. Better to prevent the cause of infection from entering a wound than to treat it once it has settled itself in place. Except for wounds that were already dirty, antisepsis began to become less useful even as its underlying theoretical framework was achieving universal recognition and its innovator was being hailed as a surgical savior. In 1883, Gustav Neuber of Kiel built a private hospital based on the aseptic principle that germs should be destroyed before, rather than after, they come into contact with patients. He designed a dust-free ventilating system, and he was the first to operate in surgical cap and gown. William Stewart Halsted of Baltimore popularized the use of rubber gloves in 1889. The Russian - born Ernst von Bergmann, Professor of Surgery in Berlin, introduced steam sterilization in 1886, and established the basic steps in our modern aseptic ritual in 1891.

In the final analysis, Listerism must be seen as a transitional phase. The excellent results obtained by its practitioners confirmed the practical validity of the germ theory and established the dictum that surgeons must apply the teachings of science in their daily hospital routines. But once the bacterial basis of infection had become firmly established in the laboratories of Pasteur and Koch, Listerism's shining hour came to an end. Ultimately, Joseph Lister deserved the encomiums of a grateful humanity not because of his methods, but because he awakened his fellow surgeons to the real cause of putrefaction in wounds and led them into scientific patterns of thought by which it could be prevented.

There was, however, one contribution of Joseph Lister that lives virtually in its original form to this very day. I refer to his perfection of the catgut suture so that it could safely be used in surgical operations. Because I have been unwilling to sidetrack the narrative of anti-germ warfare with anything that might detract from its intensity, I have omitted, up to this point, one of the most practical innovations ever made in technical surgery.

Since the days of classical Greece, the strings of musical instruments have been made from the intestinal lining of sheep and other animals. Some ancient authors described the use of such strings to tie blood vessels; under the name graciliu chordaru, catgut was used by Galen for this purpose. Its great virtue was that it dissolved in the healing tissues and could be absorbed by them. But the tying off of blood vessels went in and out of fashion; every few hundred years it needed to be rediscovered, as by Ambroise Par6. In Joseph Lister's day, catgut was in use only for stringing instruments, and perhaps rackets of various sorts. In fact, the material had gotten its name as a bastardization of kit-gut, the kit being a small fiddle customarily favored by dancing masters. Both kit and gut seem to be derived from the Greek kithara, which was a lyre, a harp, or a lute.

When Lister began his work on antisepsis, it was the practice to tie off large blood vessels with nonabsorbable threads or metal wires pulled from a handful suspended through the buttonhole of the surgeon's bespattered frock coat. The ends of these ligatures were left long enough so that they hung out of the incision. In this way, they could be withdrawn through the soft decomposing tissues when infection occurred, an act which sometimes resulted in alarming hemorrhage from the lacerated vessels, and all too frequently in death. In wounds treated by the antiseptic method there were far fewer infections, which meant that there was no way, without re-opening the wound, to remove the foreign bodies which the long ties had become.

In seeking a suture material that would be dissolved and absorbed, Lister remembered catgut. Beginning in 1868, he carried out a long series of experiments with the material until he had arrived at the perfect way to prepare it for surgery, and to sterilize it in carbolic acid. He found that it would dissolve in the body in about a week, but could be given much longer life by permeating it with salts of chromic acid. Although various synthetic absorbable sutures have been invented in the past decade, there is not an operating room in the world where a goodly percentage of surgeons do not use plain and so-called chromic catgut as their preferred ligatures in certain types of tissues.

Lister's years at King's College were more leisurely than had been his tenures at Glasgow and Edinburgh. Although he was at first vexed by having so few patients, he soon came to appreciate the freedom this gave him for unhurried laboratory work and occasional recreation. Even when his London private practice eventually expanded, he remained free of many of the administrative and teaching obligations that had occupied so much of his time in Scotland. He became much sought after as a lecturer at British medical societies, and he accepted every invitation that he could fit into his schedule, with the same evangelical zeal that had brought him to King's in the first place. At the Seventh International Medical Congress, held in London in 1881, he had the richly deserved pleasure of introducing Louis Pasteur to Robert Koch, and receiving the brotherly praise of both of them.

Most important, Joseph and Agnes Lister began to take longer and more frequent holidays. He taught himself fly-fishing, not because he was an enthusiast, but because it gave him the opportunity to get out into the country and allowed a peaceful respite alone with his wife, who joined him on these expeditions. Together, they became expert bird-watchers, a hobby to which they applied themselves with the same excitement that had characterized all of their years of partnership in scientific study. In Sir Rickman Godlee's biography of his uncle Joseph, there is reproduced a typical page from the diary the couple kept on their birding expeditions. In every way, it reproduces the mutuality of their lifelong comradeship in the laboratory. A sketch appears of the bird they studied on the excerpted day, April 23, i8gi. The sketch and its description are by Sir Joseph himself, while the remainder of the text on the page is by Lady Lister.

Although Lister attended many medical congresses and meetings, the most dramatic of them all was the grand celebration of Louis Pasteur's seventieth birthday, held at the Sorbonne on December 27, z892. Sir Joseph had retired from King's the previous July, at the mandatory age of sixty-five. He now came to France not only as the representative of both the London and the Edinburgh Royal Societies, but also as the central personality in the dissemination of Pasteur's teachings. He delivered an eloquent address in French, through the final portion of which he looked directly at the great scientist whose genius he was acclaiming. As he concluded, Pasteur, enfeebled by a stroke from which he was not fully recovered, rose slowly to his feet, made his way with difficulty toward the rostrum, and, clasping Lister to him with both arms, kissed him on each cheek. It was a historic moment, made all the more moving by its spontaneity.

The following March, the Listers left the cold of London to seek the earliest touches of spring warmth at Rapallo on the Italian Riviera. While there, Lady Lister developed pneumonia. In less than a week, the most devoted of companions was dead. Something died in her husband as well on that day. A man whose life has been so closely intertwined with that of another, whose every worldly accomplishment has really been the accomplishment of both, is not likely to say farewell to thirty-seven years of communion without a great piece of himself having been torn away. Joseph Lister never stopped mourning his best friend. Though he would live nineteen more years, it was without the same optimism of spirit that he had shared with Agnes. He continued to receive the honors that should come to the great as they age their way toward immortality, but without Agnes they were rewards empty of promise. In 1895 he was elected president of the Royal Society; in 1897 he was elevated to the peerage. Joseph, Baron Lister, was the first medical man to bear such a title. At his eightieth birthday in 1907, celebrated all over the world, a special "Lister Meeting" was held by the Surgical Institute in Vienna, at which the audience of five hundred rose and broke into a loud ovation when his portrait was projected above the platform. He accepted the world's gratitude humbly, and alone.

Baron Lister continued to write and to publish until the creeping fingers of infirmity began to clutch at his strength. As late as 1909, a letter of his, dealing with the catgut ligature, was published in both the Lancet and the British Medical Journal. But his sight and hearing were beginning to fail him. Rickman Godlee describes the sadness of going to visit his uncle during the last year of his life: "He looked wistfully at us and told us he had 'so much to say.' But alas, he was not able to give expression to these last thoughts."

Imperceptibly, the architect of germ-free surgery lapsed into unconsciousness. He died on the morning of February 10, 1912. A great public funeral was held in Westminster Abbey, but Baron Lister had left specific instructions that he was not to be buried there. He lies in the West Hampstead Cemetery, alongside his beloved Agnes.