From Medscape General Surgery > Historical Perspectives in Surgery

Famous Patients, Famous Operations, 2005 - Part 3: The Surgeon Who Dramatically Lowered Operative Mortality Rates by Defying Evidenced-Based Medicine

Albert B. Lowenfels, MD

Posted: 10/10/2005

 

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Introduction

The surgeon, a 38-year-old man, was professor of surgery at a prestigious university. He belonged to an elite surgical society and was widely respected for his research and teaching abilities. This case report describes how his management of a patient transformed the surgical practice.

Case Presentation: The patient, an 11-year-old boy, was run over by a cart. At the time of admission to a large urban medical center, he was alert, awake, but in considerable pain. Physical examination revealed a compound fracture of the midportion of the left tibia and fibula. There appeared to be no other injuries.

At the time, because of the high incidence of fatal gangrene, the conventional "evidence-based" treatment for open fractures was immediate amputation of the injured extremity. Instead of amputation, the surgeon opted for a highly unconventional approach -- reduction of the fracture and application of a new type of moist protective dressing.

Four days later, when the surgeon changed the dressing, the surgeon, the patient, and the hospital staff were astonished to observe a clean wound with no signs of gangrene. The surgeon noted superficial wound irritation caused by the dressing, but the patient was eventually discharged with a sound, well-healed, functional left leg. A few years later, the surgeon published the results of this and similar cases in a high-impact medical journal.

Who was the surgeon?

  1. Ambrose Pare
  2. John Hunter
  3. William Halsted
  4. Joseph Lister

View the correct answer.

Joseph Lister


Discussion

The surgeon was Joseph Lister (1827-1912) (Figure 1). Appointed professor of surgery at the University of Glasgow, Glasgow, Scotland, in 1860, he soon became surgeon-in-chief at the Glasgow Royal Infirmary -- a position that he occupied at the time when he treated James Greenlees, the patient described above. Lister had a sustained interest in compound fractures because they carried an unacceptably high risk for gangrene. Because gangrene was nearly always fatal, the accepted mid-19th-century treatment for lower extremity compound fracture was amputation, even though the operation was a formidable undertaking with a mortality rate of at least 50% for thigh amputations.[1] Lister's new concept was to prevent contamination of the wound overlying the compound fracture with an occlusive dressing containing carbolic acid -- a strong antiseptic. Not all of his early cases were successful, but the mortality rate with Lister's treatment was much lower than with amputation, and most patients retained a functional extremity.

Figure 1. Portrait of Joseph Lister, the acknowledged father of antiseptic surgery.

Surgeons were slow to adopt Lister's new ideas. European surgeons became enthusiastic only when Lister's methods saved the lives of many soldiers during the 1870-1871 Franco-Prussian War. American surgeons accepted the new concept only after it was popularized by William Halsted. However, Lister lived to see his new concepts change surgical practice, unlike Ignaz Semmelweiss (1818-1865), a Hungarian physician who had similar ideas but who became insane (in some accounts perhaps because his concepts were never accepted). It is ironic that Semmelweiss died at age 47 from an overwhelming infection resembling puerperal sepsis -- the disease that he had studied so intensively.

Today, Lister's fame rests upon his concept of antisepsis, which eventually led to the more advanced concept of asepsis. However, Lister made several other important contributions to surgery: He invented several instruments, including today's commonly used blunt-tipped "bandage" scissors, and, most importantly, he popularized the use of absorbable catgut ligatures.

 
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References

  1. Wangensteen WH, Wangensteen SD. The Rise of Surgery. Minneapolis, Minn: University of Minnesota Press; 1978.
  2. Lister J. On a new method of treating compound fractures, abscess, etc. with observation on the condition of suppuration. Lancet. 1867.
  3. Jenkinson J, Moss M, Russell I. The Royal: The History of the Glasgow Royal Infirmary 1794-1994. Glasgow, Scotland: HarperCollins Manufacturing; 1994:113.
  4. Wu J. Could evidence-based medicine be a danger to progress? Lancet. 2005;366:122.
  5. Doebbeling BN, Stanley GL, Sheetz CT, et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327:88-93.
  6. Weintraub S. Victoria: An Intimate Biography. New York: E P Dutton and Co; 1987.
  7. Gordon B. The Alarming History of Medicine. New York: St. Martin's Griffin; 1997.
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Authors and Disclosures

Albert B. Lowenfels, MD, Professor of Surgery, Department of Surgery, New York Medical College, Valhalla, New York; Staff Physician, Westchester Medical Center, Valhalla, New York

Disclosure: Albert B. Lowenfels, MD, has disclosed no relevant financial relationships.

 
 
 
 
 
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