Statistics and the British controversy about the effects of Joseph Lister's system of antisepsis for surgery, 1867-1890.

Abstract

In his revisionist book Bad medicine. Doctors doing harm since Hippocrates, historian David Wootton1 claims that, by introducing antisepsis with carbolic acid in surgery, Joseph Lister (1827–1912) was the first doctor to merge ‘science’ with the practice of medicine with resulting prolongation of life: ‘Lister thus begins the modern history of medicine, defined in terms of constant improvements in therapy grounded in developing scientific understanding, and it is striking that it is surgery’ (p. 227). Wootton points out that Lister had a ‘scientific’ motive for doing what he did. Although it is true that he was convinced that ‘living bodies’ caused wound suppuration, in view of all the challenges he encountered (see below), he did not care too much about the theory underlying his method provided people used it. Wootton refers to ‘Lister’s revolution in surgery’ (p. 229), but Worboys2 had shown previously that there had been no surgical revolution caused by Listerism; rather this view was created by ‘Listerians’ after 1880 (p. 83). The alleged sequence antisepsis (Lister) to asepsis (Koch, German and Swiss surgeons) is probably too simplistic in that the latter can be retraced to the earlier ‘cleanliness-school’, which most surgeons combined in one way or another with antiseptic measures. Wootton’s celebratory presentation of Lister’s work and its influence is quite common, but it is an oversimplification. In fact, there was considerable controversy about the effects of Lister’s system of antisepsis. As historians have pointed out, this fight was to last for over a decade, at least in Britain.3,4,55 It can be followed in the annual meetings of the British Medical Association between 1867 and 1879 as well as in the medical press.5 The arguments in this controversy have long been described and contextualised by historians with varying perspectives (see, for example, bibliograpies in Nicolson6 and Cartwright3). The theoretical principles underlying Listerism, that is that germs caused wound diseases (infection, putrefaction, gangrene) were more readily accepted in continental Europe,2 perhaps because carbolic acid had already been used to prevent and treat wound disease by Lemaire7 in France and Bottini8 in Italy.2,9 In this article, I focus on the type of evidence that was presented in Britain in support of, or against, the claims of beneficial effects of the antiseptic method. Of particular interest are the kinds and role of numerical data used. I begin by examining the nature of Lister’s initial reports, then reassess the short-term mortality statistics from his wards in the Glasgow Royal Infirmary (GRI) compared with those of all surgical wards of the Infirmary, and then consider a longer-term perspective. I raise questions about whether, how and why Lister selected his data. Finally, I look at the way important opponents of Lister’s claims presented their arguments. The results will shed light on the epistemic status of the evidence on which this momentous case in surgical history took place.