How Antiseptic Surgery
Arrived in America

By Richard H. Kessin, Ph.D., and Kenneth A. Forde, M.D.

Lewis Atterbury Stimson
Lewis Atterbury Stimson
On Nov. 19, 1876, Dr Lewis Atterbury Stimson, recently appointed attending surgeon at Presbyterian Hospital in New York City (now New York-Presbyterian/Columbia) wrote his brother, the Rev. Henry Stimson: “I have rather an important affair on hand next Friday, the amputation of a leg for a large tumor of the knee ….”
    At first blush this would not appear unusual. Amputations were commonplace among surgical procedures of the day. Most were performed for traumatic injury, either as primary treatment or for the management of complications, primarily infection. In fact, early amputation was the treatment of choice for compound fractures of the extremities. Less common were operations for tumor and even there, wounds were not sutured closed for fear of late recognition of infection.
    What was special about this procedure heralded by Stimson was that it was to be done “antiseptically” by the method of Joseph Lister. Stimson knew well that if successful (that is, free of infection) it had the potential of ushering in a new era in American surgery. Mortality for such operations normally approached 70 percent. Although the operation was for a malignant tumor, the doctors expressed more concern about the outcome of the operation than for the prognosis of the disease.
    
In the second installment of a two-part series, Richard H. Kessin, Ph.D., professor of pathology & cell biology and former associate dean of graduate students, and Kenneth A. Forde’59, the José M. Ferrer Professor Emeritus of Surgery and Columbia University Trustee, share the history of the first antiseptic surgical procedure at Presbyterian Hospital — and in America.
As described in the first article of this series, Lewis Atterbury Stimson was well prepared to perform this procedure. Having heard and met Louis Pasteur, he knew the argument for and against antiseptic surgery. Among the theoretical issues surgeons discussed in the latter part of the 19th century was Listerism. The germtheory of disease and the need to practice antisepsis had a slow and painful birth not only in Europe but also in America. Stimson had surgeon colleagues who had not yet accepted the germ theory of disease but nevertheless were attracted to the desirability of some cleanliness in the operating room, without thought of attempting sterility.
    Joseph Lister’s visit to the United States in September 1876 to present a paper at the International Medical Congress in Philadelphia did not cause a revolution, but it sparked further interest in a carbolized surgical environment. On reviewing the hospital records of the period it is clear that some surgeons at Presbyterian Hospital had by the mid-1870s adopted the practice of washing instruments with a solution containing carbolic acid (phenol) but none had attempted the full method of antisepsis as described by Lister. Many thought Listerism a passing fad and without merit.
    A young Presbyterian Hospital house officer of the day, D. Bryson Delavan, who went on to become a respectedpractitioner of otorhinolaryngology, was so impressed with the results of Stimson’s adoption of stronger standards of cleanliness in the operating room that he risked losing his hospital appointment in a confrontation with one of the attending surgeons, who was also a long-standing family friend. The case concerned a 14-year-old boy who was being evaluated after having been struck by a moving train. The boy sustained multiple rib and pelvic fractures as well as a deep laceration of the knee that appeared to enter the joint. The attending surgeon announced that he was about to explore the knee wound — with his unwashed, bare little finger, as was the custom — before proceeding with amputation. Delavan “made strenuous objection,” incurring the wrath of the surgeon, who withdrew from involvement with the patient. Delavan took over the management of the case, irrigated the wound with carbolic acid solution, and sealed it with a collodion dressing. The wound healed without infection and amputation was avoided. Seen 14 years later, the patient suffered no loss of function or late wound problem.
    So who was Lewis Stimson, the bold young attending about to challenge conventional surgical behavior? Stimson was by several accounts a “dominating personality,” a “benevolent autocrat,” and “the shining example of a master surgeon.” Delavan, the house officer who assisted him in the November 1876 operation and other operations, recalled 50 years after his residency at Presbyterian Hospital that Stimson was “of fine presence and personality,” an excellent teacher, whose writing demonstrated unusual literary skill, judgment, and profound knowledge. Stimson’s correspondence reveals his fondness for French, dating from his years as a medical student in Paris. He sprinkled his English prose with French words and expressions. He also had many interests outside of medicine, including outdoor sports and extensive voyages on his schooner-rigged yacht, the Fleur-de-Lys. He was the father of the future Secretary of State and Secretary of War, Henry L. Stimson.
    Here was a young surgeon, two years after graduation from medical school (which then took only two years), recently appointed to the attending surgical staff of Presbyterian Hospital, becoming a major proponent of a new and, to most of his peers, unproven approach to surgery. Only three months earlier he had used a new method of wound management in a patient with an old infected compound comminuted tibial fracture (caused by the kick of a horse). He had used a carbolic acid dressing to successfully clear the wound of massive infection. As Delavan recalled a half-century later, “When at the end of three days, Dr. Stimson finally removed the dressing he disclosed to our amazement the first case treated in this country under the rules of Mr. Lister and that case a success. I can recall no such moment of ecstasy in my entire professional life.” Now Dr. Stimson was about to launch an even bolder assault on established practice.
    To determine where and when Listerism began to affect American surgery and medicine we searched clinical
Fragments of the case report of the 1876 amputation carried out 
by Stimson. The report covers four full folio pages. The conclusions of a number of cases, not all so successful, are shown.
Fragments of the case report of the 1876 amputation carried out by Stimson. The report covers four full folio pages. The conclusions of a number of cases, not all so successful, are shown.
case records and discussions and comments made at medical society meetings. We located medical and surgical casebooks of Presbyterian Hospital from the mid-1870s, some of which are housed in Archives & Special Collections in the Augustus C. Long Health Sciences Library. The casebooks are bound volumes of neatly handwritten notes, each documenting patient demographics, history, physical examination, clinical course with operative and pathology reports where relevant, and always concluding with a one-word assessment: Unimproved, Improved, Cured, Deceased, or Eloped (left against medical advice). In searching these records we found the index case in which Stimson used, for the first time, the full Lister technique of continuous carbolic acid spray, the case he described to his brother and which has been so movingly verified by Bryson Delavan.
    Stimson’s anxiety about this impending event is evident in his Nov. 19, 1876, letter to Henry: “Naturally I am in somewhat of a twitter over it. Not nervous exactly, but it runs a good deal in my mind, and I am anxious that it should go off smoothly and satisfactorily. However, it will be steadying to have Keyes and Van Buren there.”
    William Van Buren, son-in-law of the celebrated surgeon, Valentine Mott, was a professor of surgery at Bellevue Medical College and an able and respected consulting surgeon at Presbyterian, Bellevue, and St. Vincent’s hospitals. He had already accepted and employed some portions of the antiseptic technique. In fact, returning from a European visit he had brought over a complete Lister outfit, including a machine that sprayed carbolic acid over the operating field, which he gave to Stimson. Edward Keyes, an associate of Van Buren, was a Yale classmate of Stimson’s who became a consulting surgeon to Presbyterian Hospital.
    The Nov. 21, 1876, casebook entry described a mid-thigh amputation. Before the operation, sponges and instruments had been soaked in carbolic acid solution. “During the operation a constant play of carbolic acid spray (solution 1-20) was kept directed upon the operators hands. … When from any cause the spray was intermitted [sic], a cloth or protective saturated with carbolic acid was placed over the wound.” Bleeding vessels were ligated with antiseptic catgut ligatures which had been prepared by suspending them for a week in an emulsion of oil and carbolic acid. Contrary to custom, the wound was closed. “The anterior and posterior flaps were closed over a drain and the flaps brought together by fine silk sutures prepared by soaking in carbolic acid solution.”
    The almost daily postoperative notes in the casebook document the patient’s uneventful course. The primarily closed wound healed without suppuration. A week after the operation Stimson wrote his brother: “My operation came off last Tuesday and was quite a success. … 50 to 75 people were in attendance.” His further assessment in his Dec. 10 letter to his brother demonstrates his realization of his achievement. “My amputé [sic] has made a brilliant recovery and for that I am grateful. The case had a certain retentissement [effect] on account of the antiseptic method which was used for the first time in all its details in a capital case and publicity in the City and perhaps in the country...”
    On Jan. 11, 1877, the casebook records that the patient was discharged: Cured. Interestingly, in Stimson’s Dec. 17 letter to his brother, indicating that he was including an account of the operation, with surgical bravado he wrote:
    “Don’t make too much of it. It is no great shakes.”
    However, the surgical community in America and in Europe did not rush to embrace this innovation. Stimson presented his work at regional medical society meetings, and in his 1878 “Manual of Operative Surgery” he detailed the various steps involved in the full Listerian antiseptic technique to be used in the treatment of surgical wounds. At Presbyterian Hospital fellow surgeon Dr. John H. Hinton performed a below-knee amputation in January 1877 and he did it “antiseptically according to the method of Lister,” which, we assume, included the use of carbolic acid spray, although the record does not say so specifically. Other surgeons at Presbyterian Hospital seemed able to go no further than to use carbolic acid to wash their instruments.
    Dr. Robert F. Weir, surgeon to the New York and Roosevelt hospitals, in a paper read before the New York
The carbolic acid spray apparatus redesigned by Dr. Robert F. Weir. 
The spray apparatus was abandoned in the late 1880s when it 
was determined that most contamination came from surgeons’ hands, clothing, or instruments or from the skin of the patient. The idea that 
most contamination came from the air derives from Pasteur. In a long 
and crucial series of experiments Pasteur studied contaminants 
from dust in the air. He showed that wine grapes become covered 
with airborne yeast after they mature.
The carbolic acid spray apparatus redesigned by Dr. Robert F. Weir. The spray apparatus was abandoned in the late 1880s when it was determined that most contamination came from surgeons’ hands, clothing, or instruments or from the skin of the patient. The idea that most contamination came from the air derives from Pasteur. In a long and crucial series of experiments Pasteur studied contaminants from dust in the air. He showed that wine grapes become covered with airborne yeast after they mature.
County Medical Society on Nov. 26, 1877, noting that practically nothing had been contributed to the medical literature on the results of the antiseptic technique, bemoaned its slow acceptance by American surgeons and suggested the following reasons:
    Lister kept changing details of the technique.
    The procedure was so complicated that it required the surgeon’s direct involvement and supervision.
    Some surgeons who tried it were unsuccessful in executing the prescribed steps.
    It was expensive. (Weir presented a simpler device for delivering the spray.)
    Nevertheless he made the case for it, detailing the rationale for the various steps. In another paper, “On the Antiseptic Treatment of Wounds and its Results,” Weir described his own experience with the technique in several cases and reviewed the reports of other early converts to Listerism. He described decreased mortality in his own patients which he attributed, in large measure, to the specific use of carbolic acid spray. He agreed with Nussbaum in Munich, who after consulting with Lister had reduced the rate of infection in his surgical ward from 80 percent in 1872 to zero in 1875.
    There were other developments that stemmed from this movement to rid the surgical environment of bacteria. It was not only operating theaters that were contaminated: Whole surgical wards were infected with Streptococcus, Staphylococcus and Clostridia, as Lister’s ward in Glasgow had been. Perhaps impressed by carbolization for cleanliness during surgery, disinfecting the hospital environment took an interesting turn. As Delavan recalled, “Everything was removed from the room. The floors were scrubbed, the windows closed and calked [sic] and the room saturated with steam. Basins containing salt were placed upon the floor in a row. Beginning with the one farthest from the door of exit hydrochloric acid was poured upon each one in rapid succession. There was instantaneous evolution of chlorine gas which required some alertness on the part of the one using the acid to retire before being choked. The door was then closed and the room left for upwards of twenty-four hours.”
    With the damaging chemical effects of carbolic acid on tissues, Lister’s antiseptic technique was eventually supplanted by aseptic surgery, which has included the use of sterile gloves, introduced serendipitously by William Stewart Halsted (P&S 1877) because of the marked dermatitis his surgical nurse Miss Hampton (later his wife) developed from the carbolic acid solution used to clean the instruments.
    By 1879 the surgeons of Great Britain and Europe were widely employing the antiseptic method and that year Lister received an overwhelming ovation at the International Medical Congress in Amsterdam. As late as 1882 at the annual meeting of the American Surgical Association, America’s most prestigious academic surgical society (then and now), anti-Listerism was still the posture of a majority of members, but by the turn of the century the page had been turned.
    The event that took place on Nov. 21, 1876, at Presbyterian Hospital in New York did much to usher in a new age in surgery, to further the understanding of surgical bacteriology, and to provide vast improvement in the safety of surgical procedures. As Delavan noted, “There, visibly demonstrated before us, was the triumphant proof that gone forever was the old regime of surgical uncleanliness, infection and death.”

 

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