time of his death was Director Emeritus of Ortho- pedics, and Emeritus Professor of the Department of Orthopedics of Mount Sinai School of Medicine.
Dr. Lippmann was a superb craftsman, capable of translating his mechanical concepts into reality.
In his office was a workshop with power tools and a lathe to work out the designs of devices that were later fabricated, or new instruments to facilitate his surgery. Among his many original contributions were the first compression bolt for fractures of the hip, spike osteotomy of the femur in children, repair of tibial condyle fractures, a transfixing hip prosthesis, etiology and treatment of adhesive capsulitis and parainflammatory joint instability, and auscultatory percussion of bone as a means of detecting fractures and assessing their progress of healing. The Robert K. Lippmann Orthopedic Research Laboratory at Mount Sinai was established in 1965 in his honor.
Outside his hospital practice, Dr. Lippmann participated in community, national, and interna- tional orthopedics. He was a Fellow of the New York Academy of Medicine, serving as secretary (1949–1950) and chairman (1950–1951) of the orthopedic section, and as a member of the advi- sory committee (1951–1956). He was a Fellow of the American College of Surgeons (1932), serving as a member of its New York and Brooklyn Regional Fracture Committee (1949).
He was a Fellow of the American Academy of Orthopedic Surgeons (1932) and a member of the American Orthopedic Association (1954), the Orthopedic Research Society (1959), and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT) (1957).
Dr. Lippmann developed a spirit of cooperation and dedication on the Mount Sinai Orthopedic Service. He encouraged free discussion, dis- agreements, and thorough exploration of clinical problems. These were his basic techniques in resident-training. He was an accomplished pianist and taught himself how to play the organ. In the back of his mind was always the idea that he would some day describe the principles of con- servative orthopedics that he taught—a task that must be completed by his students. Dr. and Mrs.
Lippmann’s great friendliness was evident in their many contacts with the residents and staff, particularly at the monthly evening journal club meetings at their home in New York and at their summer home in Stamford.
At Mount Sinai Hospital, Dr. Lippmann’s service and leadership over a period of 43 years,
his scientific inquiry and teaching, his sense of humanity and the ethical code manifest in his practice and in his approach to patients formed the foundations of the orthopedic service and had great influence on the growth of the hospital as a whole.
Until his untimely and sudden death on June 9, 1969, at the age of 70, Dr. Robert Korn Lippmann was actively engaged in orthopedic practice. Dr.
Lippmann was survived by his wife, his daugh- ter, Mrs. Nancy L. Heon, his son, Robert D.
Lippmann, and his grandson, R.R. Dennis Heon.
Joseph LISTER
1827–1912
Joseph Lister was born at Upton House, Essex, on April 5, 1827. For generations his family had belonged to the Society of Friends and the early influence of this body continued to govern his whole life. His father, J.J. Lister, was exception- ally versatile. He had considerable success in business in the city and somehow managed in his leisure to acquire a worldwide reputation for his researches in optics, which led to the perfection of the modern microscope and his election to the Fellowship of the Royal Society. He also collab- orated with Thomas Hodgkin in the publication of papers on microscopic observations of blood and animal tissues. Furthermore, he was an accomplished artist and a good linguist. From this it may be gathered that the young Lister was born into an environment highly favorable for the
pursuit of science; and in his great quest he was destined to gaze at the amazing new world of microorganisms through an apparatus perfected by his own father.
As a boy, he was sent to private schools where he showed an early taste for natural science and which led to his choice of medicine as a career.
At the age of 17 he entered University College Hospital, London, where he took his BA degree before proceeding to professional training. He proved himself a brilliant student, occupied a leading place in his own school, and took honors at the university examinations.
He was particularly attracted to physiology and was fortunate in his masters. Wharton Jones and Sharpey were inspiring teachers, who at that time were laying the foundations upon which a succession of great investigators built a school of physiology at University College, which became justly famous. Both these men taught him the scientific method of research. Wharton Jones, a prolific worker, was interested in the mechanism of the circulatory system and the stages of inflam- mation; for his investigations he used the frog’s web and the bat’s wing. Lister undoubtedly owed much to this master of research; he copied his method, in the use of web and wing, in his own later researches upon inflammation, which led to the revolutionary discovery of the antiseptic principle in surgery. Sharpey was both friend and teacher to Lister and it was he who commended him to Syme.
Inspired by these two men, Lister, while yet an undergraduate, carried out original work on the involuntary muscle in the eye and skin. Kölliker had discovered that the iris consisted of involun- tary muscle, and Lister, extending the research, found that it consisted of two separate muscles—
the sphincter and the dilator. This particular work attracted considerable attention and led to a firm friendship between the two observers that lasted throughout their lives.
It was at this time too that anesthesia was intro- duced into surgical practice. Sir Humphry Davy had worked on nitrous oxide in his laboratory, and from the narcotic effect of the vapor upon his own person declared as early as 1800 that the gas might have its uses in surgery; and in 1824, Henry Hickman of Ludlow proved its efficacy in opera- tions upon small animals. At last Horace Wells in America used the gas successfully in his private practice as a dental surgeon, but when he attempted to demonstrate its use in general surgery, he failed dismally and had to face piti-
less ridicule. But in 1846 W.T.G. Morton, whom Wells taught, succeeded in inducing anesthesia while J.J. Collins Warren removed a tumor from a patient at the Massachusetts General Hospital, Boston. On December 21 of the same year, Robert Liston at University College Hospital carried out the first operation under anesthesia in England by performing an amputation through the thigh.
This was a memorable time—the birth of a new epoch in surgery—days to which men would look back. No longer need a patient be terrified at the whisper of an operation, nor a surgeon be called upon to quash his feelings almost to the point of callousness. At long last surgery had become more humane. But surgery was not yet safe. Anes- thesia promoted adventure; but sometimes sadly disastrous adventure; the patient survived the operation but risked death from later gangrene or sepsis. However good a craftsman the surgeon might be, he was, in the words of Volkmann,
“Like a husbandman, who having sown his field waits with resignation for what the harvest might bring, and reaps it fully conscious of his own impotence against the elemental powers which may pour down on him rain, hurricane, and hailstorm.” And yet, strangely enough, actually looking on at Liston with wondering eyes was the very man destined for the task of making surgery safe.
At the proper time Lister qualified with the MB (London) and was appointed house physician and later house surgeon. In 1852 he gained the FRCS (England) and the next year went to Edinburgh with an introduction to Syme. The great Scottish surgeon received him cordially and there began a friendship between them that the years increased.
Syme was one of the most original surgeons of his time and was an outstanding teacher. Lister became his house surgeon, reported his lectures to the Lancet, and was a most enthusiastic pupil, eventually marrying his eldest daughter Agnes.
After a period assisting Syme in hospital and private practice, Lister was elected, on October 13, 1856, to the post of assistant surgeon to the Edinburgh Royal Infirmary. He held this post for 4 years, during which time he lectured on surgery;
his teaching of which was suffused with pathol- ogy, for he held that students should have their knowledge built upon, and their reasoning stimu- lated by, a scientific foundation. At the same time he continued his researches, the fruit of which was embodied in papers read before the Royal Society. He gained a reputation as a first-rate investigator, a stimulating teacher, and a good
operator, added to which he was transparently honest and modest.
In 1860 the Chair of Surgery at Glasgow Uni- versity became vacant and Lister was appointed Regius Professor. He was soon lecturing to one of the largest classes of medical students in Britain, but what impressed him most were the limitations of surgery as a means of relief for human suffer- ing; gangrene and suppuration were only too rife in hospital wards. It is difficult for us to imagine the state of affairs that prevailed. In the case of a compound fracture, the scales were weighted on the side of the loss of life or limb. Hospital gan- grene is to us a term in medical history, but to our predecessors it was a perpetual black menace.
Most surgeons were resigned to the occurrence of inflammation and suppuration in wounds and looked upon them as a natural and inevitable consequence of injury. But Lister, pained and distressed by the frustration of surgery, was unwilling to accept this fatalistic attitude and regarded “hospital diseases” as an evil to be over- come. More and more did his thoughts turn to their cause and prevention. His ideal of what should happen in a wound was what occurred in a subcutaneous injury, such as a simple fracture in which repair took place without inflammation, suppuration, or constitutional disease; and none was better placed or better equipped for the solu- tion of this baffling problem. From early life he had been accustomed to the scientific attitude towards phenomena around him and he had been fortunate in the masters who trained him. When he arrived in Glasgow, he was already mature as a scientific investigator; indeed among surgeons there was scarcely anyone so well equipped; he belonged to the Hunterian tradition.
Of his many papers embodying the results of researches, two in particular were of great signi- ficance, indicating the trend of his thinking and the preparation leading to the accomplishment of his great task. The study of coagulation of the blood attracted his attention for many years. This physiological phenomenon in the healing of wounds formed the subject of his Croonian Lecture before the Royal Society in 1863. In con- sidering the pathology of the open wound, he was led to the study of the genesis of inflammation.
The later stages had been studied by other observers, but information about the earliest onset was uncertain. Lister, with his microscope, observing the capillaries of the frog’s web and the bat’s wing when they were subject to irritants of all kinds, accurately described for the first time
the beginning of the inflammatory process. The vascular reaction to irritation was found to be pro- duced indirectly through the medium of the central nervous system. This work he communi- cated to the Royal Society in 1857 in a paper enti- tled “The Early Stages of Inflammation”. This particular study led him to regard putrefaction as the cause of suppuration and wound infection;
decomposition was set up, though inexplicably, by the air. Such had been his teaching to students when, in 1865, he became acquainted with the writings of Pasteur, and learned that putrefaction was a fermentation due to the growth of minute microscopical organisms, which were dissemi- nated by dust, blown about in the air, and which could also be found on all material objects. This was an astounding revelation; it was the opening of a biological new world of microorganisms.
Lister soon realized that Pasteur’s explanation of putrefaction was applicable to the decomposi- tion of wounds. Already he had thought the air to be a contaminating influence, and this view was now confirmed and the active agent revealed. The next step was to prevent microorganisms from gaining access to the open flesh. To the attainment of this ideal, and to the perfection of its accom- plishment, Lister dedicated the rest of his life. He started by casting about for a suitable antiseptic and on learning of the success of carbolic acid as a disinfectant in dealing with sewage at Carlisle, he decided to give this chemical a trial on wound treatment. After investigation with the pure acid, he finally adopted a 1 in 20 watery solution, and this strength of carbolic acid became a permanent feature of his technique. With this solution he cleansed his hands, his instruments, the patient’s skin, and the wound itself. Lint soaked in car- bolized oil was first used as a dressing but after many experiments was abandoned in favor of a putty made of carbonate of lime and a solution of 1 in 6 carbolic acid in linseed oil.
The result of this treatment upon abscesses and compound fractures was astonishing. Suppuration disappeared; wounds became healthy; patients were comfortable; the number of amputations diminished rapidly; and Lister was able to say:
“But since the antiseptic treatment has been brought into full operation, and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their charac- ter; so that during the last nine months not a single instance of pyaemia, hospital gangrene, or
erysipelas has occurred in them. As there appears to be no doubt regarding the cause of this change, the importance of the fact can hardly be exaggerated.”
His first paper announcing this new principle of surgical treatment appeared in the Lancet in 1867, entitled “On a New Method of Treating Compound Fracture, Abscess, etc., with Observa- tions on the Conditions of Suppuration.” And the same year at a meeting of the British Medical Association in Dublin he read a paper on “On the Antiseptic Principle in the Practice of Surgery.” It should be noticed that he stressed the principle and not the use of a particular drug in treatment;
it was as though he foresaw that the method might change but that the principle was unchangeable.
His constant aim was the prevention of sepsis in wounds, with the least irritation to the tissues.
From then on, Lister’s main purpose in life was to gain acceptance of the antiseptic principle as fundamental in the practice of surgery. The road he had to travel in gaining his objective was more arduous than he imagined. For some years his teaching was misunderstood and he had to meet violent criticism. Strangely enough, many medical schools were indifferent, or accorded the doctrine a chilly reception. On the other hand, well-known surgeons in France and Germany were not slow to see the merits of the antiseptic principle and he was encouraged by the enthusi- asm of some industrial surgeons at home. The best missionaries of the new surgical learning were Lister’s house surgeons and pupils. They had been witnesses of the principle in practice and with conviction they went out to preach the new doctrine. The rest of Lister’s time at Glasgow was occupied in the observation and recording of various diseases and injuries dealt with by the new treatment. He also introduced carbolized catgut for the ligature of arteries after testing it in the calf.
In 1869 he was elected to the Chair of Clinical Surgery at Edinburgh, in succession to Syme, and the students received him with enthusiasm. He became fully occupied with the duties of the Chair and of his large private practice, but in the laboratory in his own home he carried out end- less experiments with the object of improving methods of carrying out the antiseptic principle and rendering its use in everyday practice more simple.
He remained in Edinburgh until 1877, when he was invited to a Chair of Clinical Surgery at King’s College, London. The position he occu-
pied in Edinburgh was far superior to the one offered him in London, but he was attracted by the great city itself and the opportunity it gave him of converting London schools to acceptance of the antiseptic principle, for hitherto it had made little headway there. He therefore migrated south, back to the city of his youth, where he had many friends who pressed him to come. He continued to occupy the Chair at King’s College until 1892 and during these years perfected details of the antiseptic method and gave up the carbolic spray.
He had the gratification of seeing his teaching accepted in London, and indeed throughout the world.
Acceptance of the antiseptic principle revolutionized the practice of surgery and led to phenomenal advance in all its departments. No branch of surgery felt the impact more than ortho- pedic surgery. The introduction of subcutaneous tenotomy had been hailed as a great advance in the treatment of deformities, but it had strict lim- itations. With the prospect of safe open operations there dawned a new era of immense possibilities for the treatment of injuries, diseases, and defor- mities. Indeed the successful management of the compound fracture by Lister stands at the very beginning of the introduction of the antiseptic method. He pointed out that blood clot, protected by an antiseptic, would be organized by the ingrowth of cells and vessels from its vicinity; in this way callus was formed. He also explored the badly united fracture, reset the fragments and wired them. He was the first to explore simple transverse fractures of the patella and olecranon and to bind them with wire until union occurred.
In 1880, William Macewen of Glasgow, a pupil of Lister, operated upon a boy whose shaft of the humerus had been destroyed by osteomyelitis. He sewed tibial grafts along the former track of the bone and a new shaft was reproduced. Another pupil, Thomas Annandale of Edinburgh, in 1883 for the first time deliberately explored a knee joint for internal derangement and discovered an internal semilinar cartilage completely separated from its anterior attachment to the tibia. The cartilage was stitched back in its proper place, the man recovered perfect movement of the joint and returned to his work. For many years before Esmarch introduced his elastic bandage, Lister had operated upon bloodless limbs. He would have a lower limb lifted as high as possible from the table and kept elevated for a few minutes, and then he applied a tourniquet at the upper part of the thigh. This provided a bloodless field for
operation. He proved experimentally that blood left the limb not by gravity alone but also by reflex constriction of the arteries induced by stim- ulation of the vasomotor nerves. This is still a valuable procedure, particularly when it is inad- visable to use an Esmarch bandage.
Lister retired from practice in 1896 but contin- ued his scientific work. In the next year he was elected President of the Royal Society. Many other academic honors and foreign orders had been showered upon him. His appearance at sci- entific meetings in foreign countries had been greeted with triumphal acclaim. He was made a baronet in 1883, a peer in 1897, and was one of the original 12 members of the Order of Merit instituted in 1902. He died at Walmer in Kent on February 10, 1912. The universal and abiding value of Lister’s work for the physical ills of mankind has made him one of the outstanding benefactors of humanity.1,2
References
1. The Collected Papers of Joseph Baron Lister (1909) Oxford, Clarendon Press, 2 vols
2. Godlee RJ (1917) Lord Lister. Macmillan & Co.
Ltd. (This work should be read by everyone embark- ing upon a surgical career.)
William John LITTLE
1810–1894
Orthopedic surgery was one of the earliest spe- cialties to emerge in England but its evolution was slow and gradual. In our own day we have wit- nessed the growth of special branches of surgery from infancy to maturity; but it required more than a generation to bring orthopedic surgery to full stature. It started at the beginning of the Victorian era and, like many another movement, owed its inspiration to the leadership of one man, in this instance William John Little. He was afflicted with a deformity of the foot due to infan- tile paralysis and, being compelled to contemplate his own disability and seep its cure in vain, he was aroused to the misery of thousands of cripples here in England. He came from Norfolk farming stock who had lived for many generations in and about the village of Carbrooke near Kimberley.
His father, John Little, migrated to London and eventually became proprietor and host of “The Red Lion” in Aldgate, a famous hostelry, which was haunted by the memories of Dick Turpin who had often called there.
William John Little, the third child of his parents, was born on August 7, 1810. His earliest recollection recalls a fragment of social history that can be read with appreciation today:
The year 1814–15 was remarkable in my child history.
The long war of over twenty years with France was ter- minated, but it left a heavy burden of debt upon our nation. Scarcity of food was experienced by the poorer classes on and off during the war. Bread riots occurred
