The Origin of Antiseptic Methods

Kai Tiaki : the journal of the nurses of New Zealand, Volume III, Issue 1, 1 January 1910, Page 23

The Origin of Antiseptic Methods

A lecture delivered by Ernest Robkrton M.D. (Ed in) to the Auckland Trained Nurses' Association, 20th April, 1909.

In discussing the origin of antiseptic methods, I intend to centre my remarks around the work of two men — Pasteur and Lister. Lister's work consisting of the practical application of surgery to the discoveries which Pasteur had made. To understand, however, what Lister accomplished, and the reasons for his proclaiming the principles on which his methods of surgical procedure were founded, it is first of all necessary that we should consider the conditions under which surgical work was carried out between forty and fifty years ago, when he began to treat his cases by what he called antiseptic methods. The surgical world had, a few years earlier, been startled by the announcement that operations might be painless if chloroform or ether were used. The use of anesthetics had increased the possibilities of operating by removing to some extent the fear of the knife from the minds of patients, and by encouraging surgeons to undertake operations which previously, through the suffering involved, were regarded as impossible. Anesthesia had also done away with the necessity of extreme dexterity and rapidity m operating, and had enabled surgeons to operate with such deliberation, that a writer of that time, m a standard book on surgery wrote as follows : — " It appears to me as if we had already reached something like finality m the mere manipulative art of surgery We can scarcely hope to pass beyond the line at which we have arrived m the direction of extreme precision, and almost absolute certainty m the mechanical performance of the operations of surgery ; and m this direction the progress of modern surgery is nearly barred." So much for the art of surgery. The same author, however, went on to say that, " as regards the science of surgery, i.e., the knowledge of the essential nature and pathology of surgical diseases and injuries, or m reference to all those circumstances which, independently of the skill of the operator, influence for good or ill the result of his procedure, we have a field before us, the extent of which it is difficult to estimate."

During the few years following the writing of these words so great a change took place m the knowledge of those circumstances which are independent of the skill of the operator, that it was possible to revolutionise the whole practice of surgery. It is difficult for those acquainted only with the conditions prevailing at the present time, to grasp what the conditions were surrounding surgical work fifty years ago. At that time the scourge of surgery was the inflammation which followed not only accidental wounds, but wounds made by the surgeon himself, causing a prolonged painful healing, extending, perhaps into months of suffering ; often leading rapidly to severe forms of inflammatory mischief such as erysipelas, sloughing, or gangrene ; or leading to septicemia and pyemia, with their fatal issue. To operate on certain parts of the body was to court disaster. For instance, m regard to the peritoneum and the brain, only under urgent circumstances was the awful risk run of adding peritonitis or meningitis to the odds already against the patient. A nurse m those days saw and felt m her ward work horrors which are almost incredible to the nurse of the present day. A comparatively small inconvenience was the foul air of the surgical ward, with its heavy, sickening odour of suppurating wounds, or the worse stench of gangrene continuing or recurring m spite of what seemed to be every care and cleanliness. Heart-rending it must have been to see the mortality m cases of accident or operation. Just as the shock of operation was over, and so one grave danger passed, another loomed m front. Would the wound m a day or two suppurate, and a long, exhausting, and painful illness precede healing ? Would hospital gangrene declare itself, w r ith its almost invariably fatal issue ? These were questions which inevitably arose m the minds of those m whose care the patient was. Compare with this anxiety the condition at the present day, when there is a practical certainty of a favourable issue when once a patient has recovered from the immediate risk of an operation. Sometimes, m those days, the entry of a case into the

ward seemed only the prelude to a certain exit to the mortuary ; for patient after patient m succession fell victims to gangrene, or pyemia, until the ward was of necessity closed. In maternity hospitals the same occurred. Epidemics of puerperal fever arose to which almost every patient succumbed. Long experiences had indeed shown that these diseases — hospital gangrene and puerperal fever — were infectious, but the essential cause of infection no one knew. As to prevention, experience had taught the" benefit to be derived from cleanliness, from fresh air, from good sanitation ; but even with what seemed proper attention to these matters, epidemics occurred, or individual cases went wrong, and the cause remained a mystery. Much was known to depend on the general health of the patient at the time he was wounded, and yet sometimes the strongest and the weakest seemed equally liable to erysipelas or hospital gangrene. Again, it was recognised that the free drainage of wounds secured better results than those when the secretions were pent up. So certain was this that it was common for surgeons to allow the surfaces of amputation flaps to granulate before they were stitched. Still, m rare cases, serious punctured wounds healed well enough without any drainage. Results were irregular. A surgeon or hospital would be proud of a long succession of successful operations, and then, without apparent reason, have to bewail an experience as disastrous as the previous record had been fortunate. In spite of his manipulative skill, the surgeon, ignorant of the real meaning of the complications he most feared, was powerless to entirely avoid or combat them. There were dangers before which patient and surgeon were equally powerless through their ignorance. The nearest approach to truth m the many attempts to explain the causation of inflammation m wounds, gangrene, and pyemia, was the recognition that decomposition m wounds was accompanied by the formation of poisons which, acting locally, caused irritation, and which, absorbed into the system, caused constitutional disturbance. It was suggested that these poisons were formed through fermentation; but further progress was blocked by ignorance of what fermentation was. It was Pasteur's great work to prove that fermentation of organic matter depended on the action of minute living bodies, and that putrefaction was merely a special fermentation. It was

Lister's triumph to apply Pasteur's discoveries to the treatment of wounds, and to devise methods to prevent the entrance of these living bodies into the wounds, or to destroy them if they had entered. s|c ifc * * * * We turn now to Pasteur and his work. The story of his discoveries reads like a romance, and yet nothing is plainer than that all depended on indefatigable plodding — on the simple, diligent search for what is true. Pasteur himself writes : "In the field of observation chance favours only the mind which is prepared." Pasteur's whole life was a constant advance and preparation for further advance into the realms of hidden truth. Born without any advantage of wealth or social position, his advancement was due to his indomitable perseverance, and his unwillingness to go aside from what seemed to him the path of real knowledge. Devotion to duty and self discipline he learned from his father, who had served with honour as a sergeant m Napoleon's army m Spain, and after Napoleon's fall had returned to his native district and had become, like his forefathers, a tanner. The elder Pasteur felt the loss to himself which a lack of liberal education had entailed, and had struggled to afford his son the advantages to be obtained under the national system of education then existing m France. At the local school Louis Pasteur was an average pupil. Even then, however, a characteristic marked throughout his life showed itself — he worked so carefully that he was considered slow, and never affirmed anything of which he was not absolutely sure. When he was sixteen years old a pathetic incident occurred. The help of friends, and the ambition of Pasteur and his father, enabled him to be sent to Paris to one of its famous schools. But m spite of pride and ambition, so desperate a homesickness took possession of him, that within three or four weeks he was back at the country tannery. However, after a year or two at the neighbouring college of Besangon, where he became a junior master, he once more ventured to the Capital, and taking up the study of science, he became m time a Professor at the University of Strasburg, and later at Lille. By this time he was famous as a chemist and physicist. It was at Lille that he made his first researches regarding fermentation. Lille depended largely on its production of alcohol. The

prospect of doing a kindness made him undertake some experiments on behalf of a manufacturer who had met with great disappointments m the manufacture of alcohol from beetroot. In the fermenting of beetroot juice Pasteur noticed globules, which varied as fermentation was healthy or otherwise. These globules displayed many of the phenomena of living matter. Similar cells had been noticed m the fermentation of yeast twenty years before, and it had been suggested that they exerted an influence on the fermenting substance, but no proof had been given of this hypothesis. Hitherto the prevailing opinion had been that fermentation was caused by the oxygen of the air acting on unstable animal or vegetable products, which broke up under its influence. Pasteur, continuing his studies, not only m connection with beetroot alcohol, but also m regard to the fermentation of our milk, found m that similar bodies, although much more minute, and believed that fermentation was actually caused by them. Lactic acid had hitherto been produced commercially by fermenting a solution of sugar through adding to it some animal substance, such as fibrin. Fibrin was considered the active, ferment. Pasteur, noticing that the minute bodies he had discovered increased m number during fermentation, took sugar m solution, added to it mineral salts containing the other element necessary for life, and added a trace of the sediment which, m previous experiments, he had found to consist entirely of the minute bodies he wished to experiment with. Lactic fermentation resulted. Other experiments showed that all fermentations were due to similar microorganisms. His next experiments were for the purpose of deciding whence those small bodies came which he considered he had proved to be the cause of fermentation. At this time, others were engaging themselves m similar studies, and the theory had been propounded that under certain conditions spontaneous generation was possible, i.e., that living matter could arise, de novo, from dead matter. Pasteur was not at all convinced by such arguments as were advanced m favour of this theory, and himself undertook experiments on the supposition that life m any form, and therefore these small organisms, could only proceed from similar pre-existing organisms or their germs. Presuming that these micro-organisms must be conveyed to

the fermenting material from the air, he experimented to see if he could obtain them from the air by filtration. This he readily did. He next tried whether air so filtered, when allowed access to fermentable matter previously sterilised, caused any change. It did not. Then followed an interesting set of experiments lasting many months. Flasks were partly filled with an easily decomposed fluid, each was boiled, so securing that the flask was emptied of air by the steam from the boiling liquid, and then the narrow neck of the flask was sealed while the fluid was still boiling. If the narrow neck of the vessel was later broken, a certain amount of air would rush m, carrying with it the suspended dust of the atmosphere. The flask could again be sealed and kept under observation to see if fermentation occurred. From many series of flasks, opened m different places — m the cellar of his laboratory, m the yard, m the street, m the country, and finally, on the glaciers of the Alps — Pasteur concluded that the dust suspended m the air was the exclusive source of life m infusions, and that spontaneous generation did not occur. In his paper submitting his results was one little sentence long unnoticed : <l What would be most desirable would be to push these studies far enough to prepare the road for a serious research into the origin of various diseases." So far the experiments were made with materials sterilised, as we should now say, by boiling. They were repeated with fresh putrescible matter— blood drawn from a dog. This was sealed m a sterilised flask, and remained pure for six weeks. Pasteur felt himself justified m saying that " his conclusions were applicable m all cases to organic substances." About this time he had an interview with Napoleon 111, and m writing an account of it stated that he had assured the Emperor that all his ambition was, to arrive at the knowledge of the causes of putrid and contagious diseases. This rapid review of Pasteur's researches on fermentation brings us to its connection with Lister's work. Joseph Lister was born m London. Differently from Pasteur, he had the advantages which comparatively wealthy * surroundings could bestow. His father, too, was a man of considerable scientific attainment, and had especially distinguished himself by improvements m the construction of the microscope. Lister was educated at University

College, London, and took his medical degree m 1852. He was then appointed house surgeon to Professor Syme, of Edinburgh, and as such enjoyed intimate association with the leading British surgeon and teacher of surgery. Later, he became himself assistant surgeon to the Edinburgh Royal Infirmary, until he was appointed Professor of Surgery m Glasgow University. It was m Glasgow that he formulated the principles and details on which his antiseptic methods of treatment were founded. His own account of his work at this time is contained m the " Lancet "of 1867. Lister's mind, even m his house-surgeon days, had been busied m searching for a means of ameliorating the conditions of surgical work, and m trying to come to a proper knowledge of the causes of the inflammation and gangrene which occasioned such appalling mortality m severe injuries. Certain facts presented themselves forcibly to his mind, and first among them, that such a difference existed m regard to the relative danger m simple and compound fractures. So great indeed was this difference, that it is related that on one occasion Syme remarked to Lister that he had doubts whether it was justifiable m any case of compound fracture to attempt to save the limb. Yet m some cases compound fractures did do well, the wound healing by first intention. Why did these exceptions occur to the general rule ? John Hunter, nearly 100 years before, had shown that m many cases of compound fracture, where there was a very small wound, and this had been early closed by clotted blood with the resulting dry scab, the course of the healing process was similar to that m simple fracture. This naturally suggested that the graver results of compound fracture were m some way due to the access of the atmosphere through the external wound communicating with the fracture. Lister concluded that this access of air, " induced decomposition of the effused blood, which so loses by putrefaction its natural bland characteristics, and assumes the properties of an acrid irritant, occasioning both local and general disturbance." He noticed how these acrid products of putrefaction seemed to act especially on the raw surface of a wound before the formation of granulations. Granulations evidently afforded a certain amount of protection against both the evil influence of the atmosphere, and the absorption of the products of inflammation. It seemed, therefore, that if he

could prevent putrefaction m a wound until granulations had formed, the risks of constitutional disturbance through the absorption of putrefactive products would be greatly lessened. But there would still be the tedious delay which is involved m the healing of granulating surfaces. He asked himself if it were not possible to entirely prevent decomposition m wounds, and so obtain healing by first intention, not as an exception but as a rule, with the resulting gain m time and safety. The difficulty lay m the want of positive knowledge of the causes of putrefaction. The idea then mcst prevalent was that putrefaction was due m some way to the action of the oxygen of the air, and it appeared impossible to prevent oxygen from finding access to a wound. At this stage Pasteur's work came under Lister's notice, and he saw how the discovery that putrefaction is due to living micro-organisms afforded a foundation on which to construct methods of successfully preventing putrefaction m wounds. "If a wound could be treated with some substance which, without doing too serious mischief to the human tissue, would kill the microbes already contained m it, and prevent future access of others m a living state,, putrefaction might be prevented, however freely air with oxygen might enter." Support was lent to this idea by the fact that where through a fractured rib the lung is injured, and emphysema or pneumothorax is caused, suppuration does not result as a rule, unless there is also an external wound. The air is filtered m passing through the lung. In cases of compound fracture, the germs had already entered the wound when the patient came under the surgeon's notice. It was therefore necessary to seek a means of destroying them m the wound. Sometime before, while at Carlisle, Lister had heard that the foul smell ordinarily arising from decomposing sewage had been m some measure prevented by the admixture of a small proportion of carbolic acid. This suggested that carbolic acid would be an agent fitted for his purpose, and he determined to make a trial of it m cases of compound fracture. As a matter of fact, carbolic acid had been previously used as a local dressing. Lister applied it with the definite purpose of destroying germs. He used it m the beginning of his experiments m undiluted form. The first case m which it was used was a failure owing to faulty detail, but later cases proved that the method of£treating

compound fractures with carbolic acid, had its foundation on sound principles. The course of healing m cases so treated was as favourable as that of simple fracture. It was naturally not at once that Lister elaborated a fully satisfactory technique. NAt first the wound was well swabbed with undiluted carbolic acid, then covered with a paste made by mixing blood clot and carbolic acid. Later, putty was used instead of blood, or a paste of carbolic acid and flour or starch. The air was kept from the wound by a layer of block tin over the putty mass. The carbolic acid first used was very impure, and seemed to be insoluble m water /so that Lister tried many combinations m the^form of plasters Tor ointments. When a purer drug was obtained, it was found to be much more soluble m water, and solutions of varying strengths were used, such' [as are still m use m modern hospitals. With gradual improvement m the details of his methods, better and quicker results were obtained. A French surgeon, visiting Lister's wards about this time was struck, not only by the absence of inflammation m wounds, but by the remarkable absence of pain. The anesthetic action of carbolic acid had been early apparent. Lister's first efforts were directed against the harmful effects of the air and its contents, and under the impression that the chief risk of infection of wounds lay m the access of germ-containing air ; a spray of weak carbolic lotion was constantly sprayed upon any part under operation. It was a clumsy and uncomfortable procedure, for operator and assistants shared m the distribution of the sprayed moisture ; but for many years the use of the carbolic spray was regarded as an

essential part of Lister's methods. Gradually the part played by aerial germs was accorded less and less importance, and the spray was abandoned, while more attention was paid to the disinfection of the hands of the surgeon, the skin of the patient, and other things which might come into actual contact with the wound. The recognition of the value of Lister's methods of treating wounds did not come at once. Prejudice, and a disbelief m the power of sWh minute organisms to effect so great an evil, for years prevented the general acceptance of the principles of antiseptic treatment % Lister returned to, Edinburgh m 1869 as successor to Professor Syme, and eight years later to London as Professor of Clinical Surgery at King's College ; but as late as 1884 a standard text book spoke sceptically of the benefits of his method. During the FrancoPrussian war (1870) individual surgeons applied Lister's methods with success. Pasteur, whose patriotism was unbounded, had the mortification of knowing that, while the French surgeons were working on old lines and a tremendous mortality was continuing among the French wounded, some of the German field hospitals were equipped on the principle which an English surgeon had founded on his own work, and were obtaining incomparably better results. Lister's development of the details of antiseptic methods was progressive. The work was continued by his pupils, and as the details have become more and more exact, so it has become possible for the first place m certain departments of surgery to be taken by what we call aseptic methods, m which the direct application to the wound of irritating antiseptics is avoided.