Paréian and Listerian Slants on Infection in Wounds

PARÉIAN AND LISTERIAN SLANTS ON INFECTION IN WOUNDS DONALDJ. FERGUSON, M.D.* "During the last seventy years surgery has become a new art which differsfromthat ofpreceding times in that it is basedupon a surer scientific basis. This speedy advance has been due to several causes. First and foremost was the avoidance ofinfection which became possible owing to the discoveries ofPasteur and their application by Lister" [i]. This statement by Sir Zachary Cope, published in 1953, seems to imply that bacterial contamination alone is sufficient to generate infection in surgical wounds. Such a view probably finds general acceptance, but it can be qualified by three observations: (1) surgical and traumatic wounds often heal without infection, even when nothing has been done to reduce bacterial contamination ; (2) in spite ofmodern aseptic precautions, bacteria capable of producing infection can be demonstrated in about one-third of surgical wounds, yet only a few become infected [2]; and (3) experiments have shown that large numbers ofvirulent organisms put into surgicalwounds in animals do not infect when adequate attention is paid to details of making and closing the wound [3, 4]. In a more comprehensive view, therefore, avoidance of infection in surgical wounds perhaps should not be attributed entirely to the "discoveries ofPasteur and their application by Lister." Pare and Lister In the early sixteenth century, gunshot wounds were cauterized by application ofboiling oil, which was thought to destroy poisons. Copiously applied, this treatment was capable of sterilizing the wound, but only at the expense ofcreating a deep burn, which delayed healing and promoted later infection, to say nothing of the pain it caused. Ambroise Paré, a young French army surgeon, was instructed to use this method during a * Department ofSurgery, University ofChicago. 63 campaign in Italy in 1536 [5, p. 63]. The casualties were so numerous that he ran out of oil. Being obliged to substitute a blander mixture of egg yolk, oil ofroses, and turpentine to dress wounds, he discovered that they remained less painful and swoUen than those which had been cauterized. He subsequently led a reform in treatment, eliminating the use of hot oil, and he also revived the use ofligatures to stop bleeding, in place of the heated metal cautery. This was a further advance in the care oftissues as weU as in hemostasis. Paré represents a surgical contingent looking primarily to the protection ofliving tissues, while Lister represents those mainly concerned with an attack on contaminants ofthe wound. Listerians include not only a majority of doctors, but nearly aU bacteriologists, nurses, hospital administrators, and manufacturers ofdrugs. Joseph Lister (1827-1912), "horrified by the appaUing sepsis and mortality that foUowed operations in city hospitals, was stimulated to try and find the cause. The problem was essentiaUy one of interruption of the process ofwound healing. A surgical incision made elsewhere than in a crowded hospital could, even in those days, heal quickly and cleanly. Surgeons in country practice or operating in a private house seldom met the frightful sepsis that ended fatally or mutilated horribly" [6]. After Pasteur showed that putrefaction was caused by bacteria, Lister employed phenol as an antiseptic, applying it to traumatic wounds and spraying it into the air during operations. Although he probably reduced the incidence and extent of infection in hospitals, phenol injured normal tissue and caused systemic poisoning of patients and surgeons. Control of infection at the present level awaited fuU development ofaseptic methods, antiseptics and antibiotics, discovery of the principle of debridement in traumatic wounds, and other improvements in surgical technique. Surgical Infection Infection in a wound is manifested by pain, sweUing, redness, local warmth, fever, and discharge ofpus from which bacteria can be cultured. Consequences to the patient may be smaU ifthe process is localized and if it is promptly and adequately drained. In a few cases there is a dangerous spreading process, septicemia, secondary renal or cardiac damage, or herniation ofthe wound. Although there are individual variations in resistance , most human beings are susceptible to the strains ofstaphylococci, streptococci, and gram-negative baciUi that are cultured from infected 64 DonaldJ. Ferguson · Infection in Wounds Perspectives in Biology and Medicine · Autumn 1970 surgicalwounds. Hemolytic streptococciwere the notorious cause ofmost hospital infections in the...