Chapter Three - How do we know that treatments are safe?

Luer recently remarked that he survived due to being deposited in a museum, even if he felt that he was in his coffin. At least, unlike billions of other destroyed syringes, he could reminisce with the other museum syringes about all the changes they had seen!

This chapter’s memories cover early patients’ fears, such as the pain of injections and risk of infections after the injection. Luer relates that, following the general recognition of the ‘germ theory’ of disease from the early 1880s, syringe-related infections likely declined. However, general confidence from the public in adequately sterilised syringes and needles still took decades to achieve!

Luer witnesses the frustrations of physicians and patients on this matter. For instance, textbooks would have limited advice about sterilising syringes and needles, or contradict the physicians own positive experience with the matter. So it is hardly surprising that patients found inconsistencies among different practitioners’ methods. However, the differing methods and differing advice would not have done much to make people confident in this way of administering medicine…

Ouch!

A cry I have often heard – ‘ouch, that hurt!’ Father saw that fear of needles, and the abscesses and inflammation that could follow, from the 1860s onwards.

Blame over pain or infection was often due to blunt, dirty, rusty or unsharpened needles, unclean syringes, even the poor health of some patients. Some injections, too, were particularly painful. I remember mercury preparations to treat syphilis sent some patients into great agony, never to return.

 

Pointing abscess on the knee. St Bartholomew’s Hospital Archives & Museum. CC BY 4.0.

I must say, while some physicians had few injection abscesses, others had many. Some, no doubt, were likely due to carelessness of the physician. Once, an abscess appeared after the needle of my father’s syringe snapped, leaving the tip under the skin! His physician blamed the patient for pulling her arm away, but, truthfully, he was not paying attention!

Physicians often blamed self-injecting patients for most abscesses and bad scarring. 

Did patients feel safe?

The Doctor, Leon Salles (after Fildes). Wellcome Collection. CC BY 4.0.

I remember that until well into the 1900s, physicians might overlook minor problems and claim their injections rarely produced any side effects! Horror stories of infections were dismissed or attributed to a peculiarity of the patient, not to incompetent physicians.

Improvements only came later, with constantly revised guidelines based on new understandings of bacteria, contamination and transmission. 

For a long time, we instruments in the physician’s office heard of different ‘resistances’ of bacteria and bacterial spores – imagine! The older generation of us Luers tell stories Some were not beaten by heat (a quick and easy trick was to hold the instrument over a flame), some were even not affected by new antiseptics or disinfectants! The physicians were talking about ‘cross-contamination’ (apparently we could pass diseases between one another!) and virus ‘transmission’. They were trying to work out how diseases moved among people and what we could do to stop it.

Luke Fildes’ iconic picture, The Doctor (1891), has long been considered to capture ideals of a general practitioner. It also reminds us of difficulties in practice, certainly on house calls, in following advice on sterilising a needle by dipping it in alcohol, and then flaming it over a spirit lamp.

Lots of new guidelines came in, such as handwashing and increased hospital sanitation. Unfortunately, guidelines were not always followed – I know some hospitals just did not have the resources to sterilise all their equipment! 

In fact, only by the late 1950s with the introduction of disposable syringes could patients have complete confidence in the sterile injections…

The problems with sterilising...

I came into use at an interesting time. The ‘germ theory’ of disease, catalysed by Louis Pasteur’s studies, had been generally accepted some years earlier, around 1880.

This was the theory that certain diseases are caused by microorganisms invading the body. These organisms were too small to be seen except through a microscope. Some people were still critical of this theory. 

During the 1870s, controversies flared among researchers over sterilisation techniques. 

Much of this reflected the growth of specialist areas of medical science such as bacteriology.

John Tyndall. Pencil drawing. Wellcome Collection. Public Domain.
Louis Pasteur in his laboratory, looking through a microscope. Wood engraving by A. Marie, 1885. Wellcome Library no. 568853i.

 One key player was John Tyndall, not a physician, but a physicist. His introduction of intermittent sterilisation ─ it came to called Tyndallisation, if I recall correctly ─ added significantly to understanding sterilisation. 

However, translating all the research being done into everyday practice was hard. Differing opinions continued over the use of antiseptics & disinfectants versus heat (boiling, steam, steam under pressure, dry heat) to ensure sterile injections. I know some physicians continued to feel that heat (such as boiling) was not suitable for all syringes or needles. 

These worries were exacerbated by the growing numbers of injections for new treatments and for prevention (such as, antitoxins, vaccines and insulin), and by the increasing instances of this ‘creoss-contamination’.

Cross-contamination: a critical issue

Hints of cross-infection problems emerged in the 1860s, but only received general attention when the germ theory of disease (not solely from bacteria) was fully established.

But then, over decades, sterilisation methods failed to deal with the problem adequately until change was precipitated by catastrophic outbreaks of infectious diseases during World War II. Some were linked to use of human serum in vaccine production, others to contamination through needles and syringes.

Reviews and studies from 1945 onward focused attention on changing existing practices and habits (for instance, to always changing needles between patients), and demands that hospitals establish central sterilising services.

In 1951 Sir Alexander Fleming, of penicillin fame, confirmed that not only needles could account for cross infection, but also syringes. Without stating as much, he clearly agreed with others that while risks from injections were small, “potential danger” remained.

Unfortunately, Fleming’s recommended means of sterilisation (hot oil) was not convenient in general practice.

Unquestionably, the immediate post-war publicity helped to foster immediate acceptance of disposable syringes in the 1950s (see chapter 5).

(Left, above) Hypodermic syringe with spare needle and decorated metal case. Mid-late 19th century. Science Museum, London.
(Left, below) Syringes. Adrian Wressell, Heart of England NHS FT. Attribution 4.0 International (CC BY 4.0)

The Lister Institute of Preventive Medicine Calf Lymph in metal tubes. Wellcome Collection. Public Domain Mark.
Circular sterilising drum, 1930s, for dressings and minor surgical instruments. Buckwell, E. W. C. Science Museum Group. CCBY-NC-SA

Here are various ways of sterilising. The Lister Institute advertises a new packaging process for the Smallpox vaccine involving metal tubes, which claims to be more sterile and have increased potency. 

The Lister Spray was to sterilise rooms during surgery, and items such as the bath and drum often used heat to sterilise equipment. 

Carbolic steam spray used by Joseph Lister, England, 1866-18. Science Museum, London. Attribution 4.0 International (CC BY 4.0)

“Imagine you’re working in a large hospital in 1867…  It’s your job to operate the spray while both you watch Joseph Lister perform surgery. The patient has an open fracture of the leg – the bone is visible and at risk of infection… The way infection spreads is not fully understood, but Lister knows that since he started using carbolic acid fewer patients’ wounds have become infected.” – Wellcome Collection.

Metal Sterilising Bath for syringes. 1900-1980. Institute of Medical Labratory Sciences. Science Museum Group. CCBY-NC-SA

Dosage

Handwriting of prescriptions... can you read it?

Often, my father overheard patients asking why they became addicted to morphia but their friends did not. The physician would respond that it all depended on dosage and length of treatment, though I was not convinced. 

Appropriate dosage of morphia was an issue. One peculiar advertisment for some hypodermic tablets read: “We would suggest to the profession the necessity for caution” over the large doses sometimes recommended (½,¾, and even 1 grain.) Such doses were indeed large and apparently employed by some physicians as their “usual dose.” 

Father told me that it was recognised that this exposed patients to the danger of ‘narcotism’ and possible death.

Accurate dispensing by a chemist was also important, perhaps correctly reading a doctor’s handwriting!

Safe physicians?

I have told you that some practitioners did not always follow guidelines.  Maybe they were out-of-date, or over-confident in their methods… Father told me he felt it was hard for patients to recognise the ‘safe physician’. But he did say that medical education standards had improved by the end of the 1800s.

I have often felt, as I still do, that it is to know just how much confidence a patient has with a physician after a visit. Perhaps it is a change for the better that, nowadays, patients are more comfortable in asking questions.  

As a side-bar, father was fascinated by 19th-century physicians (real or not!) who were serial murderers. Although certainly the infamy and salaciousness of news-reporting would scare many…

Whether Jack the Ripper (occasioning vigilante groups in 1888 as shown here) was one has vexed many minds. Vexing, in a different way, is the recent story of general practitioner, Harold Shipman. The unfortunate question arises: Does the medical profession attract some people with a pathological interest in death?

 
A wealthy and well-dressed doctor; suggesting he has a large number of patients. Wood engraving by J. Orrin Smith after J.K. Meadows, 1840. Wellcome Collection. Public Domain.

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