ASEPSIS and ANTI-SEPSIS

Attention to hygiene can be traced back to the Ancient Hindus, who left examples in the Indus Valley - dating from 2000BC - of waste removal, steam baths and swimming pools(1). Hindu surgeon, Susruta, in 600BC, published an account of surgery, insisting on extreme cleanliness. Hippocrates (460-370BC) advocated aseptic methods with attention to absolute cleanliness and advised surgeons to thoroughly cleanse their hands before operating. Hippocrates believed in avoidance of greasy dressings of wounds and promoted wounds to be in a dry state, but if a wound had to be irrigated then only water which was pure and boiled should be used(2).

Celsus in his `De re Medica`, in 53AD, wrote "Let nothing be undertaken until the inside of the wound has been cleared, lest any congealed blood remain within it. For this will turn to pus and cause inflammation which will prevent the wound from healing"(3)

Galen (131-201AD), an animal experimenter in Rome, put forward the idea that formation of pus was an essential part of the healing process(4). His "laudible pus" theory was taken up, with the result that human wounds were allowed to become contaminated(5). Because Galen was held in high regard, his "laudible pus" theory continued to be used for centuries(6).

Theodoric of Cervia worked at the Univeristy of Bolgnia and in the 13thC AD published his `Chyrurgia`, in which he described the use of simple dressings to treat wounds, maintained that pus was not an essential part of the healing process, and that messy applications hindered healing(7). This was the first attack on Galen`s doctorine, which was denounced by Andreas Versalius in his `De humari corpus farica libri septem` of 1543(8).

Meanwhile, in 1536, Ambroise Pare had treated wounds with a mixture of egg yolk, oil of roses and turpentine, which caused little pain and the treated wounds of the human patients were not inflammed(8).

The term "antisepsis" was coined by John Pringle, an army surgeon, in 1751, to describe substances which resisted putrefaction in wounds(9). But despite this, the standards of health care in hospitals of the 18th century were poor - so much so that from 1775 to 1796, only 45 out of 10,339 infants survived in a Dublin hospital(10), and overall hospitals "sank to the lowest level known in the history of medicine"(11). During this period, John Howard visited English and Welsh jails, and in 1777 wrote a report recommending baths, soap and water, ovens for disposal of louse-ridden clothing, and segregation of the sick from the healthy(12). In 1789, Howard reported on his vists to hospitals, describing the stench and lack of hygiene measures he had found(13). It was not until later that his recommendation for improvements in prisons were adopted by hospitals, together with fumigation, ventilation and lime-washing of wards(14).

Alexander Gordon practised and taught at Aberdeen University from 1786 to 1795. During this time, from December 1789 to March 1792, an epidemic of puerperal fever broke out. In 1795, Gordon wrote a small book in which he noted 77 cases of the disease and recorded that 28 patients had died. He established that the cause was not due to a noxious constituent in the atmosphere but was transmitted from one patient to another by doctors or midwives - as carriers, as they were not, themselves, affected(15). Gordon argued that "this disease, seized such women only, as were visited, or delivered,by a practitioner, or taken care of by a nurse,who had previously attended patients affected patients affected with the disease" and concluded "the cause of the puerperal fever, of which I treat, was a contagion or infection altogether unconnected with a noxious constitution of the atmosphere". Gordon advocated that steps should be taken to prevent the disease and "the nurses and physicians who have attended patients affected with puerperal fever ought carefully to wash themselves and to get their apparel properly fumigated before it be put on again"(16).

John Bell, in 1801, wrote "In hospital... the patient sinks almost inevitably under the suppuration [formation of pus] of a compound fracture"(17). At the time, some surgeons still taught that formation of pus was one of the essential processes of healing - a legacy from the days of animal experimenter Galen - and various methods of treatment were suggested(18) - the "open method", whereby the wound was left uncovered, believing that this promoted the formation of a "healthy" scab, so that the wound would heal without incident(18); the "occlusion method", aimed at keeping air out of the wound by covering it, but which meant that poisons were trapped under the dressing and entered the blood-stream of the patient, with disastrous consequences(19); "water dressings" - suturing the surface of the wound and applying bandages soaked in water - if pus did develop, the sutures were removed and a poultice was applied; "irrigation method", immersing the wound or the patient in water to sooth inflamed wounds and help remove discharges from the wounds; "fresh air regime" where hospital windows were left open - but the practice of washing, disposal of infected articles, and sweeping of floors was less common(20).

Surgical operations increased five-fold with the introduction of anaesthetics, but about two-thirds of the total number of deaths was due to sepsis(21). Eventually, surgeons began to agree that sepsis was favoured by dirt and by formation of pus in the wards(22), but they did not realise that they themselves were poisoning their patients - the probe, used for examining wounds, was never steralized and pieces of cord, used for suturing, hung from old frock coats, encrusted with blood and pus, which might not be changed for over a year(23).

In 1840, James Simpsom was teaching his students that puerperal fever was communicated from one patient to another by the doctor or midwife carrying the disease. Simpson noted that the lack of cleanliness and fresh air seemed to promote the disease and advocated reforms such as smaller, airier and less crowded wards. But this was seen as very costly, and doctors remained unconvinced that doctors or nurses could "carry" puerperal fever from one patient to another. At that time, some 3000 mothers were dying from puerperal fever every year in England and Wales - equivalent to a death-rate of one in 210 confinements. Oliver Wendall Holmes published, in 1843, a pamplet on "The Contagiousness of Puerperal Fever", based on a wide knowledge of the medical literature in France (where he had studied), Britain and America. Holmes also emphasised the work of Gordon and re-stated his case. But Holmes`s work attracted little attention, until he was attacked by C L Meigs, an American obstretician, who felt insulted that doctors and midwives were being blamed for spreading puerperal fever. Meigs attributed the deaths - attributed to puerperal fever - to accidents or providence rather than a contagion(24).

During the 1840s, Ignaz Semmelweiss was an assistant in the obstetrics department of the General Hospital in Vienna, Austria. The department had two divisions - one attended by medical students under instruction, the other attended by trainee midwives. The overall death-rate of pregnant women, who had been admitted to the hospital was between 5 and 10 per cent. Semmelweiss found that - for the period 1841-1846 - the death-rate for those attended by medical students was 9.92%, whilst for those attended by midwives the death-rate was 3.38%. In 1847, a colleague of Semmelweiss died of septicaemia - resulting from a cut to his hand during a post-mortem examination. Semmelweiss noted that the cause of death of his colleague was identical to puerperal fever. He deduced that in all cases of peurperal fever, the cause was the same - infection transmitted from a dead body. Semmelweiss was then able to explain the differences in mortality - it was higher in those women who had been attended by medical students who had come straight from the dissecting room to the ward without washing their hands. With this information available, Semmelweis put forward his theory that infected material from a dead body was the only cause of puerperal fever. He insisted that everyone passing from the dissecting room to the wards should first their hands in chlorine water or chlorinatedl lime. This asepsis measure reduced maternal mortality in Vienna(24).

 Joseph Lister became interested in wounds and the formation of pus. From 1853, he published papers on his animal experiments and in 1857 investigated inflammatory changes in circulation in the web of feet of frogs and in the wings of bats(25). He, later, claimed that his early experiments on the blood of animals "had the effect of giving me a kind of pathological information without which I believe I could not by possibility have made my way in the subject of anti-sepsis"(26).

Having read of Pasteur`s "germ theory"(27), Lister set out to destroy the germs in a wound(28), by chemically destroying unwanted micro-organisms(29). To test Pasteur`s theory, Lister used in vitro methods(30) - but, like Pasteur, Lister erroneously believed that pathological organisms were entirely carried by the air(31) so germs in the wound had to firstly be destroyed before tackling the affected air(32). In his quest for an agent to destroy the germs, Lister hit upon carbolic acid(33). Lister`s first paper on antisepsis described 11 patients treated with carbolic acid(34) - two suffered from "hospital disease", one of whom died, and one had a limb amputated(35).

Lister introduced the idea of lint soaked in undiluted carbolic acid in March 1867 - but this proved to be irritating, causing death of the tissue with which it came into contact. After failure in many experiments, Lister came up with the idea of replacing lint covering with a putty of carbonate of lime mixed with a solution of one part of carbolic acid in four parts of boiled linseed oil(36). In 1869, Sir James Paget reported in the `Lancet` of a patient having been operated on for a compound fracture. Carbolic "putty" was applied, and three days later "after the manner in which has so strongly recommended by Prof Lister [the limb had become] swollen, tense, very hot, and very painful... [showing] all the signs of very acute fever"(37). By 1870, the original dressing of a crust of blood and carbolic acid; dressings of lint dipped in carbolic acid; and "putty" dressings had all been abandoned(38).

Having used long ligatures hanging from the wound to drain discharges(39), from 1868 onwards, Lister conducted experiments to try and improve ligatures. At first, he tried soaking silk thread in carbolic acid for two hours before use, but this was largely unsuccessful and so turned to catgut made from the small intestine of a sheep, and in 1869 began a series of animal experiments. He tied the carotid artery of a calf with catgut. A month later the calf was killed and Lister found that the catgut had disappeared(40). But when this method was used clinically and failed, Lister blamed the poor results or failure on the practitioner not the method(41).

By 1870, Lister had become concerned over exposure of a wound to "septic air" whilst a dressing was being changed. He devised a spray of a one-in-forty solution of carbolic acid which could be applied by syringe to the surface of a wound from the moment that the dressing was removed until it was replaced by another. A year later, Lister introduced his carbolic acid spray, at first operated by hand, then a foot-operated pump was introduced(42). In 1872, Lister developed a steam-powered spray which was capable of filling the whole of the operating theatre with carbolic acid - but carbolic acid soaked the hands of the surgeon and the patient; everyone present inhaled the vapour which made them sick; the spray released acrid chlorine gas which immediately affected the nose, throat and eyes of the surgical staff(43).

Lister attended several meetings but his method was either criticised or ignored. By the mid-1870s, many London surgeons had given Lister`s method a prolonged trial but had rejected it. Lister disliked statistics and was accused of suppressing data. Nevertheless in 1879, he allowed Watson Cheyne to pubish statistics on the use of his antisepsis method. At this time, Sir James Paget noted that mortality in his own operations had continued to fall - from over 15% for 1847-57; to 10% for 1857-67; down to less than 5% for 1867-77. This decline in mortality was not due to antisepsis but because the practices of bleeding, leeches,and purging had been abandoned, and sanitation and asepsis measures had improved(44).

Around 1880, Dr Lawson Tait had turned away from Lister`s antisepsis method towards asepsis. Instead of application of Lister`s carbolic acid to the surface of the skin at the site of the operation, Tait replaced this with thorough cleansing of the site of the wound with soap and water; instead of Lister`s method of soaking the hands in carbolic acid, Tait paid attention to his own preparations - washing his hands with soap and hot water, and scrubbing his nails with a brush; instead of, as Lister had done, merely removing his jacket and pining an unsteralized towel to his waistcoat, Tait wore a large, clean mackintosh; instead of Lister`s method of a constant supply of carbolic-soaked towels and spraying carbolic acid around the operating theatre, the wounds and the surgical instrument, Tait used clean towels, and cleaned the area he was operating on, and used clean, washed instruments; instead of treating sponges with carbolic acid  to mop up blood and fluids, Tait used a solution of washing soda; instead of using Lister`s carbolised catgut sutures, Tait used silk- which had been steralized by boiling; instead of Lister`s carbolised dressings which were applied after the operation, Tait relied on clean, dry dressings(45).

Ernst von Bergmann, a German surgeon, first suggested steam steralization of surgical instruments(46), and introduced in 1886, having gradually merged the corrosive sublimate method(47). Von Bergmann also moved from the antispesis process of germ-destruction to the asepsis method of working germ-free from the begining of his operations(48).

Towards the end of the 19th century, refinements were bringing about an acceptance of the asepsis method, with particular attention to cleanliness and disinfection by the surgical team, of the patient, of the operating theatre, and steralization of the surgical equipment and instruments(49). By 1900, many surgeons had changed to asepsis, and by the end of World War I (ie 1918), only a few "old-guard Listerians" still held on to the belief in antispesis(50).

refs

1. Venzmer,G. 5000 Years of Medicine. Macdonald. 1972.

2. Garrison,FH. History of Medicine. WB Saunders.1929.

3. Celsus. 53AD. quoted in Margotta,R. Hamlyn History of Medicine. Hamlyn. 1996.

4. Guthrie,D. A History of Medicine. Nelson. 1945.

5. Wingate,P [ed]. Penguin Medical Encyclopaedia. Penguin. 1976.

6. Garrison,FH. History of Medicine. WB Saunders. 1929.

7. Bishop,WJ. The Early History of Surgery. Robert Hale Ltd. 1960.

8. Margotta,R. Hamlyn History of Medicine. Hamlyn. 1996.

9. Shepherd,J. Lawson Tait - the Rebelious Surgeon. Coronado Press. 1980.

10. Cartwright,FF. A Social History of Medicine. Longmans. 1977.

11. Garrison,FH. History of Medicine. WB Saunders.1929.

12. Lloyd,WEB. A Hundred Years of Medicine. Paperduck. 1971.

13. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

14. Lloyd,WEB. A Hundred Years of Medicine. Paperduck. 1971.

15. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

16. Gordon,A. A Treatise on the Epidemic Puerperal Fever.1795. quoted in ibid.

17. Bell,J. The Principles of Surgery. vol 1. 1801.

18. Lloyd,WEB. A Hundred Years of Medicine. Paperduck. 1971.

19. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979. 

20. Lloyd,WEB. A Hundred Years of Medicine. Paperduck. 1971.

21. Cartwright,FF. A Social History of Medicine. Longmans. 1977.

22. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

23. Lloyd,WEB. A Hundred Years of Medicine. Paperduck. 1971.

24. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

25. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979. 

26. Lister, Lord J. evidence before Royal Commission on Vivisection. 1 Nov 1875

27. Loyd,WEB. A Hundred Years of Medicine. Paperduck. 1971. 

28. Williams,G. The Age of Miracles. Constable & Co Ltd. 1981.

29. Goodman,M. Lister Ward. Adam Higler. 1987.

30. Cartright,FF. A Social History of Medicine. Longmans. 1977.

31. Garrison,FH. History of Medicine. WB Saunders. 1929.

32. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

33. Goodman,M. Lister Ward. Adam Higler. 1987.

34. Lister, Lord J. ward book.cited in ibid. 

35. Lister, Lord J. Lancet. 21 Sep 1867.

36. Godlee,RJ. Lord Lister. Clarendon Press. 1924.

37. Paget,J. Lancet. 1869.

38. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

39. Godlee,RJ. Lord Lister. Clarendon Press. 1924.

40. Williams,G. The Age of Miracles. Constable & Co Ltd. 1981.

41. Lister, Lord J. quoted in Traux,R. Joseph Lister. George G Harrap & Co

42. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

43. Cartwright,FF. A Social History of Medicine. Longmans. 1977. 

44. Youngson,AJ. The Scientific Revolution in Victorian Medicine. 1979.

45. Shepherd,J. Lawson Tait - the Rebellious Surgeon. Coronado Press. 1980.

46. Williams,G. The Age of Miracles. Constable & Co Ltd. 1981. 

47. Garrison,FH. History of Medicine. WB Saunders Co. 1929.

48. Venzmer,G. 5000 Years of Medicine. Macdonald. 1972.

49. Henderson,M. Infection Control. Edward Arnold. 1989.

50. Cartwright,FF. A Social History of Medicine. Longmans. 1977.

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