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In the late 19th century, with the development
of germ theory by Louis Pasteur and its subsequent application to surgical
sterility by Joseph Lister, surgeons were able to operate with a substantially
reduced risk of infection. Infection was the major contributor to morbidity and
mortality rates, occurring after practically all operations and taking the
lives of almost half of all surgical patients. The earliest known attempts to
access the calvaria date to circa 10,000 BC. Skulls collected throughout the world
show the square and ovoid marks left by the ancient "healers" who
ground and scraped the skull with sharpened stones. Some patients survived, as
evidenced by the smoothed corners of some Neolithic skulls found in East
Africa.[4, 17] Nevertheless, it may be assumed that the mortality and morbidity
rates were less than acceptable by today's standards.
Some years after the Neolithic era, surgeons
may have taken a more conservative approach to opening skulls. Under the
guidelines imposed by The Code of Hammurabi (circa 1750 BC), surgeons in
Mesopotamia were provided monetary compensation for their services; however, if
the patient died under their care, the surgeon's hands were amputated.[7] With
these stakes, many surgeons may have limited their caseload of elective
surgical procedures. Around this time the first account of attempted wound
management appeared. The world's oldest medical text outlines the procedures
for wound management practiced by the Sumerians. The wound was cleansed with
beer and then bandaged with a cloth soaked in wine and turpentine.[4] The
practice of using alcoholic beverages and turpentine would remain the treatment
of choice until the modern era.[1]
The proliferation of medical texts originating
from the Golden Age of Greece would provide guidelines for the practice of
medicine for 2000 years. Nevertheless, because of the intellectual rigidity of
the medical community, expansion on the ideas and practices of the Greeks would
remain stagnant for the same two millennia.[7] Every few hundred years,
courageous men dedicated to the practice of the healing arts would challenge
the false assertions and even produce verifiable data to support their claims,
but their ideas would not wield the influence necessary to cause change. In the
practice of wound healing, two issues would become recurring points of
contention: first, the role of suppuration; and second, the origin and
transmissibility of infection.
As recounted in Alexander,[1] more than a
century before Leeuwenhoek's microscope and three centuries before Pasteur's
studies on putrefaction, Hieronymus Fracastorius (1478–1553) postulated that
the cause of infectious disease was from invisible living seeds ( seminaria
contagionum ). In his work, "De contagione," published in 1546, he
described three modes of disease spread: direct contact with infected persons,
indirect contact with fomites, and airborne transmission (see Meade).[11] As
Hamby[8] reported, Ambroïse Paré (1510–1590), considered the father of modern
surgery, similarly believed infection was introduced from the environment.
Furthermore, others after Fracastorius and Paré correctly noted the importance
of a sterile environment in the prevention of disease transmission. In 1822
Gaspard demonstrated the pathogenicity of suppuration by injecting pus into a
dog, and when that dog fell ill, injecting its blood into another animal,
causing death. According to two histories of surgery,[11, 17] in 1842 Oliver
Wendell Holmes of Harvard recommended that physicians wash their hands with a calcium
chloride solution to prevent the spread of infection from the autopsy rooms to
the wards. Similarly, Ignaz Philipp Semmelweis (1818–1865), in his attempt to
universalize the practice of hand washing, reported that hand washing with
chloride of lime solution reduced puerperal sepsis mortality from 9.92 to 1.27%
in 2 years. The views of both Holmes and Semmelweis encountered a cold
reception from the medical community.
Joseph Lister (1827–1912; In April 1867 he
published his ground-breaking paper on antisepsis, stating that "all the
local inflammatory mischief and general febrile disturbance which follow severe
injuries are due to the irritating and poisoning influence of decomposing blood
or sloughs." Lister began applying carbolic acid to compound fracture
wounds. The wound healed without suppuration, amputation was averted, and the
mortality rate from amputation plummeted from 45 to 15%.
Keen was one of the few surgeons who realized
the practical importance of infection control, and he became one of the first
American surgeons to implement Lister's system.[7] The following is a
description of Keen's surgical setup:
All carpets and unnecessary furniture were
removed from the patient's room. The walls and ceiling were carefully cleaned
the day before operation, and the woodwork, floors, and remaining furniture
were scrubbed with carbolic solution. This solution was also sprayed in the
room on the morning preceding but not during the operation. On the day before
the operation, the patient's head was shaved, scrubbed with soap and water, and
ether, and covered with wet corrosive sublimate dressing until operation, then
ether and mercuric chloride washings were repeated. The surgical instruments
were boiled in water for 2 hours, and new deep-sea sponges (elephant ears) were
treated with carbolic and sublimate solutions before usage. The surgeon's hands
were cleaned and disinfected by soap and water, alcohol, and sublimate
solution.
in 1891 Ernst von Bergmann introduced heat
sterilization of instruments, which proved superior to chemical sterilization.
Sterile gowns and caps were introduced in 1883 by Gustav Neuber of Kieland, and
then the surgical mask by Mikulicz in 1897. The use of rubber gloves became
widespread after 1890 when William Stewart Halsted (1852–1922;) commissioned
the Goodyear rubber company to fashion gloves for his nurse to protect her
hands from the mercuric chloride solutions used to disinfect the instruments.
Harvey Cushing (1869-1939), under the tutelage
of William Halsted, became committed to precision and meticulous surgical
technique, producing phenomenal results. In 1915, of 130 surgically treated
tumor cases, he reported an 8.4% mortality rate. Of these deaths, only one was
due to infection; the patient died of streptococcal meningitis on the 6th day
postsurgery. Cushing explained his success this way:
[Our results] depend so greatly on
such details as perfection of anaesthesia, scrupulous technique, ample
expenditure of time, painstaking closure of wounds without drainage, and a
multitude of other elements, which so many operators impatiently regard as
triviality.
