Antisepsis
Antisepsis is the destruction or inhibition of growth of microorganisms on living tissue. Antiseptics are the substances that carry out antisepsis. Real understanding of the nature and use of antiseptics was not possible until the discovery of bacteria.
From the earliest times, physicians and healers were aware of the anti-infective and anti-spoilage properties of certain substances. Egyptian embalmers used resins, naphtha, and liquid pitch to decrease body decay, along with oils and spices. The ancient Greeks and Romans recognized the antiseptic properties of wine, oil, and vinegar. Balsam, an antiseptic of both southeast Asia and Peru, came to Europe in medieval times and remained in use in Europe through the 1800s. Turpentine was a favored antiseptic of the Middle Ages.
A thirteenth-century surgeon, Theodoric Borgognoni (1205-1298; Theodoric of Bologna), recommended dressings dipped in wine to ward off the development of pus in wounds. The eminent English physician Sir John Pringle (1707-1782) published a series of papers titled "Experiments Upon Septic and Antiseptic Substances (1750-52)" which contains one of the first uses of the word antiseptic (from the Greek anti, "against," and sepsis, "decay"). Genevieve Charlotte d' Arconville introduced the use of chloride of mercury as an antiseptic in 1766. After iodine was discovered in 1811 by Bernard Courtois (1777-1838), it became popular as an antiseptic treatment for wounds.
However, none of these antiseptics, nor any others, were sufficient to prevent the almost inevitable infection of wounds, particularly following surgery. Amputations, for example, were common in the 1800s, especially in cases of compound fracture, yet they yielded a 40 to 45 percent mortality rate. The introduction of anesthesia in 1846 aggravated the problem, as it permitted more invasive and lengthy surgical operations, increasing tremendously the likelihood of postoperative infection.
Another deadly form of infection was puerperal, or childbed, fever, a streptococcus infection of the uterus that struck women who had just given birth. As hospital birth attended by doctors became more common, epidemics of puerperal fever raced through maternity wards, sharply increasing maternal death rates. Most obstetricians were totally baffled by the causes and possible prevention of this fever.
The reason for this epidemic of infections in hospitals lies in the lack of knowledge about the existence of bacteria until Louis Pasteur's discoveries. Physicians, and surgeons in particular, had no concern for cleanliness. They wore unwashed street clothes or filthy operating gowns, used unclean instruments, and did not wash their hands before examining or operating on patients--even going from a postmortem on an infected corpse directly to examination of a fresh patient. Many took pride in the accumulation of blood and pus on their medical garments.
Attempts to understand and stop puerperal fever brought some of the early advances in antisepsis. Dr. Charles White (1728-1813) of England in 1773 recommended antiseptic injection in some and strict cleanliness in all cases of childbirth. The Scottish physician Alexander Gordon (1752-1799) advocated hand and clothes washing for obstetricians in 1795. Dr. Oliver Wendell Holmes of the United States presented his conclusions about the spread of puerperal fever by unwashed doctors in 1843. The Hungarian doctor Ignaz Semmelweiss made the same discovery in 1847. When he required his students to wash their hands in an antiseptic chloride solution before examining patients, maternal mortality rates plunged from a high of eighteen percent to a low of nearly one percent.
Unfortunately, while Semmelweiss was correct about the transmission of infectious materials, he could not explain what those substances were. Pasteur pointed the way. In his studies of fermentation, Pasteur proved the existence of airborne microorganisms in the 1850s. Joseph Lister applied this new knowledge of bacteria to develop a successful system of antiseptic surgery, a tremendously important innovation that released surgery from the limitations imposed by the threat of infection.
Concerned about the high rate of infection after surgery, Lister—an English physician--studied wound healing, aided by microscopic analysis. After reading Pasteur's work, Lister concluded that microorganisms in the air caused the infection of wounds. Drawing on a report of the effects of carbolic acid on sewage bacteria, Lister developed an antiseptic system using the acid, both spraying the wound and surrounding areas to destroy infectious organisms and protecting the wound with multiple-layer dressings from new invasion by bacteria. He first used the method successfully in an operation on a compound fracture of the leg in 1865.
Lister's antiseptic method was not simple—it involved a series of six essential steps--but it was effective. Lister's published accounts of his successful surgical application of the technique The Lancet in 1867 and ignited controversy, especially since Pasteur's germ theory of disease was still in dispute. Nevertheless, Listerian antiseptic surgery gained adherents worldwide, especially in Germany, where they were applied somewhat successfully in treatment of soldiers during the Franco-Prussian War (1870-71). The United States was especially resistant to the practice of antisepsis. Widespread acceptance came in the 1890s after the German bacteriologist Robert Koch had effectively proven that germs cause disease.
Modifications of and improvements on Lister's techniques were soon developed. The carbolic spray that inundated the operating arena was abandoned in the 1880s in favor of cleanliness, sterilization, and topical antiseptics.
A final obstacle to surgical antisepsis was the human hands: while surgical instruments and dressings can be sterilized, the surgeons' and nurses' hands can only be washed with antiseptics. An American doctor, William Halsted, solved this problem in 1890. Halsted received his medical degree from Columbia University in 1877; he returned to the United States from two years of study in Europe as a convert to the Listerian method of antisepsis. After breaking an addiction brought on by his experiments with cocaine as an anesthetic, Halsted became chief of surgery at Johns Hopkins Medical School. There, he pioneered the use of rubber gloves in surgery to protect his head nurse, Caroline Hampton, from the antiseptic that was irritating her hands. Today, of course, sterile gloves are a requirement for surgical procedures.
Modern methods of preventing infection are very different from the techniques pioneered by Lister and others. Antibiotics, penicillin, and sulfa drugs fight infection internally, and aseptic methods such as sterilization prevent bacteria from existing in a given area. Nevertheless, external antiseptics continue to be important and are a lasting monument to Lister's vision.
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