History Of Wound Management And Advancements In Asepsis
Proper control of wound disease developed around two key moments: the adoption of antiseptic practices from the 1860s and the discovery of antibiotics from the late 1930s. Early Wound Management The earliest known attempts to access the dead date to circa 10,000 BC. Skulls collected all through the world show the square and round marks left by the ancient “healers” who ground and scraped the skull with sharpened instruments. Some people survived, as evidenced by the smoothed edges of few Neolithic skulls found in East Africa.
Nevertheless, it may be assumed that the mortality and morbidity rates were very high and cannot be accepted to modern standards. Few years after the Neolithic era, so called surgeons had taken a more conservative approach to exploring skulls. Under the guidelines in The Code of Hammurabi (circa 1750 BC), surgeons of Mesopotamia were paid for their services; however, if the patient succumbed under their care, the surgeon’s hands were cut. With these high stakes, many surgeons had limited their patients to 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 the alcholol from beer and then bandaged with a cloth drenched in wine and turpentine. The practice of using alcoholic drinks and turpentine would remain the treatment of choice until the modern era.
Pre-Listerian Philosophies
The growth of medical texts originating from the Golden Age of Greece would provide rules for the practice of medicine for 2000 years. But because of the intellectual stringency of the medical society, spread of ideas, principles and practices of the Greeks would remain idle for the next 2000 years. Every few 100 years, bold men dedicated to the principles and the practice of medical arts would challenge the false allegations and even bring out verifiable and acceptable data to support their claims, but their ideas would not make necessary influence to cause change. In the art of wound healing, two problems would be repeated problems: first, the role of pus; and second, the origin and spread of infection. Laudable Pus Hippocrates (circa 460–370 BC) was the first to hold an opinion on pus discharge, saying that the formation of pus was not a natural component in the healing process and should be avoided. Similar to ideas of the Sumerians he management protocol involved: cleansing with alchoholic wine, applying a bandage, and then pouring alchoholic wine on the bandage.
Claudius Galen (circa A. D. 130–200), a surgeon to the gladiators in Pergamum, idealized Hippocrates and championed Hippocratic doctrines in the practice of medicine. Galen was an outspoken proponent for experimentation, encouraging the questioning of established doctrines to expand scientific knowledge. His works on medicine were translated into many languages and became the norm for medical practice until the era that is the modern era. Many of his ideas proved to be correct; however, one very important assumption was terribly false: the formation of pus was an important part of wound healing. This idea was aberration from the Hippocratic principles and practice is one that would haunt surgeons and stop the surgical progress till Listers. 1 1000 years after, Theodoric Borgognoni of Cervia (1205–1298) contradicted Galen’s view of the laudable pus.
Theodoric devoted to finding the ideal conditions for wound healing and came uo with four essentials: bleeding control, excision of contaminated or dead and necrotic material, obliteration of dead space, and careful placement of wound dressing. He proposed that the “laudable” pus should be avoided at all costs. Even then, his ideas were not accepted against the well-known ideas of Galen, he was outcast his church and co- workers. Galen’s principle of suppuration would remain the steadfast principle on wound management till late 1800. Wounds could be classified into two different categories: those with suppuration and those without. Wounds productive of pus would run a very long course, some may take many months to heal, these kind of patients will generally will have smooth overall course. were as a patients wound with a thin watery secretion will was associated with the patient dying of sepsis within days. With an infection rate of almost hundred percent, a wound with pus discharge represented the lesser of the two evils. Therefore, it is of little wonder that even the most carefull surgeons preferred and even encouraged the formation of pus.
Transmissibility of Infectious Agents
Another issue that proved elusive to science before the 19th century was the origin and transmissibility of infection, Hieronymus Fracastorius (1478–1553) came up the idea 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. 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 was not received by the then the medical community. As a result, operations were still performed with very little regard for a environment that must be kept sterile. Hand washing was rarely practiced by the surgeons and their hand would be directly placed into the patients wound. The surgical residents would also be encouraged to place their hands also for the “feel”. Surgeons boots would be used to sharpen the surgical instruments and little or no regard was given to cleanliness or sterility of the instruments, these instruments will be wiped with dirty cloths and the placed back into their velvet carriers and reused. The ground of the post-operative wards will be covered with human excrement, blood, suppuration and the hospital walls splashed with sputum. All these lead to mortality rate of nearly 50%.
Consequently, the major cause death will be infections and eighty percentage of the operations afflicted with the so called “hospital gangrene”. The bad odour of dead bodies and infectious leftovers made some to believe that purulent wounds were caused by particles in the air or bad “humors. ” In 1880, William Halsted reportedly operated in tents outside of Bellevue Hospital for better ventilation the prevailing view was that if infectious particles did exist, then they arose by spontaneous generation. Infectious Disease and Antisepsis Louis Pasteur (1822–1895) crushed the long-held myth of spontaneous generation and attributed fermentation and meat putrefaction to living microscopic organisms. It was the simplicity and rationality of his experiments that persuaded many of his contemporaries to adopt and accept germ theory. 7,11 Joseph Lister (1827–1912), a professor of surgery at Glasgow, noticed that the Louis pasteurs experiment on the fermentation process and the infectious pus in the surgical wounds. 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 started using carbolic acid on fracture wounds. The wound healed with no signs of suppuration, this leading to averting of amputation, and the mortality rate from amputation came down from 45 to 15%.
In 1876, Lister went to the US to talk about his ideas at the International Medical Congress in Philadelphia. In attendance was William W. Keen (1837–1932) of Jefferson Medical College in Philadelphia, well known neuro surgeon at that time. 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.
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’shands were cleaned and disinfected by soap and water, alcohol, and sublimate solution.
Advancements in Asepsis Improving on listerian practices, in 1891 Ernst von Bergmann introduced heat sterilization of instruments, which proved better to chemical sterilization. In 1883 Gustav Neuber of Kieland introduced sterile gowns and caps. and Mikulicz, surgicals caps in 1897. 11 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.
