ACS Antisepsis/Asepsis Module Thomas Schlich and Peter Kernahan 1 Traditional Surgery • No special operating rooms • No knowledge of germs • “Laudable pus” – Natural part of healing Image: Hans von Gerssdorff, Feldtbuch der Wundtartzney, 1517 2 • Higher rate of wound complications in the 19th century ‐‐ factors: • More, and more extensive surgery (e.g. amputations) • Because of existence of anesthesia and new, localist views of disease as rationale for surgery • Higher density of patients in hospitals or in wars (e.g. Civil War) Image: Leg amputation, 18th century, unknown artist, Royal College of Surgeons, London 3 Operating Room ‐ 1847 • First use of anesthesia • Calm environment • Note: surgeons in street clothes, touching the patient, no antiseptic or aseptic measures Digital Image Courtesy of the Getty’s Open Content Program 4 Southworth & Hawes 1847 PD‐US Sanitary Response • Various strategies for dealing with higher complication rates • Sanitation: better and cleaner hospitals, better air circulation against “miasmas” • General hygiene, sanitary environment Image: The Medical and Surgical History of the War of the Rebellion (1861‐1865) 5 Surgeon‐Generals Office PD‐US Technologies of Cleanliness • Ignaz Semmelweis • Vienna 1840s • Hand disinfection • Drastic decrease of puerperal fever • Not much impact on practices Semmelweis 1860, Copper plate engraving by Jenö Doby. 6 https://en.wikipedia.org/wiki/Ignaz_Semmelweis US PD‐1923 Technologies of Cleanliness • clean hospitals, hands, DISINFECTION OF THE SKIN. 55 Fro. 6. towels, wounds, Spigot attachment. • e.g. Thomas Spencer Wells’ – “cleanliness and cold water” surgery 7/chi.64453974 – good results for ccess_use# pd-google abdominal surgery Image: Hunter Robb, About Surgical Technique Public Domain, Google-digitized / http://www.hathitrust.org/a / Google-digitized Domain, Public (Philadelphia: Lippincott, 1894), pp. 55 and 57 http://hdl.handle.net/202 / GMT 00:19 2013-07-02 on Generated 7 Technologies of Cleanliness • Cleanliness allowed Robert Lawson Tait to remove gall bladders safely in the 1870s Robert Lawson Tait. 1879,from Birmingham Med. Review, June 1913, fig. XIX, 8 Wellcome Images, M0010490 Creative Commons CC BY 4.0 License Technologies of Cleanliness • E.g. George Callender, St. Bartholomew’s, London • Camel hair brush for every patient to keep wound clean, as seen in this caricature in his right hand Image: St. Bartholomew’s Archives and Museum 9 Germs and Antisepsis • One technical measure: use of carbolic acid to kill living germs in the air and the environment • Suggested by Joseph Lister in 1867 • Theoretical basis: Louis Pasteur’s germ theory – environment is full of microscopically small germs –if they enter the wound, suppuration and wound fever results 10 Image: Louis Pasteur in his laboratory, painting by Albert Edelfeldt, 1885, in the public domain. Germs and Antisepsis • Developed into a complex system of antiseptic surgery • Disinfection of surrounding air by antiseptic spray Images: (1) Cheyne, Antiseptic Surgery, Elder: London, 1882, fig. 23. US PD‐1923 11 (2) Lister Spray Wellcome Images Creative Commons CC BY 4.0 License Germs and Asepsis • Strategy: Avoiding contamination in the first place by keeping everything sterile that might touch the wound • Based on Robert Koch’s bacteriology 12 Image: ?? Germs and Asepsis • “Infection” of wounds by specific bacteria • Image: shows bacteria invading living tissue Image: ?? 13 Germs and Asepsis Technologies from the laboratory – To kill bacteria • heat sterilization of instruments, towels, dressings – To monitor sources of infection • systematic taking of samples and bacterial cultures. Bacterial colonies on solid culturing media, from swabs taken from hands washed with different methods (1909) Image: Haegler, Händereinigung und Händeschutz 14 (Basel, Schwabe: 1900), table II, in the appendix. Technologies of Asepsis • New technologies keep germs out: – sterility of operating field – sterile gowns, drapes – autoclave for instruments • “Local cultures of asepsis” – a lot of variation – example Ziegelstrasse Hospital on Berlin ca. 1906 , depicted in a celebratory painting – no masks, gloves, or caps – nurse & observers in street clothes Image: Painting, 1906 by Franz Skarbina, (1849‐1910). bpk, 15 Berlin / painting missing since 1945 Technologies of Asepsis • New elements in surgical equipment: – masks introduced by Johann Mikulicz, Germany • Image shows him in aseptic gear in 1899 – gloves, masks, caps – Note: elbow‐length fabric gloves Image: Photograph in possession of Sumiko Hiki, Tokyo, published in: Sumiko Hiki, Yoshiki Hiki, “Professor von Mikulicz‐Radecki, Breslau: 100 Years Since His Death”,16 Langenbeck Archives of Surgery (2005) 390: 182‐185, p. 183. Operating Room ‐ 1904 • New elements in surgical equipment: – William Halsted at Johns Hopkins introduced rubber gloves • Image shows him operating in 1904 – Note: separate room, no audience, gowns, rubber gloves, no masks . The “all star operation”, 1904 William Halsted operating with his senior staff to inaugurate the new operating theatre Image: Harvey Cushing/John Hay Whitney Medical Library Historical Library Yale University PD‐US 17 Operating Room – 1930s Image: Courtesy of the Wangensteen Library 18 University of Minnesota Conclusion “It can be demanded of us that we improve as much as possible the arrangements for the safety of the people who are entrusted to us” Johann Mikulicz, 1897 Image: Pfree2014 Creative Commons CC BY SA 4.0 International License 19 https://commons.wikimedia.org/wiki/File:Cardiac_surgery_operating_room.jpg Further Reading • J.T.H., Connor, ‘Listerism Unmasked: Antisepsis and Asepsis in Victorian Anglo‐Canada’, Journal of the History of Medicine and Allied Sciences 49 (1994), 207‐239. • Thomas P. Gariepy, ‘The Introduction and Acceptance of Listerian Antisepsis in the United States’, Journal of the History of Medicine and Allied Sciences, 1994, 49: 167‐206 • Lindsay Granshaw, ‘Upon this Principle I Have Based a Practice’: The Development of Antisepsis in Britain, 1867‐ 90’’, in John V. Pickstone (ed.): Medical Innovations in Historical Perspective (St. Martin’s Press: New York, 1992), 17‐46. • Anna Greenwood, ‘Lawson Tait and Opposition to Germ Theory: Defining Science in Surgical Practice’, Journal of the History of Medicine and Allied Sciences, 1998, 53: 99‐131 • Peter Kernahan , ‘Causation and Cleanliness: George Callender, Wounds, and the Debates over Listerism’, Journal of the History of Medicine and Allied Sciences 64 (2009), 1‐37. • Christopher Lawrence and Richard Dixey, ‘Practicing on Principle: Joseph Lister and the Germ Theories of Disease’, in Christopher Lawrence (ed.), Medical Theory, Surgical Practice: Studies in the History of Surgery (London and New York: Routledge, 1992), 153‐215; • T.H. Pennington, ‘Listerism, its Decline and its Persistence: The Introduction of aseptic surgical Techniques in three British Teaching Hospitals, 1890‐99’, Medical History, 1995, 39: 35‐60, • Thomas Schlich: ‘Asepsis and Bacteriology: A realignment of Surgery and Laboratory Science’, Medical History 56 (2012), pp. 308‐343. • Thomas Schlich: ‘Railways, Industry, and Surgery –The Introduction of Risk Management’, New England Medical Journal 369; 21 (November 21, 2013), pp. 1978‐1979. • Thomas Schlich: ‘Negotiating Technologies in Surgery: the Controversy about Surgical Gloves in 1890s’, Bulletin for the History of Medicine 87 (2013), pp. 170‐197. • Michael Worboys, Spreading Germs. Disease Theories and Medical Practice in Britain, 1865‐1900 (Cambridge: Cambridge University Press, 2000) 20.