How Did Antiseptics Change Surgery? When the Operation Stopped Killing the Patient
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In the middle of the nineteenth century a patient could survive an amputation and die of the wound. Mortality after major surgery in hospitals ran at rates that made an operation close to a coin toss, and it was worse in large hospitals than in cottages. The explanation was not understood, the solution was resisted for decades after it was demonstrated, and the people who demonstrated it were treated badly.
The problem before
Surgeons operated in street clothes or in a frock coat stiff with old blood, worn as a mark of experience. Instruments were wiped rather than cleaned, sponges were reused between patients, and the same hands moved from the dissecting room to the ward. Wounds routinely became infected, and the resulting conditions had names that described appearances rather than causes: hospital gangrene, pyaemia, erysipelas and septicaemia, collectively called hospitalism. The prevailing explanation was miasma, bad air arising from decay, which led to sensible interventions like ventilation for entirely wrong reasons. Anaesthesia, introduced from 1846, made the situation worse in one respect: surgeons could now operate slowly, carefully and deeply, opening body cavities that speed had previously kept them out of, and the deeper the operation the more reliably the patient died of infection afterwards. The problem was therefore not solved by anaesthesia but sharpened by it.
Semmelweis and what happened to him
Ignaz Semmelweis, working in Vienna in the 1840s, investigated why the maternity clinic staffed by doctors and medical students had a maternal death rate from puerperal fever several times higher than the adjacent clinic staffed by midwives. He noticed that the doctors came to the wards from performing autopsies and the midwives did not, and after a colleague died of an identical illness following a cut sustained during a post-mortem, he concluded that some cadaverous material was being transferred. He instituted handwashing in chlorinated lime solution in 1847 and the death rate in his clinic fell dramatically, by a factor of several. He had no theory to explain why, since germs were not yet established, and his finding implied that respected physicians were killing their patients, which was not received well. He was not reappointed, his ideas were rejected by the profession, he grew increasingly angry and erratic, and he died in an asylum in 1865, reportedly of an infected wound.
Lister and the change
Joseph Lister, professor of surgery in Glasgow, read Louis Pasteur's work showing that fermentation and putrefaction were caused by living microorganisms rather than by air itself, and drew the surgical conclusion: if wounds putrefy because organisms enter them, killing those organisms should prevent it. He chose carbolic acid, used to treat sewage, and from 1865 applied it systematically:
- •Dressings soaked in carbolic acid applied to wounds and left in place
- •Instruments, hands and the surgical field treated with carbolic solution
- •Catgut ligatures treated so they could be left inside and absorbed rather than being left hanging out of the wound to be pulled later
- •A carbolic spray producing a mist over the operating field, which Lister later abandoned as unnecessary and harmful to the staff breathing it
- •Results published in the Lancet in 1867 showing mortality in compound fracture cases falling from around forty-five percent to fifteen
- •Adoption was rapid in Germany and slow in Britain and the United States, with prominent surgeons continuing to reject the underlying theory for years
From antiseptic to aseptic
Lister's method killed organisms already present, which is antisepsis. The method that replaced it prevents them arriving at all, which is asepsis, and it came largely from German surgery in the 1880s and 1890s, drawing on Robert Koch's work on sterilisation. Steam sterilisation of instruments, dressings and gowns, developed by Ernst von Bergmann, proved more effective and far less damaging to tissue than soaking everything in acid. Surgical gowns, caps and masks followed. Rubber gloves entered use at Johns Hopkins in the 1890s, introduced by William Halsted initially to protect a nurse whose hands were being damaged by disinfectant, and only afterwards recognised as protecting the patient. The combined result transformed what surgery could attempt: abdominal, chest and eventually cardiac and neurological operations became survivable, and the operating theatre changed from a place of speed and spectacle into the controlled environment it now is. The modern descendant of the same insight is hand hygiene compliance in hospitals, which remains a measured and imperfect quantity nearly two centuries after Semmelweis.
The takeaway
Nineteenth-century surgical wounds became infected so reliably that anaesthesia made matters worse by allowing longer and deeper operations. Semmelweis showed in 1847 that handwashing in chlorinated lime cut maternal deaths sharply, had no theory to explain it, was rejected and died in an asylum. Lister, applying Pasteur's germ theory from 1865, used carbolic acid on wounds and instruments and published a fall in amputation mortality from about forty-five percent to fifteen. Steam sterilisation and gloves then replaced antisepsis with asepsis.