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History of cleanliness in healthcare31st of October 2012
In the third part of our special series looking back at the history of hygiene, ECJ looks back at when the consequences of bad hygiene first became apparent in hospitals and other healthcare institutions, and how proper practices were put in place.
In modern Europe we like to think we can take it for granted that our hospitals are clean, hygienic and safe. Numerous outbreaks of hospital-acquired infections (HAIs) in recent years have illustrated, however, that the battle against infection can never truly be won, and that proper hygiene practices are absolutely vital. Here we look back at the pioneers of hospital hygiene and how their knowledge directly affects how we behave today.
The earliest hospitals are thought to have been established in Sri Lanka in 431 BC, with Indian hospitals established from 230 BC. Before that, in ancient Israel for example, quarantine for sick people was the norm – with isolation measures put in place for individuals and the household in the case of infectious disease outbreaks. And in ancient Babylon the sick were laid out in the street so passers-by could offer advice!
It was Aulus Cornelius Celcus of Rome who first advocated cleanliness, wound-washing and treatment with vinegar and thyme oil, both of which have antiseptic properties. That was in the first century. Other early antiseptics included pitch, wine, copper, silver and mercury.
In the 1840s ether became the first anaesthetic to be used during surgery, followed by chloroform, then nitrous oxide. Local anaesthetic was introduced in 1877. However, longer and more complicated operations without sufficient knowledge of infection or antisepsis meant that the infection rate was very high.
It was also in the 19th century that the importance of hand hygiene in hospital settings was recognised for the first time. While assisting on a maternity ward in Vienna Hungarian Dr Ignaz Semmelweis noticed that the expectant mothers in his care shared a terror of being brought to term by a team of medical students on the ward rather than by a midwife.
Their fear was justified: the death rate from puerperal sepsis – or childbed fever, as it is commonly known – was three times higher among the women whose babies were delivered by the students.
This fact could have been overlooked, since childbed fever was extremely common at the time. In fact, up to 25 per cent of women who gave birth in European or US hospitals would die from the condition, later found to be caused by Streptococcus pyogenes bacteria.
Dr Semmelweis then realised something else. The medical students were coming into the maternity suite straight from the pathology unit where they had been dissecting bodies for their studies. And they were not washing their hands before delivering babies.
It was a ‘eureka’ moment for Dr Semmelweis. He knew he had discovered something important and immediately instigated a hand washing programme at the hospital. He was fairly sure that infections were being carried from the dead to the living via the hands of the medical staff, and he insisted that anyone examining a woman in labour should wash their hands with a chlorinated solution first.
And the results spoke for themselves. The mortality rate in April 1847 was 18.3 per cent, hand washing was instituted mid May, the rates in June were 2.2 per cent, July 1.2 per cent, August 1.9 per cent and, for the first time the death rate was zero in two months in the year following this discovery.
Semmelweis lectured publicly about his results in 1850, however, the reception by the medical community was cold, if not outright hostile. His observations went against the current scientific opinion of the time, which blamed diseases on an imbalance of the ‘basic humours’ in the body. It was also argued that even if his findings were correct, washing one's hands each time before treating a pregnant woman, as Semmelweis advised, would be too much work. Nor were doctors eager to admit that they had caused so many deaths!
Semmelweis spent 14 years developing his ideas and lobbying for their acceptance, culminating in a book he wrote in 1861. The book received poor reviews, and he continued fighting the establishment vehemently. In 1865 he suffered a nervous breakdown and was committed to an asylum where he soon died. Only after Dr Semmelweis's death was the germ theory of disease developed, and he is now recognised as a pioneer of antiseptic policy and prevention of nosocomial (hospital-acquired) disease.
Surgery in the 19th century was a dangerous prospect for the patient. If the shock caused by the pain and loss of blood did not kill them during the operation, it was very likely that infection from blood poisoning afterwards would. In fact some 50 per cent of patients died due to infection after surgery. And although people had made a connection between dirt and disease, this knowledge was not applied to the operating theatre. Surgeons wore coats covered with the pus, blood and germs of countless operations!
Infected wounds were generally known as 'hospital gangrene' or sepsis, the Greek word for 'putrefaction'. The common belief seemed to be that sepsis was caused by the exposure of moist body tissue to air, with the resultant claim that wounds should be covered to keep the air out.
Surgeon Joseph Lister, who was working at Glasgow Royal Infirmary, did not believe that exposure to bad air alone led to infection, but that some form of decomposition of the open wound was happening. After reading the work of Louis Pasteur, he thought that he might be able to kill bacteria which were getting onto the wound from the air.
It has been suggested that he had recalled the old idea of covering amputations with tar and got the idea that the pure carbolic acid found in tar could destroy the bacteria. As a result, he soaked dressings in carbolic acid and had them applied to wounds immediately after an operation. He then developed his idea further by devising a machine that pumped out a fine mist of carbolic acid into the air around an operation. The number of patients operated on by Lister who died
Lister continued his experiments for two years, and in 1867 made public that carbolic acid was an antiseptic, ie it prevented the wounds he had treated from going septic.
As a result of Lister's work and similar work in hospitals in Germany, the drive for cleanliness gathered pace and it became commonplace for staff in operating theatres to wear long white gowns which easily showed dirt and use surgical gauze to meticulously clean sores and wounds.
Meanwhile, Joseph Lister was rewarded for his pioneering work by being invited to lance an abscess from Queen Victoria’s left armpit in 1871!
In the treating and care of patients, nurse, writer and statistician Florence Nightingale first observed the link between sanitary conditions and healing. Her most famous contribution came during the Crimean War which started in March 1854. Nightingale was asked to become a nursing administrator to oversee the introduction of nurses to military hospitals. Her official title was superintendent of the female nursing establishment of the English general hospitals in Turkey.
Although being female meant Nightingale had to fight against the military authorities at every step, she went about reforming the hospital system. With conditions which resulted in soldiers lying on bare floors surrounded by vermin and unhygienic operations taking place it is not surprising that, when Nightingale first arrived in Scutari, diseases such as cholera and typhus were rife in the hospitals. This meant that injured soldiers were seven times more likely to die from disease in hospital than on the battlefield.
Nightingale collected data and organised a record keeping system, this information was then used as a tool to improve city and military hospitals. Nightingale's knowledge of mathematics became evident when she used her collected data to calculate the mortality rate in the hospital. These calculations showed that an improvement of the sanitary methods employed would result in a decrease in the number of deaths.
By February 1855 the mortality rate had dropped from 60 per cent to 42.7 per cent. Through the establishment of a fresh water supply as well as using her own funds to buy fruit, vegetables and standard hospital equipment, the mortality rate in the spring had dropped further to 2.2 per cent.
These unsanitary conditions, however, were not only limited to military hospitals in the field. On her return to London in August 1856 Nightingale discovered that soldiers during peacetime aged between 20 and 35 had twice the mortality rate of civilians. Using her statistics, she illustrated the need for sanitary reform in all military hospitals.
Ironically, having transformed nursing and hygiene in military hospitals Florence Nightingale was bedridden for most of the remainder of her life due to an illness contracted in the Crimea. This did not stop her from campaigning to improve standards, however, and she published 200 books. She died at the age of 90 in 1910.