The history of intracranial infections.

The 19th and 20th centuries heralded the advancement of our understanding of surgical infections, reducing the risk of morbidity and mortality to patients by overturning long-held dogmas surrounding infections and perioperative care. These advancements impacted the development and establishment of the field of neurological surgery by minimizing surgical risk through aseptic techniques and promoting surgical benefit via improved neurological localization and surgical technique. Infections were significant contributors to morbidity and mortality for all surgical patients, and historically almost half of patients lost their lives as a consequence of perioperative wound contamination. With advancing understanding of germ theory, contagion, antisepsis, and subsequently asepsis, the surgeon began embracing the knowledge and techniques which would hone their craft and allow for a renaissance in the management of neurological disorders in an unprecedented manner.

Daniel Mollière (1848-1890), the French anatomist and surgeon, and his encounters with nosocomial infections in the operating theatre.

Daniel Mollière, was a French anatomist and surgeon, born in Lyon, who succeeded in his short life in making his mark in surgery. He was a prolific writer who left a series of medical treatises and a committed surgeon who was responsible for various significant innovative apparatuses in the medical sper. As he lived in an era when the role of microbe had already been recognized, he was among the first to use antisepsis and install extreme measures against microbes, both in the air and on the skin'. Fountains with fresh clean water, carbonic acid, cross ventilation, medical blouses, combined with Valette's apparatus for the dressing of amputations, were some of his precautions to reduce surgical infections and post-operative mortality.

The Bolognese surgeon Giuseppe Ruggi: how and why the aseptic surgery was introduced in Bologna in the middle half of the XIX century.

BACKGROUND: The first reliable statistic data about perioperatory mortality were published in 1841 by the French Joseph-Francois Malgaigne (1806-1863): he referred to a mean mortality of 60% for amputations and this bad result was to be attributed mainly to hospital acquired diseases. The idea of "hospital acquired disease" although vague, included five infective nosologic entities, which at that time were diagnosed more frequently: erysipelas, tetan, pyemia, septicemia, and gangrene. Nonetheless, the suppuration with pus production was considered from most of the surgeons and doctors of that time as a necessary and unavoidable step in the process of wound healing. During the end of the eighteenth century, hospitals of the main European cities were transforming into aggregations of several wards, where the high concentration of patients created poor sanitary conditions and a consistent increase of perioperatory mortality. In 1865, Lister applied his first antiseptic dressing on the surface of an exposed fracture. These experimental attempts lead to an effective reduction of wound infections respect to the dressing with strings used previously. DISCUSSION: Lister's innovations in the field of wound treatment were based on two brand new concepts: germs causing rot were ubiquitarious and the wound infection was not a normal step in the process of wound healing. The concept of antisepsis was hardly accepted in the European surgical world: "Of all countries, Italy is the most indifferent and uninterested in experimenting this method, which has been so favorably judged from the greatest surgical societies in Germany". This quotation from the young surgeon Giuseppe Ruggi (1844-1925) from Bologna comes from his article where he presented his first experiences on aseptic medications started the previous year in the Surgical Department of Maggiore Hospital in Bologna. In his report, Ruggi described the adopted technique and suggested that the medication should be extended to all the surgical patients of the hospital:"… this is needed to totally remove from the hospital all those elements of infection which grow in the wounds dressed with the old method". The experimentation of this new dressing for the few treated cases was rigorous and concerned both the sterilization of surgical tools with the fenic acid (5%) and the shaving of the skin. Ruggi also observed that there was no correlation between the seriousness of the wound and its extension or way of healing: when "simple" cases that "should heal without complication" showed fever he often realized that "it was often due to a medication performed without following the rules for an accurate disinfection and dressing". Ruggi thought that the fever was connected to "reabsorption of pyrogenic substances, which can be removed cleaning and disinfecting the wound" in cases of wounds not accurately dressed and rarely medicated. Frequent postoperative medications of the wound were able to eliminate the fever within 2 h. Ruggi's attitude toward the fine reasoning lead him to introduce the concept of immunodeficiency related to physical deterioration: "… patients treated for surgical disease may sometimes suffer from complications of medical conditions, which initially escape the most accurate investigations… The surgical operation could, in some cases, hold the balance of power". CONCLUSIONS: The obtained results, published in 1879, appear extremely interesting. As he wrote in 1898, for the presentation of his case record of more than 1000 laparotomies, he had started "… operating as a young surgeon without any tutor, helped only by his mind and what he could deduce from publications existing at the moment …".

[Antiseptics in Germany. The formation of surgical knowledge 1872-1892]. / Antisepsis in Deutschland. Zur Wissenschafts-geschichte der Chirurgie 1872-1892.

The paper deals with the impact of antisepsis on German surgery between 1872 and 1892. It describes the acceptance of Lister's treatment as the result of a therapeutic mass experiment. In the face of tremendous mortality rates in the surgical wards of general and larger academic hospitals, the evidence persuaded the critics within only few years, wile the discussion on theoretical questions was intentionally avoided. The author suggests to reconsider the impact of bacteriology on modern surgery and to put more emphasis on professional and social developments, and on the role of evidence in hospital medicine.

The classic: On the antiseptic principle in the practice of surgery. 1867.

This Classic Article is a reprint of the original work by Baron Joseph Lister, On the Antiseptic Principle in the Practice of Surgery. An accompanying biographical sketch of Baron Joseph Lister is available at DOI 10.1007/s11999-010-1319-3 . The Classic Article is (c)1867 and is reprinted with courtesy from Lister J. On the antiseptic principle in the practice of surgery. Br Med J. 1867;ii:246.

Biographical Sketch: Baron Joseph Lister, FRCS, 1827-1912.

This biographical sketch on Baron Joseph Lister corresponds to the historic text, The Classic: On the Antiseptic Principle in the Practice of Surgery (1867), available at DOI 10.1007/s11999-010-1320-x .

Learning from mistakes: early twentieth-century surgical practice.

Archibald Watson was an Australian anatomist and surgeon who kept operating theater diaries. He made detailed notes on the work of surgeons that he observed in Britain and North America, as well as in Australia. Watson's diaries provide significant evidence that early twentieth-century surgeons did not just apply scientific knowledge produced somewhere else. They generated new surgical knowledge themselves and worked within a culture that valued innovation. Some of the surgeons observed by Watson practiced in academic centers and regularly engaged in laboratory research, but most did not. Nevertheless, it is clear that whether in Australia, Britain, or North America, the active search for improved techniques was a routine feature of the practice of full-time surgeons. In the process, they often made mistakes--or rather, they often did things with which at least some of their colleagues did not agree. Much of surgical practice was contestable. Doing things the "right" way and finding better ways to do things were overlapping categories; but it is often difficult or impossible to draw any distinction at all between doing things the "wrong" way and failed attempts at finding a better way to perform an operation. This article examines some aspects of the relationship between scientific ideas, clinical experience, contestable errors, and the generation of new knowledge through surgical practice.

Surgical dressings and turbulent years of cotton industry.

Everyday use of a simple cotton bud should remind us of our not so distant past and of the appalling trade in people. Harvesting this precious commodity required forced labour eventually leading to a key turning point in the history of surgery, as civil war raged in America during the 1860s. The fight to end slavery was to reveal a new weapon against disease and certain death. A material used in this struggle against wound infection was the available stockpiles of redundant cotton. Once boiled to make softer, its use on patients in military hospitals proved to be the first clinical application of sterile surgical dressings.

Prophylactic antibiotics in orthopaedic surgery.

The use of prophylactic antibiotics in orthopaedic surgery is effective in reducing surgical site infections in hip and knee arthroplasty, spine surgery, and open reduction and internal fixation of fractures. To maximize the beneficial effect of prophylactic antibiotics while minimizing adverse effects, the correct antimicrobial agent must be selected, the drug must be administered just before incision, and the duration of administration should not exceed 24 hours.