Doris C MacClelland, RN, MS
The evolution of sterilization To the nurse Eurycleia then said he: “Bring cleansing sulfur, aged da,me, to me A n d fire, that I may purify the hall.” Written the eighth century BC, these words from Homer’s Odyssey’ describe one of the earliest known methods of disinfection and mark the prelude to the evolution of sterilization. Probably
Doris C MacClelland, R N , M S , is a commander in the US Navy Nurse Corps and chairman of the A O R N Editorial Committee. S h e is operating room supervisor at the Naval Regional Medical Center, S a n Diego, Calif. A graduate of Emanuel Hospital School of Nursing, Portland, Ore, she received her BA from S u n Francisco State College and her MS from Indiana University.
the first recorded words alluding to the concept of cleanliness and disinfection are Moses’s instructions in the Bible proscribing the strict sanitation code and the acts of purification by fire. The early Greeks (450 BC) spoke of fumigation as a means of combating epidemics, Hippocrates (460-370 BC) demonstrated antiseptic methods in wound care by using boiled water or wine and pitch cerate, and Herodotus (484-424 BC) indicated that certain chemicals such as salt and niter were found to be of antiseptic value to the Egyptians. Tracing the beginnings of antisepsis and sterilization becomes a formidable task. Many centuries and many cultures, some of which were destroyed with their concepts later rediscovered, have contributed to the evolution of sterilization. Numerous references in early literature describing disinfection, fumigation, wound management or control of pestilence make apparent the necessity and motivation of historic man to discover methods of protecting them from a diseased environment. A brief resume of the evolution of antisepsis will highlight major events leading to present day methods of sterilization. Several decades before Christ, one of Caesar’s physicians wrote, “Small
AORN Jourriul. Ju1.y 1976, Vol 2 4 , N o 1
37
creatures, invisible to the eye, fill the atmosphere, and breathed through the nose cause dangerous diseases.”2 Yet, it was not until the mid-1500s that Fracastorius, later known as the first epidemiologist, published his famous work dealing with airborne pestilence. In De Contagione, he wrote that diseases were spread three ways: by direct contact, by handling things that infected persons had handled, and by transmission from a d i ~ t a n c e .The ~ discovery of the microscope by Leeuwenhoek in 1683 confirmed the existence of minute organisms and marked the beginning of the science of bacteriology. It was through this discovery that Louis Pasteur was able to pursue his work in fermentation and spontaneous generation nearly two centuries later. Bacteriologists and microbiologists are credited with the major discoveries in the field of antisepsis during the 1700s and 18OOs, but no history would be complete without mentioning the work of some physicians during this period. “Laudable pus” was expected in the normal course of treatment; but in the late 1700s, two physicians, Charles White of England and his collaborator, Thomas Kirkland, were concerned about the diseased conditions in the Manchester Lying-in Hospital and insisted on strict cleanliness and ventilation for patient^.^ Later, Robert Collins used chlorine gas to disinfect rooms of the Rotunda Hospital in Dublin and, along with his strict sanitary precautions and heat-treated bed linens, experienced a notable decrease of infections among his patient^.^ Even though these measures proved effective in controlling outbreaks of fever, they were never really accepted and even discarded. In 1847, Semmelweis again revived the concept of cleanliness in lying-in hospitals and through his strict 38
The tall, cylindrical Koch steam sterilizer. (Robb, Aseptic Surgical Technique, Lippincott. 7894.)
hand-washing techniques, saw a dramatic reduction of deaths from puerperal fever. Again, his ideas were rejected though a few were privately adhering to his principles while publicly reviling him. Semmelweis died a broken man, and it was nearly 50 years later before his original concepts were again brought into focus. Joseph Lister, known as the father of antiseptic surgery, is best known for his use of carbolic acid solution and spray as a means of controlling infection. He also became an advocate of Semmelweis’s concepts but, once again, encountered stubborn resistance until corroborative studies were publicized in Germany by von Volkmann and Nussbaum. Beginning aseptic technique based on disinfection
AORN Journnl, July 1976, Vol24, No 1
Semmelweis’s frustration only in soap and water but also in chlorinated lime solution after leaving the necropsy rooms and after examining each patient. The result was the death rate dropped from 18% in April 1847 (prior to handwashing) to 2.4% in June after the procedure was introduced and to 1.2% in July. Urged by many to publish his results, he instead was condemned by his superiors who were prejudiced against him because of his Hungarian ancestry. Rather than being honored, he was demoted-allowed to maintain his professorship but not allowed to see patients. Semmelweis left the hospital to go into private practice and the death rate soared to its previous levels. Of the years that followed, Wheeler wrote of Semmelweis, “Thoughts of the needless deaths of young mothers haunted him. In 1860, Semmelweis wrote an open letter to the director of the Krankenhaus denouncing him as a murderer for not investigating the theory. Semmelweis held him responsible for the deaths of thousands of women over the course of several years.” Semmelweis was disturbed over the stubbornness of his colleagues in not accepting his theory, and the stress finally affected his sanity. He was committed to an asylum and died of blood poisoning the day after Lister began his investigations of the use of carbolic in preventing wound infections.
The frustration of lgnas Semmelweis in proving his handwashing theory is recounted by Ervin S Wheeler in “Development of antiseptic surgery,” American Journal of Surgery 127 (May 1974) 574. Semmelweis, a Hungarian appointed assistant obstetrician at Allgemeines Krankenhaus, Vienna, Austria, in the mid-l840s, noticed a striking difference in the death rate between the two lying-in wards of the maternity hospital. The mortality rate in the First Clinic where medical students were trained was more than 4 times that of the Second Clinic where only midwives were trained. “Daily routine for the physicians and medical students included mornings in the necropsy room. Then, in the afternoon, they proceeded directly to the clinic to examine pre and postpartum patients. Midwives never attended the necropsies,” wrote Wheeler. An autopsy on one of Semmelweis’s friends, who died after receiving a small scalpel wound during a necropsy, showed similarities between that death and those of women who died of puerperal fever. Semmelweis remembered that students frequently performed examinations of injured perineums of clinic patients after handling cadaver specimens. According to Wheeler, “He also noted that women on the wards died in rows because they were examined in rows.” He concluded that “cadaveric poisoning” was carried from the necropsy rooms to the clinics by students and physicians who did not wash their hands. In an attempt to prove this theory, Semmelweis required every student and physician to scrub his hands thoroughly, not
Semmelweis published his theories in 1861 in The Cause, Concept, end Prophylaxis of Childbed Fever. His method was successful in reducing mortality; but why it worked was not then understood.
with bichloride of mercury was developed in Berlin by von Bergmann, and in 1892, his technique was described in writing by his assistant, Curt Schimmelbusch.6 As the Germans continued to contribute to the transition from antisepsis to asepsis, Gustav Neuber was the first to insist upon complete cleanliness of the operating theatre. He demanded thorough scouring of the room and
furniture with a disinfectant solution and was the first to introduce the wearing of gowns and caps to exclude everyday clothing from the operating theatre.‘ During this same period of time, Robert Koch demonstrated the pathogenicity of bacteria, a milestone which verified the practices of Semmelweis and brought meaning to antiseptic techniques. In 1880, Davidsohn pro-
AORN Journal. J u l y 1976, V o l 2 4 , No 1
39
vided the rationale for using heat (boiling water) rather than chemicals for sterilization.s Koch later developed a nonpressure steam sterilizer for laboratory media, and during the next several decades, attention was directed to the development of heat sterilizers. Schimmelbusch was the first to use the steam sterilizer for surgical dressings, and by 1885, Neuber was sterilizing everything that came in contact with the surgical wound. The discovery of heat resistant bacteria in 1876 by the English physicist, John Tyndall, invalidated boiling as a method of ridding laboratory materials of organisms. Pasteur and his collaborator, Charles Chamberland, were therefore forced to develop the first pressure steam s t e r i l i ~ e r .Paul ~ Redard, a French orthopedic surgeon, demonstrated that resistant spores could be killed by using steam to increase the pressure; thereby, raising the temperature and the need for sterilizers with steam under pressure was well established.1° While progress was being made in the area of sterilization, other antiseptic techniques were being devised. Hand coverings were first introduced by Watson in 1843 to protect parturient women, and in 1885, Mikulicz first used cotton gloves. Although Halsted is credited with being the first to use rubber gloves in 1889, it was, in fact, one of his residents who first advocated the use of gloves. Halsted merely popularized their use." Gauze facemasks came on the scene around 1896-97 and were probably first used by either Mikulicz or Berger.12 Sterilizers in America. Much of the original sterilizing equipment used in America was designed in Europe. The following sign probably marks the introduction of American-made equipment: Pressure Sterilization The Necessity to the Best Results in Aseptic Surgery 40
A hot air sterilizer consisted of an oven made of sheet iron with double walls with shelves. Heat is supplied by the gas burner underneath. (Robb, Aseptic Surgical Technique, Lippincon, 1894.)
Sprague-Schuyler Company Works: Rochester, NY Main Office: 136 Liberty St, NYC (Dated 1895)13 The first complete pressure sterilization system of the vacuum type was installed in 1890 in Whitbeck Memorial Surgical Pavilion, Rochester Hospital, Rochester, NY, and two years later, a n improved system was incorporated into the W J Syms Surgical Theatre in Roosevelt Hospital, New York City. Other manufacturers appeared on the scene, including Kny-Scheerer, Wilmot Castle, and J J Kinyoun, but evolution was slow. It was not until about 1915 when W B Underwood introduced the concept of air clearance by gravity that the first sterilizer of modern-day use was marketed. In 1933, the American Sterilizer Company manufactured the first temperature-regulated pressure steam sterilizer, thus marking the beginning of a more scientific measurement of the process of sterilization. Hot air sterilizers. Although not as popular as in the past, dry heat methods such as hot air ovens, hot beads, and infrared lights are still in use for selected materials under certain conditions. As progress is made in newer methods of sterilization, it can
AORN Journal, July 1976, Vol24, No 1
probably be anticipated that dry heat sterilization will become even less popular and perhaps be totally replaced by other means of sterilization.
Ethylene oxide sterilization. Although gaseous agents have been used for many years as fumigation and disinfection agents, it was not until 1859 when Wurtz described ethylene oxide that a suitable agent was available for sterilization.'* Gaining in popularity as a fumigant in the early 19OOs, it was recognized as a bacteriocidal in 1929 and by 1949 was accepted as a sterilizing agent following the publication of parameters for achieving sterility of bacterial spores. Now well established as a sterilizing agent in hospitals and industry, ethylene oxide sterilization enjoys a variety of uses ranging from food processing to interplanetary space vehicles and probes. Sterilization by irradiation. Sunlight, long recognized as beneficial in controlling the spread of disease during epidemics and in crowded conditions, was the forerunner of the use of nonionizing irradiation for sterilization purposes. The ultraviolet wavelengths were identified as the therapeutic effect of sun about the same time Roentgen discovered x-rays in 1895.15 X-rays, a form of ionizing sterilization, were soon observed to have properties lethal to bacteria, with these observations beginning this era of sterilization. The serious pursuit of this concept was not to begin until the mid-1940s when atomic research was a t its peak. The availability of particle accelerators and the production of radioisotopes in nuclear reactors stimulated interest in the development of this highly effective method of sterilization, and in the early 1950s, the first of these radioisotope sources was made available for use.16 In spite of the progress in this field, the routine use of irradiation for sterilization is not yet feasible because of the expense and the type of equipment in-
volved. Continued research will undoubtedly make this method readily accessible within the near future, marking another milestone in the evolution of sterilization. It has been just one brief century since the concept of sterilization developed from a primitive beginning to a scientific and sophisticated process. Perhaps in the next hundred years, scientific achievements will make today's use of heat from pressurized steam, ethylene oxide, and irradiation appear as peculiar to our successors as boiling and carbolic acid sprays seem to us today. As man continues in his quest for a safer and better world in which to live, we can be assured that progress will be great and achievements many in all the specialized fields of health sciences. 0 Notes 1. Homer, The Odyssey, translated by J W Mackail (London: Oxford Press, 1932) Book XXII, 474. 2. J J Perkins, Principles and Methods of Sterilization in Health Sciences, 2nd ed (Springfield, 111: Charles C Thomas, 1969) 3-4. 3. lbid. 4. Ervin S Wheeler, "The development of antiseptic surgery," American Journal of Surgery 127 (May 1974) 574. 5. lbid. 6. Christopher's Textbook of Surgery, 9th ed, Loyal Davis, ed. (Philadelphia: W B Saunders, 1968) 12-13. 7. Wheeler, "Development of antiseptic surgery," 578. 8. 0 H Wangensteen, et al, "Some preListerian and post-Listerian antiseptic wound practices and the emergence of asepsis," Surgery, Gynecology & Obstetrics 137 (October 1973) 689. 9. Perkins, Principles and Methods, 11. 10. Carl W Walter, The Aseptic Treatment of Wounds (New York: Macmillan Company, 1948) 21. 11. Wheeler, "Development of antiseptic surgery," 579. 12. Wheeler, "Development of antiseptic surgery," 579. 13. Perkins, Principles and Methods, 24. 14. Perkins, Principles and Methods, 501. 15. G Sykes, Disinfection and Sterilization, 2nd ed (Philadelphia: J B Lippincott, 1965) 146. 16. lnternational Anesthesiology Clinics, 10 (Boston: Little & Brown Co, Summer 1972) 123127.
AORN Journal, July 1976, V o l 2 4 , No 1
41
The evolution of sterilization To the nurse Eurycleia then said he: “Bring cleansing sulfur, aged da,me, to me A n d fire, that I may purify the hall.” Written the eighth century BC, these words from Homer’s Odyssey’ describe one of the earliest known methods of disinfection and mark the prelude to the evolution of sterilization. Probably
Doris C MacClelland, R N , M S , is a commander in the US Navy Nurse Corps and chairman of the A O R N Editorial Committee. S h e is operating room supervisor at the Naval Regional Medical Center, S a n Diego, Calif. A graduate of Emanuel Hospital School of Nursing, Portland, Ore, she received her BA from S u n Francisco State College and her MS from Indiana University.
the first recorded words alluding to the concept of cleanliness and disinfection are Moses’s instructions in the Bible proscribing the strict sanitation code and the acts of purification by fire. The early Greeks (450 BC) spoke of fumigation as a means of combating epidemics, Hippocrates (460-370 BC) demonstrated antiseptic methods in wound care by using boiled water or wine and pitch cerate, and Herodotus (484-424 BC) indicated that certain chemicals such as salt and niter were found to be of antiseptic value to the Egyptians. Tracing the beginnings of antisepsis and sterilization becomes a formidable task. Many centuries and many cultures, some of which were destroyed with their concepts later rediscovered, have contributed to the evolution of sterilization. Numerous references in early literature describing disinfection, fumigation, wound management or control of pestilence make apparent the necessity and motivation of historic man to discover methods of protecting them from a diseased environment. A brief resume of the evolution of antisepsis will highlight major events leading to present day methods of sterilization. Several decades before Christ, one of Caesar’s physicians wrote, “Small
AORN Jourriul. Ju1.y 1976, Vol 2 4 , N o 1
37
creatures, invisible to the eye, fill the atmosphere, and breathed through the nose cause dangerous diseases.”2 Yet, it was not until the mid-1500s that Fracastorius, later known as the first epidemiologist, published his famous work dealing with airborne pestilence. In De Contagione, he wrote that diseases were spread three ways: by direct contact, by handling things that infected persons had handled, and by transmission from a d i ~ t a n c e .The ~ discovery of the microscope by Leeuwenhoek in 1683 confirmed the existence of minute organisms and marked the beginning of the science of bacteriology. It was through this discovery that Louis Pasteur was able to pursue his work in fermentation and spontaneous generation nearly two centuries later. Bacteriologists and microbiologists are credited with the major discoveries in the field of antisepsis during the 1700s and 18OOs, but no history would be complete without mentioning the work of some physicians during this period. “Laudable pus” was expected in the normal course of treatment; but in the late 1700s, two physicians, Charles White of England and his collaborator, Thomas Kirkland, were concerned about the diseased conditions in the Manchester Lying-in Hospital and insisted on strict cleanliness and ventilation for patient^.^ Later, Robert Collins used chlorine gas to disinfect rooms of the Rotunda Hospital in Dublin and, along with his strict sanitary precautions and heat-treated bed linens, experienced a notable decrease of infections among his patient^.^ Even though these measures proved effective in controlling outbreaks of fever, they were never really accepted and even discarded. In 1847, Semmelweis again revived the concept of cleanliness in lying-in hospitals and through his strict 38
The tall, cylindrical Koch steam sterilizer. (Robb, Aseptic Surgical Technique, Lippincott. 7894.)
hand-washing techniques, saw a dramatic reduction of deaths from puerperal fever. Again, his ideas were rejected though a few were privately adhering to his principles while publicly reviling him. Semmelweis died a broken man, and it was nearly 50 years later before his original concepts were again brought into focus. Joseph Lister, known as the father of antiseptic surgery, is best known for his use of carbolic acid solution and spray as a means of controlling infection. He also became an advocate of Semmelweis’s concepts but, once again, encountered stubborn resistance until corroborative studies were publicized in Germany by von Volkmann and Nussbaum. Beginning aseptic technique based on disinfection
AORN Journnl, July 1976, Vol24, No 1
Semmelweis’s frustration only in soap and water but also in chlorinated lime solution after leaving the necropsy rooms and after examining each patient. The result was the death rate dropped from 18% in April 1847 (prior to handwashing) to 2.4% in June after the procedure was introduced and to 1.2% in July. Urged by many to publish his results, he instead was condemned by his superiors who were prejudiced against him because of his Hungarian ancestry. Rather than being honored, he was demoted-allowed to maintain his professorship but not allowed to see patients. Semmelweis left the hospital to go into private practice and the death rate soared to its previous levels. Of the years that followed, Wheeler wrote of Semmelweis, “Thoughts of the needless deaths of young mothers haunted him. In 1860, Semmelweis wrote an open letter to the director of the Krankenhaus denouncing him as a murderer for not investigating the theory. Semmelweis held him responsible for the deaths of thousands of women over the course of several years.” Semmelweis was disturbed over the stubbornness of his colleagues in not accepting his theory, and the stress finally affected his sanity. He was committed to an asylum and died of blood poisoning the day after Lister began his investigations of the use of carbolic in preventing wound infections.
The frustration of lgnas Semmelweis in proving his handwashing theory is recounted by Ervin S Wheeler in “Development of antiseptic surgery,” American Journal of Surgery 127 (May 1974) 574. Semmelweis, a Hungarian appointed assistant obstetrician at Allgemeines Krankenhaus, Vienna, Austria, in the mid-l840s, noticed a striking difference in the death rate between the two lying-in wards of the maternity hospital. The mortality rate in the First Clinic where medical students were trained was more than 4 times that of the Second Clinic where only midwives were trained. “Daily routine for the physicians and medical students included mornings in the necropsy room. Then, in the afternoon, they proceeded directly to the clinic to examine pre and postpartum patients. Midwives never attended the necropsies,” wrote Wheeler. An autopsy on one of Semmelweis’s friends, who died after receiving a small scalpel wound during a necropsy, showed similarities between that death and those of women who died of puerperal fever. Semmelweis remembered that students frequently performed examinations of injured perineums of clinic patients after handling cadaver specimens. According to Wheeler, “He also noted that women on the wards died in rows because they were examined in rows.” He concluded that “cadaveric poisoning” was carried from the necropsy rooms to the clinics by students and physicians who did not wash their hands. In an attempt to prove this theory, Semmelweis required every student and physician to scrub his hands thoroughly, not
Semmelweis published his theories in 1861 in The Cause, Concept, end Prophylaxis of Childbed Fever. His method was successful in reducing mortality; but why it worked was not then understood.
with bichloride of mercury was developed in Berlin by von Bergmann, and in 1892, his technique was described in writing by his assistant, Curt Schimmelbusch.6 As the Germans continued to contribute to the transition from antisepsis to asepsis, Gustav Neuber was the first to insist upon complete cleanliness of the operating theatre. He demanded thorough scouring of the room and
furniture with a disinfectant solution and was the first to introduce the wearing of gowns and caps to exclude everyday clothing from the operating theatre.‘ During this same period of time, Robert Koch demonstrated the pathogenicity of bacteria, a milestone which verified the practices of Semmelweis and brought meaning to antiseptic techniques. In 1880, Davidsohn pro-
AORN Journal. J u l y 1976, V o l 2 4 , No 1
39
vided the rationale for using heat (boiling water) rather than chemicals for sterilization.s Koch later developed a nonpressure steam sterilizer for laboratory media, and during the next several decades, attention was directed to the development of heat sterilizers. Schimmelbusch was the first to use the steam sterilizer for surgical dressings, and by 1885, Neuber was sterilizing everything that came in contact with the surgical wound. The discovery of heat resistant bacteria in 1876 by the English physicist, John Tyndall, invalidated boiling as a method of ridding laboratory materials of organisms. Pasteur and his collaborator, Charles Chamberland, were therefore forced to develop the first pressure steam s t e r i l i ~ e r .Paul ~ Redard, a French orthopedic surgeon, demonstrated that resistant spores could be killed by using steam to increase the pressure; thereby, raising the temperature and the need for sterilizers with steam under pressure was well established.1° While progress was being made in the area of sterilization, other antiseptic techniques were being devised. Hand coverings were first introduced by Watson in 1843 to protect parturient women, and in 1885, Mikulicz first used cotton gloves. Although Halsted is credited with being the first to use rubber gloves in 1889, it was, in fact, one of his residents who first advocated the use of gloves. Halsted merely popularized their use." Gauze facemasks came on the scene around 1896-97 and were probably first used by either Mikulicz or Berger.12 Sterilizers in America. Much of the original sterilizing equipment used in America was designed in Europe. The following sign probably marks the introduction of American-made equipment: Pressure Sterilization The Necessity to the Best Results in Aseptic Surgery 40
A hot air sterilizer consisted of an oven made of sheet iron with double walls with shelves. Heat is supplied by the gas burner underneath. (Robb, Aseptic Surgical Technique, Lippincon, 1894.)
Sprague-Schuyler Company Works: Rochester, NY Main Office: 136 Liberty St, NYC (Dated 1895)13 The first complete pressure sterilization system of the vacuum type was installed in 1890 in Whitbeck Memorial Surgical Pavilion, Rochester Hospital, Rochester, NY, and two years later, a n improved system was incorporated into the W J Syms Surgical Theatre in Roosevelt Hospital, New York City. Other manufacturers appeared on the scene, including Kny-Scheerer, Wilmot Castle, and J J Kinyoun, but evolution was slow. It was not until about 1915 when W B Underwood introduced the concept of air clearance by gravity that the first sterilizer of modern-day use was marketed. In 1933, the American Sterilizer Company manufactured the first temperature-regulated pressure steam sterilizer, thus marking the beginning of a more scientific measurement of the process of sterilization. Hot air sterilizers. Although not as popular as in the past, dry heat methods such as hot air ovens, hot beads, and infrared lights are still in use for selected materials under certain conditions. As progress is made in newer methods of sterilization, it can
AORN Journal, July 1976, Vol24, No 1
probably be anticipated that dry heat sterilization will become even less popular and perhaps be totally replaced by other means of sterilization.
Ethylene oxide sterilization. Although gaseous agents have been used for many years as fumigation and disinfection agents, it was not until 1859 when Wurtz described ethylene oxide that a suitable agent was available for sterilization.'* Gaining in popularity as a fumigant in the early 19OOs, it was recognized as a bacteriocidal in 1929 and by 1949 was accepted as a sterilizing agent following the publication of parameters for achieving sterility of bacterial spores. Now well established as a sterilizing agent in hospitals and industry, ethylene oxide sterilization enjoys a variety of uses ranging from food processing to interplanetary space vehicles and probes. Sterilization by irradiation. Sunlight, long recognized as beneficial in controlling the spread of disease during epidemics and in crowded conditions, was the forerunner of the use of nonionizing irradiation for sterilization purposes. The ultraviolet wavelengths were identified as the therapeutic effect of sun about the same time Roentgen discovered x-rays in 1895.15 X-rays, a form of ionizing sterilization, were soon observed to have properties lethal to bacteria, with these observations beginning this era of sterilization. The serious pursuit of this concept was not to begin until the mid-1940s when atomic research was a t its peak. The availability of particle accelerators and the production of radioisotopes in nuclear reactors stimulated interest in the development of this highly effective method of sterilization, and in the early 1950s, the first of these radioisotope sources was made available for use.16 In spite of the progress in this field, the routine use of irradiation for sterilization is not yet feasible because of the expense and the type of equipment in-
volved. Continued research will undoubtedly make this method readily accessible within the near future, marking another milestone in the evolution of sterilization. It has been just one brief century since the concept of sterilization developed from a primitive beginning to a scientific and sophisticated process. Perhaps in the next hundred years, scientific achievements will make today's use of heat from pressurized steam, ethylene oxide, and irradiation appear as peculiar to our successors as boiling and carbolic acid sprays seem to us today. As man continues in his quest for a safer and better world in which to live, we can be assured that progress will be great and achievements many in all the specialized fields of health sciences. 0 Notes 1. Homer, The Odyssey, translated by J W Mackail (London: Oxford Press, 1932) Book XXII, 474. 2. J J Perkins, Principles and Methods of Sterilization in Health Sciences, 2nd ed (Springfield, 111: Charles C Thomas, 1969) 3-4. 3. lbid. 4. Ervin S Wheeler, "The development of antiseptic surgery," American Journal of Surgery 127 (May 1974) 574. 5. lbid. 6. Christopher's Textbook of Surgery, 9th ed, Loyal Davis, ed. (Philadelphia: W B Saunders, 1968) 12-13. 7. Wheeler, "Development of antiseptic surgery," 578. 8. 0 H Wangensteen, et al, "Some preListerian and post-Listerian antiseptic wound practices and the emergence of asepsis," Surgery, Gynecology & Obstetrics 137 (October 1973) 689. 9. Perkins, Principles and Methods, 11. 10. Carl W Walter, The Aseptic Treatment of Wounds (New York: Macmillan Company, 1948) 21. 11. Wheeler, "Development of antiseptic surgery," 579. 12. Wheeler, "Development of antiseptic surgery," 579. 13. Perkins, Principles and Methods, 24. 14. Perkins, Principles and Methods, 501. 15. G Sykes, Disinfection and Sterilization, 2nd ed (Philadelphia: J B Lippincott, 1965) 146. 16. lnternational Anesthesiology Clinics, 10 (Boston: Little & Brown Co, Summer 1972) 123127.
AORN Journal, July 1976, V o l 2 4 , No 1
41
