Postsurgical Infections

The impact of anesthesia on the frequency of operations has been a matter of debate, but careful analyses of patterns of surgery in nineteenth century hospitals indicate a positive correlation between the development of anesthesia and the number and range of surgical operations. In part, the rise in surgical cases was an outgrowth of urbanization and industrialization, but the increase in gynecological surgery, especially ovariotomy was dramatic; many of these operations were done to treat nonspecific ''female complaints'' and emotional problems. Those who harbored suspicions that surgeons were driven by a ''savage desire for cutting'' were convinced that surgeons operated on moribund accident victims not because they expected to save them, but because doctors saw them as ''teaching material'' or experimental specimens. Sir John Bell (1774-1842), eminent surgeon, physiologist, and neurologist, said that the ideal surgeon had the ''brain of an Apollo, the heart of a lion, the eye of an eagle, and the hand of a woman,'' but his contemporaries were more likely to see the surgeon as an ''armed savage.''

A striking upsurge in novel operations occurred in the postanesthetic, pre-antiseptic period, but there is some evidence that the notoriously high rates of post-surgical infections associated with this era had more to do with changing patterns of urbanization, industrialization, poverty, and malnutrition than anesthesia. The deplorable conditions of hospitals, the misery of the typical hospital patient, and the growing evils of poverty and industrialization provide an explanatory framework for the prevalence of hospital infections in the nineteenth century.

Ideally, surgery should be judged in terms of the survival and rehabilitation of the patient, but the drama of the operation tends to overwhelm the mundane details of post-surgical management. In the pre-anesthetic era, the dazzling speed, strength, and daring of the master surgeon were displayed to good advantage in a limited range of operations. The legendary surgeon who amputated a leg at the thigh, along with two fingers of his assistant, and both testes of an observer, represented the epitome of this genre of surgery. Better authenticated heroes of this era were men like William Cheselden (1688-1752) who could perform an operation for bladder stones in less than one minute, and James Syme (1799-1870), who amputated at the hip joint in little more than 60 seconds. Surgeons were as obsessed with setting speed records as modern athletes, but their goal was the reduction of the stress, pain, and shock endured by the patient. In this context, surgical anesthesia might be seen as a prerequisite for the standardized antiseptic ritual, because it would have been virtually impossible for the lightening-quick surgeon to carry out such procedures while coping with a screaming, struggling, conscious patient.

When the art of anesthesia had been mastered, the surgeon was no longer damned as the ''armed savage,'' but, in the crowded, filthy wards of the typical nineteenth-century hospital, wound infection was transformed from a sporadic event into an array of epidemic conditions generically referred to as hospitalism. Although surgeons might admit that the patient on the operating table in a hospital was more likely to die than a soldier on the battlefield, the poor prognosis did not inhibit rising interest in surgical intervention. The cause of wound infection was not clearly understood until the elaboration of germ theory, but

"uncleanliness" had been a prime suspect since the time of Hippocrates. Hippocratic physicians knew that it was preferable for a wound to heal by first intention, that is, without suppuration (pus formation). Surgeons could only hope that if a wound was washed with wine, vinegar, freshly-voided urine, or boiled water, cleansed of foreign objects, and covered with a simple dressing, healing would proceed without complications. Wound infection was, however, such a common occurrence that by the medieval period, surgeons had developed elaborate methods to provoke suppuration. The theoretical rationalization for these procedures is known as the doctrine of ''laudable pus.'' According to this offshoot of humoral pathology, recovery from disease or injury required casting off putrid humors from the interior of the body. The appearance of nice creamy white pus in a wound was, therefore, a natural and necessary phase of healing.

Assessing the relationship between changing surgical practice and post-surgical mortality rates in the nineteenth century is complicated by the simultaneous shift to hospital-based medical practice. Crude statistics, such as the 74 percent mortality rate among Parisian hospital patients who had undergone amputation at the thigh in the 1870s, however, seems to speak for itself. Knowing how often successful operations were followed by fatal infections, doctors were famously among those who refused to submit to the knife. For example, when the great French surgeon, diagnostician, and anatomist Guillaume Dupuytren (17771835) faced death, he rejected the possibility of an operation, saying he would rather die by God's hand than by that of the surgeon. The motto so popular with anatomists, medical examiners, and pathologists, ''Hic locus est ubi mors gaudet succurrere vitae'' (This is the place where death delights to help the living), would certainly not be comforting to a surgeon who found himself in the role of the patient. Respect for the sick was, however, reflected in another Latin maxim often found in hospitals: ''Praesent aegroto taceant colloquia, effugiat risus, namque omnia dominatur morbus.' (In the presence of the sick, all conversation should cease, laughter should disappear, because disease reigns over all.)

Despite the reputation of hospitals as places where people went to die, perhaps comforted by an atmosphere imbued with compassion and piety, the annual reports of some hospitals suggest a respectable success rate. For example, the 1856 annual report of Philadelphia's Children's Hospital claimed that of 67 children admitted that first year, 41 were discharged as cured, and none had died. In contrast, in 1870, when Dr. Abraham Jacobi (1842-1906) publicly revealed the appalling mortality rate at a children's hospital in New York, he was forced to resign. Hospital administrators had refused to institute reforms suggested by Jacobi, one of the founders of American pediatrics. The philanthropists who controlled many hospitals often considered moral guidance more important to the mission of the institution than medical science.

Physicians and surgeons knew all too well that even a pinprick opened a doorway to death. The doctor was no more immune to the danger than his patient; minor wounds incurred during dissections or operations could lead to death from a massive systemic infection known as pathologist's pyemia. With but slight exaggeration, doctors warned that it was safer to submit to surgery in a stable, where veterinary surgery was routinely and successfully performed, than in a hospital. When miasmata generated by ineluctable cosmic influences permeated the hospital, patients in the wards inevitably succumbed to hospital gangrene, erysipelas, puerperal fever, pyemia, and septicemia. Physicians endlessly discussed the nature of these disease entities, but all of these hospital fevers can be subsumed by the term hospitalism. When epidemic fevers were particularly virulent, the only way to prevent the spread of infection was to burn down the hospital.

Ironically, the evolution of the hospital into a center for medical education and research may have been a major factor in the appalling mortality rates of the large teaching hospitals. Changes in the hospital's social role may also have contributed to the pandemic of hospitalism. By the nineteenth century, the reputation of many urban hospitals was so low that no horror story seemed too implausible. Impoverished slum dwellers were convinced that hospital patients were doomed to death and dissection to satisfy the morbid curiosity of doctors. Hospital managers in France were confronted by terrifying rumors of secret dissection rooms where human fat was collected to light the lamps of the Faculty of Medicine.

Descriptions of major hospitals invariably refer to the overcrowding, stench, and filth of the wards. Surgeons complained that nurses were rarely sober enough to work; patients complained that they were being starved to death. Blood, pus, expectorations, excrement, and urine covered hospital floors. Operations were often performed in the center of the ward when a separate operating room was unavailable. The same washbasin, water, and sponge were used to treat a whole row of patients, and the pus-saturated dressings were collected in the common ''pus-bucket.'' On a more positive note, pus-saturated surgical bandages provided the cells that Johann Friedrich Miescher (1844-1895), physician and chemist, used in the research that led to the discovery of nucleic acid. Moreover, the great quantity and diversity of patients provided invaluable clinical experience for young surgeons, physicians, and pathologists. Hospitals began as places of refuge and charity that cared for the sick and comforted the dying. Changing medical theory, training, practice, and intense interest in pathological anatomy, as well as socioeconomic factors, created new roles for this institution. But the hospital remained embedded in a matrix of poverty and charity in which the virtues of economy and efficiency were more important than cleanliness. Philanthropists, administrators, and physicians, as members of the

"better classes,'' expected their "lower class'' patients to be conditioned to crowding, discomfort, and filth; excessive cleanliness might even shock and distress such people.

Surgeons began operations without any special preparation, although a brief hand wash was considered appropriate when leaving the dissecting room. During operations, surgeons protected their clothes with an apron or towel, or wore an old coat already covered with blood and pus. Patients were ''worked up'' for surgery by the removal of their outer clothing and a swish of a well-used sponge. Observers were often invited to probe and examine interesting wounds. After the introduction of anesthesia, the pace of surgery became less frantic, but certainly not leisurely. Habits acquired in the pre-anesthetic era were not easily broken. A surgeon took pride in his ingenious methods for saving time, such as holding a knife in his mouth while operating. Using the same coat for all operations was convenient, because needles, sutures, and instruments could be kept handy in the lapel, buttonhole, and pockets.

It would be wrong to extrapolate from the epidemics of infection that swept through nineteenth-century hospitals to the problem of surgical infection in other ages. Indeed, it has been suggested that fluctuations in hospital mortality rates reflected the level of distress in the community. Famine, scurvy, and disease would certainly affect resistance to infection. This hypothesis is consistent with the observation that veterinary surgery was relatively free of the problem of wound infection, although it was carried out under rather primitive conditions with little concern for asepsis. Hospitalism might, therefore, have been a unique nineteenth-century plague, perhaps caused by the effects of the Industrial Revolution, rather than a reflection of surgical practice from Hippocrates to Lister.

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