|Sue Hawkins, Honorary Research Fellow, Kingston University
|The UKAHN Bulletin
|Volume 9 (1) 2021
The first thought that occurred to me on beginning to read this absorbing account of the history of hospital infection was, what a shame the authors didn’t write this a year or so later. Our recent experiences of dealing with a pandemic and the myriad public health issues it has thrown up chime with so many of the themes covered in this collection that a chapter on the pandemic could have made an intriguing link between history and the present day. Perhaps, if it goes to a second edition, a new chapter on the Covid could be added.
So, we are where we are, and the collection of essays brought together by Rafferty, Dupree and Alberti do not disappoint. They provide food for thought in our approach to recognising and dealing with hospital acquired infections, by taking the reader on an historical tour of the development of ideas about HAIs, what caused them, where and when did they arise, what approaches have been taken in an attempt to either control or eradicate them, and who was to blame? The answer to this latter question appears often to have been ‘the nurses’. The book is divided into themed sections, and Section II ‘Infection control: nurses and medical students’, contains three essays which describe how, historically, the finger was pointed quite firmly at nurses and how they responded to this charge. In the first of these, Pamela Dale discusses how ‘dirt shaped surgical nurse training’(p81) in the first three decades of the twentieth century. Throughout this period, which also marks rapid growth in the practice of surgery, a major issue facing surgeons was post-operative sepsis. In order to save their own reputations, argues Dale, surgeons were quick to place the blame for post-operative infection at the hands (quite literally) of the nurse. So much so that ‘nurses recognised the shame of the presence of pus’ (p85) in their post-operative patients – an indication of a job badly done. Surgical nurse training and textbooks focussed to a great extent on the importance of the nurse in creating and maintaining aseptic operating environments and practice, stressing nurses should not only understand sepsis from a scientific point of view, but they should also understand why the ‘intelligent appreciation of the reasons for aseptic measures’ was so important in a good surgical nurse. The connection between good nursing, cleanliness (both personal and in her work practices) and the absence of ‘dirt’, all bore echoes of Nightingale’s nineteenth century ideas on hygiene and good sanitary practice. Dale makes an interesting observation on the link between hierarchy within the nursing profession and the ‘gradient of dirt’ (p90) as this period progressed: as ‘dirt’ became smaller, moving from the visible to the invisible (ie microbial), so the status of the nurse who dealt with it increased. In other words, visible dirt, on the ward’s surfaces or the patient’s body, was the responsibility of the junior nurse, while the invisible dirt (septic matter) within wounds was the senior nurse’s responsibility. The surgeons, who seemed totally oblivious to their own potential contribution to a breakdown in aseptic procedures, were quite happy for the nurses to accept full responsibility.
Claire Jones also takes up this theme of blame and accountability for prevention of infection. Her chapter covers a wider period taking the reader from 1870 to 1970, examining the role of nurses (and doctors) in transmitting infections to their patients, especially focussing on the phenomenon of septic finger. As Jones explains, the issue of wound sepsis and its transmission by medical attendants spans the whole period, and unlike other infections which are epidemic in nature, wound sepsis was and continues to be a chronic challenge for hospitals, especially in the modern era of antibiotic resistance. In her chapter, Jones discusses how from the beginning of her period, septic wound infections in staff (particularly nurses) plagued hospitals: a nurse with a septic finger was a walking infection risk for her patients. She uses numerous examples from nineteenth- and early-twentieth century accounts of nurses incapacitated and banned from the wards for long periods of time as they recovered from such infections, and played havoc with rotas and hospital staffing (in echoes today with Covid positive NHS staff). Moving into the the era of the NHS and the emergence of antibiotic resistance, and especially the rise of Staphylocccus as a causative organism, Jones turns her attention as to how infection control became the focus, with controversial plans to regularly test staff and prophylactic nasal antibiotic therapy. So problematic did the issue of HAIs become that infection control committees were established to develop strategies to monitor and restrain infections within the hospital, and the post of Infection Control Nurse was established, and became a senior role within a hospital’s management hierarchy.
The final chapter in this section comes from Susan MacQueen, a nurse who has spent her whole career working in the field of infection control. She describes the rise of importance of the infection control nurse within the NHS, her arguments for the inclusion of infection control and microbiology in general nurse training and the challenges in persuading senior managers (including consultants) and politicians within the Department for Health to take the issue seriously.
From a nursing history perspective the book is worth reading for these three chapters alone, but they are accompanied by a group of other themed essays on subjects such as policy and infection control and the development of laboratory-based approaches to infection control which will also be of interest. I found the two essays on the role of glove use in infection control to be thought provoking, particularly Thomas Schlich’s chapter ‘Wax paste and vaccination: alternatives to the surgical glove for infection control, 1880-1945’. Schlich makes the very good point that histories of medicine often focus exclusively on successful technological advances; they ignore the alternatives which were present before the paradigm was shifted, mirroring the often-quoted aphorism that history is always written by the winners. Schlich presents a number of alternatives which were being tried as an alternative to the rubber glove, such as the application of very thin layer of wax on the surgeons hands which would provide a barrier to infection without loss of dexterity associated with rubber gloves; or the idea promulgated by Johannes Mikulicz in the early twentieth century, of ‘vaccinating’ against sepsis-inducing intestinal bacteria released by ruptured organs during surgery, by boosting the body’s immune system prior to the operation. As history tells us, the use of gloves won out and perhaps another aphorism, that the simplest answer is usually the best, is also the case here; but it is interesting to read about other approaches, now consigned to the dustbin of history, to tackle a problem that was continuing to challenge medical practice and does to this day.
The issue of antibiotic resistant pathogens is discussed in various chapters with the book but perhaps surprisingly does not get a chapter of its own.
Overall, this is a fascinating collection of essays, and as suggested at the beginning, many of the historical debates discussed within them have been brought into sharp focus with the events of the last 18 months or so. The section on nurses delivers insights into the role of the nurse in infection control within the hospital setting, and adds a new dimension to the history of the nursing profession in the UK.