| The Fashion Issue | Winter 2007 |
Dressed Not to Kill This is a story of symbol and science, of the extraordinary being expressed through the practical, of competition, and even of love. This is February can be a harsh month in Massachusetts, but as Oliver Wendell Holmes put the final touches on the speech he would deliver that month in 1843, he focused on a harsh reality of a different sort. Holmes, Class of 1836, was preparing to relate to the Boston Society for Medical Improvement a “long catalogue of melancholy histories” involving cases of puerperal fever. This litany of sadness and death was not all Holmes would present; he was also preparing to suggest the audacious: that physicians could contain, possibly even curtail, the spread of this infection among their female patients by modifying their personal hygiene regimens. Holmes’s presentation, “On the Contagiousness of Puerperal Fever,” drew upon his observations, common sense, and bedside experience. And his suggestions—that physicians who tend women with this condition “change every article of their dress” after the visit, perform a “thorough ablution” of their persons, and wait 24 hours or more “before attending to any case of midwifery”—would be not simply a hard sell but a close cousin to fighting words. It was difficult for physicians of his time to accept that their personal cleanliness could play a role in the health of their patients. Where, they asked, was the evidence? Their skepticism was understandable: Holmes’s suggestions were not moored to the science of the past. They forecasted facts of the future. badges that discourage To appreciate hospitals and patient care in the early to middle nineteenth century it is necessary to engage the senses. To enter the hospital of the day was to step into a chamber of fetid aromas emanating from flesh that was losing its battle to such bacterial infections as gangrene, pyemia, septicemia, erysipelas, tetanus, and puerperal fever—conditions collectively referred to as “hospitalism.” Moans and cries from patients on the wards were often punctuated by screams from patients in the surgical theater. Until anesthesia was publicly introduced by HMS faculty in 1846, surgeons tried to minimize their strapped-down patients’ exposure to pain by working with all possible dispatch. A blur of motion, they often completed amputations in seconds and wound closings and dressings in mere minutes. Time spent operating was nearly matched by that spent in preoperative preparation. Surgeons readied for their task by simply rolling up their shirtsleeves and pinning well-waxed silk ligatures to the lapels of their operating coats. The coats themselves bore histories of their owners’ surgeries. Covered, usually crusted, with blood and pus, the garments were hung on hooks after one surgery and shrugged on before the next, a sequence of use that would repeat—unbroken by a cleaning—throughout the decades of a physician’s tenure. Some considered their coats to be statements. In Memoirs of a Small-Town Surgeon, John Brooks Wheeler, Class of 1879, tells of the blue broadcloth garment the senior surgeon at Massachusetts General Hospital wore. With its velvet collar and long tails, the tunic had once been natty enough for home and street wear, but the years’ toll had rendered it sufficiently shabby to qualify as surgical garb. Stiff with blood and other dried fluids, the coat was sported by that surgeon throughout the four years Wheeler spent at the hospital. The young Wheeler avoids speculating on where those four years fell in the surgical lifetime of the garment. Given these conditions, it may not be surprising to learn that hospitalization and surgery were considered last-ditch efforts reserved for the poor and the hopeless. Statistics from the period provide some grim detail. In antebellum America, hospitals lost nearly 25 percent of amputation patients, as recorded by institutions such as Massachusetts General Hospital and Pennsylvania Hospital. In Europe, mortality rates for such patients were even greater: 43 percent reported by infirmaries in Scotland, 46 percent at Zurich’s surgical hospital, and 60 percent in hospitals in Paris. Yet infections stemming from surgical conditions could not receive all the blame; mortality rates for other hospitalism infections were similarly stark. John Bell, reporting in his Principles of Surgery about one Paris hospital, sums up the situation of that time, “It was the gift which the Hôtel-Dieu, the House of God, dispensed to all who sought or were forced into its charitable wards, so that no less than twenty-five out of every hundred who entered living were borne out dead.” rinse and repeat Holmes was not alone in deploring this state of affairs or in seeking ways to correct it. But he and his reformist peers made little headway until a British surgeon, Joseph Lister, rewrote scientific convention. In the mid-1850s while serving as a surgeon in Scotland, Lister had become appalled at the rates of infection surrounding him. To change this, he implemented new hygiene and sanitation practices on his wards. And he began testing different methods for treating wounds. A series of failures ended when he came across the findings of French chemist and biologist Louis Pasteur and realized it was the introduction of microorganisms into the wound that caused the infections. Knowing the enemy, Lister could now devise a way to eliminate it. His choice: chemical intervention. He began to expose surgical instruments, incisions, and dressings to differing concentrations of carbolic acid, a sewage deodorant of the time. His results, when published in The Lancet in 1867, showed that even the usually fatal compound fracture could heal without becoming infected provided the surgeon’s hands, surgical field, wound, and dressings were cleaned, soaked, or kept wet by a solution of carbolic acid. The age of Listerian antisepsis had dawned, and the camps for and against it quickly formed. Acolytes of the Listerian method sought knowledge from the source; by the early 1870s physicians such as J. Collins (“Coll”) Warren, Class of 1866, and Henry Orlando Marcy, Class of 1864, were returning from Scotland armed with knowledge they hoped to implement. It was not easy; at Massachusetts General Hospital, Henry Jacob Bigelow, Class of 1841, doubted Lister’s methods and blocked their implementation. Marcy, in a break from the constraints of that institution, set up his own clinic where his rules for antisepsis included the requirement that all members of surgical teams wash their mouths out with a solution of carbolic acid before beginning any procedure—foreshadowing, perhaps, that Lister’s accomplishments would be immortalized in the United States through the name of a mouthwash. Physicians elsewhere embraced Lister’s technique—and cleanliness thesis. An early convert and proselytizer was Gustav Neuber. By 1883, this German surgeon was chemically sterilizing the implements and field of his operating room in Kiel. He also was the first physician to require sterile gowns for members of his surgical team. The white stuff Gowns were not exactly new for surgeons; thirteenth-century barber surgeons were allowed to wear long robes as they plied their trade, thus distinguishing themselves from lay barbers, to whom short robes were consigned. The advent of antiseptic technique and the rising importance of laboratory analysis in medicine, however, spurred a move to adopt clothing that reflected cleanliness and science. As the nineteenth century drew to a close, medicine embraced science to a degree previously unmatched. Reforms included moves for an overall costume change, one that answered the needs of antisepsis and economics. In 1894, Hunter Robb, a gynecologist at Johns Hopkins Hospital, wrote in his Aseptic Surgical Techniques that surgeons should wear specially crafted suits that could be easily sterilized. These, he suggested, could be constructed of a “twilled muslin, costing about 13 cents per yard.” John Allen Hornsby gave similar recommendations in his 1914 manual The Modern Hospital. Hornsby, then the director of Michael Reese Hospital in Chicago, suggested that special garments be worn by all who entered the hospital precinct. These garments included knee-length, back-tied operating gowns for surgeons, house coats for visiting physicians who were making rounds, and sleeveless mantles “almost like a pillow case…for visitors in the maternity and children’s departments and in the operating rooms.” Each version, according to Hornsby, should be fashioned from “drilling or Indian head” or, in a pinch, from similar cotton goods. Hornsby and Robb agreed on the necessary color: white. The pervasiveness of white in hospitals and scientific laboratories welded the symbolic attributes of the color onto the profession, according to physician and medical anthropologist Dan Blumhagen. And as medicine increasingly became cloaked in science, the more tangible characteristics of the two disciplines became linked in the mind of the public. White, carrying with it the attributes of life, innocence, purity, cleanliness, and candor—the latter firmly rooted in the Latin candidus, bright white—became the visual definition of doctoring. And the calling card bearing that message? The physician’s white coat. The hierarchy of hem Among items that speak of personal and professional hygiene, few can match the power of a screaming clean white coat. And as nineteenth-century science and scientists began to migrate from the laboratory to the hospital—and physicians began the trek in the opposite direction—the universal adoption of the white coat allowed for a seamless exchange. The garment did, however, need to fill certain requirements, at least according to Hornsby: “These coats should be made with some regard to pattern, which makes an excellent impression on the observer if the physicians…have on well-made and well-fitting coats....[As for closures] there is no button that will go through the laundry....Tapes do not look well, and physicians and surgeons will not tie them....There seems, therefore, to be only one form of fastening, that of the brass snap button. Besides enhancing professional carriage, the coats were decidedly practical. They covered one’s street clothes, saving wear and tear while also, as needed, masking fashion sins. They said “Doctor,” thus allowing their wearers to avoid the pronouncement. And they had pockets. Physicians could carry critical tools while leaving their hands free to probe, prod, or comfortingly pat their patients. To-do lists and pens or pencils have consistently been common contents, often sharing space with the wisdom of the Pocket Pharmacopoeia, the Washington Manual of Medical Therapeutics, or, in contemporary times, the fully loaded personal digital assistant. Perhaps best of all, the coat’s pockets have provided a home from which the curved horns of that signature tool, the stethoscope, can peek. The coat also acts as a semaphore, signaling to those in the know the rank of the wearer. Tradition has it that medical students and often residents wear short coats while the coats of attending physicians tastefully touch the knee. One of the few institutions to buck that tradition has been Massachusetts General Hospital, which, until recently, took an egalitarian approach by clothing all ranks—student through attending physician—in short coats. By the 1920s, however, most of the nation’s hospitals had adopted the long, white “lab” coat as on-the-ward wear for their physicians. Blue’s anatomy Once coats and gowns were convention, street clothes became the next item to receive a sartorial makeover, becoming swapped for white pants and shirts as physicians scrubbed in for surgery. These “scrubs” provided yet another barrier to bacteria shed from the skin of surgeons and their attendants. Soon, with the acceptance of the pants uniform by nurses, surgical teams began to take on the look of, well, a team. In 1914, a San Francisco surgeon, Harry Sherman, recognizing that the whites and lights of surgery hurt the eyes of surgeons and their teams, suggested using instead a complementary color of hemoglobin—green, specifically spinach green. This color provided many benefits: Studies showed it eased eyestrain, was psychologically cool, and allowed surgeons to maintain their visual acuity to pinks and reds. Green quickly became the new white and gave birth to “surgical greens.” Soon spinach green itself morphed to a gentler “misty” green. By the 1930s, scrubs included a dusky palette of gray, dark blue, and plum. Today, the garments come in a rainbow of pastels and patterns. As more colors came into use, one, “ciel” or sky blue, found a niche, one it has held since the 1950s: television. Ciel blue played well on color television, a tool that was increasingly being used as a teaching aid. Thus, more than a century after Holmes proposed the merits of clean clothes for each procedure, physicians were not only prepared to wear fresh, sterile garments, but they were also, it seems, ready for their close-ups. a slip of a thing The slow pace of medicine’s acceptance of gowns and coats was played out in equal manner for the accessories of the trade: gloves, caps, and masks. Oddly, the use of gloves seems to have hit the greatest number of roadblocks, needing nearly 150 years to move from the first published mention to standard use. Although people had long used gloves to protect their hands against harsh weather and difficult working conditions, it wasn’t until 1758 that a German physician, Johann Julius Walbaum, reported to his peers the merits of an obstetrical glove he had developed for in-utero manipulations of a fetus. Walbaum’s glove, constructed from the “blind gut of a sheep,” was simply drawn over the hand, exposing the thumb and index finger through a four-inch slit while covering the back of the hand and the other fingers. Walbaum’s mitt allowed him to smoothly insert his hand without having it stick to the walls of a woman’s vagina or uterus. As an asepsis aid, however, it was a non-starter. In 1808 a Viennese dermatologist presented the next evolution in the argument for glove use by advising physicians who served as midwives to wear gloves when tending patients with venereal disease, introducing the notion that gloves could protect the practitioner from the patient. Another 30 years would pass before the idea was launched that gloves could also protect patients from their physicians. In the early 1840s, British physician Sir Thomas Watson made an understated suggestion with profound implications for the management of puerperal fever: “…a glove, I think, might be devised which should be impervious to fluids, and yet so thin and pliant as not to interfere materially with the delicate sense of touch in these manipulations.” Watson was on to something. In the early 1800s, chemists had begun experimenting with rubber sap with the aim of finding new applications for it. In the 1830s, Richard Cooke, a young New Jersey physician, described using a latex-based “spirit of turpentine” to make single-use gloves that he painted on his hands before dissections and vaginal examinations and rubbed off when finished. By 1878—the same year the German physician and bacteriologist Robert Koch published his seminal work on wound infection—British and U.S. patents for the manufacture of rubber gloves for surgical operations had been secured. Most surgeons, however, continued to work ungloved while their assistants and nurses wore gloves only as needed. It was the need of one nurse, in fact, that would lead to the acceptance of gloves in the operating suite of one well-known surgeon of the era—and the spread of their use throughout the profession. glove conquers all In the late 1880s, William Halsted, a surgeon at Johns Hopkins Hospital, took a special interest in the havoc that the chemicals used to sterilize his surgical instruments were wreaking on the hands of one Caroline Hampton. Hampton was an unusually efficient assistant, according to Halsted, so the work-hampering dermatitis on her hands and arms troubled him. Halsted was being slightly coy. He was in love—and how better to woo Hampton than to cure her? Halsted decided to test whether gloves would do the trick. He asked the Goodyear Rubber Company to manufacture “two pair of thin rubber gloves with gauntlets.” The gloves proved to be up to both tasks: Within a year Halsted had slipped a wedding ring on Hampton’s now-calmed hands. Although Halsted was several years away from accepting gloves for his own work, another physician on his team, Joseph Bloodgood, reported in 1899 that his use of gloves during more than 450 hernia operations cut infection rates from nearly 30 percent to next to nothing. The successful use of gloves by members of Halsted’s team helped promote their use in surgeries throughout the nation, a moment of progress triggered, as one of Halsted’s colleagues put it, when “Venus came to the aid of Aesculapius.” Gloves evolved in the following decades; the early, tough, reusable rubber coverings had, by the 1930s, become a more flexible, better fitting, “brown milled” item made from a solution of rubber cement. Single-use latex gloves debuted in 1958 and were widely adopted by the late 1960s and early 1970s. Their acceptance was no doubt hastened in 1970 when hospitals became subject to minimum-wage laws, a move that made the maintenance of reusable mitts—a laborious process carried out by nurses—too expensive to perpetuate. to top things off Considering the fashion dictum of coordinating hat with coat, it is unsurprising to learn that surgical caps surfaced in use at the same time as surgical gowns. The German surgeon Gustav Neuber required caps of his surgical team and, in the United States, Hopkins researcher Hunter Robb fanned the flames for their use. In a 1902 report, caps were part of the aseptic technique practiced at New York’s Albany Hospital. Three years later, the literature carried correspondence telling of their use by surgeons in Boston, Baltimore, and Cleveland. By the 1930s, microbiological evidence that hair harbored and shed bacteria led to the widespread wearing, although not the mandating of, turbans, shower-cap toppers, and other styles of head coverings during surgeries. The surgical mask was being promoted for use by surgeons in the late 1800s, but unlike the cap, its use had research backing early. In 1897, German physician Johann Mikulicz proposed the use of masks after research in another laboratory found live bacteria in droplets expelled from the mouth. A growing body of research showing the dangers of spittle-borne bacteria added evidence to the argument for mask use. In 1905, it was shown that streptococci were disseminated in sputum. And gauze masks worn by physicians helped check the spread of the dreaded 1918 influenza pandemic. The research that nailed the mandatory use of masks came in the mid-1920s, when patients’ wound infections were shown to harbor the same organisms found in the noses and throats of the surgeons and nurses who had attended them. ready to care The physicians who contributed to the development of the gowns, gloves, and other accessories of their profession differed in persona, location, and moment in time. Yet they represent one of those loose leagues of visionaries that recognize a problem and resolve to chip away at its solution. The threads of advice begun by such pioneers as Holmes and Lister provided the foundation upon which progress in the area of antisepsis was achieved. As these pioneers predicted and as research has helped codify—with, perhaps, a dash of television—clothes not only make the doctor, they also make for good medicine. Ann Marie Menting is associate editor of the Harvard Medical Alumni Bulletin. Photo caption: A surgeon at Boston City Hospital, when it was still affiliated with Harvard Medical School, simply rolled up his sleeves to begin work. An apron covered his clothing, but he wore no cap, mask, Photo: Harvard Medical Library in the Francis A. Countway Library of Medicine |
a story that spins through time, one woven with history and tied with myth. This is a story of physicians, of hospitals, and of lives saved. This is a story about what doctors wear.
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