Summary This paper looks at the history of operating room nurses in the light of the history of nursing and the history of surgery at a time of change in both domains. Geographically, its focus is on the United States as a national context where the specialization in this field occurred early on. The examination of instructional literature, e.g., textbooks, provides insight into the normative universe of the American operating rooms at the time. It shows how nurses played an integral, yet often overlooked part in the development of modern surgical practices. At the same time, operating room nurses were confined to a very gender-specific sphere of activities – they were basically responsible for cleanliness and maintaining order – and they were strictly subordinated to the operating surgeon’s authority. Operating room nursing thus offered a new field of professional activity for women while simultaneously reproducing and cementing contemporary gender roles. History of nursing, history of surgery, gender history, surgical nursing Since the late nineteenth century, specialised nurses have been essential members of the surgical team. As a historical subject surgical nursing in the operating room is located at the intersection of the history of nursing and the history of surgery. Both areas are closely entangled: modern nursing in general has been shaped to a large extent by surgery, mirroring the way modern surgery, with its demands of pre- and post-operative care, has been conditioned by the emergence of a modern nursing profession. This paper looks at the history of surgical nurses in the United States. It examines the specific distribution of labour in the operating room in light of both the history of nursing and the history of surgery more generally, using the instruction literature written by surgeons and nurses as source material. These sources do not necessarily reflect correctly what went on in practice, but they provide a fascinating insight into the normative universe of the operating rooms of the time. In previous historical research, operating room nurses have been examined in four different contexts. First, historians of nursing frequently have mentioned the role of nurses in surgery as an important impetus for the professionalisation of their occupational field. Secondly, histories of surgery have often acknowledged the existence of operating room nurses as an important factor in the rise of modern surgery.1 Thirdly, historians of the hospital have shown that the presence of professional nurses was also a significant factor in making the modern hospital acceptable to the middle classes. They have also demonstrated that nurses played a significant role in making technologies such as antisepsis, asepsis and anaesthesia practicable in hospital settings, which in turn attracted even more patients to the hospitals of the time.2 Finally, the topic of surgical nursing has also been relevant for gender history. Interestingly, the development of the field of surgical nursing occurred at the same time as the first women surgeons appeared in the operating rooms, in the second half of the nineteenth century. Contemporary discussions about this new development, which have recently received increased historical attention, were deeply shaped by gender issues.3 The new historical work on the topic has brought together gender, nursing and surgery in relevant ways. Thus, Claire Brock has investigated the distribution of responsibilities in operating rooms in Britain in the late nineteenth century and looked at the gendered roles of both nurses and women surgeons within this setting.4 Vanessa Heggie has looked at the interrelationship between the professionalisation of nursing and the entry of women into the medical profession. By examining how women’s roles and identities as doctors versus nurses were discussed at the time she has illuminated how the two occupations were related to each other through specific gender attributions.5 Despite historians’ interest in these related topics and even though the operating room would be an especially useful focus of investigation, the history of the operating room nurse as such has not yet been studied in detail.6 In the operating room, surgery and nursing came together in a way that makes the gendered role of both nurses and surgeons stand out in particular clarity. Historians have discussed the gendered character of the domain of nursing for a long time. More specifically, they have found that, in the course of the second half of the nineteenth and the early twentieth centuries, doctors in hospitals gradually accepted nurses as assisting practitioners with specific expertise, but that they were also careful that nurses did not interfere with their control of the patient’s medical treatment.7 It is important to note that this division of labour followed the gender roles of the time. The nurses’ sphere of responsibility reflected the female role model of caring and nurturing, which was conceptualised as determined by the physiological constitution of the female organism. Thus, roughly speaking, women were considered suitable for work in the domestic sphere but biologically unfit to be doctors. In keeping with such ideas, women nurses were charged with the more basic domestic tasks in modern hospitals, such as cleaning the wards and feeding the patients.8 Yet, female nurses also took on an indispensable role in the highly technical environment of the operating room and eventually became integral members of the emerging surgical team. This is remarkable because, originally, operating venues were a male-dominated work environment. This was partly due to the nature of surgery, which was seen as being incompatible with feminine sensitivities. Only when anaesthesia ‘made the operating theatre a place of quiet science rather than violent physical assault on a conscious patient’, historian Richard Barnett has observed, did it become ‘a setting in which the Victorian concept of feminine sensibility would be less vulnerable to offence’.9 These changes went along with a growing need for nursing staff, as hospitals were transformed from places of care for the sick poor into centres of sophisticated, specialised—and often surgical—therapy.10 The need for surgical nurses was met by a nursing profession that was undergoing a significant transformation at the time. In the second half of the nineteenth century, the role of nurses was redefined to include more and more medical functions. A recognised body of specific knowledge and skills associated with nursing was established and a structured programme of education and training was introduced.11 In addition, nursing textbooks started to include medical and scientific themes. Newly added sections on physics and chemistry, anatomy and physiology, as well as drug therapy, reflected and enhanced the idea that nursing was a profession. Nurses’ need for scientific and medical knowledge was particularly emphasised in the USA, where nurses were increasingly expected to be informed about the latest scientific advancements. They became responsible for performing basic tasks in the medical assessment of patients, for example taking their temperature and checking their pulse.12 At the same time, even in the American context, nurses had to remain firmly subordinate to the physician, who was in charge of the patient’s treatment. Along these lines, the newly instituted programmes of training for nurses also sustained ideas of subordination, obedience and respect for medical doctors.13 During the same time period, the field of surgery went through rapid and far-reaching technological changes. These affected the tasks performed by the attendants in the operating room. As mentioned, the introduction of anaesthesia transformed the working condition in the operating rooms; but anaesthesia also required new skills in peri- and post-operative care.14 Moreover, antisepsis and, even more so, asepsis, turned operative surgery into a form of teamwork, as Ulrich Tröhler has noted.15 Thus, the history of surgical nursing is a central part of the history of the surgical team—a topic that has been relatively neglected in historical research so far.16 We will see in the following sections how the surgical nurse was situated within the hierarchy of the emerging operating team and its particular distribution of expertise and responsibility. Cleanliness and Order: Surgical Nursing Cleanliness was always a priority of modern nursing, and as a corollary, also played a crucial role in the history of surgical nursing. Even before antisepsis, Florence Nightingale, in her Notes on Nursing of 1860, linked surgery and nursing through cleanliness: ‘The surgical nurse’, she demanded, has to be ‘ever on the watch, ever on her guard, against want of cleanliness, foul air, want of light, and of warmth.’17 She thus addressed two of the main themes of surgical nursing: attentiveness and cleanliness.18 Nightingale herself probably never entered an operating room and the nurses trained in her system received no special education in surgical practice. Instead, nurses trained in the Nightingale tradition ‘brought bourgeois codes of cleanliness and order into the often filthy and chaotic setting of large city hospitals’.19 Nightingale’s attitude was thus associated more with sanitation than with surgical antisepsis. However, her goals turned out to be perfectly consistent with the implications of germ theory later on.20 Nightingale’s approach is a good example of how cleanliness was closely associated with morality. The professional nurses occupied the role of ‘carers, moral guardians and experts in the order of the sickroom’.21 As we will see, this underlying morality played out in the operating room in specific ways. In the second half of the nineteenth century the operating room underwent substantial changes. With the growing range and invasiveness of surgical operations, surgery became ever more dependent on the strict control of the environment in which it was performed. Hospitals offered these environments.22 Electric lighting, X-ray machines, endoscopes, special operating tables, new instruments and the sterilising facilities needed for aseptic techniques, as well as complex technologies for anaesthesia became available in the modern hospital. Its organisational framework, including 24-hour nursing, house staff and clinical laboratories, turned out to be an indispensable condition for the practice of modern surgery.23 With the growth of the technical sophistication of their field, surgical practitioners were confronted with new kinds of demands. For example, novel surgical techniques required heightened attention to detail. The main challenge of successful antisepsis in the 1860s and 1870s, for example, was not its technical difficulty, but the constant and uninterrupted attention to small details. It thus required discipline of the body and discipline of the mind. The characterisation of the ideal surgeon shifted away from its traditional emphasis on masculine bravado, and moved toward less stereotypically male attributes marked by technicality, diligence and attention to detail.24 Attention to detail became even more critical when the strategy of asepsis replaced or supplemented antisepsis in the 1880s. Unlike antiseptic surgery, which was based on eliminating micro-organisms with carbolic acid, aseptic practices aimed at preventing micro-organisms from entering the surgical environment and the patient’s body in the first place. In asepsis, accidental contagion was irreversible. The smallest gap in the aseptic conditions could lead to a catastrophe.25 Therefore conscientiousness was now considered to be more important for surgeons even than manual skill, as we can see from the statement of Chicago surgeon Carl Beck who claimed in 1895 that ‘the operations of less skillful surgeons, performed with a comparatively small degree of dexterity are more successful in their final results, provided they are thoroughly aseptic, than the operations of surgeons less scrupulous in their preparations …’26 This shift of the surgical value system after 1860 was the context in which surgeons called on women. With this step, they were taking particular tasks out of their own domain of responsibility and delegating them to nurses. These tasks included the changing of antiseptic dressings, which, as Barnett has noted, gave nurses ‘their first role in the management of surgical cases and an entrée to the operating theatre’. ‘The first theatre nurses’, he remarked, ‘were assistants in the rituals of surgical antisepsis, turning the traditionally female tasks of cleaning, swabbing and stitching into clinical necessities’.27 The entry of nurses into the operating theatre thus stayed within the bounds of the traditional gender-specific division of labour in medicine. However, surgical nurses had to meet certain criteria in terms of their qualifications. As James Walsh has pointed out, antisepsis ‘made it absolutely necessary that nurses should be of such an intellectual caliber permitting them to be trained in the prevention of infection through absolute cleanliness’.28 With a growing need for ‘more careful handling of dressing and instruments’ and for greater skill in providing post-operative care, historian Richard Shryock noted, requirements for the training, character and intelligence of the nurses who were attending in the operating room increased.29 It was cleanliness in particular and its specific incarnations as antisepsis and asepsis that were associated with surgical nursing. In his 1895 manual on surgical asepsis Beck detailed how nurses were responsible for specific tasks in cleaning and preparation, such as boiling water for sterilisation purposes, thorough disinfection of instruments after use, and removing sterilised instruments after disinfecting their hands ‘according to principles of prophylactic disinfection’.30 This is a good example of the delegation of housekeeping tasks to female nurses in order to create a clean environment for the operator’s work. The operation itself was performed by male surgeons. Reverend Louis Hinssen, the director of St John’s School of Nursing in Springfield, Illinois, noted in his 1899 Manual for Candidates and Novices of Hospital Communities, that it was the nurses’ responsibility to maintain absolute cleanliness in all aspects of medical care. This included taking care of the patients, their wounds and the surgical environment.31 Hinssen was a Catholic priest and nurse educator, not a surgeon. In his Manual he cultivated a distinct Catholic worldview as a reaction to the secular cultural environment of his time. Accordingly, the text was written ‘in a simplistic question and answer style that resembled the catechism’, as the historian of nursing Barbra Mann Wall has noted.32 It took the form of a question-and-answer sequence such as the following: ‘Q. How is the operating room prepared? It must be antiseptically clean, well ventilated and warmed. Q. With what should everything therein be washed off? With bichloride solution.’33 The parallel with the catechism is interesting since it points to the moral dimension of this kind of instructions Hinssen stressed the importance of absolute cleanliness. This concerned the patient and the patient’s environment, the surgical dressings and instruments as well as the person of the nurse herself.34 His instructions amounted to a combination of antiseptic and aseptic techniques—in daily practice, the two strategies were almost always used in some combination with each other. Antiseptic and aseptic surgical techniques worked best hand-in-hand, as Conrade A. Howell, a medical doctor at the Columbus Academy of Medicine, stated in his 1913 lectures on surgical nursing.35 Their distinction probably owes more to the scientific allegiances and strategies of surgical authors than to differences in practices.36 Cleanliness also loomed large on those instructional books that were written by nurses. In 1903 Martha Luce of the Boston City Hospital wrote a series of two articles, entitled The Duties of an Operating Room Nurse, in which she placed special emphasis on the details of preparing the operating room. This included dusting the room with clean, damp cloths, polishing glass, tables and utensils and regulating the temperature and ventilation of the room. In addition to the daily wipe-down, it was desirable to clean the rooms with a solution of corrosive sublimate (1 to 3000) before an operation, especially before an abdominal operation. The basin used for sterile water or any of the antiseptic solutions should be thoroughly cleaned with the same strength of the solution. Alongside the operating table, nurses prepared four different cleaning basins for surgeons to use to clean their hands while in surgery. The instructions are full of technical details such as the necessity to clean the knives ‘with soap and water, ether and alcohol (95%)’ wrap them ‘in separate sterile towels’ and boil them for three minutes, whereas ‘the rest of the instruments are boiled one-half hour in water in which a small amount of bicarbonate of soda has been added’.37 The operating room nurse was typically also in charge of the sterility of the surgical dress. Every person involved in an operation had to wear sterilised linen gowns, as Beck, for example, prescribed. Aside from the surgeon’s hands, the operator’s clothing was seen as the most probable source of infection.38 For nurses as well as for surgeons, asepsis went along with utmost bodily discipline and strict concentration of the mind. Potential sources of distraction needed to be minimised. This comes out in Beck’s instructions too: ‘Nothing should be required of the nurses except to hand to the surgeons the gauze mops, the towels, and the dressing materials, and to attend to the solutions, etc.’ Movement had to be restrained and disciplined: ‘Once being disinfected’, nurses ‘must not touch anything that may be contaminated.’ Sources of contamination were everywhere, so that ‘if a nurse or an attendant has to perform any non-aseptic manipulations—such, for instance, as holding the patient in a certain position or putting away a pus basin—he should not do any work which may bring him into contact with the wound’. Interestingly, nurses were allowed to touch the wound if they had worn sterilised gloves during non-aseptic manipulations and had taken them off afterwards.39 We would not find this rule in a present-day surgical manual. It points back to the original function of surgical gloves, which were at first worn not for protecting the patient’s wounds, but to keep the surgeon’s and nurse’s hands from being contaminated.40 Such detail in instruction might be familiar to today’s reader, but it was new at the time. It was during the decades around 1900 that the operating room came to be the well-ordered, compartmentalised and utterly controlled environment that we know today, and the surgical nurse was part of that process.41 Order and control was thus another focus of the nurses’ job in the operating venue. Thus, Hinssen pointed out that nurses were responsible for the proper placement of instruments and preparing the patients’ dressings prior to surgery.42 Similarly, Luce explained that nurses were in charge of instruments and material, such as sponges, cloths, gauze and dressings. They also had to mark rubber gloves with the surgeons’ names to prevent any confusion during surgery. ‘The operating-room nurse’, Luce noted, ‘is responsible for every detail of the preparation.’ She had to ensure that emergency stocks of instruments and materials were sterilised and available if needed. ‘If all has been well done,’ the author stated, ‘it will prevent awkwardness and delay during the progress of the operation.’43 Maintaining cleanliness and tidiness were considered typically female tasks, for which women were seen to be particularly suitable. Thus, when the Swedish surgeon John Berg in 1931 compared German and British surgery he found the operating rooms in Germany much tidier and cleaner. He explained the difference by the presence of female nurses in the German case.44 He obviously assumed that it takes women to keep operating rooms in good working order. However, even if women were seen as being especially talented for housekeeping jobs, operating room nurses also needed to be educated and well-trained in the scientific basis of their work. Despite her step-by-step instructions for correct cleaning procedures, Luce, for example, emphasised that nurses had to be familiar with the principles of asepsis in order to properly clean instruments and prepare the environment for surgery.45 And Katherine de Witt in 1900 demanded of the nurse to ‘try constantly to keep up with the rapid advance in medical science’.46 Similarly, in 1933 an outline for a course on surgical nursing showed a very strong emphasis on scientific knowledge. However, it was all centred on knowledge that would serve the patient’s physical and mental well-being, maintaining a clean environment both during and after surgery, and included the ‘housekeeping duties peculiar to the operating room’.47 Some textbooks and articles went even further in terms of the special relationship of nurses to medical science. De Witt pointed out that nurses should be able to contribute in their own way to scientific progress: ‘There is always the possibility that by careful observation she may collect data which will be of use to the doctor who cannot spend as much time as she over the minute details of a case.’48 The author also hypothesised that nurses’ specialisation was following the pattern of the specialisation of the doctors, with surgery being one possible field for those among the nurses who ‘can never forget the fascination of the operating room’.49 Along similar lines, the surgeon George F. Foster noted in 1911 a growing tendency towards specialisation which, as he thought, offered attractive career paths to nurses. According to the surgeon ‘the time is near at hand when we will see those of the nursing profession specialize as the present-day doctor does’.50 Some nurses were thus seen to be specialists in surgery in the same way as some doctors were specialist surgeons. Over time new types of science-based work were added to the responsibilities of the operating nurse. Surgery’s growing sophistication in the decades around 1900, often characterised with the term ‘physiological surgery’ by contemporaries as well as historians, required an increasing degree of surveillance of the patient’s body. The continuous evaluation of patients’ vital functions became part of surgical routine. Control tasks, such as blood pressure measurement, multiplied. Before the operation, laboratory values, measurement of red and white blood cells, hemoglobin and a variety of urine tests were performed. During the procedure, a minute-by-minute chart of the pulse, respiration and blood pressure kept surgeons informed about the patient’s physical state. After the operation, the staff had to watch the patient’s blood pressure as a means of spotting hemorrhage, to conduct white blood cell counts and temperature measurements to indicate infection, and to monitor urine flow to warn of renal damage. Surgeon George Crile in Cleveland added an assistant to his surgical team to watch blood pressure and adjust anesthesia, intravenous fluids intake and medication. It was clear that for performing this kind of physiological surgery, one needed highly trained support staff.51 It was in this context that the American College of Surgeons launched its hospital standardisation programme. The reformers defined modern surgery as ‘applied physiology’, which, as they claimed, placed additional demands on the surgeon, the nursing staff and the hospital. Therefore, a large part of the College’s hospital standardisation efforts aimed at improving the support available to the operating surgeon. Hence the control of the competency of the nursing personnel was an important focus of the project.52 Accordingly, the chief protagonist of the programme, Albert J. Ochsner from Chicago, pointed out that ‘such members of the personnel as may be found incompetent to carry out the methods contemplated by the plan’, had to be identified and eliminated from the team. Since the definition and description of the nurses’ role, including her cleaning and preparation duties, was part of the standardisation effort, in his article on aseptic technique, Ochsner gave detailed instructions about bodily discipline and the control of the nurses’ movements in the operating room.53 Trust and Service: Gender Roles The instruction literature of the time emphasised the essential, but often invisible, role of surgical nurses. Foster noted in 1911: ‘No other person can help any surgeon as the surgical nurse. She stands in a sphere by herself and many times deserves much credit which is not given to her.’ In surgical work, he explained, it must be borne in mind that ‘any chain is as strong as its weakest link’. The nurse is such a link in the chain of any operation ‘and her duties are quite as important as those of the operator’.54 Nurses themselves agreed with this. In her article of 1900 in the American Journal of Nursing De Witt noted that nurses who had proven themselves worthy assistants were valuable members of the surgical team.55 At the same time, it was emphasised that there was a clear separation of the sphere of the nurse from the sphere of the surgeon. As Hinssen phrased it in his catechism style: ‘Q. When the doctor is ready what will be the duty of the Sister?—To wait on the doctor, keep out of the way and to see that nothing is handed to the doctor which has touched any doubtful surface.’ ‘Q: When an operation is going on what should a Sister always remember?—That she is present as an assistant, not as a spectator. Q. What must she therefore look out for?—To see what is wanted next and not exactly what the surgeon is doing.’56 This meant that the nurse should focus on her role within the distribution of labour and not meddle with the surgeon’s tasks. De Witt, on her part, stressed the particular place of ‘the nurse who is a specialist’ in the surgical team and who, in spite of her highly developed expertise, does not replace the surgeon but will ‘supplement the doctor’s work’.57 Their responsibility for cleanliness, order and surveillance were seen as requiring particular character traits in surgical nurses. This was not specific to surgical nursing. Questions of character and morals were central for the modern nursing profession in general. Thus, nursing schools in the USA looked for tact, manners and respect for authority in all of their trainees.58 Such rules were even more emphasised when it came to operating room nurses. James G. Mumford, an instructor of surgery at Harvard Medical School, gave the following list of character qualities for the successful surgical nurse in his 1908 Surgical Memoirs: ‘Good temper, tact, courtesy, gentleness, courage, interest, fidelity, unselfishness’, in combination with good health and ‘cleverness’. The character traits that were demanded from surgical nurses had a lot to do with their special relationship of subordination to the surgeon. Mumford explained that the main duty of a nurse was her commitment to service, which included her patient as well as the surgeon. Some nurses, as he further discussed, would even say that they were ‘taught to consider the doctor first and the patient second’. This the author found exaggerated, since nurses had to serve both doctors and patients equally. Along these lines the surgeon ended one of his chapters—a reprint of a speech he originally gave to an audience of nurses of the Lakeside Hospital in Cleveland, Ohio—by reminding them that ‘whatever your careers, whatever your special lines, whatever your health or your fortunes, all will be ashes between the teeth, unless you set apart and cling to that master word—Service’.59 Even for the specialist nurse with all her expertise and scientific knowledge, service was the reason for her existence. The American journalist Samuel Hopkins Adams explained in 1905 that the various roles within the operating team aimed at making it possible ‘that the operator’s time may be devoted wholly to one point’. ‘A deft nurse,’ he continued, ‘adept in the use of every instrument, needle, and chemical preparation, is at the surgeon’s elbow, ready to hand out at a word—sometimes before the word—the shining implements already filed in order of their probable use’.60 Foster noted that ‘the surgical nurse should ever be alert to the needs of the operator,’ and she should ‘study carefully the peculiarities of the operator for whom she is working’. ‘Whenever an operation is in progress’, he wrote, ‘the operating room should command the continuous services of three well-trained surgical nurses’. Surgeons were dependent on having one surgical nurse by their side to assist them with maintaining a sterile field. It was the responsibility of the sterile nurse to [primarily] see that every step of the operation is followed up by having in readiness each instrument, namely, the needles, sutures, sponges, gauze, ligatures, towels, sheets, etc. This young woman should anticipate every move of the operator and his assistants. The latter should never be compelled to audibly ask for working material. Signs, gestures and familiarity with the operator’s ideas should be keynotes upon which the surgical nurse works.61 This description echoes the importance of nurses’ subordination in the division of labour in the operating room as discussed above. It adds the expectation of intuitive obedience, which is another sign of the operating nurse’s specific place in the surgical hierarchy. Such an intuitive anticipation of the surgeon’s needs is a recurring theme in the instructive literature. The priest Hinssen put it this way: ‘Q. What can a Sister not always tell when a doctor dresses the wound for the first time.—What he may just call for. Q. But what must she always have ready?—The things she knows he wants’.62 De Witt even mentioned the possibility of tensions and of temper tantrums and how the nurse had to put up with them: ‘It is a great convenience to the doctor … to have as an assistant a nurse who “knows his ways”, who is not disturbed by his explosions of impatience, and under whose hands all arrangements are sure to go smoothly’.63 This is the expression of what one could call the emotional hierarchy in the operating room. Hierarchies and Teamwork In many ways, the operating room at the beginning of the twentieth century was run as a complex orchestration of a hierarchical team with precision and accuracy. At the top of the hierarchy was the operator with his tasks of manipulating tools and mastering techniques to treat the patient. Further down, well-trained surgical nurses were expected to aid the operator and his assistants. Within the hierarchical system of the modern hospital, unquestioning obedience was a typical expectation from nurses in general.64 The strict hierarchical order of the nursing profession extended into the operating venues and by the early twentieth century, different ranks of surgical nurses had emerged in the American operating rooms. Contemporary descriptions give an impression of how each person within the hierarchy was expected to contribute to maintaining the carefully orchestrated organisational system to allow for a smooth surgical procedure.65 The ranking followed the gradation of closer and more remote contact within the operating field. In the context of the American College of Surgeons’ hospital standardisation programme, Ochsner detailed the zoning and the associated hierarchy in the operating room. Only the head surgical nurse was allowed to have direct contact with the patient: ‘one nurse alone touches anything coming in contact with the wound, her assistant does anything else that may be necessary’.66 This nurse was to be selected for her ‘special fitness for the work … she prepares all the dressings, sutures, and ligature material, sterilizes the instruments, supervises the preparation of the operating-room and the patient on the day previous to the operation’. This nurse had ‘three assistants, who are undergraduate nurses, whom she instructs but who do not come directly in contact with anything which comes into contact with the wound’.67 Similarly Nicholas Senn’s guide to surgery for the general nurse describes how only the head nurse assisted the surgeon directly. She was responsible for maintaining asepsis in the operating field and in charge of maintaining order amongst the other surgical nurses. She was the surgeon’s right hand assistant, who could delegate tasks in the operating room, while being subordinate to the authority of the surgeon and his assistants. At the start of the operation, it was the head nurse’s duty to drape the patient with dry, sterilised towels. She had to be aware of attending to the needs of the operating surgeon. The strong bond between the head nurse and the operating surgeon was seen as crucial for the successful outcome of a surgery. It was the head nurse in the first place, who was charged with the anticipative obedience mentioned above. She, as Senn pointed out, had to ‘anticipate every want of the surgeon, beginning with the scalpel, following with forceps, scissors, etc., as may be required’. At the other end, she received the used instruments on ‘a separate tray, she brushes the soiled, instruments when necessary and takes each needle from the surgeon when he is through with it’.68 The senior nurse was the assistant of the head nurse, Jenevieve van Syckel explained in her paper on the arrangement of the operating room at St Luke’s Hospital, New York. Her main responsibility was maintaining the instruments during the surgery. If the instruments were clean, they were placed in a bicarbonate solution until needed; if dirty, the senior nurse would take the soiled instruments to the sink and scrub them before placing them in a boiler to undergo sterilisation again. She would then change gloves to maintain sterility. After the operation, she was responsible for cleaning and storing the instruments until they were needed for the next surgery. Additionally, she was in charge of wound compression. During surgery, she did not wipe the wound, but merely compressed it when told to by her superior. A senior nurse would also be in charge of maintaining surgical sponges and know their location to prevent any mishaps of contamination.69 Assistant nurses played a vital role as trusted members of the surgical team in preparing the operating room and the patient for surgery. This becomes particularly clear in cases when the surgery was conducted at the patient’s home. As Beck describes it, the preparation of the operating venue often began a day in advance. He recommended ‘to send a nurse to the patient’s home at least twenty-four hours before the operation is to take place, to make the necessary arrangements in the operation room, and to see that the patient takes a warm bath …’70 He also recommended ‘the nurse to have an operation blank prepared by the surgeon to insure that all necessary preliminary arrangements have been clearly defined.’71 In preparation, all unnecessary items needed to be removed and, according to Senn, everything including ‘ceiling, doors, floors, walls, windows, or blinds’ scrubbed with corrosive sublimate or carbolic acid.72 In the hospital, the assistant nurse was also involved in preparing the patient prior to surgery. On the night before surgery, patients were required to take a bath to rid their body of any germs from the outside environment. First, the assistant nurses would use hot water and potash soap to scrub down patients and rinse them with clear water. Next, they would disinfect the patient’s skin in the area where the operation was to take place using an alcohol and diluted bicarbonate solution, before covering the operating field with a moist antiseptic towel.73 During surgery, assistant nurses aided the surgeons by removing towels that were soiled with bodily fluids and were no longer considered aseptic. The junior nurse was the lowest ranking surgical nurse. Her main duty was to complete tasks in the operating room under the direction of the head nurse. She was responsible for handling material that was not sterile. The junior nurse had to be ‘on alert to notice and supply every want, if so directed by the head nurse’. This may go as far as wiping the surgeon’s brows to avoid the danger of sweat dripping into the open wound.74 Additionally, she would provide assistance to the surgeon by adjusting the patient and bringing a new, clean table in order to move the patient out of the operating room at the completion of surgery. She remained in the operating room to put away unused materials and the dressing drums. Lastly, she was also responsible for boiling, drying and powdering surgical gloves in preparation for the next surgery. The relationship between surgeon and nurse was often expressed in terms of ‘trust’—a type of relationship that required more than technical competency from the nurse and was once more intertwined with expectations concerning her character and morality.75 An example is an article of 1928 by Walter G. Elmer, a reputable American surgeon at the Philadelphia Academy of Surgery, in which he emphasised the nurses’ particular position of trust within the surgical division of labour: ‘Perfect surgical asepsis in an operating room’, he explained, ‘depends upon the nurse in charge of it. The surgeon is preoccupied with the patient and the successful outcome of the operation he is performing and it is impossible for him to give close attention to everything that goes on around him. He believes in his surgical nurse and trusts her implicitly.’76 The expert role of the surgical nurse seems to have been especially well developed in the USA. Thus, the German surgeon Nikolai Guleke on his trip to the USA in 1909 was particularly impressed by the importance of nurses in American surgery. While surgical assistants often changed, he reported, and were therefore not able to assist the operator in a useful way, the nurses stayed the same. They were well trained and competent, in the operating room as well as on the wards. They enjoyed, as he noted, a high social standing and they were licensed (‘graduated nurse’). He reported to have seen young nurses who possessed a higher competence than the doctor they worked with. The level of expertise in surgical nursing, he judged, was incomparably better in the USA than at home in Germany: ‘Anyone who has seen the operating nurse acting as William Mayo’s sole assistant even in the most difficult laparotomies, could not imagine better assistance.’77 Nurses formed part of what was increasingly viewed as the surgical team. As surgical interventions became more frequent, more extended and more elaborate, particular tasks were delegated to various members of the team. ‘The surgeon, the assistants, and the nurses’ were mentioned in the same breath, because they had, for example, to employ the same great care ‘in purifying their hands and everything that may come in contact with the wounds’.78 As Brock has described it for Edwardian Britain, surgeons recognised that they ‘were now supported by a skilled team within the operating theatre and without’, so that ‘in the 1890s and 1900s the promotion of individual surgical skill jostled uncomfortably with the crediting of the wider team—anesthetists, pathologists, bacteriologists, physiologists, trained nurses’.79 The British surgeon Berkley Moynihan now used the term ‘team’ when he announced in 1920: ‘Surgery is nowadays no longer the work of an individual, but of a “team” in which every member plays his exact part, in which all contribute to success, and in which each may bring about disaster.’80 As we have seen in the instruction literature in this article, this was also true for the USA, perhaps even more so considering that the professionalisation of nursing was more advanced there. In the early twentieth century, surgical expertise was thus more and more distributed across a team, whose performance became ‘much more than the sum of its parts’. The team members increasingly coordinated ‘the resources of the operating theatre in time and space, thereby enabling the surgeon to assume power and control’, as Roger Kneebone and Abigail Woods have phrased it in a recent study.81 Open Questions and Conclusion There are many open questions that should be addressed by further research into the history of surgical nursing in the operating room. One of them is the role that wars played in this history. There is considerable literature on nursing in the First World War and its positive effect on the professional status of nurses more generally.82 Christine Hallett has described how military nursing services symbolised ‘the care and security which could be offered to anyone injured in the line of duty’.83 However, as much as nurses were ‘important executors of treatment and care’, she has found, they had ‘no clear role or status’. ‘Nurses of all nationalities’ were left ‘vulnerable to being at best ignored, at worst victimized’. As a consequence, after the war nurses tried to improve their status and working conditions through state registration and educational reform.84 In Britain, professional nurses gained their formal recognition through the Nurses Registration Act in 1919. However, the ethos, the gendered character, and the economic situation of nursing did not really change, so that, after the war nurses’ ‘hard-won expertise and prowess was once again buried within a patriarchal society’, as Hallett has stated.85 In general, trained American nurses fared better in the war than their European counterparts. During the war, they gained specialist skills and knowledge in surgery, for example, concerning wound treatment and anaesthesia, and widened their scope of practice to ‘areas that would probably never have been dreamed of in peacetime’.86 The exact influence of the First World War on surgical nursing, in the USA and elsewhere, however, still needs to be determined. Another question for future research is about how the normative attitudes examined for this paper played out in the day-to-day work of operating room nurses. The use of normative sources is only a first step in exploring the history of surgical nursing. The investigation of what went on in the operating rooms in practice requires a different kind of source material, such as operation reports, etc. Brock’s and Heggie’s work about Britain provides a good model and starting point for such work.87 What we can say on the basis of the instructional literature about surgical nursing in the decades around 1900 is that, at the normative level, the boundaries between the different domains of nursing and of medicine were strict and well-guarded. The controlled environment of the operating room lent itself in many ways to a rigid division of labour, with clear-cut domains of responsibility, in particular, avoiding any overlap with the surgeon’s role. Within this context the responsibility of the specialised nurse was focused on cleanliness and order. Anything that had to do with performing the surgical operation itself was outside her purview. Surgical nurses were thus given the cleaning and surveillance tasks that have been characterised as part of the typically gendered distribution of labour for nurses in modern hospitals more generally.88 As Barnett has phrased it for the British context, ‘the tasks allotted to the middle-class housewife were not far from that which a hospital matron would be expected to undertake for a consultant surgeon. Both would supervise the work of servants, ensure a reliable supply of food and clean linen, and provide an efficient and supportive backdrop for the work of professional men’.89 This is also true for nurses in the operating room whose position thus reproduced and cemented the gendered character of surgery more generally.90 Thus while surgical nursing opened up a new realm of activity for highly qualified and trained women, it also reflected and stabilised rather than questioned contemporary gender roles. Thomas Schlich’s research interests include history of modern medicine and science (eighteenth to twenty–first centuries). He has published books on transplantation and on surgery, science and industry and is currently writing a monograph on the history of modern surgery, 1800–1914. Audrey Hasegawa works at Tufts Medical Center in clinical care. She holds a Bachelor of Life Science and a minor in Social Studies of Medicine from McGill University. Footnotes 1 See, e.g., Richard Barnett, Crucial Interventions. An Illustrated Treatise on the Principles and Practice of Nineteenth-Century Surgery (London: Thames and Hudson, 2015), 142–7; Ulrich Tröhler, ‘Surgery (Modern)’, in W. F. Bynum and R. Porter, eds, Companion Encyclopedia of the History of Medicine, vol. 2 (London and New York: Routledge, 1993), 984–1028, see 995–6. 2 Lindsey Granshaw, ‘The Hospital’, in Bynum and Porter, Companion Encyclopedia of the History of Medicine, vol. 2 1180–203, see 1193. Charles E. Rosenberg, The Care of Strangers: the Rise of America’s Hospital System (New York: Johns Hopkins University Press, 1987), 246. 3 Claire Brock, ‘Surgical Controversy at the New Hospital for Women, 1872–1892’, Social History of Medicine, 2011, 24, 608–23; Vanessa Heggie, ‘Women Doctors and Lady Nurses: Class, Education, and the Professional Victorian Women’, Bulletinof theHistoryofMedicine, 2015, 89, 267–92, see 274. For a survey, Deborah Brunton (ed.): Medicine Transformed: Health, Disease and Society in Europe, 1800–1939 (Manchester University Press: Manchester, 2004). Regina Morantz-Sanchez, Conduct Unbecoming a Woman. Medicine on Trial in Turn-of-the Century Brooklyn (New York, Oxford: Oxford University Press, 1999). 4 Claire Brock, ‘Risk, Responsibility and Surgery in the 1890s and Early 1900s’, Medical History, 2013, 57, 317–37, see now also Claire Brock, British Women Surgeons and their Patients, 1860–1918 (Cambridge: Cambridge University Press, 2017). 5 Heggie, ‘Women Doctors’, 267–92. 6 For calls for such a history, see, e.g., Elinor S. Schrader, ‘A Bicentennial Look on Early OR Nursing’, AORN Journal, 1976, 24, 13–14; Ruth S. Metzger, ‘The Beginnings of OR Nursing Education’, AORN Journal, 1976, 24, 73–90. Recent publications on the topic are relatively brief, e.g. Sharon L. Oetker-Black, ‘Preoperative Preparation: Historical Development’, AORN Journal, 1993, 57, 1402–11; Rose Marie Lee, ‘Early Operating Room Nursing’, AORN Journal, 1976, 24, 124–38. 7 See, e.g., Rhodes, ‘Women in Medicine’, 172. 8 E.g. Susan M. Reverby, Ordered to Care. The Dilemma of American Nursing, 1850–1945 (Cambridge: Cambridge University Press, 1987), 226; Rhodes, ‘Women in Medicine’, 152, 165–72. 9 Barnett, Crucial Interventions, 146. 10 Rosenberg, The Care of Strangers, 181, 212–36. 11 Rhodes, ‘Women in Medicine’, 172. 12 Christopher Maggs, ‘A General History of Nursing: 1800–1900’, in Bynum and Porter, Companion Encyclopedia of the History of Medicine, vol. 2, 1309–28, see 1310, 1321. 13 Reverby, Ordered, e.g. 70–6; for a survey, see Rhodes, ‘Women in Medicine’, 151–79. 14 Maggs, ‘A General History’, 1322. 15 See, e.g., Tröhler, ‘Surgery (Modern)’, 995–6. 16 On the neglect of the history of the surgical team, see e.g. Roger Kneebone and Abigail Woods, ‘Recapturing the History of Surgical Practice Through Simulation-Based Re-enactment’, Medical History, 2014, 58, 106–21, see 108–9. 17 Florence Nightingale, Notes on Nursing: What It Is and What Is Not (Boston: Carter, 1860), 96. For a survey on Nightingale’s role for nursing reform, see Rhodes ‘Women in Medicine’, 165–72. For her scepticism vis-à-vis the surgical healing strategy, see Rosenberg, The Care of Strangers, 234. 18 Geneviève de Galard, ‘Gender Issues in Nursing’, in Mary Ellen Snodgrass, ed., Historical Encyclopedia of Nursing (Santa Barbara: ABC-CLIO, 1999), 50. 19 Barnett, Crucial Interventions, 142–6 quote on 142. 20 Charles Rosenberg, ‘Florence Nightingale on Contagion: The Hospital as Moral Universe’, in Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press 1992), 90–108. 21 Rhodes ‘Women in Medicine’, 173. 22 For North America, see Rosenberg, The Care of Strangers; Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore and London: Johns Hopkins University Press, 1995), 30–68. For Britain, see Lindsay Granshaw, ‘The Rise of the Modern Hospital in Britain’, in Andrew Wear, ed., Medicine in Society. Historical Essays (Cambridge: Cambridge University Press, 1992), 197–218, see 211–12. 23 Howell, Technology, 58–9; Rosenberg, The Care of Strangers, 149. 24 Thomas Schlich, ‘“The Days of Brilliancy Are Past”: Skill, Styles and the Changing Rules of Surgical Performance, ca. 1820–1920’, Medical History, 2015, 59, 379–403, see 388. 25 Thomas Schlich: ‘Asepsis and Bacteriology: A Realignment of Surgery and Laboratory Science’, Medical History, 2012, 56, 308–43. 26 Carl Beck, A Manual of the Modern Theory and Technique of Surgical Asepsis (Philadelphia WB Saunders, 1895), 243. 27 Barnett, Crucial Interventions, 146. 28 James J. Walsh, History of Nursing (New York: PJ Kennedy, 1929), 5. 29 Richard H. Shryock, The History of Nursing. An Interpretation of the Social and Medical Factors Involved (Philadelphia and London: Saunders, 1959), 267. And cf. Claire Jones, 'Personalities, Preferences and Practicalities: Educating Nurses in Wound Sepsis in the British Hospital, 1870–1920’, Social History of Medicine (in press). 30 Beck, Manual, 238–9. 31 Rev. L. Hinssen, The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities (Springfield: EW Rokker Co., Printers and Binders, 1899), 189. 32 On Hinssen and his textbook see Barbra Mann Wall, ‘Textual Analysis as a Method for Historians of Nursing’, Nursing History Review, 2006, 14, 227–42, see 231–2, quote from 231. 33 Hinssen, Nursing Sister, 204. 34 Hinssen, Nursing Sister, 214. 35 Conrade A. Howell, A Series of Lectures on Surgical Nursing and Hospital Technic. (Columbus: The Stoneham Press, 1913), 32–3. 36 Schlich, ‘Asepsis and Bacteriology’, 316–18. 37 Martha Luce, ‘The Duties of an Operating-Room Nurse’, American Journal of Nursing, 1903, 13, 404–5, 471–3, quotes on 404–5. 38 Beck, Manual, 247–8; on the history of clothing in the operating room, see Nathan L. Belkin, ‘Perioperative Nursing Apparel. Looking the Part Through the Ages’, OR Nurse Journal (Nov./Dec. 2008), 40–43. 39 Beck, Manual, 245–6. 40 Thomas Schlich, ‘Negotiating Technologies in Surgery: The Controversy about Surgical Gloves in 1890s’, Bulletin of the History of Medicine, 2013, 87, 170–97. 41 Thomas Schlich, ‘Surgery, Science and Modernity: Operating Rooms and Laboratories as Spaces of Control’, History of Science, 2007, 45, 231–56. 42 Hinssen, Nursing Sister, 189. 44 John Berg, ‘Några synpunkter på antiseptikens genombrottstid av en som upplevat den Föredrag i Svenska Läkaresällskapet den 17 mars 1931 av prof. John Berg’, Hygiea, 1931, 93, 449–73, reprinted in Svensk Medicinhistorisk Tidskrift, 2012, 16, 38–53, see 49. Our thanks go to Nils Hansson for this information. 45 Luce, ‘Duties’, 404–5, 471–3. 46 Katherine De Witt, ‘Specialties in Nursing’, The American Journal of Nursing, 1900, 1, 14–17. 47 Anon., ‘Advanced Course in Surgical Nursing,’ The American Journal of Nursing, 1933, 33, 1084–87, 1179–88, quote see 1186. The outline was a proposal for a course to be taken by all nurses who were to work as operating nurses. It was presented by a subcommittee of the Education Committee of the National League of Nursing Education; its six members were all women. 49 De Witt, ‘Specialties’, 15. 50 George S. Foster, ‘The Modern Surgical Nurse’, The American Journal of Nursing, 1911, 11, 621–5, ‘well-trained nurses’, see 621–2, ‘near at hand’, 625. 52 Peter Kernahan, ‘Franklin Martin and the Standardization of American Surgery, 1890–1940’ (unpublished PhD thesis, University of Minnesota, 2010), 31. See also, Howell, Technology, 57–68; Susan Reverby, ‘Stealing the Golden Eggs: Ernest Amory Codman and the Science and Management of Medicine’, Bulletin of the History of Medicine, 1981, 40, 156–71. 53 Albert J. Ochsner, ‘Aseptic Surgical Technique. Minimum Requirements for Aseptic Surgical Operating in a Hospital in which the Personnel of the Operation Room is Permanent’, Annals of Surgery, 1904, 40, 453–63, ‘such members’: 453. 54 Foster, ‘The Modern Surgical Nurse’, ‘no other person’: 625, ‘any chain’: 622. Foster was a surgeon and pathologist to the Hospital of Notre Dame de Lourdes; he also served as an Assistant Surgeon to the Beacon Hill Hospital. 55 De Witt, ‘Specialties’, 16. 57 De Witt, ‘Specialties’, 16. 58 Rosenberg, The Care of Strangers, 222–6. 59 James G. Mumford, Surgical Memoirs (New York: Moffat, Yard and Company, 1908), 321–38; list of qualities and ‘doctor first’ on p. 321, ‘master word’ on p. 338. 61 Foster, ‘The Modern Surgical Nurse’, 622–3. 62 Hinssen, Nursing Sister, 193. 63 De Witt, ‘Specialties’, 16. 64 Rhodes, ‘Women in Medicine’, 167. 65 Jenevieve van Syckel, ‘The Operating Room Technique of St. Luke’s Hospital, New York’, The American Journal of Nursing, 1910, 10, 635–63. 67 Ochsner, ‘Aseptic Surgical Technic’, 462–3. 68 Nicholas Senn, A Nurses Guide for the Surgical Room (Chicago: WT Keener and Co, 1902), 54. 69 Van Syckel, ‘Operating Room Technique’, 636–8. 71 Beck, Manual, 294–6. 72 Senn, Nurses Guide, 2. 73 Senn, Nurses Guide, 53–4. 74 Senn, Nurses Guide, 55. 75 About trust in surgery more generally see Sally Wilde, ‘Truth, Trust, and Confidence in Surgery, 1890–1910: Patient Autonomy, Communication, and Consent’, Bulletinof theHistoryofMedicine, 2009, 83, 302–30. Brock, Risk, 319, points to the limits of trust in the relationship between the surgeon, the surgical team and the patient. 78 A. W. Mayo Robson, ‘The Advance in Surgery During 30 Years’, The Lancet, 1902, 4, 912–16, see 914. 79 Claire Brock, ‘Risk’, 319. 81 Kneebone and Woods, ‘Recapturing’, 108–9. 82 For a survey, see Rhodes, Women in Medicine, 172–6. The authors would like to thank Christine Hallett for her valuable advice about the historiography of nursing in the First World War. 83 Christine E. Hallett, Veiled Warriors: Allied Nurses of the First World War (Oxford: Oxford University Press, 2014), 27. With a special focus on Britain, see also Christine E. Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009), specifically on surgery see 92–101. 84 Hallett, Veiled, 223. 85 Hallett, Veiled, 259–60. 86 Hallett, Veiled, 92–3, quote on 258. On the American experience more generally, see Mary T. Sarnecky, A History of the US Army Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999). 87 Brock, ‘Risk’; Brock, ‘Surgical Controversy’; Heggie, ‘Women Doctors’. 88 Maggs, ‘A General History’, 1313. 89 Barnett, Crucial Interventions, 145. 90 On the relevance of this discourse for women surgeons, see Heggie, ‘Women Doctors’, 268, 27, 290; Brock, ‘Surgical Controversy’, 614–15; for the USA, see, e.g., Morantz-Sanchez, Conduct, 66–72. 43 Luce, ‘Duties’, 406. 48 De Witt, ‘Specialties’, 16. 51 Peter English, Shock, Physiological Surgery, and George Washington Crile: Innovation in the Progressive Era (Westport, CT: Greenwood Press, 1980), 35–7, 92–105. 56 Both quotes: Hinssen, Nursing Sister, 211. 60 Samuel Hopkins Adams, ‘Modern Surgery’, McClures Magazine, 1905, 24, 482–92, 491. 66 Ochsner, ‘Aseptic Surgical Technic’, 457. 70 Beck, Manual, 294. 76 Walter G. Elmer, ‘Surgical Technic’, Annals of Surgery, 1929, 89, 328–33, 328. 77 N. Guleke, ‘Chirurgische Reiseeindrücke aus Nordamerika’, Münchener Medizinische Wochenschrift, 1909, 2321–4, 2380–3, 2426–8, see 2380. 80 Berkeley G. A. Moynihan, ‘The Ritual of a Surgical Operation’, British Journal of Surgery, 1920, 8, 27–35, see 35. Acknowledgements The authors would like to thank Cynthia Tang for reading and commenting on a previous version of this paper. © The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
Social History of Medicine – Oxford University Press
Published: Feb 1, 2018
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