Age of Invention: Wash your Hands!

Welcome to my weekly newsletter, Age of Invention, on the causes of the British Industrial Revolution and the history of innovation. You can subscribe here:

When we say the word invention, the image that springs to mind is usually of some kind of machinery. Whirring cogs, pumping pistons, or swivelling robotic arms. But as I mentioned last time, many of our most important inventions are intangible. Check-lists and rules of thumb, pivot tables and diagrams — techniques, as well as tools — helped usher in world-shrinking improvements to navigation and communication. And much the same could be said of healthcare. Whereas a lot of our focus is on medicines or on life-support machines like ventilators — the chemical, physical, and tangible aspects of the industry — so much of what saves lives is really about technique.

Take Edward Alanson, pioneer of washing hands in hospitals. Such an accolade often goes to Ignaz Semmelweis, who in the 1840s invited the ridicule of his colleagues by suggesting that surgeons wash their hands between conducting an autopsy and delivering a baby; or to Florence Nightingale, who in the 1850s introduced hand-washing to the war hospitals of the Crimean War. But Alanson was experimenting with the technique decades earlier, to great effect.

Alanson practised as a surgeon in Liverpool in the late eighteenth century, coming to prominence during the War of American Independence when he published a new method of amputating limbs. He, as well as Edward Jenner (later famous for vaccination), had been among the first pupils of the innovative surgeon John Hunter, a pioneer of applying systematic observation and experimentation to the field. (When it reopens, I highly recommend the Hunterian Museum in London, which is based on Hunter’s collection of anatomical specimens).

It seems that Alanson picked up Hunter’s mentality of improvement. He patiently collected observations of his own and others’ surgical procedures, making small tweaks and experiments based on what appeared to work. His case illustrates how every invention, when you look at it closely, dissolves into a mass of marginal adjustments. And it also illustrates the difficulties of innovating in such a perilous field. Alanson complained of “how slowly the most valuable improvements are adopted”, though he recognised that innovation in healthcare was overwhelmingly a matter of trust. “When we attempt to introduce any new and important deviations from the common mode of practice into general use”, he wrote, “the public have a right to be fully acquainted with the author’s reasons and motives for such attempt”.

To gain that trust, Alanson meticulously described his experiments with amputations, noting his success relative to the usual practices (no deaths out of 35 operations, and with far fewer complications, against a baseline of 10 deaths out of 46), and reassuring readers as to his lack of bias. As surgeon for the Liverpool Infirmary, a charitable institution supported by local subscriptions and open to the public, Alanson noted that he did not have the option of turning patients down and only amputating those more likely to survive. Nor, for the same reasons, could he conceal or obfuscate his results. His colleagues and patients could all testify to the truth of what he had done.

Apart from the surgery itself, however, Alanson’s success was in large part due to the organisation of the infirmary. In the eighteenth century, public hospitals were often considered to be more like quarantine stations, or Lazarettos, than treatment centres, each “having its own peculiar disease within it.” As one contemporary put it, the “jail or hospital fever, has long been known as the inbred pestilence of the crowded receptacles for the sick, and has thinned our fleets and armies more than the sword of the enemy”. But Alanson’s Liverpool Infirmary was different.

Although he may not have understood how germs spread — like so many medical practitioners of the time, Alanson believed that noxious airs were a cause of disease — his horror of the stink and rot, or “unwholesome effluvia”, was enough for him to recommend important improvements. Every ward, he said, should be cleared of patients every four months, to be “scraped, white-washed, and every other necessary means used for the purification of the air”. For this purpose, it was necessary to keep at least a room free at all times — like crop rotation, but for hospitals. “A hospital”, he chided, “should never be crowded on any account”.

The bed frames were to be made of iron, “to prevent the lodgement of vermin, and the more easy absorption of putrid matter.” And the bedding was more frequently changed than was common, stuffed with cheaper materials like chaff, hay, and cut straw in order to make this affordable. But don’t for one moment think that the patients were to be coddled. If they were able, patients were ordered to “carry out their bedding, and expose it in the open air, for several hours every day” — weather-permitting, of course. Given the theory that it was the smell and putrefaction that caused disease, gangrenous patients were the ones most isolated, and those undergoing an operation were put in the most ventilated rooms. If a nurse did not ventilate her ward enough by opening the windows, she was liable to pay a fine.

And, of course, there was the washing. Not much by modern standards, but a lot by those of the eighteenth century. New patients, especially those coming from ships, jails, cellars, or workhouses, or who simply had dirty clothes, were to be stripped, washed, and clothed before admittance to the ward. Their old clothes were to be disinfected by baking them in a special oven and returned upon discharge. And there was to be regular washing of hands, and even feet: “let the nurses see that every patient’s hands and face are washed every morning; and their feet once a week”, Alanson advised.

Alanson was quite modest in his hope that such improvements could “make but a gradual advance” to healthcare. He hoped that with the example of the Liverpool Infirmary, his hygienic techniques might one day “be extended to all ranks, nations, and ages.” With the entire world now washing their hands (though perhaps not their feet), his wish has come true.

Until next week,


P.S. I have written up a short guide, here, on what inventors are doing right now to combat the current pandemic.