Hospital Infection: From Miasmas to MRSA (review)

In starting with theories of contagion/infection in the Middle Ages and ending with present-day issues over hospital infection, Graham Aycliffe and Mary English (with careers in microbiology and mycology) offer a very broad sweep. Historians may well categorize the book as an "internal" history preoccupied with names and dates of milestones, and with plotting progress—but they must not dismiss the real merits of the study. It has the value of bringing together information on an extremely important topic at a time of growing fears of major epidemics. Ayliffe and English close their account with comments on the present and future that are hardly reassuring—and that is without covering the SARS outbreak, which, in Toronto in 2003, uncovered both problems of and mistakes in infection control in large hospitals.

Yet while this is essential reading for all those concerned with hospital infection, more insights could have come from a closer look at the social, cultural, and idiosyncratic factors that have been, and are, very much part of the story. One such topic is the way theory—for instance, the concept of cross-infection—has shaped practice over time: although one chapter, "Theories of Infection: From Miasmas to Microbes" (pp. 87-103), spotlights miasma/contagionist controversies, the reader is really given no feeling for the long-standing uncertainties and controversies over just how a disease is "caught," nor for how the diverse opinions affected decisions in hospital planning and management. (It is not without interest that beliefs of miasmatic causes were not entirely absent from last year's public fears about SARS.)

Another topic, "hospitalism," might well have been explored in much more detail. The authors indicate that the term, popularized by James Young Simpson, covered hospital-acquired septic infections (p. 83)—but it extended beyond this: by the end of the 1800s, for example, it was even applied to children in hospital who developed loss of weight, indeed a state of marasmus. Hospitalism could have been used to tease out the interplay of concepts of hygiene, the quality of the air, miasms, and microorganisms.

The book is most rewarding in its coverage of the last fifty years or so, due to the firsthand experiences of the authors. They provide (with emphasis on the United Kingdom) a clear outline of milestones. However, their exploration of sociocultural factors remains limited. It would perhaps have been useful to examine the kind of mistakes made by hospital personnel that have sometimes led to a breakdown in the application of well-founded principles and improvements associated with the development of central sterile supply departments, increased commercial (rather than within the hospital) production of sterile fluids, and disposable syringes and needles. One suggestion (relevant to all recent history) is to consider the insights from oral history, perhaps along the lines of the successful series Wellcome Witnesses to Twentieth-Century Medicine (now in its seventeenth volume). Oral history, too, may well point up ethical issues ignored by Ayliffe and English, albeit raised in 1998 by V. A. Sharpe and A. I. Faden in "From Hospitalism to Nosocomial Infection Control," issues such as hospitals' wanting to keep infection data confidential amid the need for informed consent for patients.¹

Despite this reviewer's wish list, this book serves as a significant stepping stone to an important topic that needs much more exploration in our present era of anticipated global epidemics, new accountability in health care, and growing public sensitivity to issues surrounding medical error.