Editor’s note: This essay is part of a series of historical vignettes that the Bulletin is publishing as part of the “From the Archives” column. These brief articles center on key individuals and events in the history of the American College of Surgeons (ACS) and are written by members of the ACS Surgical History Group.
Before World War II, postoperative infections were the most common causes of surgical complications and deaths and would create havoc for hospitals, surgeons, and patients. One of the primary methods of preventing infections was the proper application of a dressing on the wound at the completion of an operation, with daily dressing changes occurring until the wound healed.
In 1928, the ACS Hospital Research and Information Department conducted a study of the types and numbers of dressings used in hospitals. The investigators estimated that the average hospital, performing 10 operations per day, would use 545,000 dressings per year on surgical patients.* Most dressings were made by hand to the specifications of the hospital and often to the individual surgeons. Dressings were usually stitched by the hospital’s nurses, forcing them away from their more important patient care duties. The materials used to make dressings, such as gauze and cotton, were not standardized, although detailed specifications for gauze were recommended by the U.S. Department of Commerce in 1928.
The ACS study showed that more than 5,000 types of dressings, such as laparotomy pads or sponges of various sizes, were used in the nation’s 7,000 hospitals, and as many as 1,500 varieties of a single type of dressing were used for the same purpose, such as a sponge for absorbing blood during a laparotomy.
ACS leaders believed that reducing the types of dressings and their variations would save hospitals money, eliminate material waste, and reduce the workload burden on nurses. Committed to achieving these goals, the College undertook the standardization of dressings in 1930.
The standards, which were published in the June 1930 issue of the Bulletin, categorized dressings into the following eight classes*:
- Sponges for wiping blood and fluids
- Abdominal packs for walling off organs during operation
- Sterile gauze dressings to cover incisions during an operation
- Pads to absorb drainage after operations
- Gauze drains and tampons
- Dressings for specialized purposes
Specifications were established for dressings of different sizes in each class, such as large, medium, small, and pointed tonsil sponges. The fabrication for each sponge was explained in minute detail. For example, the creation of a small 2˝ x 2˝ sponge was explained through the following steps:
Cut 20˝ x 12˝ gauze to 6˝ x 6˝, folded to approximately 1¾˝ x 1½˝, 12 ply. Fold over two opposite edges ½˝. Bring other two edges to center line of cut gauze. Fold again at same center line, giving piece four ply, approximately 1½˝ x 5¼˝. Fold each end in so that length is divided into three equal parts, giving finished sponge approximately 1¾˝ x 1½˝.
Cotton or cellulose wadding was incorporated between layers of gauze for absorbent dressing pads and maternity pads. Abdominal packs were quilted by sewing along the edges and at designated points of length and width. Additional instructions were given regarding the use of abdominal packs:
It is advisable that intra-abdominal sponges, packs, or rolls be rendered visible to the X ray by means of dyes or by inclusion in the fabric of a metal object, such as a disk or flat ring, which should be well covered with fabric, securely fastened, and non-corrosive. No sponge, dressing, or similar article should be allowed to enter or to remain in a cavity during an operation unless firmly anchored to a tape or a heavy cord extending to the outside and having a metal ring, disk, or forceps attached to the outer end.
The impact of standardization
These requirements for abdominal packs, or laparotomy pads, became the standard for every hospital in the nation, and they remain the standard to this day. They have saved an untold number of patients from the complications of retained sponges and the additional operations needed to remove them.
The ACS classification and specifications for dressings markedly reduced the varieties of dressings used throughout the country. The need for larger quantities of more specific types of dressings meant an expanded market for ready-made dressings, a void which commercial firms rapidly filled by using mass production techniques.
Within a few years of implementing dressing standards, the College had achieved its goals of reducing hospital costs, eliminating waste, and returning nurses to the bedside.
*Hospital Research and Information Department of the American College of Surgeons. The standardization of surgical dressings. Bull Am Coll Surg. 1930;14(2):3-19.