Smells in surgery
Smells in clinical surgery – this is a subject I do not remember reading or hearing about much. I sometimes raise the topic with students. On at least one occasion I have found it saved the life of a patient, and it has improved the care of other patients on several occasions.
Everyone knows the following smells:
Highly significant at bedside:
- Diabetic ketosis in a patient with acute abdomen and previously undiagnosed diabetes
- Mousy [mouse faeces] smell of clostridial sepsis
- Sweet faeculent smell of pseudomonas pyocyaneus pus, which is mainly on the blue dressing, where the nurses have not noticed that there is an infection, an easy signal for the prescription of silver sulphadiazine cream.
- Stinking smell of E coli pus
- Lack of smell of staph aureus pus
- Uraemia
- Melaena
Others in ward:
- Aspirates in various stages of bowel obstruction
In operating theatre:
- Faint whiff of colonic gas from a small colonic perforation
- Typical burnt armpit smell of diathermy cutting of breast fibroadenosis
- Fried smell of diathermised normal breast tissue
Other smells I am not able to describe clearly:
- Infected varicose ulcers
- So-called abdominal breath once considered a feature of appendicitis
The above is an informal list where I have doubtless left out many common ones and some interesting obscure ones. I would be grateful for any additions from others, which can be emailed straight to me, or posted WITHOUT reprinting the whole of the above message.
A few months ago I wrote about the 93 year old man with a a strangulated inguinal hernia extending down to his knee. While replacing the bowel in the abdominal cavity I smelled a faint whiff of faeces, which the other two at the operating table did not notice. When I withdrew small bowel again I found two tiny punctures in dilated ileum, leaking a little liquid faeces, which I had to oversew gently. They were from the “autraumatic” De Bakey forceps. Since then I use a spongeholder for handling or replacing fragile bowel, where my fingers can not do the job.
As a new resident in an English hospital I had a fit middle-aged man die 4 days after an ordinary cholecystectomy, because his diabetic ketosis was not recognised till too late. The nurse’s record of glycosuria on admission was not noticed because it was hidden in the usual mess of unimportant admission information. [This is part of another study on data availability in clinical surgery]. More awareness of clinical smells might have saved his life. Others may have had similar instances they can remember.
I’m not sure if this is germane to your topic, but I’ve heard several surgeons refer to the “smell of death”. I can’t describe the smell, but I know it when I smell it. To the best of my recolection it seems to appear in Abd. cases, usually emergent. I have no idea what causes it, maybe metabolic acidosis or some other condition that happens with ischemic changes? If you have anymore info on this smell or any others I would be very interested in hearing about them. If you need any type of clarification don’t hesitate to write back.
TPN (total parenteral nutrition) smells like Pseudomonas – you will get this odor when the nurses spill some on the floor (common in my residency) – you can tell the difference because the floor is sticky.
Feculent breath of neglected bowel obstruction.
Smell of death as you mentions – I had this recently in a 54 year old patient on whom I did a palliative total gastrectomy for extensive posteriorly perforated gastric cancer – -her drain sites and jejunostomy sites had a noticeable odor of death – she is still alive 2 or 3 months later, but her one goal was to see the birth of a grandchild in April.
One day I was helping a colleague in an abdominal surgery, when becames a very intensive fecal smell. He concludes that we have perfurated the colon somewhere and we spend more than 20 minutes exploring all the colon. I didn’t had the courage to tell him (with the instrumentist and all the O.R. personal hearing) that I’ve just had a very nice and alleviating flattus.
Thanks for your fascinating expose’ about smells. I was thinking about smells in clinical surgery last week but in a different conotation. Not as a clinical surgeon but as a story teller. I was thinking about the various smells deriving from the surgical team, sweating together with you for around the table hours. The sour wine , the yesterday’s garlic and so forth. BTW, They told me that fecal smell is NOT from E,Coli which is smelless but from the anaerobs. Am I wrong?
I’m very weak on knowledge of smells and bacteria. Quite likely there is a sub-branch of smellology in clinical bacteriology. One of us will sooner or later look at this unless someone his this info on the tips of their tongue or fingers. The other smells across the operating table are halitosis, alcohol from the previous night, and many types of ethnic food. In passing, I am amazed at two doctors [all identifying cues removed] with spectacular halotosis. Should the surgical colleges offer a free testing service at conferences, in something like a confessional booth? It would upset some patients when they are being examined but too scared except to put up with the experience. Of course this is nowhere near as bad as verbal roughness with patients.
Please try and have the courage next time. Of course there are much more important failures. I have some I will only own up to in my final autobiography or anonymously.
Recent story about the dead man who sat up also described the nightmares of a surgeon and the mistakes he had made. A confidential collection and study of these is liekly to be very educational to all of us. The role of such a collection of mistakes is not to provide the comfort of a confessional but to provide practical lessons for the benefit of the next surgical patient in a similar situation. I remember removing an inflamted appendix from a young man who was to be married in a week. In five days he finally had his gangrenous Meckel’s diverticulum removed by the more senior surgeon. The appendix had been inflamed, with pus aound it, but the inflammation was on the surface. In retrospect I am not sure how inflamed the adjoining peritoneal surfaces were like.
I don’t know if you have noticed, but I seem to be able to tell if the appendix is ruptured or not by the smell of the breath of the patient. He has a certain anaerobic halithosis very similar to the fetor of a patient with generalized peritonitis from ruptured colon.
I did (and usually do) an appendectomy from a 1.5 cm Rockey-Davis incision on a thin patient. It turned out that the appendix was ruptured and there was pus all over, more than where I could see my incision. I had to enlarge in order to clean out the pus and then I discovered a Maeckel’s diverticulum which I removed with a resection anastomosis, it was my first Maeckel’s diverticulum in ~300 appendectomies and now I lie awake at night thinking how close I came to missing out on the Maeckel’s and the wisdon of small incisions, fast recovery, less post-op pain to “adequate” surgery.
Sorry,but I am not agree with you if you think that halitosis is a sygn of appeniceal rupture.I think that this halitosis is only produced by poor clean of the mouth of the patient. My old professor of surgery,think as you.But,this one of the few knowledgment that I do not learn.
This reminds me of the way to make a spot diagnosis of diabetes mellitus
and benign prostatic hypertropy.
Smells in surgery: I do not think, in this day and age, it has a role, and who wants to do the smelling ? Besides, the commercialisation of surgery itself stinks.
I once removed an ‘inflammed’ appendix, but fortunately noticed pus collecting in the right paracolic gutter. Turned out to be perforated duodenal ulcer. This condition has been described though I can not recall the name that goes with it.
Valentino’s appendix, after Rudolph Valentino who died from a perforated duodenal ulcer misdiagnosed as an appendicitis.
A GYN I once knew did a diagnostic laparoscopy for pelvic pain and found green fluid, luckily, he called a general surgeon to help, who found a perforated ulcer.