In modern times, the idea that healthcare staff have a particular obligation to keep their hands clean is part of the conventional medical wisdom. Indeed, the COVID-19 pandemic has landed good hand and respiratory hygiene right to the forefront of today’s headlines; almost everyone will tell you that they are paying more attention these days to keeping their hands clean. Yet, in the mid-19th century, hand washing was considered to be quite radical.
I recently came across the work of the German-Hungarian physician Ignaz Semmelweis, a young physician who worked with medical students in Vienna at a public maternity ward. At Vienna General Hospital, there were two obstetric clinics: One run by the students and another run by midwives.
(Note: Home birth was the norm for those fortunate enough to have help with labor, delivery, and recovery care.)
In the 1840s, maternity wards were relatively new. They provided free care for mother and infant, which made them an option for the economically-disadvantaged. In return, patients would serve as training subjects for both medical and midwifery students. At this time, hand washing was not routine in medical care.
Dr. Semmelweis was surprised to find that incoming patients preferred the midwifery ward to the medical students. So much so, in fact, that women sometimes begged on their knees to be admitted to the care of the midwives.
The belief that no one gets better in a hospital persists today, but was very common in the 1840s. Women would sometimes purposefully wait so that they would deliver their baby on the street.
Dr. Semmelweis noted that the outcomes for women delivering in the midwifery ward were better than in the medical student ward, despite having identical facilities. Death rates were often three times higher. He further observed that the women who came out best were those delivering in the street on the way to the hospital.
Above: Mortality in medical student ward (1st) vs Midwifery ward (2nd)
This was at a time where maternal deaths were part and parcel of childbirth. In addition to hemorrhage, infection (known as “puerperal fever”) caused many fatalities. Most surmised that the medical students caused more casualties due to rough treatment, but Semmelweiz wasn’t so sure.
Then, one day, a physician friend was accidentally cut by a medical student’s scalpel while performing an autopsy. His wound became infected and he died some time later. Dr. Semmelweis noticed that his deterioration was almost exactly the same as that of women who succumbed to puerperal fever.
He concluded that, since midwives weren’t involved in performing autopsies (and medical students were), that “cadaverous particles” carried by the medical students into the maternity ward was responsible for the worse outcomes in their ward.
Semmelweis placed a basin with chlorinated lime solution (calcium hypochlorite) at the entrance to the medical student ward and required all to wash their hands in it before entering. The results were impressive: In April 1847, more than 18 percent of new mothers perished as a result of infection. In May 1847, only 2% died. Some months, the death rate was zero.
He became a fierce advocate of hand washing, going so far as to call doctors who failed to do so “murderers”. Not surprisingly, the rigid medical establishment of the time took offense. When he wrote a book about his findings, it was roundly criticized and mocked. He lost his position at the Vienna hospital (maternal deaths rose six-fold as a result) and moved to Hungary.
Over time, Semmelweis became more and more adamant, to the point that some felt he had become unhinged. In 1865, a physician “friend” took him to visit a “new medical institute”. It turned out to be an insane asylum. When he realized what was happening, he resisted admission and was severely beaten by guards. Straitjacketed and tossed into a padded cell, he died within two weeks from, of all things, a gangrenous infection of a hand wound. He was 47 years old.
Although Louis Pasteur began his work on the Germ Theory of Disease around the same time, it was decades before Semmelweis’s beliefs about hand hygiene became accepted by the medical community. In the general population, it took a pandemic in 2020 to convince many that washing their hands often is a good policy to prevent infection.
Ignaz Semmelweis, disgraced and forgotten outside of Hungary, was proven right. Today, his name isn’t familiar even to most physicians. One day, however, he may be recognized for advocating a policy that has saved millions.
Joe Alton MD
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