The Weekly Dose: 150 years ago, hand washing saved lives
Dr Ignaz Semmelweis, a 28-year-old Hungarian who was appointed as the First Assistant at the First Division made it his mission to understand what was causing the deaths of too many new mothers in the care of the First Division. What he found is relevant even a century-and-a-half later, and is still saving lives.
It was the middle of the 1840s in Vienna, and the Maternity Clinic of its General Hospital was puzzled by some abnormal behaviour among its prospective patients. The city’s pregnant women - many of whom were unwed mothers-to-be who desperately needed free medical services - would rather give birth in the street than allow themselves to be admitted to the First Division of the clinic. Sometimes, they’d even deliver a child right outside, then stagger in to be admitted for rest and recuperation, as well as to claim benefits from the government.
The First and Second Divisions admitted patients on alternate days of the week. Treatment in the latter, which was staffed exclusively by midwives, was much coveted by pregnant women, who begged and pleaded to be cared for there, rather than at the First Division, run by medical students and doctors. Women would risk death than submit themselves to the supposedly more evolved ministrations of medical personnel.
Why? Word on the street was that too many of the women whose children were brought into the world at the First Division left the world there themselves. Something inexplicable was killing new mothers in numbers beyond understanding; deliveries overseen exclusively by midwives and midwife trainees led to deaths too, but not as many.
What were these women dying of? ‘Childbed fever’, a mysterious illness which, at the time, was surmised to be caused by pressure from adjacent organs on the uterus, emotional trauma, errors in diet and other such spurious influences that we now know to be crock. Several medical committees were instituted to investigate why one division saw more cases of this than the other. None found anything conclusive.
Enter Dr Ignaz Semmelweis, a 28-year-old Hungarian who was appointed as the First Assistant at the First Division. He immediately noticed the disparity in the number of post-delivery deaths in the two divisions, and made it his mission to understand what was responsible. What he found is relevant even a century-and-a-half later, and is still saving lives.
Semmelweis began his research by personally conducting autopsies of all the mothers who had died of childbed fever the previous day, before starting his rounds every morning. Concurrently, he started looking for what factors differed between the two divisions that could explain the wide gap in mortality between the two.
During this time, he was shocked by the news that his friend Dr Jakob Kolletschka, a forensic pathologist, had died after a student accidentally cut Kolletschka’s finger during the course of an autopsy on a woman who had succumbed to childbed fever. Semmelweis examined Kolletschka’s autopsy findings and concluded that Kolletschka too had died of a process akin to childbed fever. Clearly, the course of this illness was not restricted to new mothers, or even to women. So what led to it?
Semmelweis found no differences between the treatment provided by the two divisions. The only distinguishing influence was that doctors and medical students of the First Division would examine women directly after conducting autopsies, which were performed without gloves, as was the norm then. Midwives didn’t conduct autopsies.
If Kolletschka died of something that resembled childbed fever, the cause of childbed fever in new mothers must be similar to that in Kolletschka. Because the germ theory for infectious disease was then still unknown, Semmelweis concluded that the causative agent of childbed fever was ‘decomposing animal organic matter’.
He wrote: “The source of decaying animal-organic matter can be a corpse of any age, of either sex, regardless of the preceding disease, regardless whether the corpse is a pregnant woman or not … whether the individual suffers from childbed fever … Decaying animal-organic matter is carried by examining fingers, operating hands, instruments, bed linen, the atmosphere, sponges, basins, hands of midwives and attendants. … In other words, anything that is contaminated by decaying animal-organic material and comes into contact with the genitals of patients”.
He also acknowledged his own past contributions to the unconscionable death rate among new mothers: “I have examined corpses to an extent equalled by few other obstetricians. Only God knows the number of patients who went prematurely to their graves because of me.”
He experimented with various methods to remove this organic matter from his hands, and concluded that a chlorine-based wash was most effective. From then on, every member of the First Division was compulsorily made to disinfect his or her hands before entering the labour ward. To preclude shortcuts, he also introduced a policy of public shaming in which the names of the midwife and student assigned to each mother in labour were displayed above her bed for all to see. Should the mother die from childbed fever - which we now know as a form of sepsis - those responsible for her death were immediately identifiable.
The results were dramatic. Compared to the period before mandatory hand washing with chlorine solution, maternal mortality from childbed fever during the next three months fell from 7.8% to 1.8% The next year, it plummeted to 1.27% - less than the rate in the Second Division.
Was Semmelweis celebrated for his achievement? Promoted, perhaps? No. His superior at the First Division, a member of the academic old guard, believed childbed fever was caused by impure air, and attributed the significant reduction in maternal deaths to the hospital’s new ventilation system. Semmelweis’ tenure as First Assistant was not extended, and he had to move back to Budapest, where he encountered the same horrifying maternal mortality, implemented even more advanced hygiene measures, and succeeded in getting the death rate to crash closer to rock bottom.
This story should have ended with Semmelweis being awarded the first ever Nobel Prize in Medicine, which was instituted at the beginning of the next century. But Semmelweis never received acclaim - or even agreement - from his own colleagues during his lifetime. For example, Dr Rudolf Virchow - now venerated as the father of modern pathology - insisted that childbed fever was caused by inadequate uterine contractions and other factors like the psychological condition of the mother. He, and most of his contemporaries, dismissed Semmelweis’ theory out of hand.
Semmelweis did not live long enough to be feted for his achievements. He was committed to a mental asylum, and died there of infected wounds sustained from a beating by the guards, at the age of 47. The cause of his death was identical to that of the many new mothers he had autopsied - generalised sepsis.
150 years ago, when one man said that washing hands saves lives, no one believed him. In 2020, in the middle of a pandemic spread partially by germs that travel on hands, there are many who still don’t.