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Namaste to Dr. Semmelweiss, the Pioneer of Hand washing

Samrakshan is a program of Indian Radiological and Imaging Association (IRIA) that aims to reach every pregnant woman in India in order to reduce avoidable deaths of babies during pregnancy. Samrakshan, led by Dr Rijo Mathew Choorakuttil, has initiated training programs for radiologists, a data collection, documentation and evidence based analysis to share results of the program, and a multilingual health education series for pregnant women and families. Samrakshan is now starting a series on medical history with a specific focus on fetal radiology, childbirth, scientific evolution and scientific methods. 

In the current times, Samrakshan feels it very appropriate to start with a Doctor who worked in child birth, used scientific methods, and brought about an impact in society by pioneering the use of hand wash as a technique to reduce disease transmission. Samrakshan presents a brief exploration of the learning from the work of Dr Ignaz Philipp Semmelweiss. 

Dr. Semmelweiss was a Hungarian physician and scientist who lived in the 19th century. He is commonly recognized as one of the early pioneers of antiseptic procedures. Dr. Semmelweiss is best known for his work in peurperal fever or “childbed fever” (a fever that occurred in women during or immediately after childbirth and led to a lot of deaths among mothers), his discovery of a cause, implementation of a solution and evaluation of the results after implementation. 

The Problem

Puerperal fever was common in mid-19th-century hospitals and often ended in the death of the mother. Dr. Semmelweis was appointed assistant in the First Obstetrical Clinic of the Vienna General Hospital in 1846.  His duties were to examine patients each morning in preparation for the professor’s rounds, supervise difficult deliveries, teach students of obstetrics and be “clerk” of records. There were two maternity clinics at the Viennese hospital. The First Clinic had an average maternal mortality rate of about 10% due to puerperal fever. The Second Clinic’s rate was considerably lower, averaging less than 4%. Dr. Semmelweis was severely troubled that his First Clinic had a much higher mortality rate due to puerperal fever than the Second Clinic. In fact, the mortality rate at the First Clinic was higher than even women who gave birth outside the hospital. 

Working on the problem

Dr. Semmelweis decided to look at possible reasons that could explain the differences between the two clinics. The two clinics used almost the same techniques, and Dr. Semmelweis started eliminating all possible differences, including even religious practices. The only major difference between the two centers was the individuals who worked there. The First Clinic was the teaching service for medical students, while the Second Clinic had been selected in 1841 for the instruction of midwives only. The First Clinic, thus had the better medical expertise, but mortality was higher there. 

Could overcrowding be the reason? Maybe more women attended the First Clinic because of the availability of better medical experts. That may have led to more deaths in the First Clinic. He excluded “overcrowding” as a cause, since the Second Clinic was always more crowded and yet the mortality was lower. He eliminated climate as a cause because the climate was the same. Almost all factors were similar for the two centers except for the people working at the two centers. 

The probable cause

He got a breakthrough in 1847, following the death of his good friend Dr. Jakob Kolletschka, who had been accidentally poked with a student’s scalpel while performing a post mortem examination.  Dr. Kolletschka’s own autopsy showed a pathology similar to that of the women who were dying from puerperal fever. Semmelweis immediately observed and proposed a connection between cadaveric contamination and puerperal fever. Medical autopsies were done only by the medical doctors and students. The midwives did not perform autopsies. Dr. Semmelweis proposed that he and the medical students were most probably carrying “cadaverous particles” on their hands from the autopsy room to the patients they examined in the First Obstetrical Clinic. This could explain why the student midwives in the Second Clinic, who were not engaged in autopsies and had no contact with corpses, saw a much lower mortality rate.

Implementing a Solution

Dr. Semmelweis decided that whatever was causing the puerperal fever was being transmitted through the hands of the doctors and medical students. He instituted a policy of using a solution of chlorinated lime (calcium hypochlorite) for washing hands between autopsy work and the examination of patients. He did this because he found that this chlorinated solution worked best to remove the putrid smell of infected autopsy tissue, and thus perhaps it would destroy the causal “poisonous” or contaminating “cadaveric” agent hypothetically being transmitted by this material.

Results

The result was the mortality rate in the First Clinic declined 90%, and was then comparable to that in the Second Clinic. The mortality rate in April 1847 was 18.3%. After hand washing was instituted in mid-May, the rates in June were 2.2%, July 1.2%, August 1.9% and, for the first time since the introduction of anatomical orientation through autopsies, the death rate was zero in two months in the year following this discovery.

During 1848, Semmelweis widened the scope of his washing protocol, to include all instruments coming in contact with patients in labour, and used mortality rates time series to document his success in virtually eliminating puerperal fever from the hospital ward

Reaction to the results

The reaction to the results has several layers of complexity. 

  1. There was a very demonstrable fall in the mortality rates, one that could not be argued with.
  2. However, Dr. Semmelweis’s hypothesis, of only one cause, that all that one had to do was as simple as cleanliness, was considered extreme at the time, and was largely ignored, rejected, or ridiculed.

Why did this hypothesis not receive the acceptance it deserved?

    • Semmelweis’s observations conflicted with the established scientific and medical opinions of the time. 
    • The theory of diseases, at that time, was highly influenced by ideas of an imbalance of the basic “four humours” in the body, a theory known as dyscrasia, for which the main treatment was bloodlettings. 
    • Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and the main difficulty of the medical profession was to establish precisely each patient’s unique situation, case by case.
  • The findings from autopsies of deceased women also showed a confusing multitude of physical signs, which emphasized the belief that puerperal fever was not one, but many different, yet unidentified, diseases.

Losing the message over the messenger

  • The conflict with established opinions of the time became a major stumbling block
  • There were several aspects in consideration. 
  • Dr. Semmelweis was an Assistant to a Professor and the findings implied he found something that the professor did not know
  • The professor argued that the better results were because he had installed a better ventilation system, that addressed the miasma theory of diseases of the time.
  • The Medical community found it difficult to accept that they may have inadvertently been, without their knowledge, transmitting the cause of the disease.
  • Dr. Semmelweis was mocked, ridiculed and ostracized even though his results, in the form of maternal mortality, spoke for themselves.

Where was the message lost?

    • An obvious scientific explanation, consistent with the knowledge of the time, could not be offered. Several leading medical professionals felt the lack of explanation was leading back to the times of speculative medicine. A scientific explanation was only possible some decades later, when Louis Pasteur, Joseph Lister, and others further developed the germ theory of disease.
  • The rejection of Dr. Semmelweis’s empirical observations is often traced to belief perseverance, the psychological tendency of clinging to discredited beliefs. Additionally, Semmelweis was an Assistant, a hitherto obscure scientist. To attribute such a discovery to him, recognize him for that, especially considering its impact on society was quite difficult.
  • Dr. Semmelweis did not publish his results for several decades. There are hypothesis that he was not fluent in the major language of conferences of the time and hence did not feel comfortable presenting his work.  This was misconstrued as arrogance. Ironically, when he did publish, his work was critiqued for being poor in communication and language. Additionally, the foundational basis of his observation, the germ theory of disease could only be identified much later.  
  • Dr. Semmelweis then became a victim of the powerful political machinations of medical leaders of the time and had to leave the First Clinic. 

Further proof or Validation of his results

  • In 1851, Semmelweis took the relatively insignificant, unpaid, honorary head-physician position of the obstetric ward of Budapest’s small Szent Rókus Hospital in Hungary. Childbed fever was rampant at the clinic. After taking over in 1851, Dr. Semmelweis virtually eliminated the disease. During 1851–1855, only eight patients died from childbed fever out of 933 births (0.85%). Didn’t that disprove that the earlier results were only because the ventilation system was changed? 
  • Several of his students published similar good results but there were also not acceptable to the medical community or Journals of the time. 

Learning from the work of Dr. Semmelweis 

  • Discoveries come from observations. Most observations are right there in front of you.
  • One could argue luck that Dr Semmelweis was there at the autopsy of his friend. The reality is that he was desperately searching for the cause, a desperation that led him to look at each person, each cause, each difference. He made the breakthrough because He was looking for it.
  • Change does not happen easily. Even when the results are in front of your eyes. The need to cling onto old beliefs, customs is high, especially if those proposing the change do not fall into the category of “elite experts”
  • Every observation may not conform to existing knowledge. Observations often lead to the discovery of new foundations or theories.
  • Important to focus on the science and to bring a sense of inclusivity rather than exclusions based on language, appearance, communication skills and other extraneous factors. 
  • It may not bear fruit in your lifetime …but if the science is good, history will record that. You cannot keep good science down.

Some questions to reflect on

  1. Who would you rather be, a Semmelweis type Doctor or one of the hierarchical conformist types that sit for decades on a simple, lifesaving discovery? 
  2. Have things, in terms of maternal mortality, changed from then (1850s) to now (21st century)?
    1. In knowledge acquisition, processing 
    2. Reactions to new knowledge, programs
    3. Acceptance of new knowledge, processes
    4. Choices that drive or hinder implementation of new knowledge
    5. Solutions for the many versus solutions for the few
    6. Priority on the common versus priority on the rare
    7. Inclusivity of rural and semi urban, non-metro doctors and their experience and knowledge
    8. Platforms to share   
  3. What enablers of change does medical history share with us

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