If ever you were frustrated with your mom because she constantly told you to wash your hands, remember this — it was because so many mothers died that hand-washing first became a thing. And that, dear reader, is how we begin the strange, sad story of Ignaz Semmelweis, a 19th-century doctor and father of infection control.
Semmelweis was born in Hungary in 1818, and after graduating from medical school, he started a job at Vienna General hospital (Austria) in 1846. There, he became aghast at the mortality rate of new mothers in a particular ward.
In this ward, up to 18 percent of new mothers were dying from what was then called childbed fever, or puerperal fever. Yet in another ward, where midwives – instead of doctors – delivered all the babies, only about 2 percent of mothers perished after childbirth, according to the British Medical Journal.
Semmelweis began reasoning his way to the root of the problem. He considered climate and crowding, but eventually ruled out those factors. In the end, the midwives themselves seemed to be the only real difference between the two wards.
Then, Semmelweis had an epiphany. One of the hospital's doctors, a pathologist named Jakub Kolletschka, accidentally nicked himself with a scalpel that he'd used during an autopsy of one of the unfortunate mothers. He was sickened with childbed fever and died.
Semmelweis believe that the doctors were dissecting infected corpses and – cue gag reflex – immediately afterward, delivering babies, without stopping to wash their hands. He suspected that this was the source of the deadly problem.
"Basically, his hypothesis here was that it was cadaveric matter from the scalpel that entered Kolletschka's blood and caused the infection, and that same material could be transferred to the women on the hands of the doctors – because the doctors would do autopsies and then go straight to examine the women who had given birth, without washing their hands, changing their clothes or basically taking any hygienic measures at all," says Dana Tulodziecki, a philosophy professor at Purdue University via email.
"He then tested this hypothesis by requiring people who had performed autopsies to wash their hands with chloride of lime – a disinfectant – before attending the women and after this the mortality rate in the first clinic fell to that of the second."
You'd think that Semmelweis' fellow doctors would be lauding him for this discovery. But you'd be wrong.
Why Semmelweis' Hypothesis Was Rejected
In the 1840s, there was no such thing as germ theory (the theory that diseases are caused by organisms only visible with a microscope). People still suspected that diseases transferred from one person to another via toxic odors, not bacteria or viruses. This was called "miasma theory." In washing their hands, they probably wanted to be rid of whatever was causing a terrible odor, not kill germs that might wreak havoc on them or someone else.
"Physicians of Semmelweis' time simply did not understand or believe that something microscopic could be wreaking such havoc on their patients," says Michael Millenson, an adjunct professor of medicine at Northwestern University and the author of "Demanding Medical Excellence: Doctors and Accountability in the Information Age."
"They literally believed their own eyes," he says via email. "Lest we feel too smug, consider how many people currently embrace a lack of COVID-19 deaths among 'people like me' (geographically, racially, economically or otherwise) as evidence that scientists are overestimating the pandemic's risk."
Better hand-washing regimens dramatically improved death rates at the maternity ward. But Semmelweis' colleagues were, at best, miffed at the implication that their ignorance was killing their own patients — and perhaps that midwives were better at delivering babies than they were. Semmelweis' own supervisor thought the hospital's new ventilation system was the reason for the decline in maternity deaths.
So, those doctors rejected his theories — and Semmelweis himself — as inferior. They opted to stick with their miasma theory, and for good measure, in 1849, didn't renew his appointment.
It didn't help that Semmelweis was a poor communicator. In his direct attacks, he essentially laid the deaths of the ward's mothers at the feet of his superiors. Semmelweis was also a Hungarian in Austria — a foreigner working in a country suffering in the throes of xenophobia. Not exactly ideal footing for suggesting a fundamental medical paradigm shift.
Semmelweis eventually got a medical position in Budapest where he "publicly harangued doctors and nurses about hand-washing and reduced maternal mortality," according to the BMJ. He eventually published a book on the subject some 14 years after his discovery. It was poorly written and poorly received.
Possibly suffering from mental illness, or else simply broken from his rejection at the hands of the medical establishment, Semmelweis wound up at an asylum in 1865. Weeks later he was dead of an infection from a wound that he received in the facility. He was just 47 years old.
The Myths and Reality of Ignaz Semmelweis' Discovery
Semmelweis left behind a monumental legacy – but one that's not without flaws. One myth that surrounds Semmelweis is that he was the first to suggest a theory about doctors transmitting germs.
"He wasn't really a pioneer — other people before Semmelweis had hit upon the idea that childbed fever could be transmitted from doctor or midwife to patient," says Tulodziecki. "For example, Alexander Gordon of Aberdeen showed in 1795 that childbed fever was almost always transmitted by doctors or midwives and also that it was connected to erysipelas (a kind of streptococcal skin rash). (He also thought the best treatment was copious bleeding, but that's a different story)."
Tulodziecki adds that many people in the first part of the 19th century confirmed Semmelweis' views about transmission. That included, to name just a few, John Armstrong, William Hey and John Robertson in the United Kingdom.
"In the states, famously, there was Oliver Wendell Holmes (who was a physician but is now much better [known] as a poet), who wrote a very elegant essay called 'The Contagiousness of Puerperal Fever' in 1843, a year before Semmelweis even completed his M.D."
Another misunderstanding is that doctors of his time outright rejected Semmelweis' ideas. They didn't. It's just that they attributed childbed fever with a range of variables, such as predisposition, environment and many other factors.
"But because people already had such a long list," says Tulodziecki, "adding cadaveric or decomposing animal matter really wasn't such a big deal to them. And lots of people – some of them pretty big shots – did add this to their list and started disinfecting their hands. So, it's just not true that that part was universally rejected."
In the 1860s, Louis Pasteur started working on what would eventually become the theoretical explanation behind Semmelweis' observations. And in the 1880s, thanks to the pioneering work of Joseph Lister and others, people started using antiseptic techniques in surgical and maternity wards, which is when mortality rates from childbed fever really began to fall. "Lister probably actually did more for reducing childbed fever than Semmelweis, even though Lister wasn't concerned with childbed fever specifically," she says.
Hand-washing Today — Still a Challenge
Even after, scientists realized that Semmelweis had been right all along about hand-washing, this simple act still remains a challenge throughout society.
That's partly because we human beings cannot see bacteria and viruses. A January 2020 poll found 40 percent of Americans don't always wash their hands after going to the bathroom. Even doctors and nurses may rationalize that their own behavior had nothing to do with spreading disease.
"Patients get infections for many reasons. They come into contact with many people and many objects and have compromised immune systems," says Millenson. "And by definition, those who forget to wash or don't do it properly don't know that they forgot or were ineffective.
Millenson points out there is still no requirement that hospitals reach a certain threshold on hand hygiene, only that they have a program in place to improve it.
"Almost as bad, the U.S. Centers for Disease Control doesn't monitor a national hand hygiene rate in hospitals, which often hovers in the 10 to 40 percent range," he says. "On average, U.S. health care providers clean their hands less than half the times they should, according to the most recent CDC study, which was 18 years ago."
But there is this bright spot: "I like to tell provider audiences, 'The good news is that we've made significant progress since Semmelweis' time. We no longer put people who insist on doctors washing their hands into an insane asylum,'" quips Millenson.
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