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Hygiene

When advocating for washing hands ended in a lunatic asylum

On today´s World Hand Hygiene Day I want to tell you the story on how hand washing became known as essential method in fighting infectious diseases.

Nowadays and especially since the COVID-19 crisis hardly anyone would doubt the effectiveness of washing hands. But in the 19th century was very different. Even though soap was used since antiquity for personal hygiene and religious purposes it was not linked to the prevention of diseases. This link was made by the Austria-Hungarian Dr. Ignaz Semmelweis (1818-1865) in 1847 in the Vienna General Hospital, a global center of medial research within the 19th century:

The scene

The Vienna General Hospital in 1784

In the 19th century maternity institution became popular all over Europe: Women were treated there for free and could deliver their babies with the support of trained doctors and midwives.

The Viennese hospital – due to its size – had even two maternity clinics: The First Clinic, where doctors and their students worked, had a much higher maternal mortality rate due to puerperal fever than the Second, where midwives supported women in delivering their babies. Women begged to be treated in the Second Clinic and even preferred giving birth in the streets than delivering in the First Clinic.

The unrecognized genius

It was 1847 in the First Obstetrical Clinic of the Vienna General Hospital where Semmelweis worked as assistant to Professor Johann Klein and tried to answer the mystery of the high death rate of the First Clinic.

What was going wrong? Both clinics used the same methods. Their difference was just in the medical personnel: doctors and their students vs. midwives.

Semmelweis studied diverse possible reasons for the issue: It was not “overcrowding”, as the Second Clinic was more crowded but had a lower mortaliy rate.

Then Semmelweis´s good friend Jakob Kolletscheka died after he was accidentally cut by a student´s scalpel during an autopsy. Kolletscheka´s autopsy revealed that he had a similar pathology to the women who died from puerperal fever. Was there a connection between “cadaverous particles” on the doctor´s hands and the puerperal fever in the First Obstetrical Clinic?

Semmelweis had the solution: using calcium hypochlorite after autopsies and before the treatment of patients.

His finding was a breakthrough as the death rate in the First Clinic could be decreased by 90% and so reached the level of the Second Clinic.

First reactions

Semmelweis success spread throughout Europe and lead to positive reactions – especially the UK – but also the upcoming of the misinterpretation of his work: This was partly due to the fact that Semmelweis did publish nothing himself but just his colleagues and students explained his findings.

No success

Semmelweis´s approach was ignored and even ridiculed by his colleagues. The Hungarian Revolution of 1848 lead to Semmelweis´s dismissal and he moved to Budapest. From 1851-1857 he worked as unpaid, honorary head-physician in the obstetric ward of Pest´s Szent Rókus Hospital and from 1855 as professor of obstetrics at the University of Pest.

In 1861 he published his main book “The Etiology, Concept and Prophylaxis of Childbed Fever”. The unfavorable international reactions to his book made him write letters to Europe´s leading professors of obstetrics in 1861 and 1862 in order to defend his findings.

From 1861 onwards Semmelweis suffered from numerous nervous complaints: including a severe depression. He was said to be obsessed with the topic of “childbed fever”.

His mental health got worse in 1865: There is no exact diagnosis: He and his surrounding sufferd from his enormous behavioural changes, including heavy drinking and changes in his sexual behaviour. These symptoms could be due to Alzheimer´s disease or syphilis. Some claim that the neglection of his theory broke him.

In August 1865, he was sent to the lunatic asylum Döbling, where he died 14 days later on blood poisoning or a sever beating attack by guards.

„Die k. & k. Irrenanstalt in Wien.“ (1858)

Just a few attended his funeral and his death was only mentioned in a few periodicals within the Austrian-Hungarian Empire.

Semmelweis´s grave in Budapest

Why Semmelweis´s attempt failed after all?

Even though figures proved the success of Semmelweis´s approach, he could not persuade the medical elite of his times: E. g. Under his successor at the Pest University the maternal mortality rates increased sixfold to 6%. Semmelweis´ life and work seemed forgotten.

Here are some reasons why his theory “failed”:

… challenging an well-established theory (with little scientific evidence)

In 1847 miasma theory was dominating the medical debate: “Bad air” was said to cause diseases. It took more than 20 years till the establishment of germ theory.

The evidence of Semmelweis´s claims were provided 2 decades latter by Louis Pasteur, Joseph Lister and Robert Koch.

… challenging autopsies

Autopsies could explain illnesses and so doctors, who performed it were very proud of it, and Vienna was a Center for this practice. It was believed that the dirtier the doctor, the better the doctor. So in blood covered coats were a kind of status symbol

the era of pathological anatomy, a “golden age of medicine” where doctors started trying to learn what caused illness by doing autopsies. These started in Vienna hospitals in 1823.

Whereas pathological anatomy was widely accepted and admired, obstetrics had little prestige. Obstetric institutes were often in old and not hygienic parts of hospitals.

… his wording and personality

In 1861, Semmelweis wrote two open letters to his main critics Dr. J. Spaeth, professor for obstetrics in Vienna, and Hofrath Dr. F. W. Scanzoni, professor for obstetrics in Würzburg.

These letters were highly offensive and didactic in tone: He accused Spaeth and Scanzoni that by not acknowledging his findings they were responsible for thousands of dead women and babies. Semmelweis clarified that he would point out their wrong reactions publicly and called Scanzoni a “medical Nero”.

… social status of doctors

Some doctors felt offended by the suggestion that their hands could be unclean, which was inconsistent with their social status as gentlemen.

… offical denial but secret use

Carl Braun, Semmelweis’s successor at the First Clinic, opposed Semmelweis´s ideas but the roughly consistent mortality rates from 1849-1953 show that Braun continued the hand washing.

… rejection by influential doctors

The rejection of e. g. Rudolf Virchow was a vicious circle as it lead to the rejection of other doctors.

… careless use

Some used the chorine washing carelessly. So Semmelweis´s approach seemed not successful.

Semmelweis´s late success

After his death, the germ theory of disease succeeded and proved Semmelweis´s findings: He became a pioneer of antiseptics.

Nowadays Semmelweis is celebrated for his findings: The university for medicine and health related disciplines in Budapest, a hospital in Miskolc and Vienna, and a minor planet are named after him. During the COVID-19 crisis many articles were written on his achievements and Google honoured him with a doodle on the 20th March 2020.

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