Why We Wash Our Hands Before Surgery

Photo by Austin Ban | Unsplash.com
Photo by Austin Ban | Unsplash.com

For every 10 pregnant women who walked into a hospital in 1840s Europe, only 9 would ever leave.1 One in 10 pregnant women died of a disease known at the time as puerperal fever, a bacterial infection of the female reproductive tract in the postpartum period that can spread to the blood and produce sepsis.2 To put this rate in perspective, using the current maternal mortality rate in the United States for every 10,000 pregnant women who enter a hospital 9,999 will leave.3

Physicians in 1840s Europe were perplexed by the high maternal mortality rate, but were relieved that Yelp’s rating system had not been invented yet to document their poor performance. One enterprising young doctor, however, was not content dwelling in Yelp-free mediocrity and undertook a study at his clinic. The doctor’s name was Dr. Ignaz Semmelweis, and he was an obstetrician in Vienna, Austria.

Dr. Semmelweis worked at a teaching clinic in which both midwives and medical students studied. When Dr. Semmelweis joined the staff, the hospital instituted an alternating admission policy wherein the midwife students admitted on one day, the medical students on next, and so on and so forth, alternating admitting days between the two groups. This alternating schedule provided the inadvertent soil for a fruitful experiment.

Townspeople quickly realized that a lot more women were dying at the hands of eager medical students than midwives, and pregnant townspeople began requesting admission to the midwife service. Dr. Semmelweis decided to quantify the disparity. After careful study, Dr. Semmelweis concluded that the midwife service had a mortality rate about 2.5 times lower than the medical student service.1

Dr. Semmelweis generated many hypotheses to explain the disparity and to reassure his students of their competency, but he could not find a satisfactory answer. Dr. Semmelweis almost had to admit academic defeat, but then his colleague, Dr. Kolletschka, fell on the proverbial sword and inadvertently provided the answer.

Photo by Sofia Roblero | Unsplash.com
Photo by Sofia Roblero | Unsplash.com

Dr. Kolletschka was working in the morgue conducting autopsies of recently deceased patients when an overeager medical student accidently skewered him with a contaminated scalpel. Dr. Kolletschka soon fell ill and died shortly thereafter. Dr. Semmelweis performed Dr. Kolletschka’s autopsy and was shocked by the similarities between Dr. Kolletschka’s pathology and the pathology present in patients who had succumb to puerperal fever. Dr. Semmelweis finally made the connection between the medical students’ lack of hand hygiene following their contact with cadavers and the high incidence of puerperal fever in the patients whom they contacted thereafter.

Today, it seems rather obvious that a medical student should wash his or her hands between rooting around in a corpse and delivering a baby, but at the time, medicine was still operating on the four humors theory developed by Galen between 100 and 200 CE.

The four humors theory alleged that health and disease could be explained by the balance or imbalance of four primary fluids: blood, black bile, yellow bile, and phlegm. The treatment involved bringing the humors back into balance through blood-letting. Insurance companies and professional boards tend to frown on this practice nowadays, but it was standard of care back in Dr. Semmelweis’s time.

When Dr. Semmelweis began to insist that his students use bleach in between cadaver exploration and baby extraction, other members of the medical establishment were at first perplexed, and then annoyed. At the time, the closest approximation of our modern germ theory was the theory that miasmas, or “bad air,” spread disease.4

Colleagues and superiors were put out by the notion that as gentlemen they might have unclean hands requiring washing. They were unfazed by the fact that in the months following Dr. Semmelweis’s hand washing mandate maternal mortality rates dropped by 90%.1

Dr. Semmelweis refused to give in to his critics who insisted that he had no scientific basis for his claim. Dr. Johann Klein, Dr. Semmelweis’s superior, decided he had enough of the hand washing nonsense and did not renew Dr. Semmelweis’s contract, giving the job instead to Dr. Semmelweis’s rival Dr. Carl Braun.5

Photo by Larisa Birta | Unsplash.com
Photo by Larisa Birta | Unsplash.com

Dr. Semmelweis moved from Austria to Hungary after losing his job and took a job at a small hospital in the town of Pest. There he again employed his hand washing technique and reduced maternal mortality to less than 1%.5 Unfortunately, colleagues at the University of Pest again disagreed with Dr. Semmelweis’s conclusions and guidelines. Seeking to change the establishment, Dr. Semmelweis applied for a position in the University of Pest’s faculty only to again lose the job to his nemesis Dr. Braun.

Dr. Semmelweis never gave up on his radical clean hands theory despite the fervor of his opposition. Unfortunately, this battle with his naysayers was tremendously taxing on Dr. Semmelweis’s mental health. In 1865, at the ripe old age of 46 Dr. Semmelweis began to drink more heavily, frequent ladies of the night, and behave in a generally reckless manner. Whether his deterioration resulted from a syphilitic process (common at the time) or depression, Dr. Semmelweis was decompensating quickly.

Photo by Hoshino Ai | Unsplash.com
Photo by Hoshino Ai | Unsplash.com

At the age of 47, a colleague invited Dr. Semmelweis to tour a new hospital. Only once Dr. Semmelweis arrived did he realize that it was an insane asylum and that he was being committed. Dr. Semmelweis put up a tremendous struggle while he was being ushered into a straitjacket by a number of guards. Sometime during this struggle Dr. Semmelweis sustained a wound that quickly became infected in the bleach-free insane asylum. In a horrific twist of irony, Dr. Semmelweis died 14 days after being “admitted” to the insane asylum of sepsis; the very same infection of the blood that the women he had spent his life trying to save had died from.

Twenty years after Dr. Semmelweis’s death, Dr. Louis Pasteur developed the germ theory of disease, validating Dr. Semmelweis’s prescient notion of contamination. Semmelweis now has multiple hospitals named after him, his visage adorns an Austrian commemorative coin, and every medical student learns about his groundbreaking establishment of the modern antiseptic technique.

References

  1. Semmelweis IF, Carter KC. The Etiology, Concept, and Prophylaxis of Childbed Fever. Madison, Wis: University of Wisconsin Press; 1983.
  2. Cunningham FG, ed. Williams Obstetrics. 24th edition. New York: McGraw-Hill Medical; 2014.
  3. Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol. 2012;36(1):2-6. doi:10.1053/j.semperi.2011.09.002.
  4. Cipolla CM. Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age. New Haven: Yale University Press; 1992.
  5. Carter KC, Carter BR. Childbed Fever: A Scientific Biography of Ignaz Semmelweis, with a New Introduction by the Authors. New Brunswick, N.J: Transaction Publishers; 2005.

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