Ideas

The dirt on handwashing: the tragic death behind a life-saving act

The resistance Ignaz Semmelweis encountered to his life-saving ideas would ultimately lead to his tragic end. With handwashing in the midst of a renaissance in the era of the coronavirus, Dr. Semmelweis deserves at least some of the credit.

Even with impeccable data, the ‘saviour of mothers’ was shunned

Contrasting images of Ignaz Semmelweis illustrate the toll that institutional resistance to his associated efforts to combat puerperal infections took on him. He is seen on the left in 1857, age 39, as he began his campaign. On the right is a photo taken a mere three years later, upon completion of his work The Etiology, Concept, and Prophylaxis of Childbed Fever. (University of Alabama Press)

* Originally published on May 28, 2020.

A university, a women's clinic and even a minor planet are named after Hungarian doctor and handwashing pioneer, Ignaz Semmelweis, to celebrate his groundbreaking findings.

But having his name attached to a frustrating feature of human psychology behaviour perhaps best reflects the reality of his short and tortured life.

The so-called "Semmelweis Reflex" refers to the propensity to reject new ideas if they challenge established ones — no matter how compelling the evidence is for the new ideas. 

The resistance Semmelweis encountered to his life-saving ideas would ultimately lead him to a tragic end. With handwashing in the midst of a renaissance today in the era of coronavirus, Semmelweis deserves at least some of the credit for it.

Semmelweis was different. He was stimulated to want to do something.- Dr. Ted Obenchain, historian and retired neurosurgeon

Through painstaking observation and statistical analysis, Semmelweis established early in his career that handwashing can save lives. 

It was the mid-19th century, so he couldn't show the precise mechanism — that would have to wait for the germ theory to be proven less than two decades later, demonstrating that microorganisms cause disease.

But his data and real-life results were irrefutable.

Empirical evidence

Semmelweis graduated at a time when medicine still lagged behind other scientific disciplines. The medical establishment's thinking was still stuck in a medieval mindset.

That mindset meant doctors still believed, for example, that miasma — or bad air — was often responsible for disease transmission. 

Semmelweis was lucky enough to study under "new school" proponents who championed empirical methodology. He started his research when he began a stint as an obstetrician at the Vienna General Hospital, one of Europe's leading hospitals at the time and a coveted institution for training.

Ignaz Semmelweis began studying law at the University of Vienna but found it boring. After a well-known anatomist got him interested in medicine, he switched his course of study, says author Theodore Obenchain. (Submitted by University of Alabama Press)

The hospital, however, had one of the highest rates of infection and death from puerperal fever, also known as childbed fever. The infection was a leading killer of women at the time, second only to tuberculosis — it rarely afflicted women who gave birth at home.

But it was endemic in hospitals. Semmelweis noted that in Division 1 of the obstetrics clinic — headed by himself and staffed by doctors, including trainees — three to four times more women were infected over a five-year period than those admitted to Division 2, which was run strictly by midwives.

God only knows the number of patients who have gone to their graves prematurely by my fault. - Dr. Semmelweis wrote

Affected women showed symptoms shortly after giving birth, and once the infection made its way to the bloodstream (sepsis), their chances of survival were zero. The mortality rate among new mothers was as high as 50 per cent.

Women who used hospitals at that time tended to be from the lower classes. At Vienna General they were often single, poor, voiceless women who had become pregnant then been left to fend for themselves in a society that didn't publicly tolerate single motherhood.

A mysterious disease

Semmelweis's career-defining interest occurred after one of his patients — a young woman — became septic following an abortion and died.

"It was such a prevalent thing; the average physician working there just kind of resignedly passed it off [as] 'that's just the way it is, and don't worry about it,'" said Dr. Ted Obenchain, historian, retired neurosurgeon and author of Genius Belaboured, a book about Semmelweis.

"But Semmelweis was different. He was stimulated to want to do something."

Using the hospital's trove of data, Semmelweis assembled 64 tables that looked at correlations with every possible contributing factor — including age, number of previous births, even the time of year. His research methods were years ahead of their time.

The morgue at Vienna General Hospital, a converted rifle factory, in 1874. Semmelweis performed his many autopsies on victims of puerperal fever here. (Image courtesy of Vienna University's Josephinum)

After her death, he also took it upon himself to perform an autopsy on every woman who died of the disease. The result: he knew more about childbed fever than any of his colleagues — a fact which caused friction with his superiors. His tactlessness also led to tension. 

Another factor working against him was that he couldn't pinpoint a scientifically defensible cause for the fever. That inability left him discouraged and wracked by guilt.

"Really and truly, I would have preferred to die," he wrote at the time. "The puerperal disease remains a mystery; only the number of the dead is a palpable fact."

A tragic breakthrough 

A breakthrough came along by way of yet more tragedy.

Back from a rare vacation, Semmelweis learned that a friend and colleague, Jakob Kolletschka, who also performed extensive autopsies, had died.

During the course of one of his autopsies, Kolletschka's finger was nicked by a scalpel by a medical student, according to some accounts. Kolletschka soon developed signs of infection, then fever, delirium, sepsis; and soon after, he died.

"What was striking to Semmelweis — and this, I think, is the moment that really had the scales fall from his eyes — is that Kolletschka, who had not had a baby, died of childbed fever," Dr. Jacalyn Duffin, historian, haematologist and professor emerita at Queen's University told IDEAS host Nahlah Ayed.

"Semmelweis then realized that it wasn't the fact of having had a baby, and it wasn't the miasma. It was what he thought of as cadaveric material, or decaying organic material."

Semmelweis understood that doctors, many of whom were still in training, were the ones spreading the infection.

It's perhaps shocking to contemplate today, but in the mid-nineteenth century, doctors were routinely performing autopsies and then examining mothers or delivering babies — all without washing their hands. 

Dr. Semmelweis developed a handwashing technique using a chlorine solution, which he insisted that every person — students and physicians working in his ward — use to rinse their hands, says Jacalyn Duffin. (Submitted by Jacalyn Duffin)

Semmelweis's remorse at this discovery was clear.

"God only knows the number of patients who have gone to their graves prematurely by my fault. I have handled cadavers extensively, more than most," he wrote.

"As painful and depressing, indeed, as such an acknowledgement is, still the remedy does not lie in concealment, and this misfortune should not persist forever, for the truth must be made known to all concerned."

Instituting a handwashing policy

Semmelweis instituted a new policy that forced doctors to wash their hands in a chlorine solution between their work at the morgue and obstetrics ward duties.

And this, says Obenchain, is where Semmelweis went beyond any other scientists trying to tackle this problem at the time: not only did he revolutionize thinking about childbed fever — correctly diagnosing the source of the infection and its mode of transmission — but he also came up with a solution that worked.

The meticulously recorded data and graphs are striking: after the washing step was implemented, the number of infections and deaths in Division 1 plummeted. 

Monthly mortality rates of puerperal fever for women giving birth at the First Division clinic within Vienna General Hospital 1841-1849, as tabulated by Ignaz Semmelweis. He devised and instituted a chlorine handwashing policy by mid-May 1847. His employment was terminated March 20, 1849. (Wikimedia)

"Best data ever. Absolutely gorgeous data. It just looks great, you can't argue with it," says Michael Loughlin, learning and teaching manager for the School of Science and Technology at Nottingham Trent University in England.

And yet, doctors and scientists at the time rejected, or ignored, Semmelweis's findings and advice. And when it was time to renew his position at Vienna General, he was replaced.

Why? There are a number of factors.

"Number one, it's group think," said Obenchain. "There's also a very strict hierarchical order in medicine."

The Semmelweis Reflex

It was also what would later come to be known as the Semmelweis Reflex at play, the refusal to accept new findings that contradict old beliefs, no matter how strong the evidence.

"They were holding on to their social status, because they clung to their practices," said Duffin. "These were the practices they had been taught. They treasured them; they hated the idea of them being dirty or somehow being inadequately clean when they examined their patients. Because they were gentlemen, and they just couldn't accept that. So there were many layers to it. And they weren't only epistemological. They were also social."

Photo taken in 1906 of a commemorative statue of Ignaz Semmelweis sculpted by Alajos Stróbl (1856–1926) and standing today at the entrance to Saint Rochus Hospital in Budapest. (Theodore G. Obenchain)

Also working against Semmelweis was his aversion to writing. While he was repeatedly urged to publish his findings, it was his associates and supporters who publicized them.

Semmelweis did eventually write a book a decade after his groundbreaking findings: The Etiology, Concept, and Prophylaxis of Childbed Fever was a painfully detailed and sometimes angry 543 pages.

He also took to writing angry letters to his critics. 

"The murder must cease, and in order that the murder ceases, I will keep watch, and anyone who dares to propagate dangerous errors about childbed fever will find in me an eager adversary," he wrote in one such letter.

Breakdown

He also began to dress and behave oddly, embarrassing himself in public and raising eyebrows among friends and foes alike. He was said to also suffer from mental health issues, and eventually had a breakdown.

His wife and a trusted colleague conspired to lure him to what was then called an insane asylum, under the pretext of taking a tour. During the visit, several aides forcefully put him a straitjacket.

Paintings occasioned by the marriage of Ignaz Semmelweis, age 39, and Maria Weidenhofer, age 20, in 1857. By Ágost Canzi (1808–1866). (Submitted by University of Alabama Press)

In the scuffle — some sources say it was a beating — Semmelweis sustained cuts and wounds. He received no care, and the wounds became infected.

Within two weeks, Ignaz Semmelweis, the tortured godfather of handwashing, died of generalized sepsis — the same kind of infection that took the lives of countless women who had died at Vienna General.

He was 47.

Fast forward nearly 155 years, and in the campaign to publicize handwashing as our most potent weapon against coronavirus — Semmelweis was the subject of a Google doodle in March, seen by millions around the world.
 
"It's pretty hard not to see him as a prophet, isn't it?" says Peter Ward, professor emeritus of history at the University of British Columbia and author of The Clean Body: a Modern History.

"I enjoy very much, in fact, that handwashing is still being appreciated and being reappropriated for its importance," added Duffin. "And he must feel somehow, if he's still out there, somewhat vindicated."
 


 

Guests in this episode:

  • Dr. Jacalyn Duffin is a haematologist, a historian and professor emerita at Queen's University. She's the author of several books including History of Medicine: A Scandalously Short Introduction.
  • Dr. Michael Loughlin is a microbiologist by training and research, and learning and teaching manager for the School of Science and Technology at Nottingham Trent University in England.
  • Dr. Theodore R.G. Obenchain is a retired neurosurgeon, author of Genius Belabored, and a medical historian.
  • Dr. Peter Ward is a professor emeritus of history at the University of British Columbia and the author of a recent book called The Clean Body: a Modern History.
     

* This episode was produced by Nahlah Ayed.

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