COVID 19, Hand Washing & Ignaz Semmelweis

Image Credits : Wiki Commons

Google is now an all pervasive lexicon, which has entered into the hearts and minds of most Indians and the Google home page is as strongly etched in our minds as the current COVID 19 pandemic. Therefore yesterday’s Google Doodle - which is continuing even today- an image that appears on the Google home page, conveyed a timely message for all of us -  ‘ Stay Home, Save Lives’. This message emphasises the need for us to be resilient for unitedly combating the global COVID pandemic by staying in our home to arrest the Covid spread. Hopefully it will help us in re-emphasising the need for all of us to strictly follow the guidelines of the government, Ministry of Health and Family Welfare, World Health Organisation (WHO) and such other credible organisations in combating the Covid menace by staying in our respective homes. 

Most unfortunately, notwithstanding the unprecedented developments in science and technology, as things stand today, there is no cure  or a vaccine to the novel Corona virus and the best way to avoid the spread of this Covid pandemic is a good hygiene - primarily hand washing and social distancing. Washing hands is a simple act, yet such an essential step in halting the spread of the COVID transmission, which has now crossed the million mark and taken away more than 50,000 lives. Good hand hygiene protects us and those around us, and it is one of the most important contributions that we all can make to keep ourselves and our communities safe. Hand washing, mundane as it may sound now, needed a visionary Doctor, in the early nineteenth century, to visualise its efficacy in saving lives. Hand washing is now linked with its founder, Ignaz Semmelweis, a Hungarian doctor, who introduced the concept of hand washing and hygiene in the 1840s while working in the famous Vienna General Hospital. In fact his colleague doctors and scientists thought it was unscientific to connect hand hygiene with medical care but then Semmelweis, who faced huge challenges in driving home his message, was proved right, though decades after his death. This blogpost of mine is therefore a tribute to Semmelweis, the father of hand washing. 

Dr. Ignaz Semmelweis, unfortunately did not get the due recognition for his profound contributions to hand hygiene and its inextricable linkage to infection control and saving of lives, when he was alive. However, that mistake has now been amended and he is now universally known as the ‘‘father of infection control’’ and saviour of precious lives. He is now recognised as one of the leading scientists and his portrait hangs majestically at the Hungarian Academy of Sciences in Budapest, which I had the honour to visit during my participation in the World Science Forum in 2015. Many lives have been lost and are continuing to be lost due to what is called the sepsis, infections acquired by patients while in hospital. Incidentally this very sepsis, took away the life of my brother in law, Pramod Angadi (my wife’s younger brother) last year, that too at a very young age of 49 years. Most of the  infections, which are acquired by patients while in the hospital are called nosocomial infections and such infections are very common in countries like India. One of the causes for these infections is  contaminated hands of people including healthcare workers, who are responsible for spreading lethal infectious agents. It is now universally accepted that hand hygiene is noted to be the single most important factor for such infection control. Ignaz Semmelweis was the first physician in medical history to demonstrate that puerperal fever - a hospital acquired infection, also known as childbed fever - was contagious and that its incidence could be drastically reduced by enforcing hand hygiene on the medical care givers. Unfortunately, although his hand washing advisory was hugely successful and led to drastic reduction in the fatality rates during the delivery in pregnant women yet, it was rejected by the powers that be since Semmelweis’s discovery directly confronted the then held beliefs of medical doctors, who were in disagreement with Semmelweis.

Ignaz Semmelweis, the fifth child born to Teresia and Josef Semmelweis, Jewish immigrants to Hungary, was born in the formerly divided town of Buda - subsequently Budapest (in Hungary) from 1937, after its twin city Pest was merged with Buda - on 1st July 1818. The young Ignaz attended his school in Buda, and finished his primary education at the Catholic Gymnasium in 1835. On the advice of his father, Semmelweis left Buda in 1937, for studying law at the University of Vienna, in Austria. Fortunately, it so happened that Semmelweis became friends with a medical student in Vienna and attended one of his anatomy classes in the Vienna General Hospital. This aroused an interest in medicine in the minds of Semmelweis and thus ending his tryst with law studies. Semmelweis returned back to his home town Buda in 1840 for studying medicine.  He went to the University of Pest (later called Eötvös Loránd University in Budapest) and began studying medicine. Subsequently he once again went to the University of Vienna and obtained his doctorate in medicine (MD) in 1844, the graduation ceremony of which he could not attend because of the death of his mother, whose funeral he attended at Buda.

In the year 1847, Dr Ignaz Semmelweis was selected for an initial 2 year appointment as an assistant in obstetrics at the famous Allgemeine Krankenhaus teaching hospital in Vienna - now General Hospital Vienna. His primary responsibility at the hospital was with the ‘First Division’ of the maternity service of the hospital. The Vienna General Hospital ( Allgemeines Krankenhaus ) was a jewel amongst the European hospitals in the 1700s. This Hospital was rebuilt as an outcome of the visionary Austrian Emperor,  Joseph II. He Joseph II, was concerned with the growing need for institutional care for the sick poor and thus invested his personal fortune in building this magnificent hospital, which went on to be the leading hospital of the world. Joseph II, decided that rather than build a new hospital, it is better to reconstruct an existing almshouse. The reconstructed General Hospital in Vienna, was designed by the emperor’s private physician, Joseph Quarin and the final plan consisted of a 1500-bed, general hospital with lying-in facilities, an asylum and a foundling hospital. The design comprised a maze of 111 rooms, more than half of which were meant for men, and some private rooms. There were 15 physicians and 15 surgeons and 140 nursing attendants, who were appointed for running this hospital. The reconstructed hospital - Allgemeines Krankenhaus - was opened on 16 August 1784 and instantly became a tourist attraction primarily because of its majestic architecture. It also became a model for other hospital renovations in Germany and other countries. Although the hospital was known for its unique architecture and was also a famous tourist attraction, it soon became infamous for its medical services, since the mortality levels at the hospital was very high at 20% and therefore wealthy and prospective paying patients were frightened to turn up at this hospital. The conditions of the hospital remained much the same until the death of Joseph II. The hospital improved subsequently with the appointment of Johann Peter Frank as its director in 1795. It was in this very hospital that Semmelweis would go on to revolutionise the hand washing and hygiene theory, which has ever since been saving millions of lives across the globe and is now playing a pivotal role in the arrest of the Covid spread. 

Semmelweis, while working at the maternity wards of the General Hospital, Vienna, observed a strange phenomenon - women whose pregnancy delivery was conducted by qualified medical Doctors (physicians) and medical students had a much higher rate of post-delivery death (9%), which was caused by ‘puerperal fever’ or childbed fever. In comparison other women whose delivery was conducted by the midwives or trainee mid wife’s at the same hospital, the fatalities were quite low, at about 2%. It was quite baffling an observation by Semmelweis and it would have been foolhardy of him to suggest that the number of fatalities during the deliveries conducted by professionally qualified physicians and medical students was much higher than those conducted by less qualified midwifes and trainee midwifes. But then Dr Semmelweis was prepared to risk his career and reputation for the search of scientific reasons, which was causing higher fatalities when Doctors performed deliveries. 

During his quest for finding answers as to what caused these higher mortality, Semmelweis learned about the death of a forensic Professor at the hospital. Jakob Kolletschka, a professor of forensic medicine at the General Hospital in Vienna, had died after a student had accidentally pricked Kolletschka's finger with a knife that was used in an autopsy. Semmelweis read the autopsy report of Kolletschka and noted  that the symptoms Kolletschka exhibited before his death were similar to those of the maternity patients who had died of puerperal fever. Because of the similarities, Semmelweis inferred that the two incidents had a common connect. After detailed examination and observations, he came to the conclusion that the medical students in the First Obstetric Clinic, who also dissected cadavers at the morgue, were actually transferring ‘cadaverous material’ from the dead bodies in the morgue to maternity patients and that the mode of transmission was their hands. He further established that the ‘cadaverous material’ was actually causing ‘puerperal fever’ and that it was this same material, which had led to the death of the forensic Professor - Kolletschka. He noticed that the midwives who were responsible for the deliveries in the  Second Obstetrical Clinic at the hospital did not work in the morgue and therefore he inferred that they were not transferring the ‘cadaverous material’ to their maternity patients thus the fatalities were much less at this clinic.

Semmelweis conducted further observational studies on this issue at the General Hospital and came to a compelling conclusion that it was the doctors unhygienic hands that were reasons for the increased fatalities. He was convinced that the exposure of physicians and medical students to cadavers resulted in an increased risk of  puerperal fever (childbed fever). Dr Semmelweis called his studies - Control Analysis.  Semmelweis spoke about his findings with some of his colleagues and medical students, while most were dismissive of his findings, some were quite positive. He was able to convince them to practice a ‘mandatory hand washing regime’ before carrying out the deliveries. He further conducted trials to see if improved hand hygiene by doctors and medical students could reduce mortalities. During these trials, of hand hygiene before delivery, Semmelweis advocated use of chloride of lime solution for washing hands. To the surprise of most of his seniors and also his fellow doctors and medical students, the death rate in all the deliveries conducted using the prescribed hand washing regime fell drastically from 9% to  2%. Semmelweis further advocated for washing of the medical instruments, which were used in the deliveries, and true to his expectations, the fatalities rate decreased further to about 1%. What his findings meant was that for all these years the unhygienic conditions practiced by his fellow doctors, including his seniors, was responsible for the increased number of deaths. As expected his findings did not go well with most of his seniors, who refused to buy his arguments and called them unscientific and aimed at stigmatising the doctors fraternity. Some of the senior Doctors even initiated a furious and vicious attack against Semmelweis.

Professor Klein, who was senior to Semmelweis, was among those who led an attack against Dr Semmelweis. Klein was a respected Doctor and was also a member of the highly respected and influential Academy ‘the Old Guard’, which also consisted of leading authors of the time. Professor Klein argued that the higher fatality was due to the faulty ventilation system and not the purported consequences of unhygienic ‘dirty’ hands of the doctors and medical students. Semmelweis was unconvinced. He was able to take on board a number of young faculty members, who supported him and practiced hand hygiene before the delivery. Some of these doctors went on to become leaders of medical profession who ensured that their hospital - the Allgemeine Krankenhaus Hospital in Vienna became the world’s greatest teaching hospital for the next half century. 

This findings of Semmelweis did not go well with Professor Klein and some of the senior staff at the Vienna Hospital and they all ganged up against Semmelweis and ensured that he did not get his assistant professorship renewed in 1849. Instead, Semmelweis was offered a clinical faculty appointment, which meant that he did not have permission to teach from cadavers, which was of paramount importance during those days. Semmelweis felt he was betrayed by his seniors, whom he accused as ‘murderers’ of pregnant women. He then fled Vienna by abandoning his supporters, and came back to Budapest. In 1851 he took up another assignment as the head of obstetrics at St Rochus Hospital. This hospital too had a high rate of puerperal fever, but with Semmelweis heading the hospital and implementing his policies, the rate of puerperal fever plummetted. In 1855, Semmelweis became head of obstetrics at the University of Pest. Semmelweis implemented the chlorine washing procedure and infection rates of puerperal fever at the university hospital fell.  By then Semmelweis’s obsession with hand hygiene had reached unprecedented proportions. Wherever he went he spoke of the ‘murderous practise’ of Doctors and medical students and this undeterred attack on the Vienna Doctors did not earn him any sympathisers. Rather, he created some more enemies in his home town.

Amidst all,his obsession with hand washing Semmelweis  married Maria Weidenhoffer, the daughter of a wealthy merchant in 1857, the year when India was fighting its first war of Independence against the British. Together Ignaz and Maria Semmelweis had five children. During this period Semmelweis wrote papers on puerperal fever and, in 1861, he published his book ‘Die aetiologie, der begriff und die prophylaxis des kindbettfiebers’ (The Etiology, Concept, and Prophylaxis of Childbed Fever). Unfortunately, although his findings had a sound base, the book was badly written and therefore it was no wonder that it was poorly received by the medical establishment. By this time Semmelweis had become obsessed with his hand washing advocacy and wherever he went he spoke of the Doctors in Vienna as some kind of a murderers. He was began to be completely ostracised by his own medical community. However contrary to his own views that his own medical fraternity did not heed to his findings, there are evidence which suggest that the General Hospital in Vienna continued to practise the hand hygiene regime which Semmelweis was advocating. 

The conventional view, which is suggested by Semmelweis's own account, is that his contemporaries were skeptical of his results, that he was marginalized and that once he was no longer directly responsible for caring for maternity patients, puerperal mortality returned to its former high levels. However the situation appears to have been quite different. Although Semmelweis went hammer and tongs to criticise the Doctors at the General Hospital in Vienna and call them murderers, who by refusing to look inwards are continuing to commit avoidable deaths at the maternity. Evidence suggests that his successor Doctors maintained a relatively low mortality rate at the Vienna Hospital, roughly consistent with the rate Semmelweis himself achieved. This suggests that the chlorine washings, which Semmelweis was advocating were probably still used conscientiously even after he left Vienna and that the opposition he encountered at the hands of the Doctors had other sources than doubts about the effectiveness of the chlorine washings. All this continued to play on the mind of Semmelweis. 

His mental health began to deteriorate after the publication of his book and he suffered from severe depression. By 1865, Semmelweis's abnormal public behaviour started affecting his professional life and he spent much of his time away from his family. Unfortunately when his behaviour turned from bad to worse, his wife and some of his colleagues in the year 1865, admitted him to an insane asylum in Vienna. Semmelweis tried to escape from the insane asylum and in the process he was beaten up badly. After two weeks in the asylum, post his bearings Semmelweis died on 13 August 1865 in Vienna, Austria. His autopsy revealed that he had died from blood poisoning in a wound that could have been sustained during the beating. He was just 47. 

It must be noted here that although Dr Semmelweis was the first healthcare professional to demonstrate experimentally that hand washing could prevent infections, it was not until 1885 or so, two decades after his death that his work was caught the attention of the Doctors and experts. This happened primarily because by then Pasteur, Koch, and Lister had produced fair amount of material evidence of the germ theory and antiseptic techniques. All these findings helped in establishing the importance of the value of hand washing and Semmelweis was given his due albeit after his death. Many countries have issued stamps honouring the contributions of Semmelweis. A university named after him ‘Semmelweis University’, has been established in Budapest, for medicine and health-related disciplines. Many other honorary establishments have been were established in his name, which include among others  The Semmelweis Klinik, a hospital for women located in Vienna, Austria and The Semmelweis Hospital in Miskolc, Hungary. His house in Budapest is now a historical museum and a library called the Semmelweis Medical History Museum.

While the whole world is combating the global COVID 19 Pandemic, hand hygiene and social distancing are two measures which are playing major role in arresting the spread of COVID pandemic and for which we must all eternally remain grateful to Semmelweis. Long live Semmelweis and RIP.

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