The Doctor Who Learned to Wash His Hands: Ignaz Semmelweis

Ignaz Semmelweis was a Hungarian doctor in the early part of the 19th century who realized that something was wrong and that people were dying, and he did what you hope that a doctor would do, try to figure out what was going on, and what he found could have saved thousands of lives if only he could have gotten other doctors to believe him. But before we get to the extraordinary story of Dr. Semmelweis, I want to talk to you about the sponsor of today's episode. I'm a believer in lifelong learning. I think that life should be fun, and I like to take on new challenges, and there's not a much better fun way to take on a new challenge and learn something than to try to learn a new language. And that's why I'm so excited about this new app I have on my phone. It's called Babbel. It's the number one language learning app in the world today. It's really intuitive to use, and the lessons are only 10 to 15 minutes long, making it easy to fit into your day. 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There's lots of free lessons, but you can also sign up for the monthly service, learn all the languages that you want. It's very inexpensive, much less than you spend, say, on getting a tutor. The more months you sign up for, the less it is, and if you go into the link in the description and you sign up for at least six months, you'll get 50% off. You'll be glad you did. The year is 1846, and Hungarian physician Ignaz Semmelweis had just been appointed to a new position as assistant to Professor Johan Klein at the first obstetrical unit of Vienna General Hospital. The next year Semmelweis would make a radical and controversial suggestion to the medical community. He suggested that doctors should wash their hands. Specifically he thought that doctors should wash their hands in a chlorinated lime solution before examining patients who were pregnant or post-delivery. Seems like common sense today, but at the time Semmelweis was denounced, he was ridiculed, his suggestions were rejected. The reason that the medical community rejected the idea of washing their hands and the tragic life of Ignaz Semmelweis is history that deserves to be remembered. Ignaz Semmelweis was born in 1818 in what is now Budapest, Hungary. He was fifth of ten children, son of a wealthy grocer. Ignaz began studying law at the University of Vienna, but after a year and for unknown reasons he switched to medicine. He received his doctorate in 1844. He spent 18 months under the tutelage of Karl von Rokotansky, a leading doctor of pathological anatomy, or that is the study of structural changes within tissues in the body due to disease. Before he decided to specialize in obstetrics, he was rejected twice, seeking other jobs. First in his attempts to become a forensic pathologist and next when he sought to become the assistant to Vienna Medical School's leading physician. He became assistant to Johann Klein at the first obstetrical clinic at the Vienna General Hospital, a job similar to chief of residents today. Puerperal fever, or childbed fever it was often known, was a major cause of death in 19th century Europe. These were deaths caused by infection shortly after birth, which actually grew in number as professional hospitals became more common. At the Vienna Obstetric Clinic, fatalities were often greater than 10% a month. The illness was horrific for the patient, with terrible infections in the birth canal, abscesses in the abdomen and chest, and ultimately a descent into sepsis and death. Doctors did not understand the illness, which they called a desecration. Symptoms usually appeared within 24 hours of giving birth. Despite the risk, maternity hospitals were still appealing, especially for the poor, as services were offered for free in exchange for allowing the doctors to train, and the hospital would also often offer care for the infant. There were two clinics at the Vienna Hospital, the first staffed by doctors, the second by midwives. The second clinic had death rates of around 2%, while the first clinic had rates as high as 18%. Women knew it too, would often beg to be admitted to the second clinic. Some would even prefer to give birth in the streets. Semmelweis wanted to understand why there was such a discrepancy between the two clinics. Even women who gave birth in the streets had lower rates of infection. What protected those who delivered outside the clinic from these destructive unknown endemic influences, he asked himself. Later he wrote that everything was in question, everything seemed inexplicable, everything was doubtful. Only the large number of deaths was an unquestionable reality. So he began eliminating possible causes. It wasn't overcrowding because the midwife clinic was more crowded. Ventilation between the clinics was similar, and what small changes he made didn't make a difference. He even considered differing religious affiliation as a possible cause. The only significant difference between the two clinics was who was doing the work. Around the same time, a good friend and colleague died after he was accidentally caught with a student's scalpel during a postmortem examination. The symptoms and death were very similar to that of childbed fever, and Semmelweis believed that he had figured out what was killing his patients. One of the most important methods for 19th century doctors to learn was by examining cadavers, and doctors regularly did dissections on women who died at the clinic. They would often go from dissections immediately to delivering babies without wearing gloves or even washing their hands. Semmelweis's colleague died after examining a corpse, and he theorized that what he called cadaverous particles were being transferred onto their hands, and that it was these particles that caused childbed fever. The midwives did not examine corpses and therefore wouldn't be carrying the particles to the patients. Well Semmelweis's cadaverous particles don't quite represent an understanding of bacteria, and bacteria had not been directly observed. He also understood that illness was caused by something contagious. He also understood that whatever was causing it, hand washing was vital in preventing the spread. He chose to have his students wash their hands with a solution of calcium hypochlorite because it eliminated the putrid smell of the cadavers, which he assumed meant that it also destroyed his particles. In reality the solution acted as an antiseptic and killed the bacteria that was causing the infections. Though his cadaverous particle theory was not entirely correct, his policy produced dramatic results. In April of 1847 the fatality rate in the clinic was 18.7%. He instituted his hand washing policy mid-May, and in June the fatality rate dropped to 2.2%. Over the next six months the fatality rate peaked at 4.5%, but in January of 1848 Semmelweis instituted strict controls to cure his students sometimes negligent hand washing habits. In February of 1848 deaths in the clinic were less than one percent, and in two months of 1848 there were no deaths from childbed fever. He had, through the implementation of a remarkably simple hygienic rule, reduced deaths in his clinic by more than 90%. Semmelweis was not the first person to suspect that doctors themselves were spreading the fever. Famous poet Oliver Wendell Holmes senior wrote an essay in 1843 called, The Contagiousness of Periperal Fever. Holmes's paper was met with disgust. A prominent obstetrician wrote that it was the June and fizzle-less dreamings of a foolish writer, and that doctors who faced epidemics of childbed fever were just unlucky. Even earlier than that Alexander Gordon became the first person to recognize childbed fever as infectious, after a particularly awful epidemic of childbed fever struck Aberdeen Scotland in the 1790s. Thomas Watson in London suggested doctors wash their hands to prevent childbed fever as early as 1842. Semmelweis was the first to use hand washing to demonstrably reduce fatalities, but his ideas weren't any more accepted than Holmes's were. Doctors were understandably reluctant to believe that they were spreading the disease. Prevailing medical thought of the time often blamed the illness on miasma or bad air. Toward the end of 1847 word about his remarkable success had started to spread across Europe to mixed results. He and his students had begun sending letters to prominent obstetricians across the continent. Ferdinand von Hebra, leader of Austria's most prestigious medical journal, reported Semmelweis's findings in December of 1847 and again in 1848, claiming the discovery could be as significant as Edward Jenner's use of cowpox vaccine to prevent smallpox. Semmelweis believed that his results spoke for themselves and did little to advertise or defend them, but across Europe resistance found hold. Even in England where they generally believed childbed fever to be infectious, they brushed his work aside as nothing new, while another British doctor said that Semmelweis had proved that miasms from the dissecting room had caused the fever. This is a misunderstanding of his work, but Semmelweis himself offered no official defense. Semmelweis's work had irritated his superior Johann Klein and Semmelweis's two-year turn at the clinic was coming to an end. Klein may have had another doctor apply for the job, who he chose despite Semmelweis's recommendations. He was then rejected when he applied to become a private lecturer on obstetrics in 1849, again because of Klein's opposition. He was given the job in 1850, but with a condition that he would not be allowed to work on cadavers. He left suddenly and without saying goodbye to his students or colleagues, saying that he was unable to endure further frustrations in dealing with the Viennese medical establishment. He returned to Budapest and accepted the unpaid honorary position of head physician of the obstetric ward at Saint Rocco Hospital. The ward had a major problem with childbed fever, which he effectively eliminated. But even other doctors in Budapest refused to take up the treatment. He became the professor of obstetrics at the University of Pest in 1855, where he again instituted hand-washing to great success. He turned down a job to become a professor in Zurich and married Maria Windhofer, 19 years his junior, in 1857. He would have five children, though two died in infancy. In 1858, he published his first account of his own work. He expanded his theory to include more decaying matter and cancer tissue when faced with events that didn't fully fit his theory. In 1861, he published his full work, an etiology, concept and prophylaxis of childbed fever. Semmelweis was deeply affected by the rejection of his work. He wrote that, in published medical works, my teachings are either ignored or attacked. The medical faculty at Würzburg awarded a prize to a monograph written in 1859, in which my teachings were rejected. A German conference of scientists, including the renowned Rudolf Virchow, known as the father of modern pathology, rejected it, which likely helped others reject it too. A doctor in Prague called the theory naive, and reflecting critics' belief that Semmelweis' work was unscientific, called it the Koran of peripheral theology. Many scientists thought the idea of cadaverous particles was returning to unscientific, superstitious explanations for disease. An 1848 critique was typical. It bemoaned that neither the observations nor the opinions grounded on them are presented with the clarity, and added that Semmelweis' experiment wasn't specific as to what cadaverous particles really were. The specific contagion seems to be of little importance to Dr. Semmelweis. Indeed, it is so little considered that he does not even discuss the direct transmission of the disease from those who are ill to healthy persons lying nearby. Doctors doubted that there could be enough material left on hands to cause infection. One response to Holmes' paper was that doctors are gentlemen, and gentlemen's hands are clean. One doctor even claimed the experimental results showing dramatic decreases in infection depended partially on periodic accidental factors, that is, on random variation. And that doctor went on to say, I must judge provisionally that his opinions are not clear enough and his findings not exact enough to qualify as scientifically founded. Negative responses to his book only inflamed him more. He wrote letters to his detractors, called one doctor a partner in this massacre, and said, should another not teach the students to wash their hands, I declare before God and the world that you are a murderer, and that it would not be unjust to you if it memorialized you as medical Nero. By 1861, he suffered from numerous nervous complaints, was absent-minded, and was obsessed with childbed fever. His friends and even his wife were concerned for his health. He was committed to a mental institution on July 30, 1865, and after an altercation with the guards, he was beaten badly. He died two weeks later of sepsis from infection, an unfortunately ironic death for men who fought in childbed infections. He was buried in Vienna, but few attended his funeral. Other doctors would make important contributions after his death. Joseph Lister used carbolic acid to treat wounds and clean instruments as a disinfectant in the 1860s. He also faced criticism for his theories. Robert Koch became the first person to link a specific microorganism with a specific disease. Most importantly, and apparently unaware of Semmelweis's work, Louis Pasteur developed experiments that provided direct evidence for the germ theory of disease, which finally convinced Europe and led to a massive paradigm shift in the field of medicine. In 1891, Semmelweis's body was moved back to Budapest, and in 1964 it was moved to the house in which he was born, which is now a museum. By the turn of the century, his work was being applauded rather than derided, and became more influential than probably he ever imagined that it could be. Even in Germany, where they followed his advice, even though they didn't necessarily believe in his theory about particles. He has been recognized as a pioneer of antiseptic policy, and many hospitals have been named after him. Postage stamps, coins, and more recently a Google Doodle have been designed in his honor. He's also the namesake for something called Semmelweis reflex, which is a metaphor to describe that human behavior that's characterized by reflexively rejecting new ideas that challenge entrenched norms and beliefs. He was perhaps a difficult man, I refuse to stoop to advertising his theory because it was so obvious to him that it was correct, but his work was important, and he has finally been rightly recognized as a man ahead of his time.