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The Semmelweis Reflex

Posted on Friday, August 4, 2017 at 12:58 pm

What if doctors started to wash their hands between patients in the 1850s? What if this became accepted practice by the Civil War? What if the concept had spread to surgical instrument cleaning? What if it had been accepted practice by 1861? Unfortunately, this did not happen because of the “Semmelweis Reflex.” Who was this man, who if his theory had been accepted, not rejected by the medical community because it was radical, would have changed the face of Civil War medicine and saved thousands of lives during the war?

Ignaz Semmelweis was born on 1 July 1818, in a neighborhood of Budapest, Hungary. His father was an ethnic German born in what is now part of Eisenstadt, Austria. He achieved permission to set up a shop in Buda in 1806 and, in the same year, opened a wholesale business for spices and general consumer goods. He quickly became a wealthy man who could afford university training for his children.

Ignaz Semmelweis first began studying law at the University of Vienna in the autumn of 1837. By 1838, he had switched to medicine. He was awarded his doctorate degree in medicine in 1844. Dr. Semmelweis decided to specialize in obstetrics. In 1847 he was given a 2 year appointment as an assistant in obstetrics with responsibility for the First Division of the maternity service of the vast Allgemeine Krankenhaus teaching hospital in Vienna. It was at this hospital where he observed that women delivered by physicians and medical students had a much higher rate of childbed fever than women delivered by midwife trainees or midwives.

Maternity hospitals had been set up all over Europe to address problems of infanticide of illegitimate children. They were set up as free institutions and offered to care for the infants, which made them attractive to underprivileged women. In return for the free services, the women would be subjects for the training of doctors and midwives. Two maternity clinics were at the Viennese hospital where Dr. Semmelweis worked.

The First Clinic had an average maternal mortality rate of about 10% due to childbirth fever. The Second Clinic’s rate was considerably lower, averaging less than 4%. Women begged to be admitted to the Second Clinic, due to the bad reputation of the First Clinic.

Dr. Semmelweis was very concerned that his First Clinic had a much higher death rate than the Second Clinic. The two clinics were very similar. Semmelweis’ concerns led him to starting the process of eliminating all possible differences to discover why one had a higher death rate. The initial difference between the two clinics was the individuals who worked in each. The First Clinic was the teaching service for medical students. The Second Clinic was for the instruction of midwives only.

A breakthrough occurred in 1847. His good friend Dr. Jakob Kolletschka had accidentally been poked with a student’s scalpel while performing a post mortem examination. Jakob soon died of a fever. Kolletschka’s own autopsy showed a similar disease to that of the women who were dying from childbirth fever. Semmelweis proposed a connection between working on the cadavers and childbirth fever.

Dr. Semmelweis concluded that he and the medical students were carrying pieces of the cadavers on their hands from the autopsy room to the patients they examined in the First Clinic. The student midwives in the Second Clinic, who had no contact with corpses, had a much lower death rate.

The germ theory of disease had not yet been accepted in Europe, or even in Vienna. Thus, Semmelweis concluded some unknown material(s) from the cadavers was being transferred by the doctors, which caused childbirth fever. He instituted a policy of using a solution of chlorinated lime (calcium hypochlorite) for washing hands between autopsy work and the examination of patients. He did this because he found that this chlorinated solution worked best to remove the putrid smell of autopsy tissue. This smell concept fit the theory of the time period that “bad air” was an indication of disease. He thought that if he destroyed the “poisonous air” or contaminating “cadaveric” agent more women might live.

The result of his efforts was that the death rate in the First Clinic dropped 90%. This was close to the death rate in the Second Clinic. Toward the end of 1847, Semmelweis and his students wrote letters to the directors of several prominent maternity clinics describing their recent observations. A leading Austrian medical journal announced Semmelweis’s discovery in both 1847 and 1848 issues of the publication.

In 1848, a lecture explaining Semmelweis’s work was presented by others before the Royal Medical and Surgical Society in London and a review published in The Lancet, the most prominent medical journal in Great Britain. A few months later a similar essay was published in a French periodical.

Some physicians thought that he had clearly misinterpreted his data. Some British doctors felt that childbed fever was contagious like smallpox (diseased persons could pass the disease on to others). Still others felt that doctors were not capable of “killing their own patients by their methods.” It just was below their status to do this no matter what “evidence” was presented by this Austrian doctor.

Dr. Semmelweis’s “discovery” was really warning that all decaying organic matter could spread diseases. It was not just against a specific disease that originated from victims of childbed fever. Unfortunately, Dr. Semmelweis himself had published nothing in the medical journals. Because of this, misinterpretations of his concept by others attempting to support or detract from it would continue to make his work controversial throughout the 19th century.

Beginning in 1861, Dr. Semmelweis started to suffer from various nervous complaints. He displayed the characteristics of severe depression and became absentminded. After a number of poor reviews of his 1861 book, Semmelweis lashed out against his critics in published letters. He denounced his critics as “medical murderers.” This, of course, did not endear him to other professionals in the medical field. By1865, his public behavior had become embarrassing to his associates at the hospital. While it is impossible to know the exact nature of Semmelweis’s disorder, it could have been Alzheimer’s disease, it may have been syphilis (a common disease of obstetricians who examined thousands of women), or it just could have been exhaustion from overwork and stress defending his theory.

On July 30, he was committed to an insane asylum. Semmelweis tried to leave. He was severely beaten by several guards, secured in a straitjacket, and confined to a darkened cell. Two weeks, later on August 13, 1865, aged 47, he died. The autopsy gave the cause of death as pyemia—blood poisoning.

Physicians of the age resisted his theory. Washing of hands before treating each patient would be too much work. All this washing would require rebuilding hospitals so that sinks and running water were within reach. Semmelweis was saying that doctors were the cause of death. This did not set well with the medical profession. They felt betrayed by his statements as professionals. Two years after Semmelweis’s death, in 1867, the Scottish surgeon Joseph Lister, proposed the theory and practice of antiseptic surgery. Dr. Lister’s theory included washing the hands with carbolic acid to prevent infection. It is of note that Dr. Lister came to the same conclusion as Dr. Semmelweis without ever reading his work. In 1876, the German physician Robert Koch successfully linked a germ, Bacillus Anthracis, to a specific infectious disease, anthrax. Unfortunately, none of this data has any effect upon the medicine practiced during the American Civil War.

In the end, his loud medical detractors were wrong and he was right. Dr. Semmelweis pushed the boundaries of medical knowledge and theory with his handwashing technique. It is to his credit that he did not reject new evidence or new knowledge because it contradicted the established norms, beliefs or paradigms of that time period. That is the essence of the Semmelweis Reflex.

-By Trevor Steinbach