October 15 is observed as a Global hand washing day. It sounds somewhat silly to be observing an event like this, that too globally, but then its importance dawns on you when you research a little deeper and get to read some history.

George Santayana said that “Those who cannot remember the past are condemned to repeat it”. Thus the importance of reading the history, and for us medical professionals (specially the Surgeons/ Obstetricians/ Physicians/ Paediatricians/ Pathologists and Psychiatrists), the importance of hand washing
Dr Adenwallla, a very senior Plastic Surgeon, from Trichur, has written this article below on one Dr Semmelweis in his inimitable style, which I wish to share with you all. It makes for some very interesting reading

Just as the life of the three men Wells, Jackson and Morton who gave anaesthesia to the world was a sad one so was the life of the man who eradicated puerperal sepsis (child bed fever) and ultimately made all surgery safe for mankind. His name was Ignaz Philipp Semmelweis. A Hungarian physician who was born near Budapest on July the 1st 1818 and died in a mental asylum in Vienna on August the 13th 1865. Semmelweis was the son of a rich grocer who was studying law and turned to medicine by chance. While he was studying law he happened to visit the “Blackhouse” which was the morgue of the famed Vienna General Hospital, there he met up with Karl Rokitansky who was pioneering a new branch of medicine which he called “Pathological Anatomy” which we today call pathology. He was dissecting cadavers to find the cause of death. Enchanted by this work Semmelweis decided to change from law to medicine. A decision which ultimately saved the lives of millions of people yet unborn.
Semmelweis’s greatest tragedy was a matter of timing. Thirty years later men like Pasteur, Koch and Lister put his theories to undeniable scientific proof, theirs too was an uphill task but they succeeded while Semmelweis failed. At age 28 Semmelweise was a fun loving gay young man. After he qualified in February 1846, he took on the post of assistant at the Obstetric clinic at the Vienna General Hospital. Unknowingly he was about to enter on the greatest challenge of his life and what ultimately also led to the greatest tragedy of his life. He was an awkward speaker and a poor writer and was not at all the type that research workers are made of. But he had what many of his colleagues lacked- a sensitive conscience, and a burning desire to find the cause of what killed a large number of his obstetric patients. All the physicians of the day believed that puerperal sepsis or child had fever was a thing inexorably fated and this was an attitude that Semmelweis had naturally imbibed from his teachers, until he personally came face to face with this terrible problem.
The obstetric department of the Vienna General Hospital was divided into two divisions. The first division where Semmelweis worked was where medical students were trained by doctors. The second division was used to train midwives here the senior midwives did the training. The mortality from puerperal sepsis was much higher in unit one compared to unit two. Semmelweis was struck by this undeniable fact which others ignored. He rushed to his Chief Professor Klein for an explanation. Klein was a callous and incompetent man who just shrugged his shoulders and told Semmelweis that there was no scientific explanation for this and not to bother him with such irrelevant questions. The system in most hospital in those days was that doctors and the professors would start work on postmortem in the morning and then attend to the obstetric cases. The more interest he took in teaching his students the method of examination, and the more examinations that were done on the patients the mortality rose even more.
            By the spring of 1847 Semmelweis was close to a nervous breakdown and so his good friend Professor Kolletschka suggested that he go to Venice for a holiday. Three weeks later he returned from Vienna a refreshed man, on March the 22nd he was back at his table in the postmortem room. To his surprise Kolletschka was not there at his habitual place by his side. He asked an attender as to where Kolletschka was? To his horror he was told that his friend has died. “How?” asked Semmelweis. “Why sir, don’t you know a careless student at the postmortem table had nicked his arm the professor developed a high fever, was delirious and died a couple of days later ”. Semmelweis was mortified and called for his friend’s postmortem report and to his surprise the findings were identical to the reports of the women who had died of puerperal sepsis.
The genius of Semmelweis lay in the fact that he at once put two and two together and realised that there was something that the students and doctors were carrying from the postmortem rooms on their hands to the patients they were examining in section one of the obstetric unit and that, that was the cause of child bed fever. The sweetish odour of cadavers on his own and on his students hands hitherto the proud attribute of a diligent pathological anatomist became for him the symbol of murder. Semmelweis realised that he would go mad if he did not fight for what he believed in. On the 15th of May 1847 his great battle began. The following notice was posted at the entrance of Unit one:
“As of today May 15th 1847 every doctor or student who comes
   From the dissecting room is required before entering the
   Maternity wards to wash their hands thoroughly in soap and
   Water and then in a basin of chlorine water which is placed
   At the entrance THIS ORDER APPLIES TO ALL WITHOUT EXCEPTION”                        
                                                         Sd. I.P. Semmelweis.
Semmelweis had no idea that microorganisms were the cause of child bed fever or of surgical infection. That came only with Pateur and Koch thirty years later. But he had fathomed the secret of transmission of the disease through the hands and the instruments that the doctors used. He had hit upon the concept that 30 years later would be the basis of antiseptic and later aseptic procedures which ultimately conquered surgical infection too. Such was the influence and magnitude of this man’s crusade.
Soap, nail brushes, chlorine water made their appearance at the entrance of division one. Professor Klein let the “Fanatic” as he called him have his way, after all he believed that he was climbing up the wrong tree.
In Semmelweis’s character there was a transition. The benign soft spoken and gentle man became a tyrant. He would stand at the entrance, shout and burst into fits of rage if he saw anyone avoiding the ritual he has said for them. During the next few months the mortality dropped by over 70% and was almost equal to that of the second division. Semmelweis thought that his troubles were over. However, on October the 2nd 1847 he was dealt a bad blow of the 12 maternity cases in the ward all were down with child had fever and all died in spite of the usual precautions. When he met the eyes of his students he could see the concealed triumph on their faces. But Semmelweis though devastated did not give up. He discovered that a case of puerperal sepsis had slipt into the ward and that though the students had washed their hands on entrance, they had not done so after examining the infected case. Semmelweis now tightened upon his regime by insisting that the doctors washed their hands between examinations too. This created more antagonism but the results were spectacular. To his delight his former teachers Prof. Skoda and Hebro accepted his methods. This upset Prof. Klein who was long weary of this trouble maker and decided to get rid of him. He fabricated evidence and denounced him as a traitor as Semmelweis had shown some sympathy for the revolutionaries. The government clamped down upon him, removed him from his post and Prof. Klein refused to allow him to use hospital statistics to prove his point. However, Prof. Skoda and Prof. Hibra took it upon themselves to write two papers on Semmelweis’s work and they were published in December 1847 and April 1948 in the Journal of the Royal Imperial Society of Physicians of Vienna. The papers created absolutely no impression on the medical fraternity. They just ignored it, and thousands continued to die of puerperal sepsis.
Disappointed and bitter Semmelweis left Vienna overnight without informing even his friends and supporters. In Vienna no one even spoke of Semmelweis and his work. It was as if he had never existed. In Budapest he turned to general practice to support his family. However, in the spring of 1851 he chanced to visit the maternity ward of St. Roch’s Hospital in Budapest- there he found six mothers dying of child bed fever infected by a surgeon who without washing his hands was alternating between his infected surgical cases and the obstetric cases. All six mothers died. This reactivated Semmelweis’s slumbering conscience, he felt duty bound to salvage these women. He took on the post of unpaid honorary Chief of the obstetric department of the hospital. Far from Vienna, far from the scientific world of the times, far from the bigoted physicians who opposed him, Semmelweis was once again on the war path. Soap and water and chlorine came back and lo and behold the mortality at the St. Roch’s hospital dropped. Less than one percentage of the women delivered died of puerperal sepsis over a six years period. Semmelweis was honoured by being made professors of obstetrics at the Budapest University. Zurich offered him a chair but he refused because he did not want to go out of his native Budapest where he was treated well and where he felt secure.
By 1860 his desire to communicate with the world became so compelling that he wrote a book. It was titled “The Aetiology, the Concept, and the Prophylaxis of Puerperal Fever”. It was a badly written book full of repetition and mistakes but it was one of the most moving books written by a doctor. It was truly a book of prophecy for Semmelweis was beginning to realise that the importance of his discovery went beyond the struggle against child bed fever. If the same principles were applied to the prevention of surgical sepsis which carried seven out of ten cases operated on into oblivion, the problem of surgical sepsis would also be solved. In spite of all this at the 36th Congress of German Scientist and physicians held in 1861 only one surgeon Prof. Lange of Heidelberg supported Semmelweis. Prof. Lange started after following Semmelweis teaching only one out of 300 cases that he had treated died of puerperal sepsis. But his was a voice in the wilderness. The arrogance, the narrow mindedness and bigotry of the acknowledged “Gods of Medicine” proved fatal to the progress of medicine. This has happened time and time again in the past and will of course happen in the future for man is what he is and will not change.
When his book made no impression on the scientific world something snapped in Semmelweis’s brain. There came from him a wild outcry that must go down in history as the protest of a great and brave soul who could not look on in silence while thousands continued to die. He started writing open letters to the leaders in his profession calling them murderers. It cut him off from his fellows who called him insane. They were not wrong for dementia of a sort had already set in. But none of them could see that their own blindness was the cause of this great man’s mental conditions. By 1864 it became obvious that Semmelweis was completely out of his mind. He would breakdown during his lectures and start weeping. He would stop young women in the streets and would beg them to make sure that doctors wash their hands in chlorinated water before they even touched them. He insisted that doctors were trying to murder his infant daughter. His wife in desperation wrote to his old friend and teacher Prof. Hibra asking for advice. He wrote back at once and asked her to bring him to Vienna without delay. The Professor spent a whole evening talking to him and ultimately realised that his brilliant pupil was beyond help. Not until Semmelweis was put into his cell did he realise that he was committed to an asylum. He became very violent and attendants forced him into a straight jacket. It was also said that he was badly beaten. A couple of days before he was incarcerated he had cut himself while doing a postmortem on a case of puerperal fever. He developed septicaemia and died on the 14th of August 1865. He was 47 years old. The autopsy revealed besides the changes of dementia in the brain all the classical signs of suppuration throughout his body, a picture that he had so often seen in the women that he had tried to save from a tragic and preventable death. The man who laid the foundation on which the outcome of all surgery depended died of the disease he had fought so hard to eradicate. A battle that he waged unrelentingly for 18years ended in his own destruction.
Future generations will ask, what manner of man was this Semmelweis who blazed a trail to ameliorate the sufferings of mankind? Was it fame he sought, and acceptance and recognition of his fellow men? Or was his a burning desire to get to the truth of a problem that baffled him and others in equal measure? Was it to him only an intellectual challenge, or was it an emotional one? Who will know it was perhaps an amalgam of many things. But this man was certainly not of the common herd. He had courage, Tenacity, and inhuman stamina and the ability to think beyond common logic. He had the ability to think what everybody thought, and the courage to do what nobody had done. He had what people call a touch of genius. I don’t think I have answered the question that I have put myself, as to what manner of man was this? None can deny that he was a man who sacrificed his life so that others might live. A man who made child births all surgical procedures safe for the generations to come. This was no ordinary man. He was certainly the flower of his age. A man to be remembered and honoured till the end of time. When Lord Lister was complemented for his work he said, “No! The laurels must be laid at Semmelweis’s feet for it was he who showed me the way.”

H.S. Adenwalla

Emeritus Professor of Surgery

Head of the Dept. of Plastic Surgery, Burns &

The Charles Pinto Centre for Cleft Lip, Palate

and Craniofacial Anomalies.

Jubilee Mission Medical College and Research Institute

Trichur-680005

To sum it up, I must quote George Bernard Shaw

‘The reasonable man adapts himself to the world as it is; the unreasonable man tries to change the world to what he wants it to be. Therefore, all progress depends on the unreasonable man.’

 

Dr. Rakesh Kalra

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