The first person in the world to propose "doctors should wash their hands" was brutally beaten before his death

Microbiology is an important foundation of modern medicine. Nowadays, even primary school students probably know that "not paying attention to hygiene may lead to bacterial infection." The concept of hygiene is so deeply rooted in people's minds that we can hardly imagine how we should deal with or explain our relationship with the world and diseases before the theory of microbiology. What you can't imagine is that more than 150 years ago, doctors dissected corpses in one second and then performed other operations in the next second without changing clothes or washing hands for disinfection. Today is World Handwashing Day. The story that Science Popularization China wants to tell happened in an era when people didn't know what microorganisms were.

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The old saying that giving birth is like stepping into the gates of hell is not an exaggeration. For a long time, human childbirth has been full of risks for both mother and baby. In addition to the fact that the large human head makes childbirth much more difficult than other primate relatives, even after successful childbirth, many mothers soon develop a fever and then die. The medical community named this fatal fever puerperal fever. Until the 19th century, the mortality rate of mothers in the First Obstetric Clinic of Vienna General Hospital, the largest obstetric clinic in the world at that time, was as high as 30%.

Today, my country's maternal mortality rate is 18.3 per 100,000 live births, which is almost the same as that of the most developed countries. According to the Outline for the Development of Chinese Women (2021-2030), our goal in the next few years is to reduce this figure to below 12 per 100,000.

The transition from pregnant women on the brink of death to relative safety is not only due to the great progress in medical technology, but also to the prosperity of the country. But first we have to start with the story of hand washing.

In 1846, 28-year-old Ignaz Philipp Semmelweis became the assistant director of the first obstetric clinic at the Vienna General Hospital. At that time, pathological anatomy was very popular, and Semmelweis admired Jacob Kolletschka, who was engaged in forensic pathology, and almost became his assistant. However, what neither of them expected was that Kolletschka eventually guided Semmelweis' research in a very special way.

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Ignaz Semmelweis, source: wikipedia

In the process of studying puerperal fever, Semmelweis found that the number of deaths of mothers in the first ward where he worked was 10 times that of the second ward, while the number of babies born each year in the two wards was roughly the same. Why was there such a big difference? During the period when puerperal fever was prevalent in the hospital, there were very few deaths among mothers who gave birth at home in Vienna, or even on the streets. Why was that?

At that time, the medical community explained puerperal fever as the influence of epidemic miasma or comets. If these conjectures were valid, then the above distinction should not have occurred. Semmelweis fell into deep thought over this.

Just when Semmelweis was at a loss for ideas, a tragedy suddenly struck. Korechika, an authority in forensic pathology, accidentally cut himself while dissecting a corpse, which caused the wound to become infected and he soon died.

‍‍‍‍The unexpected death of Korechika made Semmelweis heartbroken, but this pain brought Semmelweis, who was thinking in the dark, a flash of inspiration. He suddenly realized that the cause of puerperal fever was most likely the same as the cause of death of his friend, because the pathological changes of the two were extremely similar. If the cause of death of his friend was contamination by some substance in the corpse, then the cause of puerperal fever may also be this!

He believed that the culprit for killing mothers in labor was the hands of medical school teachers and students: after touching the abscesses on corpses in anatomy classes, they went directly to check the birth canals of pregnant women, and the pathogenic substances from the corpses entered the bodies of the mothers in labor through the doctors' hands.

This perfectly explains logically why there is such a big difference in the mortality rate between the two obstetric clinics and why not many women outside the hospital die from puerperal fever. This is because the first ward is run by doctors who frequently perform autopsies, while the second ward is run by midwives who do not perform autopsies. Births outside the hospital lack the help of professionals, and there are no risk factors caused by autopsies.

Because there was no concept of microorganisms at the time, Semmelweis did not know what those "pathogenic substances" were, but he intuitively designed a thorough hand-washing procedure and conducted experiments - he required doctors to clean their hands with soap, water and a nail brush, and then soak them in chlorine water until their hands no longer smelled of a corpse. Doctors had to follow this process before contacting each patient.

In 1848, after adopting this method, the maternal mortality rate in the first ward of the clinic dropped significantly to 1% within one month.

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Image source: unsplash.com Photographer: AlexHockett

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Obviously, strict hand washing works, but it also brings up a very embarrassing question for the medical community. Doesn't this mean that before the implementation of hand washing measures, the more autopsies a doctor performed, the more likely he was to cause maternal death?

But the original purpose of doctors performing autopsies was to understand the cause of the disease so as to better understand the disease and treat it more efficiently. But now the original intention of saving lives has led to the result of harming people. How can people accept this?

“God alone knows how many young women I have killed, for I have performed more autopsies than any other obstetrician,” Semmelweis once wrote to a colleague.

Perhaps because he felt that he had committed a serious sin, Semmelweis was eager to promote his hand-washing theory in the hope of reducing the number of innocent deaths among pregnant women. He wrote to some important doctors at the time, hoping that they would adopt the advice of strict hand-washing.

Unfortunately, this theory encountered great resistance during its dissemination process, because if doctors accepted the hand-washing theory, it would be tantamount to admitting that they had killed many women in labor with their own hands. In comparison, it would make everyone feel more comfortable to attribute the cause of puerperal fever to miasma and comets.

In the confrontation with many opponents, Semmelweis became more and more sad and angry. He once said fiercely in a letter to his opponents:

Your teaching is based on the corpses of women who died because of your indifference. I have clearly recorded the fatal mistakes you made in puerperal fever. If you still continue to educate your students in this way, I will accuse you as a murderer before God.

Semmelweis, who fought almost alone, promoted the life-saving hand-washing measures only in a very limited time and area. After experiencing several ups and downs in his life, frustrations and resentment, he passed away in a mental hospital on August 13, 1865.

Bizarrely, some evidence, including his autopsy report, showed that he had even been brutally beaten before his death. Until his death, he did not see his theory widely accepted by the medical community.

Semmelweis is undoubtedly a tragic figure in the history of medicine, and today his name is known to many people along with puerperal fever, but except for very few cases, medical progress is rarely driven by the sudden inspiration of a genius.

What is rarely mentioned is that decades before Semmelweis was born, some doctors had already suggested that puerperal fever might be transmitted by doctors.

In 1773, Charles Whit, a Manchester surgeon and obstetrician, published "The Management of Expectant Women and Maternity", pointing out that cleanliness and isolation can prevent the spread of puerperal fever and emphasizing the importance of ventilation of delivery rooms and isolation of maternity.

In 1795, Aberdeen obstetrician Alexander Gordon clearly pointed out that puerperal fever was spread by obstetricians and midwives, and according to Oliver Wendell Holmes, Gordon's writings were clear and his experience was full of the uniqueness of the man and his selfless integrity.

Gordon cited 77 cases, many of which showed obvious modes of transmission, and concluded by saying: "This is a question I am reluctant to mention. I am the one who brought the infection to many women."

Similarly, a doctor named Armstrong said: I have plenty of evidence to prove that this disease is often transmitted in this way. It pains me to say frankly that many cases of infection were caused by me.

Gustav Adolph Michaelis, a German professor of obstetrics, even realized that women who died of puerperal fever were actually killed by themselves, especially his niece who also died of puerperal fever. He was so overwhelmed with guilt that he committed suicide by lying on the railway tracks.

Image source: unsplash.com Photographer: AlexHockett

In 1843, Holmes published "The Contagiousness of Puerperal Fever". As a doctor who is remembered by Americans mainly as a writer, this book is Holmes' only work in the field of medicine. He cited sufficient evidence to prove that puerperal fever is contagious and is often carried from one patient to another by doctors and nurses.

He believed that doctors had a duty to take all precautions, to make proper investigations of nurses or assistants and to promptly warn of possible sources of danger, that doctors' arbitrary behavior and ignorance had caused many misfortunes, and that these misfortunes should be considered crimes, and that a doctor's most important obligations to society should outweigh his professional duties.

It is not difficult to see from Holmes's remarks that his criticism of mainstream medicine is no less fierce than Semmelweis's, and therefore it is bound to cause fierce backlash from the American medical community. Two obstetrics professors in Philadelphia, Meigs and Hodge, expressed ridicule and sarcasm to Holmes, and there were countless people who followed suit.

Faced with the counterattack from his peers, Holmes did not fight to the end, but chose to keep silent. He knew that this was not a battle that he could end alone. So he gave up this idea, stopped being an enemy of the traditional medical community, and lived a comfortable life. It can be said that he who knows the times is a hero.

Condorcet wrote in Outlines of the History of the Progress of the Human Mind: "According to the general law of the development of our powers, every epoch of our progress is bound to produce certain prejudices, but they extend far beyond their allure or their sphere, because men retain the prejudices of their childhood, of their country and of their age, long after they have learned all the truths necessary to overthrow them. Such are the enemies with which reason has to fight, and often only after a long and hard struggle can it triumph."

The tragedy of Semmelweis is that he put forward the correct theory in the wrong era, and his power was not enough to rewrite history.

The honor of rewriting history belongs to two other people. Shortly after his death, Pasteur and Koch, two of the most dazzling stars in modern medicine, established microbiology and rewrote the course of medical history.

Based on this theory, British surgeon Lister created surgical asepsis, which greatly reduced the incidence of surgical infections.

On August 12, 1865, Lister treated an 11-year-old child with an open fracture with antibacterial methods and successfully avoided amputation. This day was the day after Semmelweis died in a mental hospital.

It was not until then that the medical community woke up from their dream and realized that Semmelweis's insistence was correct. Many obstetricians who had originally strongly opposed the hand washing method also began to actively adopt disinfection methods to prevent the occurrence of puerperal fever.

Nowadays, it has become a medical routine for surgeons before surgery or midwives before delivery to wash their hands carefully. But who would have thought that such a seemingly ordinary action as washing hands has such an unusual origin?

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In 1906, the Hungarian government erected a statue for the tragic prophet in a square in Budapest. On the base of the statue was a woman holding a baby in her arms, looking up at the savior of mothers all over the world.

Image source: wikipedia

At the beginning of the 20th century, due to the traditional custom of home birth that had lasted for thousands of years in old China, obstetrics in my country was still in a relatively backward state. According to the Journal of the Chinese Medical Association, around 1900, midwives in Guangdong and Fujian were women with no medical knowledge, and often died of maternal exhaustion, dystocia, prolonged labor, or uterine rupture.

Even if a doctor is called home, it is usually a few days after the difficult labor. However, before that, most women have already undergone many manual operations by the midwife. Therefore, even if these women are lucky enough to have the doctor solve the difficult labor, they may still die from infection after delivery.

After the founding of New China, the country has been vigorously promoting the new method of delivery. Midwives cut nails, wash and disinfect their hands, and obstetric equipment is washed and disinfected and the operation is performed according to regulations. These measures, which seem to us to be natural now, were less than 2% in rural my country in the 1950s. It was not until the 1980s that the new method of delivery stabilized at more than 99%.

In other words, it took China nearly 30 years to popularize this not-so-complicated concept. It seems that people all over the world are the same in terms of stubbornness.

If it were not for the efforts of these obstetric pioneers and the vast number of grassroots midwives, perhaps some of the readers of this article would have become orphans at birth, or would have died of "umbilical cord wind" (tetanus) soon after birth, and would not have had the opportunity to read this article.

In Beijing Wan'an Cemetery, there is a tombstone with the following words written on the back: "Her achievements will last as long as the sun and the moon."

Dr. Yang Chongrui, the founder of my country's maternal and child health care, rests here. Dr. Yang Chongrui's greatest contribution to my country's maternal and child health care was to train a large number of midwives and teach folk midwives new methods of delivery.

Although this undertaking was not as difficult as the resistance that Semmelweis encountered when he advocated hand washing to prevent puerperal fever, it was still very difficult. Because changing customs and breaking the old to establish the new has never been easy, Yang Chongrui's undertaking was actually a fight against the ignorance and stupidity that had accumulated over thousands of years.

Yang Chongrui is undoubtedly the great successor of the midwifery career pioneered by Semmelweis, but in terms of struggle or doing things, Yang has shown more outstanding wisdom and tenacity. Her work ideas have not only benefited thousands of Chinese women and children, but also influenced the world.

As early as February 1932, the health commissioner of the League of Nations sent people to China to visit the National First Midwifery School founded by Yang Chongrui. Until the 1990s, Mexico introduced a national training system (training midwives), which was founded by Dr. Yang. The delivery kit for delivery was also created by Yang Chongrui in his early years, and it has not changed much to this day. UNICEF has provided thousands of such delivery kits, and these delivery kits are still a hot spot on the order list at the Copenhagen Children's Fund Supply Center.

Semmelweis was a tragic hero. When the medical community was stuck in the dilemma of puerperal fever and was helpless, he became the first person with the wisdom and courage to break through the suffering. He brought the flower of hope to the desperate women in labor at that time.

A journey of a hundred miles begins with a single step. It is a pity that Semmelweis did not live to see his theory being widely accepted, but every era needs troublemakers, young people who are incompatible with conservatives or vested interests and who are willing to confront them head-on.

Genius is valuable, but it is rare. If Pasteur, List, Koch and others are geniuses who ultimately promoted the progress of the times, then White, Gordon, Holmes, Semmelweis and others who failed to completely change the direction of the tide are the troublemakers who fulfilled their responsibilities of the times and stirred up a ripple in the stagnant water.

The poet said that wherever dark clouds gather, there will be lightning breaking through. Semmelweis was the lightning that split the haze. Although his life passed by in a hurry, he once broke through the sky with dazzling brilliance.

Philosophers believe that no one can cross the same river twice, but in the long river of fate of all living beings, Semmelweis was able to survive twice because he was recognized by the world again. Although his first survival in the European medical community had only a tragic ending of being destroyed by his peers, Semmelweis, who had briefly conquered puerperal fever, would eventually win immortality in his second life.

Author: Li Qingchen, deputy chief physician of thoracic surgery, Harbin Children's Hospital

Review丨Sun Yifei Director of the Medical Education History Research Office of Hebei Medical University