Thursday, March 19, 2020

Teaching an Old Dog New Tricks Will Endanger Your Career – The Ignaz Semmelweis Story.

by Melinda Pillsbury-Foster

The persistence of the avoidance of facts in medicine must include the experience of Ignaz Philipp Semmelweis, a Hungarian physician whose first job was in obstetrics as appointed assistant to Professor Johann Klein, work which was carried out at the First Obstetrical Clinic of the Vienna General Hospital beginning on July 1, 1846. 
Semmelweis’s duties included examining patients every morning in anticipation of Professor Klein’s rounds.  He also provided supervision for difficult deliveries and performed other tasks assigned to him. 
There were two maternity clinics at the hospital. 
The First Clinic had an average maternal mortality rate from puerperal fever of approximately 10%.  There were two maternity clinics at the Viennese hospital. The First Clinic had an average maternal mortality rate due to puerperal fever of about 10%. The mortality rate at the Second Clinic rate averaged less than 4%. This fact was known beyond the bounds of the hospital.  Poor women being admitted would routinely give birth on the street rather than face being admitted to the First Clinic. 
This surprised and intrigued Semmelweis and he began looking for an answer.  He was quoted as saying this,  “made me so miserable that life seemed worthless”. The two clinics used nearly the same techniques – so where was the difference to be found? 
The First Clinic was part of the training regimen for medical students; the Second was used for the instruction of only midwives. 
Semmelweis systematically eliminated possible causes for the difference in outcome.  First, he eliminated “overcrowding’; the Second Clinic always experienced a higher volume of patients. 
In 1847 a breakthrough occurred for Semmelweis arising from the death of an associate and friend, Jakob Kolletschka.  Kolletschka had accidentally poked by a student’s scalpel as the student was performing a postmortem exam.  The postmortem on Kolletschka revealing a pathology similar to those from women who had died of puerperal fever. 
Semmelweis realized this could be the variable he had been seeking, material from contaminating cadavers which carried puerperal fever.  Medical students had contact only with the First Clinic patients, not those from the Second Clinic with its much lower mortality rate.     
A policy mandating the use of chlorinated lime, known today as calcium hypochlorite, ordinary household chlorine bleach for the First Clinic.  He chose the solution because it was known to eliminate the putrid smell of infected tissue studied during autopsies.    
The mortality rate in the First Clinic dropped 90%, becoming comparable to that in the Second Clinic. “The mortality rate in April 1847 was 18.3%. After hand washing was instituted in mid-May, the rates in June were 2.2%, July 1.2%, August 1.9% and, for the first time since the introduction of anatomical orientation, the death rate was zero in two months of the year following this discovery”, according to Source
Cases of puerperal fever, which was a form of septicemia, could be reduced to near zero if doctors washed their hands in the formula Semmelweis had identified. However, this conflicted with the Theory of diseases which was accepted as fact by the existing medical and scientific opinions of his time.  Semmelweis’ ideas were rejected. 
Semmelweis continued his work in 1848, despite having his ideas and the protocols for eliminating the persistence of puerperal fever; he and documented the outcome, which went far toward eliminating incidences of the puerperal fever all together from the hospital wards.
Disagreements with conservative physicians, including his immediate superior, Professor Klein, resulted in Semmelweis leaving the hospital to return to his native Pest in 1851.
There, he took on oversight of Pest’s obstetric ward at the small St. Rochus Hospital.  Semmelweis virtually, again, eliminated incidents of puerperal fever.  From 1851 – 1855 only 8 patients died from childbed fever from 933 births. 
In his 1861 book, The Etiology, Concept and Prophylaxis of Childbed Fever, Semmelweis lamented the slow adoption of his ideas saying,  “Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. The medical literature for the last twelve years continues to swell with reports of puerperal epidemics, and in 1854 in Vienna, the birthplace of my theory, 400 maternity patients died from childbed fever. 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.”

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