Journal of The Association of Physicians of India Vol.

63 November 2015

71

Pioneers in Infectious Diseases

Pioneers in Infection Prevention - Part 1

Ayesha Sunavala1, Tanu Singhal2, Rajeev Soman3

physicianwho fails to enter the

body of a patient with the lamp
of knowledge and understanding
can never treat diseases. He
should first study all the factors,
including environment, which
influence a patients disease, and
then prescribe treatment. It is more
important to prevent the occurrence
of disease than to seek a cure.
These remarks may appear obvious
today, though they were made
over two thousand years ago by
the great physician Charaka in his
famous Ayurvedic treatise Charaka
Samhita. Centuries later, before the
germ theory was established, the
first modern-day preventionists
began advocating what we now
understand as infection control.

Oliver Wendell Holmes

(1809-1894)

Mans mind, once stretched by

a new idea, never gains its original
d i m e n s i o n s - O l i v e r We n d e l l
Holmes
O l i ve r We n dell H olm es was
an American physician, poet,
professor and lecturer at Harvard
U n i ve r s i t y . D i s m a ye d b y t h e
painful and repulsive aspects
of primitive medical treatment of
the timewhich included grisly

practices such asbloodlettingand

blistering which began in the dark
ages and lasted well into the 19 th
c en tury Holmes emphasized
close observation of the patient and
humane approaches.Amongst his
many laurels was Harvard Medical
S c h o o l s p r e s t i g i o u s B o yl s t o n
Prize, for which he submitted a
paper on the benefits of using
the stethoscope, a device with
which many American doctors
were not familiar at the time. In
1837, Holmes was appointed to
theBoston Dispensary, where he
was shocked by the poor hygienic
conditions. Based on his work
there, he published a paper, The
contagiousness of puerperal fever,
wherein he argued that the cause of
puerperal fever, a deadly infection
contracted by women during or
s h ort ly aft er childb irt h, st ems
from patient to patient contact via
their physicians. Holmes gathered
anecdotal evidence of doctors
who had become ill and died after
performing autopsies on patients
who had likewise been infected.In
concluding his case, he insisted that
a physician in whose practice even
one case of puerperal fever had
occurred, had a moral obligation
to purify his instruments, burn
the clothing he had worn while
assisting in the fatal delivery,
and cease obstetric practice for
a period of at least six months.
He was sharply criticised by his
colleagues for what they believed
were extremist views at the time.
In fact, an opponent of Holmess
theory regarding the contagious

nature of puerperal fever, wrote

that doctors are gentlemen, and
gentlemens hands are clean. His
then controversial work is now
considered a landmark in the
germ theory of disease. Looking
back its evident that Holmes
was far beyond his time. Soon
after his appointment as dean at
the Harvard Medical School, he
considered granting admission to
a woman. Facing opposition not
only from students but also from
university overseers and other
faculty members, she was asked to
withdraw her application.Harvard
Medical School would not admit
a woman until 1945. The same
ye a r , i n a n o t h e r c o n t r o ve r s i a l
move, he admitted two AfricanAmerican students who had been
previously rejected by four schools
despite impressive credentials. This
sparked a fierce debate amongst the
students and faculty and Holmes
was eventually forced to terminate
their admission. His exceptional
broadmindedness and thirst for
fresh ideas prob ab ly st emmed
from his interest in subjects other
than medicine. Its interesting to
know that Oliver Wendell Holmes
was equally renowned amongst
Bostons literary elite. He made an
indelible imprint on the literary
world of the 19th century. His
poems, humorous essays and books
won him many honorary degrees
from universities around the world.

1
Fellow in Infectious Diseases, 3Consultant Physician and Infectious Diseases Specialist, PD Hinduja National
Hospital and MRC; 2Consultant Paediatrics and Infectious Diseases, Kokilaben Dhirubhai Ambani Hospital and
Medical Research Institute, Mumbai, Maharashtra

72

Journal of The Association of Physicians of India Vol. 63 November 2015

Ignaz Philipp Semmelweis

(1818-1865)
Around the same time, in another
part of the world, a Hungarian
physician of German extraction was
struggling with his own discoveries
on puerperal fever. Ignaz Philipp
Semmelweis, now described
as the pioneer of antiseptic
policy, similarly observed
that theincidenceofpuerperal
fevercould be drastically reduced
by the use of hand disinfection
inobstetricclinics. Semmelweis
was appointed assistant professor
at the obstetrical clinic of
theVienna General Hospital in
1846. The Viennese hospital had two
maternity clinics. The first clinic
had an averagematernalmortality
rateof about 10% due to puerperal
fever, whereas the second had a
mortality rate less than 4%. The poor
reputation of the first clinic was
well known in the community and
women begged to be admitted to the
second clinic. Some women even
preferred to give birth in the streets
and strangely puerperal fever was
rare among women giving street
b i r t h s . S e m m e l we i s w o n d e r e d
what possibly protected those who
delivered on the streets from these
lethal endemic influences. Greatly
disturbed by the situation in the
first clinic, he undertook detailed
comparative studies between the
two clinics. The clinics used the
same obstetric techniques, they
were equally overcrowded and
the climate was the same. The
only difference being that the first
clinic was the teaching service for
medical students, while the second
clinic had been selected for the
instruction of midwives only. In

1847, while Semmelweis struggled

to comprehend the association, a
breakthrough occurred following
the death of a close colleague,
who had been accidentally injured
with a students scalpel while
performing an autopsy. His own
autopsy revealed pathology
similar to other women dying
from puerperal fever. Semmelweis
immediately proposed a connection
betweencadaveric contamination
and puerperal fever. He concluded
that the medical students carried
cadaverous particles on their
handsfrom the autopsy room
to the patients they examined in
the first obstetrical clinic thus
accounting for the higher mortality
rate in this clinic. He instituted a
policy of hand washing between
autopsy work and obstetrics, with
a solution of chlorinated lime
(calcium hypochlorite), which he
found worked best to remove the
putrid smell of infected autopsy
tissue. Miraculously, the mortality
rate in the First Clinic dropped
by 90%, and was then comparable
to that in the Second Clinic. The
mortality rate continued to decline
steadily and for the first time
ever, the death rate was zero in
two months in the year following
this discovery. Semmelweis
hypothesised that there was only
one cause, that all that mattered
was cleanliness. Despite various
publications of evidence based
results where hand-washing
reducedmortalityto below 1%,
his observations conflicted with the
established scientific and medical
opinions of the time and his ideas
were rejected and ridiculed by
the medical community. He was
dismissed from the hospital and
harassed by the medical community
in Vienna, being eventually forced
to move to Budapest. In Budapest,
he took up an unpaid, honorary
position as head-physician of
the obstetric ward of St. Rochus
Hospital. When he joined in 1851,
childbed fever was rampant at the
clinic. He found one fresh corpse,
another patient in severe agony,

and four others seriously ill with

t h e d i s e a s e . A f t e r t a k i n g o ve r
i n 1 8 5 1 , Se mme l we i s v i r t u a l l y
eliminated the disease. During
18511855, only eight patients died
from childbed fever out of 933 births
(0.85%). However, his medical
colleagues in Budapest continued
to believe that puerperal fever was
due to uncleanliness of the bowel.
Therefore, extensive purging was
the preferred treatment. Infact,
when Semmelweis successor
was appointed at the maternity
clinic, immediately, mortality rates
jumped sixfold to 6%, but there
were no inquiries and no protests.
Almost no one either in Vienna
or in Budapest had the humility
or the foresight to acknowledge
Semmelweis life and work. In 1865,
Semmelweis was committed to
anasylum, where he died a broken
and frustrated man. His practice
earned widespread acceptance only
years after his death, whenLouis
Pasteurconfirmed thegerm
theoryandJoseph Lister practiced
and operated, using hygienic
methods, with great success. The
so-called Semmelweis reflex,a
metaphor for a certain type of human
behaviour characterized by reflexlike rejection of new knowledge
because it contradicts entrenched
norms, beliefs or paradigms is
named after Semmelweis, whose
perfectly reasonable hand-washing
suggestions were ridiculed and
rejected by his contemporaries.
Sadly, even a century and a half
after his efforts, puerperal sepsis
still remains the second leading
cause of maternal mortality in
developing countries as per a 2008
WHO report.

References
1.

White, G. Edward. Oliver Wendell Holmes,

Jr.New York: Oxford University Press, 2006:
1920.ISBN 978-0-19-530536-4

2. http://en.wikipedia.org/wiki/Ignaz_
Semmelweis
3.

Mandell, Douglas, and Bennetts Principles

and Practice of Infectious Diseases, 8E
(2015).