The Weekly Reflektion Week 02 / 2020

In last week’s Reflektion we talked about the criticism Florence Nightingale received from Dr. James Barry and how this criticism led to hygiene changes in the military hospital at Scutari in Istanbul and the many lives this saved. This week will use an example where the criticism was warranted but the way it was communicated led to changes not being made.

Are you good at giving advice? Do you consider the attitude and feelings of the people being criticised and the culture that they are working in?

Ignaz Semmelweis was born on 1 July 1818 in Tabán, neighbourhood of Buda, Hungary, today part of Budapest. Semmelweis began studying law at the University of Vienna in the autumn of 1837, but by the following year, he had switched to medicine. He was awarded his doctorate degree in medicine in 1844 and decided to specialize in obstetrics.

Semmelweis worked at a hospital in Vienna where there were two maternity clinics. The First Clinic was run by male doctors and had an average maternal mortality rate of about 10% due to puerperal fever (childbirth fever). The Second Clinic’s rate was run by midwifes and the puerperal fever rate was less than 4%, a fact known outside the hospital. The two clinics admitted on alternate days, but women begged to be admitted to the Second Clinic, due to the bad reputation of the First Clinic. Some women even preferred to give birth in the streets, pretending to have given sudden birth en route to the hospital (a practice known as street births), which meant they would still qualify for the child-care benefits without having been admitted to the clinic. Semmelweis was puzzled that puerperal fever was rare among women giving street births. What protected those who delivered outside the clinic from these that delivered in the clinics?

Semmelweis started a systematic process to find out why the rate of puerperal fever was lower in the Second Clinic and rare among woman that gave birth outside the clinics. He eventually concluded it must be due to the different people involved. The breakthrough for Semmelweis occurred in 1847, following the death of his good friend and mentor, Jakob Kolletschka, who had been accidentally cut with a student’s scalpel while performing a post-mortem examination. Kolletschka’s own autopsy showed a pathology similar to that of the women who were dying from puerperal fever. Semmelweis immediately saw a connection between contamination from the post-mortem examination and puerperal fever. The doctors that worked in the First Clinic, himself included, often engaged in autopsies before they delivered the babies. Semmelweis concluded that there was there was a transfer of “cadaverous particles” on their hands and medical instruments to the mothers. The midwifes’ that worked in the Second Clinic did not engage in autopsies.

Semmelweis introduced a policy of washing hands and instruments with a solution of chlorinated lime (calcium hypochlorite) 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 infected autopsy tissue, and thus perhaps destroyed the causal “poisonous” or contaminating “cadaveric” agent hypothetically being transmitted by this material. The mortality rate in the First Clinic dropped by 90%, and was then comparable to that in the Second Clinic. After hand washing was instigated in both clinics the death rate from puerperal fever dropped even further.

Semmelweis presented his hypothesis on the cause of puerperal fever in an arrogant and disrespectful manner. His proposal that hygiene and cleanliness would prevent puerperal fever was largely ignored, rejected, or ridiculed. Semmelweis was dismissed from the hospital for political reasons and harassed by the medical community in Vienna, being eventually forced to move to Budapest. Semmelweis was outraged by the indifference of the medical profession and began writing open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers. He has eventually committed to a mental institution and ironically died from an injected cut similar to his mentor Jakob Kolletschka and the many women that died of puerperal fever. Semmelweis’s practice earned widespread acceptance only after his death.

Discovering or realizing something that will lead to improvements but goes against conventional wisdom and the prevailing culture is a challenge. Resistance to change and protection of established ways of working is human nature and requires a combination of tact, humility and determination to make changes.