Manuel Varela: Wash Your Hands!

Apr 18, 2017 by

An Interview with Manuel Varela: Wash Your Hands!

Michael F. Shaughnessy –

1) Professor Varela, I see it in almost every bathroom I go into. There is a sign “Have You Washed Your Hands Today?”. And obviously on every doctor show on T.V. we see those E.R. docs scrubbing their hands away. Let’s give credit where credit is due- Was it Ignaz Semmelweis in the 1850’s who started all this handwashing procedures?

Prof. Shaughnessy, you are absolutely correct. It was indeed Dr. Ignaz Philipp Semmelweis who began the early push aimed at invoking proper handwashing procedures. It was a practice that he had intended for medical students and their physician teachers. His efforts started the modern antisepsis and disinfection practices.

Today, there are periodic handwashing campaigns, encouraging people to wash their hands. In these campaigns, a variety of ways are used to encourage others to wash their hands, e.g., in bathrooms as depicted on the signs you’ve encountered. Handwashing prevents infectious disease transmission through populations.

2) Where exactly was Ignaz Semmelweis born and when? He sounds Swiss to me!

“Ignác Fülöp Semmelweis” was born on the first of July, 1818, in Budapest, Hungary. His German-speaking mother, Teresa Müller, was the daughter of a prosperous Bavarian manufacturer of horse-driven coaches, and Ignaz’s father, Joseph, was of German descent and wealthy vendor of spices and grocery goods. Their official citizenships were in the Kingdom of Hungary.

3) What were his early years like and where did he get his education?

The young Semmelweis spoke German and did not learn Hungarian until he attended secondary school, resulting in a distinctive dialect.  During this time, he apparently developed a strong dislike for writing. Together, his accent and disdain for writing would, in part, have profound ramifications for Semmelweis and his career later in life.

Semmelweis attended university in Vienna to study law in 1837, but became disinterested in the topic after having attended a life-changing lecture by Prof. Joseph Berres dealing with the subject of gross anatomy. Shortly afterwards, Semmelweis switched to the study of medicine, first at Vienna and briefly at the University of Pest, and then returning to Vienna to finish his doctorate in medicine in 1844.

4) Is it known whether his “handwashing” practices were the result of some science experiment, or observation or did he learn this from other older, wiser doctors?

In a word, Semmelweis based his handwashing policy on observation. As a newly minted doctor working in a maternity ward at the General Hospital in Vienna in 1846, Semmelweis became concerned with the high rate of mortality in women patients while giving birth. The primary cause of death was the so-called childbed fever, or puerperal fever, also known as puerperal sepsis. Semmelweis started collecting data in two distinct maternity clinics.  One of these clinics was run mainly by female midwives, and the other clinic was run primarily by male doctors and their students of medicine.  Semmelweis observed that the puerperal fever mortality rate in the doctor and medical student clinic was significantly high (between 10 and 30% mortality) compared to the midwifery clinic (only 1 to 3% mortality). The reason for this difference in the death rates was unknown at the time.

What was clearly known, however, was the stark difference in death rate between the two wards. The community certainly knew, and women who were in labor tried their best to avoid the doctor ward, often prolonging the wait to be admitted just so they could be sent to the midwives. Women who were admitted to the doctors’ section would be dismayed and rightfully frightened. Semmelweis himself recorded how women in labor and in the doctors’ ward would kneel down on the floor and beg the doctors to be discharged so they could be free to go to the midwives.

At first glance into the problem, Semmelweis noticed that in the clinic staffed by the midwives, the mothers giving birth did so while laying on their sides while in the doctor clinic, the mothers laid on their backs. So Dr. Semmelweis instructed the doctors to tell their patients to lay on their sides, too. Unfortunately, the mortality rates due to puerperal fever remained unchanged in the male doctor clinic—the mortality rates stayed high.

Next, Semmelweis turned to an observation he made regarding the doctor and medical student clinic; each time a patient died of the dread childbed fever, a priest would slowly and somberly walk through the maternity wards while a hand bell was rung, signifying that a death had occurred in the hospital. Semmelweis reasoned that this priestly behavior had so greatly terrified the mother patients that they literally took sick and were consequently prone to death by the puerperal fever. Thus, Semmelweis instructed the priests to stay clear of the ward during their walk-throughs and to lose the bell ringing while they were at it!

Unfortunately, this policy change had no effect on the puerperal fever death rates, either.

Then, an incident occurred which inspired Semmelweis to invoke a new notion to explain the high number of deaths in the doctors’ ward. The incident was the death of his good friend and colleague, Prof. Jakob Kolletschka, a medical doctor from the doctor ward. Like all of the doctors and medical students of the doctor clinic, Dr. Kolletschka had been routinely conducting autopsies on cadavers and had accidently cut his finger with a scalpel while working on a mother who had perished from the childbed fever. The doctor himself soon then got the childbed fever and shortly thereafter died from it.

While the concept had been known for some time as the so-called “miasma” or bad air, in which disease was due to something foul in the foul-smelling air, Semmelweis reasoned that the mortality rate difference between the wards may be due to “cadaver particles.” The doctors from the ward were also working on cadavers and may have unwittingly carried these cadaver particles to their women patients in labor, giving them the puerperal fever!

So, Semmelweis instructed his doctors and their medical students to start washing their hands in a bowl containing a bleach type of solution between autopsies and before their visits with maternity ward patients in the doctor ward. It was hoped that the handwashing practice would eliminate or reduce the cadaver particles from the doctors and medical students and thereby prevent transmission to the women patients. After invoking the handwashing practice, mortality rates of the childbed fever subsided within the doctors’ ward. It was a dramatic result.

5)  How long did it take before his practice caught on? And did he receive the recognition he deserves?

As a first approximation one might have reasonably concluded that doctor handwashing between patients, especially if backed up by the carefully gathered data of Semmelweis, would have immediately caused the practice to become widespread throughout all or most hospitals worldwide. Unfortunately, this was not the case at first, even surprisingly not the case in Semmelweis’s own hospital. From the very beginning certain events worked against Semmelweis to confound his efforts to implement a permanent policy of handwashing for the doctors and the medical students.

Initially, and by coincidence, a new ventilation system had just been installed in the hospital by his director, Dr. Johann Klein, during this same timeframe as the handwashing practice had begun, and the decreased mortality rate was mistakenly attributed to the better ventilation, rather than the handwashing.

Next, historians postulate that a combination of three seemingly disparate obstacles worked together further to confound Semmelweis at his hospital. The first obstacle was the refusal of the older generation to institute new practices, like handwashing, and the second obstacle was the hospital bureaucratic red-tape. The third obstacle, however, may have been Semmelweis, himself. It was reported that Semmelweis became brash, often lacking in tact when he disagreed with others, resulting in the emergence of new enemies, including his own director, Prof. Klein. The doctors and medical students eventually gave up the handwashing practice and Semmelweis was fired in 1849.  Perhaps feeling insulted by a less-than-adequate re-hire, Semmelweis left Vienna five days after starting the new post, without an explanation to anyone, even to his friends. The exact reason for his abrupt departure is still a mystery to this day.

Another important factor to consider is the fact that Semmelweis was not able to provide a definitive explanation why handwashing worked to curb the puerperal fever. This was not entirely his fault, however, as no one at the time yet knew about the germ theory of disease that microbes could cause infectious disease, a theory purported by the great Prof. Louis Pasteur in the 1850s and experimentally demonstrated by Prof. Robert Koch in the 1880s. Thus, Semmelweis did not know his handwashing practices simply washed away the sepsis-causing microbes from the hands of the doctors and medical students. His cadaver particles were bacteria, but no one knew then. Opponents of handwashing ridiculed the notion that tiny cadaver particles could be so powerful as to kill a much larger human being. His fellow doctors were further put out by the idea that they themselves could be the transmitters of the puerperal sepsis. They found that idea abhorrent; and it was more convenient to invoke the idea that the sepsis contagion was brought to their hospitals by the women patients from the community, rather than to the patients from the doctors and their cadavers.

Further, Semmelweis refused to publish his findings; you’ll recall his early disdain for writing. Additionally, he was periodically teased by his adult colleagues regarding his accent. It is speculated that Semmelweis was consequently insecure about his writing and professional work. Whatever the case may have been, he simply did not publish his handwashing ideas. This was a damaging final blow for any immediate and long-lasting implementation of handwashing by the doctors of Vienna.

After his dismissal and his abrupt departure, he took an unpaid post at the St. Rochus Hospital back in his native Hungary, in Budapest, where Semmelweis continued his handwashing practices, improving the survival rates for their patients. Unfortunately, his quarrelsome and unpleasant personality resurfaced there and again worked against him. Hence, he left that post to start a private practice and later took a new position as a professor at the University of Pest, in 1855.

Semmelweis would occasionally read criticism of his handwashing methods in the medical journals, prompting him to write to sympathetic and seemingly like-minded maternity doctors, hoping to win their public support and help to vindicate him, but to no avail. He was largely ignored.

Therefore, Semmelweis overcame his aversion to writing long enough to write and publish a book in 1861, discussing his arguments in favor of handwashing and hoping to be finally vindicated. His book, however, was longwinded, convoluted and difficult to understand. To make matters worse, he publically insulted critics of his book and ideas with name calling. Not surprisingly, therefore, even the publishing of his theory did not result in widespread adoption of handwashing by doctors or of their students.

Unfortunately, the handwashing practice did not become widespread in surgical wards until several years after the death Semmelweis, in the 1870s, after Prof. Louis Pasteur formulated his germ theory of disease and with Dr. Joseph Lister, who first instructed his surgical personnel to disinfect the surgical wards.

Sadly, the situation with Semmelweis’s personal life never managed to improve. His behavior in later years turned out to be increasingly short-tempered, unpredictable, and unpleasant. He became forgetful, occasionally not knowing where he was. His nervous breakdown complete, Semmelweis was committed to an insane asylum. While institutionalized he was reportedly mistreated and beaten so severely that he developed a chest infection as a result of the trauma he received from being beaten. He soon died at the age of 47 on August 13, 1865, from the sepsis—the very same disease he tried to wash away. Consequently, Semmelweis never received the recognition he deserved in his lifetime.

6) What were some of his other contributions or discoveries?

One of Semmelweis’s greatest contribution to science and medicine was his notion that simple handwashing by doctors using a bleach-containing solution in a bowl could not only prevent the onset of the dread puerperal sepsis, he actually came close to realizing the germ theory. He did correctly conclude that his cadaver particles, now known as bacteria, could be transmitted to others by contaminated hands.

It is speculated that had he used a microscope, he might have been able to show that his cadaver particles were in fact microbes, and he would have put a severe dent in the miasma theory (foul air) and in the doctors’ inaccurate use of contagion theory to argue that the disease was brought into the hospital by the women patients, themselves, from the community. But this did not happen for Semmelweis.

Semmelweis unwittingly made another contribution, the so-called ‘Semmelweis Reflex.’ The ‘Semmelweis Reflex’ is defined as the rapid and total rejection of novel ideas or practices, because they go against firmly established practices or beliefs, even in the face of supporting empirical data. This reflex phenomenon was named after Semmelweis by those who formulated it.

7) For the average citizen, it seems common sensical, but why should the average student in school, or worker in a fast food establishment or restaurant wash their hands?

Semmelweis’s work led to the later discovery that hands contaminated with disease-causing microbes are common and significant transmitters of infectious disease. This is because people frequently use their hands to touch many objects around them and other people. Objects that are contaminated by disease-causing microbes may be agents of transmission to others.

Another common mode of infectious disease transmission involves food or drink contaminated with pathogenic microbes. Often, these disease transmissions encompass the so-called “fecal-oral” route, in which the patient consumes fecal matter present in the food or drink.

Therefore, it is critically important that students in schools, in constant contact with many others, and food preparers, wash their hands in order to avoid microbial disease transmission and spread. In general it is important to wash your hands (warm water and soap for at least 20 seconds) before, during, and after preparing meals.

It is also important to wash hands (a) before consuming meals; (b) before and after providing healthcare to patients; (c) after using the bathroom or toilet; (d) after changing a diaper; (e) after handling waste, like garbage or feces; (f) after contact with animals or their feces; and (g) after coughing or sneezing into your hands, or blowing your nose. These practices help reduce the conditions that foster movement of pathogenic microbes through populations.

Alternatively, a common practice is to cough and sneeze into one’s sleeve on the inside of one’s elbow. This reduces hand contamination with pathogenic microbes.

On the “other hand,” as important as it is to wash hands for the reasons listed above, it’s also important to avoid getting carried away with it and acquiring the obsessive-compulsive behavior disorder of constantly and needlessly washing your hands throughout the day and night. The abnormally excessive handwashing may also damage the skin and cause the hands to become prone to cracking and bleeding. It may also wash away the healthy bacteria that reside on the skin (skin microbiome) which protects people from the rare pathogenic microbes.

8) What have I neglected to ask?

I think it’s interesting to note that necessary handwashing is currently not a practice that’s followed by the great majority of humans. Even healthcare workers are not washing hands between patients 100% of the time. In fact, in intensive care units of healthcare facilities handwashing was reported to range from only 26% to 50% of the time, with the latter higher figure resulting only if monitoring systems are present.

This is a serious issue because many of the truly dangerous bacterial superbugs, those with multidrug resistance and which are becoming increasingly difficult to treat effectively, are emerging from healthcare facilities and moving to neighboring communities. Some estimates state that, due to inadequate handwashing between patients, the morbidity rates number just over a million cases annually while the mortality numbers are in the hundreds of thousands per year. Healthcare facility acquired infections (HAI) have emerged as a serious public health concern on a worldwide scale. Lack of dedicated handwashing may be a primary cause of HAI; washing hands between patients is a fundamental solution. So the question that you have not neglected to ask about, thankfully, is “Have you washed your hands today?”

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