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Journal of The Association of Physicians of IndiaVol. 63November 2015 71

Pioneers in Infection Prevention - Part 1

Ayesha Sunavala1, Tanu Singhal2, Rajeev Soman3

1Fellow 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

P I O N E E R S I N I N F E C T I O U S D I S E A S E S

A physicianwho fails to enter thebody of a patient with the lampof knowledge and understanding

c a n n ever t rea t diseases . Heshould first study all the factors,including environment, whichinfluence a patients disease, andthen prescribe treatment. It is more

important to prevent the occurrenceof disease than to seek a cure.These remarks may appear obvioustoday, though they were madeover two thousand years ago by

the great physician Charaka in hisfamous Ayurvedic treatise CharakaSamhita. Centuries later, before thegerm theory was established, thefirst modern-day preventionists

bega n advo cati ng what we nowunderstand as infection control.

Oliver Wendell Holmes

(1809-1894)

nature of puerperal fever, wrotethat doctors are gentlemen, and

gentlemens hands are clean. Histhen controversial work is nowconsidered a landmark in thegerm theory of disease. Looking

back i t s evident that Holmes

was far beyond his time. Soonafter his appointment as dean atthe Harvard Medical School, heconsidered granting admission toa woman. Facing opposition not

only from students but also fromuniversity overseers and otherfaculty members, she was asked towithdraw her application. HarvardMedical School would not admit

a woman until 1945. The sameyear, in another controversialmove, he admitted two African-American students who had been

previously rejected by four schools

despite impressive credentials. Thissparked a fierce debate amongst thestudents and faculty and Holmeswas eventually forced to terminate

their admission. His exceptionalbroa dmin dedness and th ir st fo rfresh ideas probably stemmedfrom his interest in subjects otherthan medicine. Its interesting to

know that Oliver Wendell Holmeswas equally renowned amongstBostons literary elite. He made anindelible imprint on the literary

world of the 19th century. Hispoems, humorous essays and bookswon him many honorary degreesfrom universities around the world.

practices such as bloodletting andblistering which began in the darkages and lasted well into the 19 thcentury Holmes emphasizedclose observation of the patient andhumane approaches. Amongst hismany laurels was Harvard Medical

Schools prestigious BoylstonPrize, for which he submitted apaper on the benefits of usingthe stethoscope, a device withwhich many American doctors

were not familiar at the time. In1837, Holmes was appointed tothe Boston Dispensary, where hewas shocked by the poor hygienic

conditions. Based on his workthere, he published a paper, Thecontagiousness of puerperal fever,wherein he argued that the cause ofpuerperal fever, a deadly infection

contracted by women during or

shortly after childbirth, stemsfrom patient to patient contact viatheir physicians. Holmes gathered

anecdotal evidence of doctorswho had become ill and died afterperforming autopsies on patientswho had likewise been infected. Inconcluding his case, he insisted that

a physician in whose practice evenone case of puerperal fever hadoccurred, had a moral obligationto purify his instruments, burnthe clothing he had worn while

assisting in the fatal delivery,and cease obstetric practice fora period of at least six months.He was sharply criticised by hiscolleagues for what they believed

were extremist views at the time.In fact, an opponent of Holmesstheory regarding the contagious

Mans mind, once stretched by

a new idea, never gains its or iginaldimensions- Ol iver Wendel lHolmes

Oliver Wendell Holmes wasan American physician, poet,professor and lecturer at HarvardUniversity. Dismayed by thepainful and repulsive aspects

of primitive medical treatment of

the timewhich included grisly

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Journal of The Association of Physicians of IndiaVol. 63November 201572

Ignaz Philipp Semmelweis

(1818-1865)

Around the same time, in anotherpart of the world, a Hungarianphysician of German extraction was

struggling with his own discoverieson puerperal fever. Ignaz PhilippSemmel w ei s , n o w d esc r i b edas the pioneer of ant isept icp o l i c y , s i m i l a r l y o b s e r v e d

that the incidence of puerperalfever could be drastically reduced

by th e us e of ha nd di si nf ec tio nin obstetric clinics. Semmelweiswas appointed assistant professor

a t t h e o b s t e t r i c a l c l i n i c o fthe Vienna General Hospital in

1846. The Viennese hospital had twomaternity clinics. The first clinichad an average maternal mortality

rate of about 10% due to puerperalfever, whereas the second had amortality rate less than 4%. The poorreputation of the first clinic waswell known in the community and

women begged to be admitted to thesecond clinic. Some women evenpreferred to give birth in the streetsand strangely puerperal fever wasrare among women giving street

births . Semmelwe is wonderedwhat possibly protected those whodelivered on the streets from theselethal endemic influences. Greatly

disturbed by the situation in thefirst clinic, he undertook detailedcomparative studies between thetwo clinics. The clinics used thesame obstetric techniques, they

were equally overcrowded andthe climate was the same. Theonly difference being that the firstclinic was the teaching service for

medical students, while the secondclinic had been selected for theinstruction of midwives only. In

1847, while Semmelweis struggled

to comprehend the association, abreakthrough occurred followingthe death of a close colleague,who had been accidentally injuredwith a students scalpel while

performing an autopsy. His owna uto p sy revea l ed p a th o l o g ysimilar to other women dyingfrom puerperal fever. Semmelweisimmediately proposed a connection

between cadaveric contaminationand puerperal fever. He concludedthat the medical students carriedcadaverous particles on theirhands from the autopsy room

to the patients they examined inthe first obstetrical clinic thusaccounting for the higher mortality

rate in this clinic. He instituted apolicy of hand washing between

autopsy work and obstetrics, witha solution of chlorinated l ime(calcium hypochlorite), which hefound worked best to remove the

putrid smell of infected autopsytissue. Miraculously, the mortalityrate in the First Clinic dropped

by 90%, and was then comparableto that in the Second Clinic. The

mortality rate continued to decline

steadily and for the first timeever, the death rate was zero intwo months in the year followingth i s d i sc o very . Semmel w ei s

hypothesised that there was onlyone cause, that all that matteredwas cleanliness. Despite variouspublications of evidence basedresu l t s w h ere h a n d - w a sh i n g

reduced mortality to below 1%,his observations conflicted with theestablished scientific and medicalopinions of the time and his ideas

were rejected and ridiculed bythe medical community. He wasdismissed from the hospital andharassed by the medical communityin Vienna, being eventually forcedto move to Budapest. In Budapest,

he took up an unpaid, honoraryposition as head-physician ofthe obstetric ward of St. RochusHospital. 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 withthe disease. After taking overin 1851, Semmelweis virtuallyeliminated the disease. During

18511855, only eight patients diedfrom childbed fever out of 933 births

(0.85%). However, his medicalcolleagues in Budapest continuedto believe that puerperal fever was

due to uncleanliness of the bowel.Therefore, extensive purging wasthe preferred treatment. Infact,when Semmelweis successor

was appointed at the maternityclinic, immediately, mortality rates

jumped si xfold to 6%, but therewere no inquiries and no protests.Almost no one either in Vienna

or in Budapest had the humility

or the foresight to acknowledgeSemmelweis life and work. In 1865,Semmelweis was committed toan asylum, where he died a broken

and frustrated man. His practiceearned widespread acceptance onlyyears after his death, when LouisPa s teur c o n f i rm ed th e g ermtheory and Joseph Lister practiced

and operated, using hygienicmethods, with great success. Theso-called Semmelweis reflex, a

metaphor for a certain type of humanbehaviour character ized by reflex-

like rejection of new knowledgebecause it contradicts entrenchednorms, beliefs or paradigms isnamed after Semmelweis, whoseperfectly reasonable hand-washing

suggestions were ridiculed andrejected by his contemporaries.Sadly, even a century and a halfafter his efforts, puerperal sepsisstill remains the second leading

cause of maternal mortality in

developing countries as per a 2008WHO 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).