Dr Robert Wachter runs a blog which is well worth adding to your regular reading list. His Bio shows that he’s well qualified to talk about many things, and does so with a degree of candidness you don’t see in this country. A recent blog which interested me was the possibility of putting cameras into hospitals to try to raise the inadequate hand washing amongst staff. It would appear that since many nurses and doctors don’t appear to be motivated to wash their hands, some consider the answer is “Big Brother”. Anyone trained by the medical profession 170 years after hand washing debates started, who doesn’t think washing their hands is important needs their heads looking at.
The reluctance of the medical profession to wash their hands, is something which first became of interest to me, when analysing our family tree, which goes back to the 1500’s. In the 500 years, there was one period only, where mother and baby desecration stood out as being atypical, and that was the era of “puerperal fever”. The rest of the time, longevity was quite remarkable considering the living conditions in which my ancestors lived.
Puerperal Fever is not a topic many people know much about, which is good for medical historians, because they can continue telling people that, “The average age of survival in the early 1800’s was 26, where as now it’s 80-whatever.” The bit they don’t say is that for nearly 100 years, doctors decimated mothers and babies because they refused to wash their hands between cutting up dead bodies (cadavers), examining ill people, and sticking their hands into mothers to pull out babies and placentas. The other thing they never discuss was the very heated debate, and vicious attacks by the establishment, on anyone who suggested that doctors might be killing people left, right and centre.
In his blog, Dr Robert Wachter mentions an essay on this topic by Atul Gawande, a populist writer with a strong American readership. Dr Wachter likes Gawande’s essay. In my opinion Gawande’s essay is scattered in thinking, and limp at best. He infers that Semmelweis was the first to make the link, and was a lunatic, who did himself no favours by refusing to discuss the issues scientifically. Gawande appears not to know that way before Semmelweis, an American, Oliver Wendell Holmes, had lectured extensively and published papers discussing the evidence already accumulated. In all likelihood, Semmelweis could have heard about it from Holmes.
There are aspects of the Puerperal Fever debate, which could with equal validity, be applied to the “To-vaccinate-or-not” debate.
Here is my response which I put on Dr Wachter’s blog:
As a parent and having studied Oliver Wendell Holmes, as well as Semmelweis, the lack of hand washing even today, is something that has concerned me. Why does the medical profession have such a blasé attitude about hand washing? Perhaps they don't learn enough history?
So I, and my friends, have a solution. But it's not easy to do when parents are 'scared' of the medical profession.
I don't let anyone in a hospital or a doctor's practice, touch or examine my child until I've seen them wash their hands properly. I stop them and ask them to please wash their hands at the sink where I can see them do it. If they say they washed their hands in the previous room, I ask how many doors they have opened after they washed their hands ... did they put their hands in their pockets, blow their nose, shift their ties (ties should be banned in practices or hospitals) pick up files, or even swing around a door frame...
Usually they do it, but their body language is very grumpy. I know..., who likes being taken to task for the obvious? Their subsequent tone in conversation can make me feel that I am branded as a trouble maker. It shouldn't be necessary for a mother to say something because she wants to protect her child.
I didn't think much of Gawande's essay. It would have been far more hard-hitting had he quoted from some of Wendel Holmes papers about hand washing and puerperal fever. He was speaking out before Semmelweis. All he too wanted, was for doctors to be clean and wash their hands:
1843: The contagiousness of Puerperal Fever: "... which is no longer to be considered as a subject for trivial discussion, but to be acted upon with silent promtitude. It signifies nothing that wise and experienced practitioners have sometimes doubted the reality of the danger in question; no man has the right to doubt it any longer. No negative facts, no opposing opinions, be they what they may or whose they may, can form any answer to the series of cases now within the reach of all who choose to explore the records of medical science."
Gawande takes Semmelweis to task for refusing to put together his views in a "scientific" manner. The man didn't have to, because as Holmes said, the evidence was there to see in the records of medical science, for those who had the eyes to look. Why should he reinvent the wheel?
In Holmes's 1855 paper called "Puerperal Fever, A Private Pestilence", he was forced to make a very heated 24 page defence against all the experts arrayed against him. He named them all.
Holmes lost his temper saying on page 22, "I do not expect ever to return to this subject. There is a point of mental saturation beyond which argument cannot be forced without breeding impatient, if not harsh feelings, towards those who refuse to be convinced. If I have so far manifested neither, it is well to stop here, and leave the rest to those younger friends who may have more stomach for the dregs of a stale argument."
Semmelweis though, couldn't let go his anger. Why should that be held against him by Gawande?
On page 23 Holmes says. "If I have been hasty, presumptuous, ill-informed, illogical; if my array of facts means nothing; if there is no reason to any caution in view of these facts, let me be told so, on such authority that I must believe it, and I will be silent henceforth, recognizing that my mind is in a state of disorganization.... There is no quarrel here between men, but there is deadly incompatibility and exterminating warfare between doctrines..."
On the last page, he says, "If I am wrong, let me be put down by such a rebuke as no rash declaimer has received since there has been a public opinion in the medical profession of America; if I am right, let doctrines which lead to professional homicide be no longer taught from the chairs of these two great Institutions. Indifference will not do here."
The final paragraph is very powerful. He had such a heart for the mothers, babies and especially the fathers left without wives who he mentions many times. He points out that they should look to it, and sort it out, because if the facts, "shall reach the public ear; the pestilence-carrier of the lying-in-chamber must look to God for pardon, for man will never forgive him."
True to his word, he never wrote on the subject again, for it infuriated him, as much as it infuriated Semmelweis.
Perhaps the refusal of his colleagues to listen to the obvious, might be one reason why Holmes went on to write poetry and novels, like "Elsie Venner" (1858) and "The Guardian Angel" (1867)"A Mortal Antipathy"(1885). It was something to keep him sane, while his colleagues swanned on with the arrogance of ignorance, and puerperal fever continued in most of the USA.
I can only wonder, if the world is around in 2044, whether there will still be discussions about the abysmal rates of hand washing.
I am not a fan of the non-soap alternatives, which apparently are useless against Clostridium Difficile, another hospital nightmare.
There are forms of soap which get off the bacteria and don't trash the skin. Perhaps the problem is, they are expensive, because of the high percentages of oils in them, to stop that happening.
Hand washing, as well as the general standard of cleanliness in hospitals, is just as much an issue today, as it was in 1844, or even 1944. It's an area that can never be let up upon. But watching staff in hospitals, it's easy to see why familiarity results in contempt and laziness, only to be reigned in, when another patient dies, to the embarrassment of the hospital.
Video surveillance shouldn't be necessary.
Medical training should ensure that for nurses and doctors, hand washing should come as automatically as breathing.
I would so love to not have to be vigilant about this very simple, but very important issue.