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August 1865

From the August ACP Hospitalist, copyright © 2011 by the American College of Physicians

By James S. Newman, FACP

This month I am drawn to an important transition in medicine that occurred nearly 250 years ago. The story is one of two men whose lives helped shape the history of the fight against infection. One was a tragic hero who died in ignominy, unable to convince the world of his findings. The other also faced disbelief but overcame his doubters, and was hailed the world over as a medical hero.

It was Vienna, 1845. A post-term woman trudged up to the gates of the great medical jewel of the Hapsburg Empire, the Allgemeines Krankenhaus der Stadt Wien, where such medical giants as Virchow, Skoda and Rokitansky practiced. She fell into the arms of the waiting nurses, who helped her inside. At a desk sat a registrar, who assigned her to the first division, the one run by doctors and students. She tried to object—word was this was a dangerous ward—but she was too weak to argue, and it would have made no difference. By the next day she was a proud but exhausted mother. Two days later, she was being autopsied, just like 25% of her fellow patients on that ward.

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James S. Newman, FACP.

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With a zeal characteristic of the medical personnel at this institution, autopsy after autopsy was performed looking for the source of the high mortality rates. This was a medical era when clinicopathologic medicine was coming into fruition, relating clinical symptoms to autopsy findings. After performing autopsies, and a few hours practicing difficult deliveries on the bodies of the deceased mothers, the medical teams would head back to the wards. With unwashed hands dried on crusted lapels, the healers would examine their next patients.

In 1865, 11-year-old James Greenlees suffered an open fracture of his tibia in Glasgow after a horse cart ran over his leg. Normally he might have faced amputation, then a risky business. In London, the urban-hospital mortality from this operation was as high as 40%. A few years later, most of the French soldiers who needed amputations during the Franco-Prussian War—about 10,000 of 13,000—perished from infection, some after just a simple finger amputation.

But James Greenlees was lucky. Instead of amputating, and once the fracture was reduced, his surgeon at the Glasgow Royal Infirmary wrapped lint bandages soaked in carbolic acid around the wound, and changed them every few days. Six weeks later, James Greenlees was walking. Over the weeks to come, 10 more patients would be treated in a similar manner, and eight would recover without problems. It was the birth of antiseptic surgery, in the hands of surgeon Joseph Lister.

Around the same time, Ignaz Semmelweis, a Hungarian physician trained in Vienna, went to work on the obstetric ward of the Allgemeines Krankenhaus. He was appalled by the high death rate, and suspected it might be even higher, as patients who were ill were often transferred to the medical ward before their death. Was it a miasma? Was it seasonal? Was it caused by clogged milk ducts? After all, the material found in the peritoneal cavity of many patients at autopsy looked suspiciously like spoiled milk.

Semmelweis concluded, in that pre-germ theory era, that something from the cadavers was killing the young mothers. The death of his mentor Kolletschka after a cut from a dirty knife used during an autopsy was the epiphanic last straw. If physicians and students washed the cadaver particles from their hands using chlorinated lime solution, the deaths would stop, Semmelweis hypothesized. He tried to prove his point, but could not convince his colleagues. Frustrated, he died on Aug. 11, 1865—one day before a young boy would have his open fracture set in Glasgow, and walk the next month.

It was the end of an era, and the beginning of another, safer one.

James S. Newman is a hospitalist at the Mayo Clinic in Rochester, Minn. and editorial advisor to ACP Hospitalist.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated