First Do No Harm

You catch more flies with honey than vinegar.

Here is a tragic discovery story about one of our most important medical practices. As a practice, it stops the transmission of infection. It is the practice of washing hands.

Ignaz Semmelweis Ignaz Philipp Semmelweis1 was a Hungarian Obstetrician who made a major contribution to medicine in 1847. As an Obstetrician, Dr. Semmelweis would often find himself in front of women who were having troubles during childbirth; mostly because their babies were not positioned properly.

The optimal birthing position for a preborn baby is to be facing its mother's back, with its head down. This allows the tiny part of the head to lead the way through the mother's birthing canal.

Proper Baby Position Before Birth Every once in a while, a pre-born baby is positioned incorrectly in their mother's womb. An obstetrician can detect this and mechanically adjust the baby to make it easier for the birth to take place. To be effective, an obstetrician needs to feel the belly and reach into a woman's vagina to feel how the baby is positioned.

Dr. Semmelweis's great discovery was that a doctor should not touch a woman's uterus, her vagina or her baby right after handling corpses. Make no mistake 2, this was a major advancement in medicine. Where else could you drop the death rate so much with such a simple and inexpensive practice in 1847?

He made the discovery while holding the assistant professor position at the First Obstetrical Clinic of the Vienna General hospital. His duties in this role had him supervise difficult deliveries, teach young obstetricians and maintain the documents for the department.

The Hospital had two clinics for maternity practices, the first to train the male obstetricians and the second to train female midwives.

At the time these types of maternity institutions had been set up all over Europe to address the problems of illegitimate babies being abandoned by their mothers. Expecting mothers could access them free of charge if they agreed to participate in the training of young staff, by giving birth in the hospital. What made it even more appealing was that the newly born infants would be taken care of by the hospital, then dispatched to orphanages, freeing illegitimate mothers of their responsibility.

This policy was set up to attract underprivileged women and prostitutes, and it worked, but not the way that the administration expected it to work. It was known outside of the hospital that going to clinic 1, run by the male obstetricians, was very dangerous. Women had a 1 in 10 chance of dying if they chose to give birth in this clinic. Clinic 2, which was run by the midwives, was 5 times safer than clinic 1.

The condition that was killing the young mothers in clinic 1, was called puerperal fever. It is caused by a bacterial infection of the uterus following childbirth. In 1847 the "germ theory of disease" had not been discovered yet. So, they didn't really know what caused puerperal fever at the time.

Strptococcus Pyogenes -- puerperal fever

Dr. Semmelweis was puzzled by how women who had "street births" didn't seem to die of puerperal fever. Many of the women who had been condemned to his clinic, chose instead to give birth outside of the hospital. They were reneging on their part of the deal, but to get around this they claimed that the birth happened en route; on the street. This way they could avoid being killed by their doctors and still get access to the free child care provided by clinic 1.

Another piece of the puzzle fell into place following another tragedy. Dr. Semmelweis's friend and colleague died when a medical student accidentally poked him with an instrument following a post mortem examination. When this man's corpse was examined it seemed he died of something very much like a puerperal fever.

So, Dr. Semmelweis linked corpses with puerperal fever. In an attempt to disprove his theory he asked all of this students to wash their hands with a solution of chlorinated lime before examining patients. There was a dramatic result. Clinic 1 ended up as safe as clinic 2.

It was not lost on Dr. Semmelweis that his clinic 1 had been killing more women than it had been helping. He had been breaking a fundamental oath in medicine; first do no harm.

Hippocrates When he wrote about his time prior to his discovery he said it, "made me feel so miserable that life seemed worthless". It was his assumption that other doctors would feel the same about such irresponsible death rates. He was wrong.

At the time medical theory didn't have room for this practice. They thought that disease was a very personal thing and that there couldn't be a possible connection between washing hands and puerperal fever. Dr. Semmelweis understood that his practice was saving lives, but he marketed cleanliness as the ONE thing that mattered in medicine. This is partially true, but not absolutely correct.

Then he made another error, he described the mechanism of illness transmission as invisible "cadaverous particles", or "corpse particles". He did this in a time when the culture of medicine was trying to make a clean break from superstition. When one of his contemporaries, read his claim that particles from a corpse can turn you into a corpse, they likened it to the magical kind of thinking that plagued early medicine. Their reading stopped here because in their mind Dr. Semmelweis had lost all credibility.
Semmelweis washing his hands - credit Bettmann/Corbis Dr. Semmelweis was unpopular within his own profession. He would publically berate people who didn't agree with him and he wrote angry letters to prominent obstetricians calling them "irresponsible murders" (which they were). He made a lot of enemies and this didn't help his case. Despite his good empirical results, he was consistently ignored.

You catch more flies with honey than vinegar.

All across Europe, doctors continued to kill young mothers, but young mothers were killing doctors too. Women with syphilis were infecting the medical practitioners who touched them. It was not uncommon for obstetricians, especially those who treated prostitutes to become inflicted with syphilis (another bacterial infection). Neurosyphilis can cause erratic behavior, and as Dr. Semmelweis got older his wife and friends became convinced that he was losing his mind.

In 1865, Dr. Semmelweis's personal physician doomed him to a mental institution. Upon being committed, Dr. Semmelweis put up a fight and was beaten down by two of the asylum guards, then placed in a straight jacket. The resulting wounds became gangrenous (another bacterial infection) and he died 14 days after being admitted.

He was replaced by Dr. Janos Diescher at the Pest University where he had been working. Dr. Diescher did not follow the practice of cleanliness or hand washing recommended by Dr. Semmelweis and under his watch, the death rate in his department jumped by 6 fold. There were no inquiries. There were no protests. The physicians of Budapest said nothing.

Twenty years after Dr. Semmelweis's death, Louis Pasteur produced a theoretical explanation of why washing hands saved lives and Dr. Semmelweis was vindicated.
vindicated and placed on a stamp This is an interesting example of what Peter Theil calls a secret. Dr. Semmelweis's view was both unpopular and correct. Peter recommends that when you find such a secret, you should avoid climbing up on a cross and instead take advantage of this "dangerous knowledge" by encapsulating it within a business.

An example of what Dr. Semmelweis could have done can be found in a story from his own profession of obstetrics. In 1634 Pierre Chamberlen invented the forceps. He used the forceps to reach in and extract a child from his mother's womb during a difficult birth. This invention was kept secret within his family for 150 years, and it gave the Chamberlens such an advantage that they became the personal obstetricians of the English royal family and other high nobles. This brought them great personal wealth. When forceps were first introduced to the public, they were laughed at, despite their excellent track record as an instrument.
forceps by William Smellie Dr. Semmelweis could have used his techniques to market his unit within the hospital. He could have talked about outcomes: "death rates", rather than "corpse particles". It is hard to break an idea into the practice of what works, and the theory of why it works -- especially if you have to publish. Ignaz Semmelweis had discovered a practice of what worked, and he made the mistake of describing the why in such a way to brand himself as being a superstitious charlatan.

Crafty Prostitute The crafty prostitutes who gave birth before entering clinic 1 can teach us a lot. The scuttlebutt about the hospital saved a lot of them from being killed by young doctors.

A negligent spread of infection should be given a name that anyone in our society can understand. This way hospital bureaucrats would not be able to hide their mistakes in technical language.

The rate of infection in a hospital should be public knowledge. It should be presented in such a way that anyone can understand it, even a politician or an insurance adjuster, definitely a patient. If this information is publically presented, say on the front of a hospital's web page -- the hospital executives, doctors, nurses and janitorial staff will feel pressure to reduce the spread of infections. The hospital infection information could be aggregated so that people could compare hospitals prior to choosing the location of a procedure with their doctor.

It will be hard to measure this since you will have to know what infection someone has when they enter the hospital, and what infection they had after staying there for a while. The measure will have to be a difference and it will have to be presented in a way that is no more technical than the notion of wind chill.

Of course, this will only work if the money supply to the hospital is restricted when it is performing badly. If patients do not have a choice about which hospital to go to, like within some socialized medical systems the feedback will be missing. There should be room for error, but there should also be a bias towards the reduction of the spread of infection. Hospitals would have to be free to innovate, to try different things and to keep trade secrets.

I think that this would be enough to stop infection. The economic pressure would focus the people working within the hospital to innovate effective techniques to reduce transmission. They could make the cultural shifts to get results. They would figure it out.

Take a look at what the cruise ships have done.

3 People are concentrated on cruise ships like they are in hospitals. However, there is no expectation of being sick on a cruise. The cruise lines have made it fun for people to wash their hands because it has a direct impact on their bottom line. Transmission suppression could be set up as a prize for study by economists, anthropologists, or by those in attendance at the singularity university. It could be given as the business challenge to an technology incubator. Singularity University Doctors are often distracted, tired and they have high personal status. A nurse might not ask a doctor to wash his hands, because of the strange power dynamics that exist within their culture. A doctor would not hesitate to ask a nurse to wash her hands since he is used to issuing orders as part of his duties. It has to be extremely simple for a doctor to wash his hands, and there should be information presented to a patient if a doctor, or if any [other practitioner has not washed their hands](http://opinionator.blogs.nytimes.com/2011/04/25/better-hand-washing-through-technology/?_r=0). Janitorial staff, have a greater and greater effect on the rate of transmission of infections throughout our medical system. A way to increase their effectiveness is to dismantle unions so that an ineffective worker can be fired.4 With this said, I believe that individual janitorial staff should make a LOT more money than they are making now, based on piece work, derated by infections. This job should be renamed, to add status, and it should be a position that is of high risk and high reward. I would not be upset if a neo-janitor5 made as much money as a doctor within the same system. The neo-janitor will be saving doctors, nurses, and patients when our antibiotics fail. neojanitor What are your [ideas](https://www.youtube.com/watch?v=_NMqPT6oKJ8)? Here is Chris Hadfield washing his hands in space:
  1. Ignaz Semmelweis is pronounced as "igg-nahts semi-vice"

  2. Make no mistake

  3. Yes, this is an over-generalization.

  4. http://meritech.com/

  5. I know it's harsh, but they are killing people.

  6. Neo-janitor is a stupid name, come up with something better.