The pandemic has seen a new focus on hand hygiene – hand sanitiser has become a normal part of stepping out of our homes.

It has also shown that not everyone is willing be told what to do or to accept evidence put forward to justify doing things differently.

Freelance historian and former Reuters Foundation Fellow in Medical Journalism, Chris Holme tells the story of the Aberdonian surgeon whose insights into his own role in the deaths of his patients saved countless others.

Washing your hands to prevent the spread of infection seems such an obvious practice now but it has a troubled history.

This goes back to 1795 when Alexander Gordon published his Treatise on the Epidemic of Puerperal Fever in Aberdeen.

Giving birth at that time carried a reasonable risk of the mother dying. If she developed puerperal, or childbed, fever it was often a protracted and agonizing death.

Gordon was a Royal Navy surgeon who came back to Aberdeen to practice midwifery. He had witnessed puerperal fever infecting whole wards in a London hospital but was puzzled how it could spread easily among home births in Aberdeen.

He looked carefully at the records of 77 women infected between 1789 and 1792, of whom 28 had died. Most had been delivered by midwives and some by Gordon.

This was an era before trained midwives and obstetricians as we now know them. No-one had a clue what caused the fever. The most common explanation was miasma – something in the air – and “cure” was based on purging - taking copious amounts of blood from the mother who might have had opium to ease the pain.

Gordon’s genius was to see a pattern: the infection appeared only after he or the nurses had come from a previous patient infected by the disease.

In other words, they were the source of the infection.

His advice was clear enough: “The patient’s apparel and bed-clothes ought either to be burnt, or thoroughly purified; and the nurses and physicians, who have attended patients affected with the puerperal fever, ought carefully to wash themselves, and to get their apparel properly fumigated before it be put on again.”

Gordon’s treatise ranks among the earliest examples of evidence-based medicine, alongside fellow Navy surgeon James Lind whose controlled trials of citrus fruit greatly reduced scurvy and also provided the enduring slang term Limey.

So, what went wrong?

Gordon’s meticulous work also showed the names and addresses of patients and the names of birth attendants (Gordon himself or the midwives).

He faced much hostility when his paper was published.

Midwives were outraged that they had been identified and the suggestion they were in effect killing their patients.

Gordon was hounded out of Aberdeen. He gave up midwifery, re-joined the Navy and died in 1799 from tuberculosis.

But his paper was published widely, and his theory was later taken up by other doctors - Oliver Wendell Holmes in America and Ignaz Semmelweis in Vienna. They too suffered ridicule and abuse for arguing the need for hand washing.

Holmes drew on Gordon’s treatise with further research in Boston in his paper published in 1843. He was prompted in part by the death of a doctor one week after performing a post-mortem on a woman who had died from puerperal fever.

Semmelweis was appointed assistant physician at Vienna General Hospital in 1846. He was intrigued at the difference in maternal mortality rates at its two maternity clinics. They were more than twice as high in the one which trained medical students and conducted post-mortems than the other which trained midwives.

Semmelweis explored several hypotheses, but his turning point was also the death of a pathologist colleague from sepsis, contracted cutting a finger in an autopsy of a puerperal fever victim.

He was convinced that infection was spreading because doctors were taking little bits of cadaverous flesh from post-mortems. Semmelweis told his medical staff to clean their hands and instruments not just with soap but with a chlorine solution – not because he had stumbled on its disinfectant properties but because it got rid of the smell of the flesh. As a result, maternal mortality dropped to the levels of the midwives’ clinic.

Semmelweis tried to persuade colleagues in Austria and across Europe to follow his example, but he encountered vicious opposition. No-one likes to be criticised, least of all eminent physicians whose reputation and income depended on their sound clinical judgement.

Tact was also not Semmelweis’s strong suit – he gave out as good as he got. Nor was he helped by his failure to publish his results until 1861 which gave his opponents years to mock him based on their interpretations, not his evidence.

He got angrier, started drinking heavily and became sufficiently unbalanced to be tricked into being committed to a mental asylum in 1865. He was severely beaten trying to escape which left him with a wound to his hand. This became gangrenous and he died two weeks later, aged 47.

Everything changed soon after the death of Semmelweis with research by Louis Pasteur identifying bacteria as the agents of infection. The value of rigorous hand washing was the cornerstone of Florence Nightingale’s teachings and nursing and midwifery training by the 1890s.

Later, the focus shifted from apportioning blame to investigating patterns and learning lessons so that steps could be taken to prevent future deaths. 

Aberdeen went on to pioneer anonymous reporting of maternal deaths.

In 1917, Matthew Hay, the city’s medical officer of health, launched the world’s first confidential inquiry into maternal deaths.

That study revealed a great deal: underreporting of non-fatal sepsis which had a much higher incidence in maternity homes and hospitals, and that the mortality rate in cases attended by midwives was less than half of those attended by doctors.

It triggered further inquiries in Scotland and was copied across the UK and internationally.

Meanwhile, more than 400,000 women still die every year across the world in childbirth for want of any care of a midwife or doctor. Hand washing remains essential but impossible in so many places where there is no access to clean water.

You can read Alexander Gordon’s A treatise on the epidemic puerperal fever of Aberdeen courtesy of the Wellcome Collection

Chris Holme is founder of The History Company.

Read More by Chris: Long read: The CMO who spoke the unspeakable

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