It was the mid eighteenth century in Hungary. A young doctor joined the Vienna General Hospital’s Obstetrics and Gynaecology wing as Chief Resident. His name was Ignaz Semmelweis. There were two maternity Units in the hospital, each admitting on alternate days. Poor pregnant mothers from across the country flocked to this hospital to give birth.
At that time, a lot of mothers suffered, after delivery, from a mysterious illness called ‘puerperal fever’. It was very dangerous, and killed off a lot of women afflicted. It was caused by ‘bad air’, ‘mysterious humors’ and many similar vague things, according to the physicians of the time.
Semmelweis, reviewed the records kept in the hospital. The maternal mortality was quite high- about 7 percent. But he noticed a curious fact. Unit one had a mortality rate of 10 percent, and unit 2 had only about 4. This was repeated every month and year. It was a notable difference. There was a notable difference in the administration of the units also.
Unit 1 was run by doctors and medical students. Unit 2 was managed by midwives. Was the difference due to the ineptitude of the so-called highly trained doctors when compared to the lowly midwives?
There was another even more puzzling fact. Some mothers gave birth on the streets, on the way. Then they were brought in for after care. They had the least incidence of puerperal fever. The streets were safer than the most modern hospital at that time!
Semmelweis personally observed and recorded the working of each unit. He could find no difference. The skill, care, instruments- everything was scrutinized by him. He could identify nothing. His colleagues were least interested in these matters.
That time it was common practice for doctors to do and attend autopsies and anatomical studies on dead bodies, and then go straight to the labour rooms to conduct deliveries. It was only when one of Semmelweis’ friends died, that he got a clue. He got an accidental injury by a scalpel while doing an autopsy. The finger became swollen, and he developed symptoms identical to puerperal fever and he died.
Semmelweis proposed that some unknown ‘cadavorous particles’ was being transmitted to the patients in the labour room through the contaminated hands of the doctors. He suggested that all doctors and midwives wash their hands in a solution of soda lime before entering the room.
The maternal mortality rate plunged by 90 percent. It even came zero for many months- for the first time since the beginning of the institution. Semmelweis was dead right.
But the significance of the discovery was recognised widely only after the efforts of Lois Pasteur in France who discovered that microorganisms cause many diseases.
Joseph Lister in Glasgow was a surgeon who introduced antiseptic techniques into surgery. He had heard of Pasteur’s work. For the first time in history, cavity surgeries like appendectomy became tolerably safe. The battle against our ancient enemies, the pathogenic microorganisms, was beginning to be won.
The recognition that small microscopic animals can create diseases is an example of good science at work. It demonstrates how science works in Medicine. It is the same scientific method that lets us recognize chronic common diseases, like heart disease.
In the 1940s and 1950s, doctors and public health experts in the USA noted that people were dying of heart attacks and heart failure- coronary artery disease. The incidence was increasing. It was reaching epidemic proportions. The National Heart, Lung and Blood Institute decided to study it. The study was started in 1948 in the town of Framingham, Massachusetts. It became the famous ‘Framingham Heart study’. It was the first step in identifying a new enemy- chronic lifestyle disease.
A total of 5209 people were enrolled in this well-designed longitudinal cohort study. All the factors thought to be relevant were recorded. These people consented to yearly physical examination, blood and other tests. The diseases and deaths were recorded. The second generation of these participants were enrolled in 1971. This is an ongoing study and the third generation was added in 2002.
It was a massive and fruitful effort, and spanned three generations of participants. It has, till now, generated more than 1000 medical papers. The term ‘risk factor’ was first used in this study. The findings have been confirmed by literally hundreds of other studies.
Before the results of this study came trickling in, there was no concept that any of these diseases could be prevented. The clogging of arteries, called atherosclerosis that causes heart attacks and ischemic stroke was thought to be a normal accompaniment of ageing. Hypertension and increased blood cholesterol also were considered normal as people aged.
This study, and later, literally thousands of other studies and supporting data has given faces to our main enemies now. They were quite hazy a mere half a century ago.
Coronary artery disease of the heart is a major cause of death and disability. It is brought on by atherosclerosis- a narrowing of the arteries due to development of ‘atheromatous plaques’ in the walls of the arteries.
Ischemic stroke is a related illness with the same cause- narrowing due to atherosclerosis in the arteries supplying the brain.
Diabetes is a lifestyle disease leading to disability and death.
Some cancers, like colon, breast and prostate, has some relationship to dietary habits. Some other common cancers, like cervix, lung, head and neck etc that are directly related to unsafe sex, cigarette smoking, tobacco chewing and alcohol.
There are certain other diseases that are silent or not particularly distressing in the early stages. But later, they cause or accelerate the onset of other diseases like heart disease, stroke etc. These diseases can be considered directly lifestyle related.
Hypertension- an increase in arterial pressure. This is a silent killer. Accelerates atherosclerosis and is a main risk factor for coronary artery disease and stroke.
Disorders of blood lipids. Lipids means fats. They include increased cholesterol, LDL, triglycerides and a decrease in HDL.
Diabetes- this has to be included in both. It is a major disease in itself, and a main risk factor for many other diseases. It accelerates atherosclerosis.
Obesity. A dangerous increase in body weight. This directly correlates with all the other diseases. It also has a direct contributing effect to other risk factors, like hypertension, diabetes and hypercholesterolemia.
These are the major risk factors, and by controlling them, it was demonstrated that the burden of heart disease has come down in the west. How do we know that the advice was effective? By similar scientific methods; of course.
