RESUMO
Clinicians today have never, perhaps, been more aware of the utmost importance of handwashing prior to clinical examination and surgery. However, in the 1800s this was not the case. The simple act of handwashing was once ridiculed and debated with considerable controversy within the medical profession. It was obstetrician Ignaz Semmelweis (1818-1865) who put forward its importance, and thereafter Joseph Lister who, in 1864, developed antiseptic techniques in surgery, following on from Pasteur and Koch's work on germ theory. In 1846, Dr Semmelweis was working in Vienna, responsible for the first division of maternity services. He noticed the striking difference in mortality rate in women who had deliveries by doctors and medical students, compared with deliveries by midwives. This mortality was known as puerperal fever or childbed fever. He hypothesized that doctors and medical students were transferring 'cadaverous particles' as they handled cadavers during autopsies, and then went on to examine pregnant women. The mortality rate was lower when midwives, who did not handle cadavers, performed deliveries. Thereafter, he initiated mandatory handwashing for all those delivering babies, using chloride of lime solution. The mortality rate reduced significantly after the implementation of handwashing and the washing of medical instruments. However, Semmelweis's hypothesis was not supported by many in the medical profession, and most senior academics questioned and disregarded his conclusions. He subsequently returned to Budapest where he continued to work and undertake handwashing. He published 'The etiology, concept, and prophylaxis of childbed fever' in 1861, but it was deemed a laborious read and was poorly received. Unfortunately, reports indicate that Semmelweis's behaviour and actions deteriorated, some speculated due to early-onset dementia or syphilis. He was admitted to a Viennese psychiatric hospital and died in 1865 aged 47 years. Ironically, given his passion for hygiene, he died from sepsis due to a wound infection. Semmelweis has been acknowledged with a university hospital and museum named after him, as well as a postage stamp, issued in Austria in 1965 on the 100th anniversary of his death. Many lessons have been learned from Semmelweis. The medical establishment was slow to adopt his advice. Handwashing effectively reduces healthcare-associated infections, and clinician adherence to hand hygiene advice has increased since the advent of the COVID-19 pandemic. The World Health Organization's 'My 5 moments for hand hygiene' is known worldwide, with its most recent caption (2021) 'Seconds save lives - clean your hands'.
RESUMO
We present a literature review of dermatology features in historical pandemics. A pandemic is an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and affecting a large number of people. Smallpox was the first documented pandemic, around 10 000 BC, spread by the inhalation of airborne droplets. A few days after an initial high fever, headache and fatigue, a mucocutaneous maculopapular eruption appeared, which then developed pustules and erosions. The last outbreak occurred in the USA in 1949. Smallpox was eradicated in 1980, following a vaccination programme. Mycobacterium tuberculosis is the causative agent of tuberculosis (TB), an ongoing global pandemic. The earliest documentations were 3300 years ago. In 2020, the World Health Organization (WHO) provisionally estimated 1.5 million deaths globally. Most commonly affecting the lungs, cutaneous TB may present with inflammatory papules, plaques, suppurative nodules and chronic ulcers. Requiring long, complex antibiotic regimens, multidrug resistant TB is an increasing problem. Now extremely rare, yet still with recent outbreaks in 2021 in Madagascar, bubonic plague arrived in Europe in 1346 causing 75-200 million deaths. It is caused by the bacterium Yersinia pestis, transmitted through fleas that have fed on infected rodents. Clinical features include papules, pustules, ulcers and eschars, tender lymphadenopathy and systemic symptoms, and it responds to antibiotics. Syphilis, caused by the bacterium Treponema pallidum, is sexually transmitted. The first known outbreak was during warfare in 1494-5 in Naples, Italy. In 2020, the WHO estimated that, globally, seven million people had new infections. Primary syphilis typically produces a painless, genital ulcer (or chancre). Secondary syphilis presents with a nonitchy, maculopapular erythema over the trunk, palms and soles. Early recognition and antibiotic treatment usually lead to good outcomes. Estimated by the WHO to affect 37.7 million people in 2020, HIV is thought to have mutated from simian immunodeficiency virus by the 1960s in sub-Saharan Africa, spreading to the Caribbean and USA by the late 1960s. Initial symptoms include a fever, headache and lymphadenopathy. Dermatological features are common, including opportunistic cutaneous infections, nonspecific exanthemas, seborrhoeic dermatitis and Kaposi sarcoma. Advances in antiretroviral therapies mean people with HIV can have an excellent prognosis, although the WHO estimated in 2020 that more than 200 000 people with HIV died from concomitant TB. Since 2019, COVID-19 has had a considerable global impact on healthcare. With more than 300 million cases and 5.5 million deaths to date, some services have been overwhelmed owing to large case numbers, variable vaccine uptake, workplace changes to reduce transmission and staff shortages. Cutaneous features include perniosis, urticarial, purpuric, vesicular or maculopapular eruptions. Pandemics throughout history have been repeatedly shown to present with an element of skin involvement. We can utilize this to promote education and early recognition of these features, to facilitate diagnosis and raise awareness of the potential complications of serious diseases.
RESUMO
British and European public attitudes towards hand hygiene have evolved over time. Early examples of soap-like products date from Babylon around 5000 years ago, later probably passing along the silk route to Europe. A mixture of fats boiled with ashes were found in clay cylinders. In the fourth century BC, Hippocrates propagated ancient Chinese and Greek theories that epidemics spread via noxious 'miasma' particles. In the Roman Empire, Galen advocated health by balancing four humours (blood, yellow bile, black bile and phlegm). The Romans brought public bathhouses to Britain after invading in 55BC adding a social aspect to cleanliness, also bringing fresh water in aqueducts. Emily Cockayne's book Hubbub: Filth, Noise & Stench in England documents daily life in England from 1600 to 1770. Diarist Samuel Pepys reportedly rubbed himself 'clean' using a cloth. King Louis XIV of France reportedly took two baths during his reign, the first during his recovery from a convulsive episode. In the Middle Ages, 'cleanliness' focused on keeping up appearances. It was believed that white linen garments absorbed the body's impurities and cleaned the skin. People wore visible starched white collars and cuffs, to signal cleanliness and social superiority. British public attitudes changed during the nineteenth century, driven by discoveries showing a relationship between hygiene and health. Bulwer- Lytton disparagingly referred to the 'great unwashed' lower classes in his 1830 novel Paul Clifford. However, in 1837, Buckingham Palace did not have a bathroom. Bathing was mostly inaccessible, labourers would usually bath in sweat and were cleaned only on admission to hospitals or poor houses. In 1845, English dermatologist Sir Erasmus Wilson published a lay handbook called Healthy Skin. This was wildly popular and disseminated the health benefits of sanitation and clean skin. Public washhouses proliferated. By the 1920s handwashing was common practice in Western countries. Soap manufactures Lever Brothers launched a 'clean hands' campaign advising children to wash their hands 'before breakfast, before dinner and after school'. After the Second World War, bathrooms became widespread and home plumbing made village washhouses redundant and unappealing. Handwashing practices among healthcare workers have remained low, averaging 39%. Hand hygiene was at the forefront in tackling the COVID-19 pandemic. The public were advised to wash their hands frequently, for at least 20 s each time. Will this be a landmark in handwashing history.