Ignaz Semmelweis: The Saviour of Mothers

Ignaz Philipp Semmelweis (1 July 1818 – 13 August 1865) was a Hungarian physician of ethnic-German ancestry, now known as an early pioneer of antiseptic procedures. Described as the "saviour of mothers", Semmelweis discovered that the incidence of puerperal fever (also known as "childbed fever") could be drastically cut by the use of hand disinfection in obstetrical clinics. Puerperal fever was common in mid-19th-century hospitals and often fatal. Semmelweis proposed the practice of washing hands with chlorinated lime solutions in 1847 while working in Vienna General Hospital's First Obstetrical Clinic, where doctors' wards had three times the mortality of midwives' wards. He published a book of his findings in Etiology, Concept and Prophylaxis of Childbed Fever.

Despite various publications of results where hand washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. Semmelweis could offer no acceptable scientific explanation for his findings, and some doctors were offended at the suggestion that they should wash their hands and mocked him for it. In 1865, Semmelweis suffered a nervous breakdown and was committed to an asylum, where he died at age 47 of pyaemia, after being beaten by the guards, only 14 days after he was committed. Semmelweis's practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister, acting on the French microbiologist's research, practiced and operated, using hygienic methods, with great success.

Theory of cadaverous poisoning

Maternity institutions were set up all over Europe to address problems of infanticide of illegitimate children. They were set up as gratis institutions and offered to care for the infants, which made them attractive to underprivileged women, including prostitutes. In return for the free services, the women would be subjects for the training of doctors and midwives. Two maternity clinics were at the Viennese hospital. The First Clinic had an average maternal mortality rate of about 10% due to puerperal fever. The Second Clinic's rate was considerably lower, averaging less than 4%. This fact was known outside the hospital. The two clinics admitted on alternate days, but women begged to be admitted to the Second Clinic, due to the bad reputation of the First Clinic. Semmelweis described desperate women begging on their knees not to be admitted to the First Clinic. Some women even preferred to give birth in the streets, pretending to have given sudden birth en route to the hospital (a practice known as street births), which meant they would still qualify for the child care benefits without having been admitted to the clinic. Semmelweis was puzzled that puerperal fever was rare among women giving street births. "To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic. What protected those who delivered outside the clinic from these destructive unknown endemic influences?"

Semmelweis was severely troubled that his First Clinic had a much higher mortality rate due to puerperal fever than the Second Clinic. It "made me so miserable that life seemed worthless". The two clinics used almost the same techniques, and Semmelweis started a meticulous process of eliminating all possible differences, including even religious practices. The only major difference was the individuals who worked there. The First Clinic was the teaching service for medical students, while the Second Clinic had been selected in 1841 for the instruction of midwives only.

He excluded "overcrowding" as a cause, since the Second Clinic was always more crowded and yet the mortality was lower. He eliminated climate as a cause because the climate was the same. The breakthrough occurred in 1847, following the death of his good friend Jakob Kolletschka, who had been accidentally poked with a student's scalpel while performing a post mortem examination. Kolletschka's own autopsy showed a pathology similar to that of the women who were dying from puerperal fever. Semmelweis immediately proposed a connection between cadaveric contamination and puerperal fever.

He concluded that he and the medical students carried "cadaverous particles" on their hands from the autopsy room to the patients they examined in the First Obstetrical Clinic. This explained why the student midwives in the Second Clinic, who were not engaged in autopsies and had no contact with corpses, saw a much lower mortality rate.

Conflict with established medical opinion

The germ theory of disease had not yet been accepted in Vienna. As a result, his ideas were rejected by the medical community. Other, more subtle, factors may also have played a role. Some doctors, for instance, were offended at the suggestion that they should wash their hands, feeling that their social status as gentlemen was inconsistent with the idea that their hands could be unclean. Semmelweis's results lacked scientific explanation at the time. That became possible only some decades later, when Louis Pasteur, Joseph Lister, and others developed the germ theory of disease.

At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine, including the celebrated Rudolf Virchow, who was a scientist of the highest authority of his time. Virchow's great authority in medical circles contributed potently to Semmelweis' lack of recognition. Ede Flórián Birly, Semmelweis's predecessor as Professor of Obstetrics at the University of Pest, never accepted Semmelweis's teachings; he continued to believe that puerperal fever was due to uncleanliness of the bowel. August Breisky, an obstetrician in Prague, rejected Semmelweis's book as "naive" and he referred to it as "the Koran of puerperal theology". Breisky objected that Semmelweis had not proved that puerperal fever and pyemia are identical, and he insisted that other factors beyond decaying organic matter certainly had to be included in the etiology of the disease. Carl Edvard Marius Levy, head of the Copenhagen maternity hospital and an outspoken critic of Semmelweis's ideas, had reservations concerning the unspecific nature of cadaverous particles and that the supposed quantities were unreasonably small. In fact, Robert Koch later used precisely this fact to prove that various infecting materials contained living organisms which could reproduce in the human body; that is, since the poison could be neither chemical nor physical in operation, it must be biological.

Breakdown and death

Beginning in 1861, Semmelweis suffered from various nervous complaints. He suffered from severe depression and became absentminded. Paintings from 1857 to 1864 show a progression of aging. He turned every conversation to the topic of childbed fever.

After a number of unfavorable foreign reviews of his 1861 book, Semmelweis lashed out against his critics in a series of Open Letters. They were addressed to various prominent European obstetricians, including Späth, Scanzoni, Siebold, and to "all obstetricians". They were full of bitterness, desperation, and fury and were "highly polemical and superlatively offensive", at times denouncing his critics as irresponsible murderers or ignoramuses. He also called upon Siebold to arrange a meeting of German obstetricians somewhere in Germany to provide a forum for discussions on puerperal fever, where he would stay "until all have been converted to his theory."

In mid-1865, his public behaviour became irritating and embarrassing to his associates. He also began to drink immoderately; he spent progressively more time away from his family, sometimes in the company of a prostitute; and his wife noticed changes in his sexual behavior. On July 13, 1865, the Semmelweis family visited friends, and during the visit Semmelweis's behavior seemed particularly inappropriate.

The exact nature of Semmelweis's affliction has been a subject of some debate. According to K Codell Carter, in his biography of Semmelweis, the exact nature of his affliction cannot be determined:

It is impossible to appraise the nature of Semmelweis's disorder. ... It may have been Alzheimer's disease, a type of dementia, which is associated with rapid cognitive decline and mood changes. It may have been third-stage syphilis, a then-common disease of obstetricians who examined thousands of women at gratis institutions, or it may have been emotional exhaustion from overwork and stress.

In 1865, János Balassa wrote a document referring Semmelweis to a mental institution. On July 30, Ferdinand Ritter von Hebra lured him, under the pretense of visiting one of Hebra's "new Institutes", to a Viennese insane asylum located in Lazarettgasse (Landes-Irren-Anstalt in der Lazarettgasse). Semmelweis surmised what was happening and tried to leave. He was severely beaten by several guards, secured in a straitjacket, and confined to a darkened cell. Apart from the straitjacket, treatments at the mental institution included dousing with cold water and administering castor oil, a laxative. He died after two weeks, on August 13, 1865, aged 47, from a gangrenous wound, due to an infection on his right hand which may have been caused by the struggle. The autopsy gave the cause of death as pyemia—blood poisoning.

Semmelweis was buried in Vienna on August 15, 1865. Only a few people attended the service. Brief announcements of his death appeared in a few medical periodicals in Vienna and Budapest. Although the rules of the Hungarian Association of Physicians and Natural Scientists specified that a commemorative address be delivered in honor of a member who had died in the preceding year, there was no address for Semmelweis; his death was never even mentioned.

János Diescher was appointed Semmelweis's successor at the Pest University maternity clinic. Immediately, mortality rates jumped sixfold to 6%, but the physicians of Budapest said nothing; there were no inquiries and no protests. Almost no one — either in Vienna or in Budapest — seems to have been willing to acknowledge Semmelweis's life and work.

Aftermath 

Semmelweis' advice on chlorine washings was probably more influential than he realized. Many doctors, particularly in Germany, appeared quite willing to experiment with the practical hand washing measures that he proposed, but virtually everyone rejected his basic and ground-breaking theoretical innovation — that the disease had only one cause, lack of cleanliness. Professor Gustav Adolf Michaelis from a maternity institution in Kiel replied positively to Semmelweis' suggestions — eventually he committed suicide, however, because he felt responsible for the death of his own cousin, whom he had examined after she gave birth.

Only belatedly did his observational evidence gain wide acceptance; more than twenty years later, Louis Pasteur's work offered a theoretical explanation for Semmelweis' observations — the germ theory of disease. As such, the Semmelweis story is often used in university courses with epistemology content, e.g. philosophy of science courses—demonstrating the virtues of empiricism or positivism and providing a historical account of which types of knowledge count as scientific (and thus accepted) knowledge, and which do not. It has been seen as an irony that Semmelweis' critics considered themselves positivists, but even positivism suffers problems in the face of theories which seem magical or superstitious, such as the idea that "corpse particles" might turn a person into a corpse, with no causal mechanism being stipulated, after a simple contact. To his contemporaries, Semmelweis seemed to be reverting to the speculative theories of earlier decades that were so repugnant to his positivist contemporaries.

The so-called Semmelweis reflex — a metaphor for a certain type of human behaviour characterized by reflex-like rejection of new knowledge because it contradicts entrenched norms, beliefs, or paradigms — is named after Semmelweis, whose ideas were ridiculed and rejected by his contemporaries.