Month: May 2022

Another contemporary who suffered for his medical beliefs would not be so fortunate (as French experimentalist Claude Bernard). The Hungarian-born German Ignaz Semmelweis would make just one major discovery, and its effect would eventually transform the hospitals of the world, saving innumerable lives; though his advocacy of this discovery would be the ruin of his career, and almost certainly cost him his life.

In 1847 Semmelweis was working as a teaching assistant at the maternity clinic in the Vienna General Hospital, which was at the time the largest clinic of its kind in the world. Yet, like such clinics all over Europe it was beset by an appalling mortality rate. Puerperal fever (which attacked women after they had given birth) had reached epidemic proportions, and even some of the finest European clinics occasionally reported mortality rates over 50 percent. The fever was accompanied by a puzzling range of symptoms, which could vary from skin eruptions filled with pus to peritonitis (resulting in serious abdominal swelling), from highly malodorous vaginal discharges to pleuritis (damaging the lungs and bringing severe breathing difficulties). It was always extremely painful, and few survived its onslaught for long. Such was the variety of symptoms that some considered ‘puerperal fever’ to be no more than a blanket term for a number of similar post-natal diseases.

The Vienna General Hospital had two large maternity sections. The first was used for training medical students in obstetrics, while the second was used for training midwives. Semmelweis was surprised to note that whereas the mortality rate in the first section was 13 percent (sometimes rising to 30 percent), the rate in the second section remained around 2 percent. There were a number of myths accounting for this discrepancy. The women who came to give birth in the Vienna General were for the most part poor single mothers and prostitutes, who had nowhere else to turn. For such people, death was regarded as a punishment by God. The lower mortality rate in the midwives’ section was put down to the fact that the patients felt less humiliated when they were treated by women. Pregnant women entering the clinic would tearfully plead to be allowed into the midwives’ section, which had certain feminine touches such as a few jars containing flowers. It was also kept marginally cleaner than the medical students’ section – though cleanliness was not a major concern in the maternity clinic. Vienna was by now a rapidly expanding commercial city, with a proliferation of factory suburbs where the slum districts housing the poor were notoriously filthy, as were the people who inhabited them. It was felt that there was little point in having clean hospitals to tend for such people, who invariably brought in their own dirt.

Semmelweis would conduct autopsies on the puerperal fever victims, and he soon became convinced that this was in fact a single disease despite its varying symptoms. Around this time his colleague Jakob Kolletschka, who was a professor of forensics (criminal medical investigation), died after cutting his finger during a post-mortem examination of a cadaver. The consequent autopsy revealed that Kolletschka had what appeared to be symptoms of puerperal fever. Yet how could this have happened? Kolletschka had no contact whatsoever with the maternity clinic. In Semmelweis’s words: ‘Day and night the image of Kolletschka’s illness pursued me. As we found identical changes in his body and those of childbed women, it can be concluded that Kolletschka died of the same disease.’ Yet Semmelweis remained unable to provide an explanation for this.

Some time later, Semmelweis noticed that the medical students entering their section of the maternity clinic often came directly from their practical anatomy classes, which included post-mortem dissection and the actual handling of diseased organs. When they were finished with their dissection classes, their hands would frequently be wet with blood or pus, yet all they did was douse them under a tap and wipe them on their aprons. Many did not even bother to do that. The cadaver smell on a student’s hands was regarded as a mark of distinction. This distinguished the future physicians in the students’ maternity section from those who were merely studying obstetrics.

Semmelweis drew a simple conclusion. The students from the anatomy labs came into the maternity clinic bringing ‘invisible cadaver particles’. These were what had infected the cut in Kolletschka’s finger, and these were what infected the post-natal patients with puerperal fever. Immediately after birth the uterus was in a raw condition similar to an extensive wound, and could easily become infected by any decomposing organic material. A conducive environment for the foetus was transformed into a conducive environment for infection.

Semmelweis issued orders that from now on before entering the maternity clinic all students should wash and scrub their hands in a chlorine solution until the cadaver smell had been completely eliminated. The results were immediate and spectacular. In the following month the mortality rate in the medical students’ section of the maternity clinic fell to just 2 percent, the same as in the midwives’ section.

Yet Semmelweis was hardly prepared for the reaction which followed. The students were indignantly opposed to having to wash their hands. Semmelweis’s immediately superior Professor Johann Klein was even more opposed to the measures, which he considered to be an underhand criticism of his running of the maternity clinic. And it soon became clear that the women patients too were opposed to it: they saw such measures as implying that they were dirty. Even Semmelweis himself was far from pleased at what he had discovered. As he wrote dejectedly, ‘God only knows the number of women I consigned prematurely to the grave.’ He felt himself to be little better than a murderer.

Semmelweis found himself becoming increasingly unpopular at the Vienna General Hospital; and when his post came up for renewal, Klein refused to reappoint him. Several colleagues were sympathetic towards Semmelweis, and obtained work for him elsewhere. In the close-knit professional world of Viennese medicine this was not easy, and in going against the powerful Klein they were jeopardizing their own careers. Suddenly Semmelweis decided that he had put up with enough, and without telling anyone he simply packed up and caught the train home to Budapest. This precipitate action succeeded in alienating him from his few remaining friends.

Back in Budapest Semmelweis eventually obtained a post in the medical department of St Rochus, a large city hospital. This post was unpaid, but he gradually managed to build up a fairly lucrative private practice. He soon implemented his new hygienic methods in the maternity clinic, and here too the high death rate in the wards diminished spectacularly. But even when Semmelweis published a paper on his discovery some years later in a Hungarian medical journal, he continued to be ignored. No one outside Hungary read Hungarian medical journals.

In time, Semmelweis would become professor of obstetrics at the University of Pest (across from the Danube from the twin municipality of Buda). Despite such professional recognition in his home country, he was becoming increasingly frustrated by the reception of his great idea abroad. Plagued alternately by his guilt at having earlier been responsible for so many deaths, and by his defiance in the face of international neglect of his ideas, he began to show signs of emotional instability.

Finally he decided tp set matters right once and for all by writing a book about his discovery. The first half of the book was devoted to a painstaking elaboration of his discovery, backed by page after page of the supporting statistics which he had gathered over the years. The second half of the book was devoted to a vituperative case by case rebuttal of the many criticisms which had been levelled against him and his discovery. In the course of this, he spared none of his critics. One leading international figure was informed that before writing on medicine he ‘should first attend at least one semester in logic’. He even attacked the Society of Obstetricians in Berlin, ridiculing the great Virchow, insisting that medical students in Budapest ‘would laugh [him] to scorn if he attempted to lecture them on epidemic puerperal fever’. When Semmelweis published Etiology, Understand and Preventing Childbed Fever in 1861 it was initially ignored in Vienna. A few reviews appeared in Germany, and most of these were unfavourable. Other senior figures in obstetrics came to the same conclusion as Professor Klein: Semmelweis’s so-called ‘discovery’ was nothing more than an unwarranted attack on the way they ran their hospitals.

The reception of Semmelweis’s book all but unhinged him. He began to suffer extreme mood swings, fluctuating between periods of apathetic despair and spasms of dancing rage. He gave vent to his feelings in writing, and the leading medical figures who had criticized his book were soon receiving letters filled with violent abuse: ‘your teaching is founded on the dead bodies of women murdered through ignorance’; ‘I denounce you before God and the world as an assassin… a medical Nero’; ‘This murder must cease’. In the middle of 1865 Semmelweis started showing signs of clinical derangement. His wife and friends managed to persuade him to accompany them to Vienna, where he entered a mental hospital. Two weeks later he was dead, aged just 47. Ironically, his death was said to have been caused by sepsis resulting from a wound in his finger, with the same tell-tale symptoms as his colleague Kolletschka, the professor of forensics. It appeared he had died from the very infection he had fought so hard to allay.

This canard would remain intact for over a century, until in 1977 the Hungarian physician and writer Georg Sillò-Seidl discovered documents describing the events leading up to Semmelweis’s death. These events too should perhaps have involved a professor of forensics. It appears that Semmelweis only left Budapest with his wife and friend because he thought they were taking him to Gräfenberg, a spa in southern Germany where he could recuperate by taking the water treatment. When the train stopped in Vienna he was tricked by his friend into leaving the train. His friend said that he wished to show Semmelweis the hospital where he was working, and drove him to an imposing building. Unbeknownst to Semmelweis this was the large public insane asylum on Lazarettgasse, which all agree ‘was certainly not among Vienna’s best’. As soon as Semmelweis entered the building, he was overpowered and forcibly committed. The document outlining the reasons for his enforced commital was signed by three doctors, not one of whom had psychiatric training (one was a surgeon, another a paediatrician, the third a local internist). Unfortunately Sillò-Seidl rather undercut his claims by turning this material into a book which was ‘intended for a popular audience and reads like a spy novel’. He also came to the ‘lurid conclusions’ that Semmelweis ‘was murdered through a conspiracy between his in-laws and several prominent physicians’. Not until nearly twenty years later would a more balanced account appear in an article by K. Codell Carter and other American scholars. Its findings would be hardly less sensational. ‘The autopsy revealed major injuries that could only have been sustained in beatings to which Semmelweis had been subjected while in the asylum.’ They quote an investigator: ‘It is obvious that these horrific injuries were the consequence of brutal beating, tying down, trampling underfoot,’ and they conclude, ‘it seems most likely that Semmelweis was severely beaten by he asylum guards and then left essentially untreated.’ K. Codell Carter and his colleagues mention that Semmelweis’s funeral was attended by just a handful of former colleagues from the Vienna General Hospital, not one in-law, not one colleague from the University of Pest was in attendance. Semmelweis’s wife later explained her own absence on the grounds that after her husband had been committed she had become so ill that she had been confined to her bed for six weeks.’

After Semmelweis’s death, his diagnosis of puerperal fever would soon be overtaken by radical new medical discoveries. Ironically, it was only then that the hygienic precautions he suggested would eventually become accepted by medical authorities throughout the world, thus saving the lives of countless women. At present the major maternity hospital in Vienna is called Semmelweis Klinic, and Budapest has a large prominent public statue in honour of the man who became known posthumously as ‘the saviour of mothers’.

• Excerpt from A Brief History of Medicine from Hippocrates to Gene Therapy, Chapter 10: Giants of Physiology