Semmelweis and hygiene: why simple solutions may fail
R. MerrellAniversare, no. 5, 2006
* Medical Informatics and Technology Applications Consortium, Department of Surgery, VCU
In 1844 Ignaz Semmelweis was appointed assistant at the obstetrics clinic in Vienna. He was 26 and had just received his medical degree. This young man was not a native of this beautiful capital on the Danube.(1) His home was 282 km
further down the great river, where it divides Buda, his home city, from Pest, whose ancient university had provided his
education. His native Hungary was certainly a part of the Austro-Hungarian Empire, but, as a new man in Vienna, he would have been considered an outsider. The obstetrical
hospital was not the unit where the aristocracy bore the heirs to the Habsburg throne. Most children, indeed, were born at home. The obstetrical hospital was the place where poverty or illegitimacy drove women to bear their children, attended by students of medicine or midwives in training. Mortality in such units was 25%-30% and the cause of death in these houses of contempt was usually childbed fever (kindbettfieber, puerperal fever).(1, 2)
The young doctor from Hungary did not accept that such a fate was appropriate for poor women. He made a few observations, had a painful personal experience and developed a growing conviction upon which he was driven to act. He was driven to action in a way that eventually proved ineffectual in a campaign that drove him mad. This is the story I would like to tell you today.
In the middle of the nineteenth century medicine was in a state of agitated innovation. The forces of science were spilling from Paris, Edinburgh, London and Vienna and the old practices were to change in dramatic ways. In obstetrics, the introduction of forceps in the sixteenth century had been followed by an increasing attention to parturition from the medical community as a topic of professional care and science. Pelvic anatomy and the mechanisms of labor were actively studied and obstetrics became a standard department of faculties of medicine. However, in 1844 obstetrics was not a part of the required curriculum at the famous medical school in Vienna. In fact, Semmelweis applied for an assistantship in obstetrics only after he was passed over in two applications to study with famous pathologists at the Allgemeine Krankenhaus.(1) Obstetrics was less competitive and became his default choice. However, he brought to the service the zeal of anatomical pathology incited by Rokitansky and other young scientists who believed the autopsy was essential to understanding the processes that led to human disease and death. The notion of death as inevitable was not conceded and the etiology for human disease was avidly sought to enable physicians to anticipate and perhaps cure the afflictions that took away human life not only in great age but at almost any time in childhood or adulthood due to what ultimately proved to be infectious diseases. At the great Allgemeine Krankenhaus all the deceased were studied by autopsy under a stipulation of the imperial government applied to all public hospitals. Medical students were required to participate. Since obstetrics was not a requirement and the physicians were not even the majority of accoucheurs, the eighth courtyard of the venerable facility led to either the first division where medical students and faculty provided care or the second where the school of midwifery was housed. Patients were assigned in even numbers to the two very active wards. The hospital had opened in 1784. By 1846 curiosity was great but hygiene was deplorable. The doctors wore the same clothing throughout the day and from day to day. Pasteur would not elucidate the germ theory until later in the century. No one used a microscope in the routine course of examinations. In fact, one Joseph Lister, father of the man who later would introduce antisepsis, was just then inventing a microscope that avoided the chromatic distortion. No one wore gloves. They were patented in the 1870's and popularized by Halsted at the end of the century as a protection for doctors. The concepts of fever were still heavily contaminated with Galenic notions of humors and explanations of sepsis were fanciful conjectures. Disease, however, was certainly considered something that happened to patients and had no possible origin in the professional, compassionate and scientific efforts of the doctors themselves. The purity of medicine then, as now, was a bulwark of medical training and thought.
The medical students and faculty assigned to the first division performed postmortem exams on all patients dying under the stern leadership of Dr Klein. The midwifery unit did not participate in the postmortem exams of their deceased patients in any regular way. The medical students were also required to perform frequent vaginal examinations during labor to better learn the mechanisms of labor from their vigilant professors.
In this bold and new approach to obstetrics a pattern emerged that was soon evident to the women of Vienna although not noted so much by the faculty. Assignment to the first division with its clinical scientists and probing students was much more dangerous to maternal life than assignment to the second. The Allgemeine Krankenhaus kept excellent records and Semmelweis became curious about the difference in the two divisions. He made a series of observations based upon the data. (1, 2)
First, the difference in mortality between the two divisions was startling. In the division staffed by midwives the mortality was a few percent, while death on division one was in the 20% range. The cause of death was almost entirely puerperal sepsis. This phenomenon was called childbed fever or kindbettfieber. The day after delivery the mother became agitated as the lochia became foul. Over several days the condition rapidly progressed and the mothers died with pallor, rapid pulse, coma and skin changes of necrosis in the vaginal area. At autopsy, the abdomen was involved with a white creamy discharge and there could be abscesses as far away as the chest or joints in the arms or legs. The skin around the vagina showed stiffness, redness and blisters: a process termed erysipelas since the time of the ancients.
Second, the mortality for home delivery was very low. The epidemic was only in the first division.
Third, puerperal, fever was not seasonal like other epidemics.
Fourth, the greater the trauma of delivery, the greater the likelihood puerperal fever. This was not consistent with epidemics.
Fifth, if the ward closed, the epidemic stopped for a while.
Sixth, Semmelweis noted that the babies of dying mothers often became ill with a similar condition and died with postmortem finding of white purulence in the abdomen or lungs. He noted that the mortality rate declined whenever the students were on holiday. The students usually performed their necropsy work in the morning and went straight to the ward to perform their morning vaginal exams. He noted that the deaths would sometimes cluster along a row of beds in the ward as one woman after another succumbed to the disease.
Finally, Semmelweis was profoundly struck by the death of Professor Jakob Kolletshka, his mentor and one of the men to whom he unsuccessfully applied for fellowship after graduation. Kolletshka was stuck by a medical student while performing an autopsy on a woman who had died of kindbettfieber. Subsequently, the previously healthy mentor himself died of a rampant infection that on autopsy bore a striking resemblance to the infection that had killed the young woman in the days after her delivery in the first division.
Semmelweis reached a profound conclusion from these observations. He concluded that puerperal sepsis was due to some material brought by students and professors from the autopsy rooms. (1) This notion of contact transfer of infection had never before been so clearly seen. It was thought that bad air, bad nutrition or bad fortune was the explanation. There were a few observers who came close to the concept of infectious agents in the sixteenth century and Oliver Wendell Holmes at Harvard in the US had reached the conclusion that the doctor was the culprit in a publication in 1843. (3) He advocated changing clothes after an autopsy and not performing a delivery for 24 hours after such a dissection. He was shouted down and retreated to the study of anatomy and his writing without any appetite for controversy.
However, Semmelweis was aflame with the outrage of being, himself, the agent of death for these poor young women and began a campaign to correct the situation. He insisted the students on the first division use a brush and limewater to cleanse the hands when they returned from the dissection of cadavers before attending their patients in labor. The measure was immediately effective and death rate promptly fell to the low rate experienced in division two. The rate fell from 18% to 1.27% and in March and August of 1848 there were no deaths at all. (1,2) He assumed the logic of his approach was infallible, the truth of his insight unassailable and the rectitude of his remedy self-evident. The resistance of his colleagues and certainly his chief, Dr Klein, must have shocked him. They questioned everything he had discovered and he became hostile in his defense of the obvious to the unclean and recalcitrant faculty. The more he insulted them the more they resisted the beautiful benefit of his science.
How did he insult them? Well, his very thesis was an affront to the sincere belief by physicians that they were the doctors and could not be the purveyors. To deliver the message would have required delicacy and data. However, Semmelweis was compelled by the simplicity and clarity of his discovery. Rather than publish his findings with the logic and data that supported his conclusions he promulgated an unpublished doctrine, a Semmelweis Lehre to instruct obstetrical units. He did not publish his work for thirteen years, until 1860 and then in a poorly written, rambling scathing book. His critics were not reluctant to publish and did so with fervor and devastating diatribe. In return Semmelweis called his critics murderers!
Shortly after his discovery our discoverer became embroiled in the revolution of 1848. Prince Metternich allowed little to change in Vienna and the empire, despite riots and disruptions. More and more agents were dispatched to spy on the people. However, nationalism grew and within the empire those outsiders like Semmelweis from Hungary were even more distrusted. All of the Semmelweis brothers went into exile except one, who as a priest thought it better to change his name! When it came time to renew his appointment at the Allgemeine Krankenhaus Semmel-weis was rejected. He certainly had friends and advocates but they could only prevail in getting him an appointment in 1850 on the midwife faculty. Apparently Semmelweis was not in a particularly cooperative frame of mind. When the appointment stipulated that he would be denied access to autopsy he decided to leave. Autopsy was the one area of science where he believed he had expertise and possibilities for further discovery.
He returned to Pest without so much as a farewell to his friends in science. They felt betrayed and perplexed by such behavior. One did not just walk away from the prestige of Vienna and its medical school even if your role there was constrained. In Pest he took a post as obstetrician at St Rochas hospital and implemented his Lehre or doctrine. He was arrogant, abrupt and rude. However, the mortality at the hospital dropped immediately to 0.85%.(1) Please recall that all he insisted upon was hand washing before examining patients. He joined the faculty of the University of Pest in 1855, started a family and had something of a normal personal life that contrasted so sharply with his perpetual acrimony with colleagues about hygiene and their role as doctors of death. When he went to the university his practices were abandoned at St Rochas and women resumed dying. Back in Vienna, Klein eliminated the insultingly simple hand washing that lacked scientific justification. He installed new ventilation believing that the airs were the problem. The death rate climbed back to 15%.
In 1861, Semmelweis published "Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers". The long, ranting work did nothing to advance his discovery. He was a pariah in Europe and had no credibility.
In 1865, Semmelweis became more and more erratic in his behavior and his wife and brother reluctantly concluded he was insane. He was committed to an asylum in Vienna and died within a week on August 13.(1) Yes, there was an autopsy. He suffered from a rampant infection that may have resulted from beatings and restraint so typical of mental institutions in the days before Freud introduced real psychiatry to Vienna.
What was the legacy Semmelweis left us from a career of brilliant discovery and valiant struggle for the truth? He did not in his own efforts stop the massive loss of young life from puerperal sepsis. Wherever he could institute his regimen of hand washing the results were outstanding and indeed many lives were spared. However, whenever his critics could displace him the old practices returned with horrible results. If anything his abrasiveness may have delayed the general discovery of his simple explanation for the devastating childbed fevers. In the US, the softer appeal of Holmes caused his sharpest critic, Professor Meigs of Philadelphia, to endorse hand washing as an inexplicable benefit while rejecting Holmes thesis.(3) In Finland, the practices were adopted and improvements followed. There were no professional jealousies there! However, for the most part Semmelweis was forgotten.
In Edinburgh, Lister read Semmelweis book and incorporated its message into his studies on contact transmission
of infection.(4) His approach to academics, however, was
strikingly different. He conducted experiment after experiment and published them thoughtfully and precisely in the Lancet beginning in 1867.(4) His message was confident, strongly supported by data and presented deferentially. His seminal observations were in amputation and not obstetrics. Therefore, he was addressing a different audience of physicians than Semmelweis who only spoke to obstetricians. Lister achieved a four-fold reduction in the mortality of amputation and could repeat the study at will. He could reproduce it in animals and each publication built upon the last a sound
message of change in the face of compelling evidence. He had perhaps another advantage. His recommendation was not so simple as hand washing. He proposed killing the infection with carbolic acid (phenol).(4) He designed highly technical devices to spray the compound into the air around an operation as well as placing the substance on the wound. He also thought washing the hands a good idea if for no other reason to try to get the noxious phenol off the surgeons' hands! The Semmelweis solution was so simple and addressed the
physician as culprit. The Lister solution was vastly more
complicated and technical and placed the emphasis on the implied infectious agent and not on the physician! What a difference. His work was embraced around the world. He became Lord Lister, Baron of Lyme Reigs and the darling of English science.
Another scientist of the era was also a careful and thoughtful experimenter and published his works. Louis Pasteur used the microscope and laboratory to prove that microorganisms were responsible for many processes.(5) He was a chemist and not a physician. His efforts addressed such things as leaf mold on grapevines, beer production and preservation of milk through Pasteurization. He wandered into medicine later with a vaccine for rabies. His colleagues and nation revered Pasteur. The emperor established the Pasteur Institute and he received stipends for his work and personal needs from the state. He finally ended the mystery of puerperal fever in 1879.
At a lecture in Paris an obstetrician was yet again proposing a fantastic theory for the fatal infection and had even made reference to the failed proposals of Semmelweis. Pasteur rose from his seat and moved to the podium interrupting the speaker. He took chalk and drew a series of connected circles on the blackboard, a chain of streptococci. He turned to the speaker and in a quiet not strident voice, supported by years of integrity and science, announced that "Here sir, is your contagion".(2)
The highly infectious nature of beta Streptococcus is so well known now. The organism can survive for a while in fomites such as dirty linen and can be transmitted as an aerosol. However, its main route to humans is through direct contact and inoculation into some break in the integument. It is the perfect opportunist for invading the abraded virginal mucosa after the inexpert examination by a student who has a large number of the bacteria on the hands. The organism is readily killed by chlorine in the limewater and can be flushed from the hands by simple washing.
After Pasteur's discovery of germs with the microscope of Lister's father, the antisepsis principles of Lister himself, the principles of infectious disease propagation by Koch with his unassailable postulates, progress in obstetrics moved rapidly.(6) There was no Lehre or doctrine. There was only science and evidence based medical practice; no personal invective, no character assassination or passionately partisan debate was needed.
What lessons may we take from Semmelweis today? I propose five and leave to you to discuss them. First, it is possible that we as physicians or physicians in training could subtly adopt a practice that is horribly dangerous for patients. We are looking at so many assumptions about patient care and relative safety. What is the danger of excessive use of antibiotics on the development of increasingly resistant species? What were the dangers of blood transfusion we failed to suspect as blood borne illnesses became epidemic 20 years ago? Why is medicine so much more dangerous than air travel while we are only trying to help? We muct be willing to examine our practices with humility and suspicion in order to be conscientious physicians.
Second, we are still subject to invective and superficial arguments devoid of scientific clarity. Why are drugs sold to us by stylish representatives of great Pharma companies rather than being purchased after careful consideration of new data? This practice leads to advocacy, debate and potentially deception. We recently saw a great company remove an anti-inflammatory drug from the market after perhaps hiding the dangers of its use for many years. Science is our forum. Not the marketplace.
Third, if you make a discovery shouting EUREKA is not a responsible conclusion. A discovery must be tested, retested and carefully debated in publication and conferences. Do not be timid. Do not be arrogant. Do not be discouraged. If the discovery is sound and can be independently confirmed it will prevail as the truth. Anesthesia was such a discovery. So was the use of polypropylene mesh, blood transfusion, PAP smears, mammography and angioplasty.
Fourth, Science is really not personal. We personalize it when we need a hero like DeBakey, Favoloro or Salk. They were not heroes who made scientific discoveries. They were intensely curious scientists who were made heroes after their science led to great truths that could advance the cause of patient care. There are many struggling for the truth in laboratories who will never be heroes. Their discoveries may lead to naught. Yet I respect their process, their honesty and the work. The great discoverers we revere were not famous and then allowed to discover. They were specially favored and insightful individuals in the enterprise who were at the right place, the right time with the right preparation to advance knowledge.
Finally, do not look with disdain on a simple solution. We feel more comfortable with a solution that challenges our intellect, allows us to use big words patients cannot pronounce and have a touch of elegance about them. This would include immunotherapy, chemotherapy, radiation oncology, molecular biology and such. How do you put hand washing in this august company? We still struggle with hygiene in medical practice. There is a website devoted to encouraging hand washing. We regularly conduct campaigns in our hospitals to remind doctors and nurses to wash their hands. We put soap and sinks everywhere at great expense to eliminate any barrier to hand washing. And we regularly have outbreaks of nosocomial infections in the best hospitals in the world due to contact transmission of pathogens. That is simply amazing when the answer is so evident and so well supported by science. In a recent publication of the Journal of the American Medical Association, one of the leading science publications in the world, the esteemed editors made room for a paper by Mujeeb that scientifically proved that hand washing in villages in Pakistan reduced the incidence of infantile diarrhea by 40%.(7) To achieve that forum with a truth that should require no more clarification is simply amazing. Why in this new millennium do we need more proof that hand washing saves lives? I am not sure, but it may be because it is just too simple. That was one of Semmelweis' problems with his recommendation.
The story of our failed scientist, failed revolutionary, failed academic and finally mad Semmelweis is not very heroic. It is, however, terribly important to consider as we struggle with disease in yet another century against demons, myths, shibboleths, human pettiness and our own inadequacies. The struggle is noble, demanding and uniquely our own in medicine.
References
1. Nuland, S.B. - The Doctors' Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis (Great Discoveries) W. W. Norton & Company; Reprint edition, 2004.
2. Semmelweis, I. - The etiology: Concept prophylaxis of childbed fever (1865). Tranlation. K. Codell Carter, Madison, Wisconsin, University of Wisconsin Press, 1983.
3. Holmes, O.W. - The contagiousness of puerperal fever. New England Quarterly J. Med. Surg., 1843, 1:503.
4. Lister, J. - On a new method of treating compound fracture abscess, etc. with observation on the conditions of suppuration. Lancet, 1867, 1:326, 357, 507.
5. Pasteur, L. - Puerperal Sepsis. Bull. Acad. Med. (Paris), 1879, 8:256.
6. VanderVeer, J.B. Jr. - Lister and Osler: comparisons, contrasts, and connections. J. Am. Coll. Surg., 2003, 197:838.
7. Mujeeb, S.A. - Handwashing promotion and childhood diarrhea in Pakistan. JAMA, 2004, 291:2547.
The young doctor from Hungary did not accept that such a fate was appropriate for poor women. He made a few observations, had a painful personal experience and developed a growing conviction upon which he was driven to act. He was driven to action in a way that eventually proved ineffectual in a campaign that drove him mad. This is the story I would like to tell you today.
In the middle of the nineteenth century medicine was in a state of agitated innovation. The forces of science were spilling from Paris, Edinburgh, London and Vienna and the old practices were to change in dramatic ways. In obstetrics, the introduction of forceps in the sixteenth century had been followed by an increasing attention to parturition from the medical community as a topic of professional care and science. Pelvic anatomy and the mechanisms of labor were actively studied and obstetrics became a standard department of faculties of medicine. However, in 1844 obstetrics was not a part of the required curriculum at the famous medical school in Vienna. In fact, Semmelweis applied for an assistantship in obstetrics only after he was passed over in two applications to study with famous pathologists at the Allgemeine Krankenhaus.(1) Obstetrics was less competitive and became his default choice. However, he brought to the service the zeal of anatomical pathology incited by Rokitansky and other young scientists who believed the autopsy was essential to understanding the processes that led to human disease and death. The notion of death as inevitable was not conceded and the etiology for human disease was avidly sought to enable physicians to anticipate and perhaps cure the afflictions that took away human life not only in great age but at almost any time in childhood or adulthood due to what ultimately proved to be infectious diseases. At the great Allgemeine Krankenhaus all the deceased were studied by autopsy under a stipulation of the imperial government applied to all public hospitals. Medical students were required to participate. Since obstetrics was not a requirement and the physicians were not even the majority of accoucheurs, the eighth courtyard of the venerable facility led to either the first division where medical students and faculty provided care or the second where the school of midwifery was housed. Patients were assigned in even numbers to the two very active wards. The hospital had opened in 1784. By 1846 curiosity was great but hygiene was deplorable. The doctors wore the same clothing throughout the day and from day to day. Pasteur would not elucidate the germ theory until later in the century. No one used a microscope in the routine course of examinations. In fact, one Joseph Lister, father of the man who later would introduce antisepsis, was just then inventing a microscope that avoided the chromatic distortion. No one wore gloves. They were patented in the 1870's and popularized by Halsted at the end of the century as a protection for doctors. The concepts of fever were still heavily contaminated with Galenic notions of humors and explanations of sepsis were fanciful conjectures. Disease, however, was certainly considered something that happened to patients and had no possible origin in the professional, compassionate and scientific efforts of the doctors themselves. The purity of medicine then, as now, was a bulwark of medical training and thought.
The medical students and faculty assigned to the first division performed postmortem exams on all patients dying under the stern leadership of Dr Klein. The midwifery unit did not participate in the postmortem exams of their deceased patients in any regular way. The medical students were also required to perform frequent vaginal examinations during labor to better learn the mechanisms of labor from their vigilant professors.
In this bold and new approach to obstetrics a pattern emerged that was soon evident to the women of Vienna although not noted so much by the faculty. Assignment to the first division with its clinical scientists and probing students was much more dangerous to maternal life than assignment to the second. The Allgemeine Krankenhaus kept excellent records and Semmelweis became curious about the difference in the two divisions. He made a series of observations based upon the data. (1, 2)
First, the difference in mortality between the two divisions was startling. In the division staffed by midwives the mortality was a few percent, while death on division one was in the 20% range. The cause of death was almost entirely puerperal sepsis. This phenomenon was called childbed fever or kindbettfieber. The day after delivery the mother became agitated as the lochia became foul. Over several days the condition rapidly progressed and the mothers died with pallor, rapid pulse, coma and skin changes of necrosis in the vaginal area. At autopsy, the abdomen was involved with a white creamy discharge and there could be abscesses as far away as the chest or joints in the arms or legs. The skin around the vagina showed stiffness, redness and blisters: a process termed erysipelas since the time of the ancients.
Second, the mortality for home delivery was very low. The epidemic was only in the first division.
Third, puerperal, fever was not seasonal like other epidemics.
Fourth, the greater the trauma of delivery, the greater the likelihood puerperal fever. This was not consistent with epidemics.
Fifth, if the ward closed, the epidemic stopped for a while.
Sixth, Semmelweis noted that the babies of dying mothers often became ill with a similar condition and died with postmortem finding of white purulence in the abdomen or lungs. He noted that the mortality rate declined whenever the students were on holiday. The students usually performed their necropsy work in the morning and went straight to the ward to perform their morning vaginal exams. He noted that the deaths would sometimes cluster along a row of beds in the ward as one woman after another succumbed to the disease.
Finally, Semmelweis was profoundly struck by the death of Professor Jakob Kolletshka, his mentor and one of the men to whom he unsuccessfully applied for fellowship after graduation. Kolletshka was stuck by a medical student while performing an autopsy on a woman who had died of kindbettfieber. Subsequently, the previously healthy mentor himself died of a rampant infection that on autopsy bore a striking resemblance to the infection that had killed the young woman in the days after her delivery in the first division.
Semmelweis reached a profound conclusion from these observations. He concluded that puerperal sepsis was due to some material brought by students and professors from the autopsy rooms. (1) This notion of contact transfer of infection had never before been so clearly seen. It was thought that bad air, bad nutrition or bad fortune was the explanation. There were a few observers who came close to the concept of infectious agents in the sixteenth century and Oliver Wendell Holmes at Harvard in the US had reached the conclusion that the doctor was the culprit in a publication in 1843. (3) He advocated changing clothes after an autopsy and not performing a delivery for 24 hours after such a dissection. He was shouted down and retreated to the study of anatomy and his writing without any appetite for controversy.
However, Semmelweis was aflame with the outrage of being, himself, the agent of death for these poor young women and began a campaign to correct the situation. He insisted the students on the first division use a brush and limewater to cleanse the hands when they returned from the dissection of cadavers before attending their patients in labor. The measure was immediately effective and death rate promptly fell to the low rate experienced in division two. The rate fell from 18% to 1.27% and in March and August of 1848 there were no deaths at all. (1,2) He assumed the logic of his approach was infallible, the truth of his insight unassailable and the rectitude of his remedy self-evident. The resistance of his colleagues and certainly his chief, Dr Klein, must have shocked him. They questioned everything he had discovered and he became hostile in his defense of the obvious to the unclean and recalcitrant faculty. The more he insulted them the more they resisted the beautiful benefit of his science.
How did he insult them? Well, his very thesis was an affront to the sincere belief by physicians that they were the doctors and could not be the purveyors. To deliver the message would have required delicacy and data. However, Semmelweis was compelled by the simplicity and clarity of his discovery. Rather than publish his findings with the logic and data that supported his conclusions he promulgated an unpublished doctrine, a Semmelweis Lehre to instruct obstetrical units. He did not publish his work for thirteen years, until 1860 and then in a poorly written, rambling scathing book. His critics were not reluctant to publish and did so with fervor and devastating diatribe. In return Semmelweis called his critics murderers!
Shortly after his discovery our discoverer became embroiled in the revolution of 1848. Prince Metternich allowed little to change in Vienna and the empire, despite riots and disruptions. More and more agents were dispatched to spy on the people. However, nationalism grew and within the empire those outsiders like Semmelweis from Hungary were even more distrusted. All of the Semmelweis brothers went into exile except one, who as a priest thought it better to change his name! When it came time to renew his appointment at the Allgemeine Krankenhaus Semmel-weis was rejected. He certainly had friends and advocates but they could only prevail in getting him an appointment in 1850 on the midwife faculty. Apparently Semmelweis was not in a particularly cooperative frame of mind. When the appointment stipulated that he would be denied access to autopsy he decided to leave. Autopsy was the one area of science where he believed he had expertise and possibilities for further discovery.
He returned to Pest without so much as a farewell to his friends in science. They felt betrayed and perplexed by such behavior. One did not just walk away from the prestige of Vienna and its medical school even if your role there was constrained. In Pest he took a post as obstetrician at St Rochas hospital and implemented his Lehre or doctrine. He was arrogant, abrupt and rude. However, the mortality at the hospital dropped immediately to 0.85%.(1) Please recall that all he insisted upon was hand washing before examining patients. He joined the faculty of the University of Pest in 1855, started a family and had something of a normal personal life that contrasted so sharply with his perpetual acrimony with colleagues about hygiene and their role as doctors of death. When he went to the university his practices were abandoned at St Rochas and women resumed dying. Back in Vienna, Klein eliminated the insultingly simple hand washing that lacked scientific justification. He installed new ventilation believing that the airs were the problem. The death rate climbed back to 15%.
In 1861, Semmelweis published "Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers". The long, ranting work did nothing to advance his discovery. He was a pariah in Europe and had no credibility.
In 1865, Semmelweis became more and more erratic in his behavior and his wife and brother reluctantly concluded he was insane. He was committed to an asylum in Vienna and died within a week on August 13.(1) Yes, there was an autopsy. He suffered from a rampant infection that may have resulted from beatings and restraint so typical of mental institutions in the days before Freud introduced real psychiatry to Vienna.
What was the legacy Semmelweis left us from a career of brilliant discovery and valiant struggle for the truth? He did not in his own efforts stop the massive loss of young life from puerperal sepsis. Wherever he could institute his regimen of hand washing the results were outstanding and indeed many lives were spared. However, whenever his critics could displace him the old practices returned with horrible results. If anything his abrasiveness may have delayed the general discovery of his simple explanation for the devastating childbed fevers. In the US, the softer appeal of Holmes caused his sharpest critic, Professor Meigs of Philadelphia, to endorse hand washing as an inexplicable benefit while rejecting Holmes thesis.(3) In Finland, the practices were adopted and improvements followed. There were no professional jealousies there! However, for the most part Semmelweis was forgotten.
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Another scientist of the era was also a careful and thoughtful experimenter and published his works. Louis Pasteur used the microscope and laboratory to prove that microorganisms were responsible for many processes.(5) He was a chemist and not a physician. His efforts addressed such things as leaf mold on grapevines, beer production and preservation of milk through Pasteurization. He wandered into medicine later with a vaccine for rabies. His colleagues and nation revered Pasteur. The emperor established the Pasteur Institute and he received stipends for his work and personal needs from the state. He finally ended the mystery of puerperal fever in 1879.
At a lecture in Paris an obstetrician was yet again proposing a fantastic theory for the fatal infection and had even made reference to the failed proposals of Semmelweis. Pasteur rose from his seat and moved to the podium interrupting the speaker. He took chalk and drew a series of connected circles on the blackboard, a chain of streptococci. He turned to the speaker and in a quiet not strident voice, supported by years of integrity and science, announced that "Here sir, is your contagion".(2)
The highly infectious nature of beta Streptococcus is so well known now. The organism can survive for a while in fomites such as dirty linen and can be transmitted as an aerosol. However, its main route to humans is through direct contact and inoculation into some break in the integument. It is the perfect opportunist for invading the abraded virginal mucosa after the inexpert examination by a student who has a large number of the bacteria on the hands. The organism is readily killed by chlorine in the limewater and can be flushed from the hands by simple washing.
After Pasteur's discovery of germs with the microscope of Lister's father, the antisepsis principles of Lister himself, the principles of infectious disease propagation by Koch with his unassailable postulates, progress in obstetrics moved rapidly.(6) There was no Lehre or doctrine. There was only science and evidence based medical practice; no personal invective, no character assassination or passionately partisan debate was needed.
What lessons may we take from Semmelweis today? I propose five and leave to you to discuss them. First, it is possible that we as physicians or physicians in training could subtly adopt a practice that is horribly dangerous for patients. We are looking at so many assumptions about patient care and relative safety. What is the danger of excessive use of antibiotics on the development of increasingly resistant species? What were the dangers of blood transfusion we failed to suspect as blood borne illnesses became epidemic 20 years ago? Why is medicine so much more dangerous than air travel while we are only trying to help? We muct be willing to examine our practices with humility and suspicion in order to be conscientious physicians.
Second, we are still subject to invective and superficial arguments devoid of scientific clarity. Why are drugs sold to us by stylish representatives of great Pharma companies rather than being purchased after careful consideration of new data? This practice leads to advocacy, debate and potentially deception. We recently saw a great company remove an anti-inflammatory drug from the market after perhaps hiding the dangers of its use for many years. Science is our forum. Not the marketplace.
Third, if you make a discovery shouting EUREKA is not a responsible conclusion. A discovery must be tested, retested and carefully debated in publication and conferences. Do not be timid. Do not be arrogant. Do not be discouraged. If the discovery is sound and can be independently confirmed it will prevail as the truth. Anesthesia was such a discovery. So was the use of polypropylene mesh, blood transfusion, PAP smears, mammography and angioplasty.
Fourth, Science is really not personal. We personalize it when we need a hero like DeBakey, Favoloro or Salk. They were not heroes who made scientific discoveries. They were intensely curious scientists who were made heroes after their science led to great truths that could advance the cause of patient care. There are many struggling for the truth in laboratories who will never be heroes. Their discoveries may lead to naught. Yet I respect their process, their honesty and the work. The great discoverers we revere were not famous and then allowed to discover. They were specially favored and insightful individuals in the enterprise who were at the right place, the right time with the right preparation to advance knowledge.
Finally, do not look with disdain on a simple solution. We feel more comfortable with a solution that challenges our intellect, allows us to use big words patients cannot pronounce and have a touch of elegance about them. This would include immunotherapy, chemotherapy, radiation oncology, molecular biology and such. How do you put hand washing in this august company? We still struggle with hygiene in medical practice. There is a website devoted to encouraging hand washing. We regularly conduct campaigns in our hospitals to remind doctors and nurses to wash their hands. We put soap and sinks everywhere at great expense to eliminate any barrier to hand washing. And we regularly have outbreaks of nosocomial infections in the best hospitals in the world due to contact transmission of pathogens. That is simply amazing when the answer is so evident and so well supported by science. In a recent publication of the Journal of the American Medical Association, one of the leading science publications in the world, the esteemed editors made room for a paper by Mujeeb that scientifically proved that hand washing in villages in Pakistan reduced the incidence of infantile diarrhea by 40%.(7) To achieve that forum with a truth that should require no more clarification is simply amazing. Why in this new millennium do we need more proof that hand washing saves lives? I am not sure, but it may be because it is just too simple. That was one of Semmelweis' problems with his recommendation.
The story of our failed scientist, failed revolutionary, failed academic and finally mad Semmelweis is not very heroic. It is, however, terribly important to consider as we struggle with disease in yet another century against demons, myths, shibboleths, human pettiness and our own inadequacies. The struggle is noble, demanding and uniquely our own in medicine.
References
1. Nuland, S.B. - The Doctors' Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis (Great Discoveries) W. W. Norton & Company; Reprint edition, 2004.
2. Semmelweis, I. - The etiology: Concept prophylaxis of childbed fever (1865). Tranlation. K. Codell Carter, Madison, Wisconsin, University of Wisconsin Press, 1983.
3. Holmes, O.W. - The contagiousness of puerperal fever. New England Quarterly J. Med. Surg., 1843, 1:503.
4. Lister, J. - On a new method of treating compound fracture abscess, etc. with observation on the conditions of suppuration. Lancet, 1867, 1:326, 357, 507.
5. Pasteur, L. - Puerperal Sepsis. Bull. Acad. Med. (Paris), 1879, 8:256.
6. VanderVeer, J.B. Jr. - Lister and Osler: comparisons, contrasts, and connections. J. Am. Coll. Surg., 2003, 197:838.
7. Mujeeb, S.A. - Handwashing promotion and childhood diarrhea in Pakistan. JAMA, 2004, 291:2547.