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IN MEMORY OF IGNAZ SEMMELWEIS 1818-1865

First published 03 Jul 2017    Last edited 27 Jul 2017  06:46pm



Three morals that might be drawn from the life of Ignaz Semmelweis:

It is better to avoid catching a disease than to catch it and be cured

It is sometimes easy to see the cause of a disease, and thus easy to enable prevention by avoiding that cause, even without knowing in microscopic detail exactly how that disease works, which was the case when Ignaz Semmelweis saw that women were dying after giving birth because they were being handled by doctors and medical students who had not washed their hands after performing autopsies, but because germs had not yet been discovered, he could speak only about hypothetical "cadaverous particles" that were being transmitted.  Nevertheless, his blaming death on contaminated hands was correct, and was of immense practical importance as it permitted a large reduction of mortality.  A detailed understanding is important too, because it will be needed to discover a cure, but if it were possible to have one without the other, knowing how to prevent would be more useful than knowing how to cure, especially because knowing how to cure might arrive many years after knowing how to prevent.

Perhaps it to some degree continues to be the case that causes for some diseases lie in plain sight, although the detailing of exactly how the causes work can only be guessed in general terms.

Low level of development of scientific method leads to frequent reliance on post hoc ergo propter hoc

It will be seen below that Carl Braun varied from Ignaz Semmelweis by identifying 30 causes of the childbed fever that was killing mothers giving birth, which leads to the interpretation that Braun was victim of the pre-scientific habit of attributing causal significance to whatever events he happened to observe occurring together, seemingly unaware of the possibility that simultaneity can occur by mere coincidence.  Thus, if a woman who died of childbed fever had an unusual diet, then Braun would recognize unusual diet as a cause of childbed fever, if another woman had endured some emotional trauma, he would acknowledge emotional trauma as another cause, if a third woman had experienced cold, then Braun would add chilling to his list of causes, and so on.

This is not a manner of viewing the world which is so obviously fallacious as to be entirely avoided today.

What does it take to disarm opposition?

The "Semmelweis Reflex" refers to a hostility to the new ideas proposed by Ignaz Semmelweis, and to hostility to new ideas generally, to whose explanations presented below might be added one more — that the stronger and more obvious the evidence supporting a new idea, then of course the stronger the obligation to accept it, but at the same time, the greater is the guilt of those who have themselves been overlooking this evidence and not proposing the idea themselves.  For doctors to concede the truth of Semmelweis's ideas would have been their implicit admission that their blindness to the obvious had sent hundreds, sometimes thousands, of women to their deaths.

It might be almost axiomatic, even today, that the only improvement that a profession will welcome must be non-accusatory, which is to say must be an improvement that is either trivial or non-obvious, and preferably both.



All images and box quotes on this page are from the Wikipedia page on Ignaz Semmelweis



Women Preferred Giving Birth In The Streets Rather Than In Vienna's "First Clinic"

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?"  [...]

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.  [...]

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.

Puerperal fever mortality rates for the First and Second Clinics at the Vienna General Hospital 1841–1846:  The First Clinic has the higher mortality rate.

Semmelweis's Answer Was Hand Washing

He instituted a policy of using a solution of chlorinated lime (calcium hypochlorite) for washing hands between autopsy work and the examination of patients.  He did this because he found that this chlorinated solution worked best to remove the putrid smell of infected autopsy tissue, and thus perhaps destroyed the causal "poisonous" or contaminating "cadaveric" agent hypothetically being transmitted by this material.

The result was the mortality rate in the First Clinic dropped 90%, and was then comparable to that in the Second Clinic.  [...]

During 1848, Semmelweis widened the scope of his washing protocol, to include all instruments coming in contact with patients in labour, and used mortality rates time series to document his success in virtually eliminating puerperal fever from the hospital ward.

Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841–1849.  Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847.

Nevertheless, Semmelweis Encountered Resistance

In his 1861 book, Semmelweis lamented the slow adoption of his ideas:  "Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories.  [...]  In published medical works my teachings are either ignored or attacked.  The medical faculty at Würzburg awarded a prize to a monograph written in 1859 in which my teachings were rejected".

In a textbook, Carl Braun, Semmelweis's successor as assistant in the first clinic, identified 30 causes of childbed fever; only the 28th of these was cadaverous infection.  Other causes included conception and pregnancy, uremia, pressure exerted on adjacent organs by the shrinking uterus, emotional traumata, mistakes in diet, chilling, and atmospheric epidemic influences.

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".  [...]

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.

In his 1861 book, Semmelweis presented evidence to demonstrate that the advent of pathological anatomy in Wien (Vienna) in 1823 (vertical line) was accompanied by the increased incidence of fatal childbed fever. The second vertical line marks introduction of chlorine hand washing in 1847. Rates for the Dublin Rotunda maternity hospital, which had no pathological anatomy, are shown for comparison.

The Resistance Turned Lethal, And Eventually Acquired The Name "Semmelweis Reflex"

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 [...].  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, possibly caused by the beating.  [...]

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.  [...]

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.



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