Ignaz Semmelweis: The Savior of Mothers
Dr. Ignaz Phillip Semmelweis July 1, 1818 - August 14, 1865
Ignaz Semmelweiss: The Little Known man who Changed the World
Few know him by name, but his discoveries have impacted the lives of nearly every human being to walk the planet since.
Thanks to Pasteur we have disease free milk, wine, and a thriving silk (yes, I meant "silk.") industry. Thanks to Flemming we have anti-biotics, and the great British surgeon, Dr. Lister, created the modern operating theater and ushered in an era of scientific discovery probing, and solving, the mystery of infection prevention by means of sterile/aseptic technique. But the work of these men was based largely on the work of Dr. Ignaz Semmelweiss, a Hungarian obstetrician who discovered the cause of pupueral fever, it's prevention as well as its cure.
This malady was the scourge of mothers practically since bearing children began. The disease, simply defined, is septicemia or blood poisoning. However, the specificity of puerperal fever lies in its association with women immediately following childbirth, usually a consequence of an unsterile obstetric procedure. The language here is tricky because in 1846, the year of Dr. Semmelwess's discovery, sterility as such was not recognized. Doctors simply didn't know what they didn't know. The common belief held at the time was that infection was caused by a mysterious pathogenic vapor known as miasma.
This "miasma" manifested itself in an invisible cloud and allegedly hovered over battlefields and sick wards in hospitals. As foreign and superstitious as it seems to us today, for the time such ideas were as good a guess as any, and not completely without some semblance of scientific data. After all, dirt, soot, and lead filled the wounds of the injured on the battlefield. Without an understanding of the germ theory or asepsis it would seem reasonable to believe some mysterious cloud of disease hung over such environs. There was the occasional savant who seemed an oddity for his time, but in reality was centuries ahead of his peers. One such individual was Girolamo Fracastoro, an Italian physician, poet, philosopher, and astronomer. He was an unappreciated genius who, had his theories been taken seriously, literally millions of lives would've been saved. His book De Contagion, described "small living animals invisible to the naked eye" that were responsible for the spread of contagions. Eighty-eight years later a Jesuit priest, Athanasius Kircher, expressed essentially the same idea, but was ignored by his contemporaries in medicine. Today we realize that the source of wound infection was the dirt, grime, and bacteria, precisely those "small living animals" that infiltrated open wounds. That realization was to be revealed in a most unusual way.
Conditions of the Hospital (Algemein Krankenhaus i.e. General Hospital)
To understand the way in which Semmelweis made his discovery it is important to know, as odd as it sounds, the ward conditions, but more importantly the ward layout. First the conditions:
- Hospitals in general were not clean with the exceptions of those wards where midwives and nurses were in charge.
- Doctors rarely washed their hands between patient contacts and their smocks were covered in blood and other body fluids. This was viewed as a sign of experience and hard work. Clean smocks were viewed as being worn by someone who was not willing to "get their hands dirty."
- The word of the doctor was law and his word was rarely, if ever, challenged except by another physician.
- The Algemein Krankenhaus was a "teaching" hospital which means it was filled with medical students and resident physicians following their attending physician from patient to patient.
Now for the most important piece of information regarding the way in which Semmelweis's discovery was even possible; the layout of the hospital.
The Allgemeine Krankenhaus (General Hospital) of Vienna in the 1840's
Hospital Layout: The Double Doors of Life and Death
As patients approached the obstetrics ward from the outside they would notice a set of double doors. Upon entering the gravid patient would be directed either to the left or to the right, to the midwives ward or The First Division- the doctors ward. The air of the doctors ward was infused with particulate stench; purulent sheets remained unchanged while the poor mothers were left to sautee' in them. Attending Professor physicians strode confidently through the halls of the ward accompanied by an entourage of medical students and residents, all of whom would perform vaginal exams, one after another, on the same patient without the benefit of latex gloves as a barrier or the knowledge of how simple hand washing stops the spread of disease. As if these conditions weren't bad enough there is one more to be made aware of that completes the setting for the perfect storm of infection that awaited the patients of The First Division. However, before revealing that detail I would like to talk about the contrasting conditions of the midwives ward.
Each morning the head mother would have all the midwives stand in a line for inspection. Every midwife was to have trimmed nails, clean hands, a clean smock, and a hair bonnet. These habits were considered little more than domestic pleasantries at the time, but they were in fact the foundational elements of what would later be known as sterile/aseptic technique, and would account for the dramatic difference in survival rates between the two wards. The survival rate on the midwives ward was over 95% while mortality rates on the First Division, the doctor's ward, would reach as high as 40%.
In the other two lying in divisions (the doctors wards), the students and supervising physicians delivered the babies, which meant many more examinations during the course of labor and therefore many exploring fingers intruding into the birth canal. The student midwives and their teachers were content with far fewer interventions, and this information was well known among Viennese women.— Sherwin B. Nuland- The Doctor's Plague p.19
The Perfect Storm
As inappropriate and insensitive as we now know such excessive examinations to be, the problem was compounded by the macabre fact that the first thing medical students and physicians did in the morning, prior to their patient rounds, was head to the hospital basement to perform autopsies; autopsies on the bodies of young women who had died of puerperal fever the day before. Afterwards it was time to visit the pregnant women so close to delivery; visits that included multiple vaginal exams by hands that had just been bathed in blood, pus, and the actual contagion itself. Dirty hands literally inseminated healthy young mothers-to-be with the deadly disease that would cause many of them to be on the cadaver table the next morning. It was all of these things working together, the lack of hygiene, insensitivity, an unwillingness to listen to dissenting ideas, that made this preventable plague possible. These were all overcome by Dr. Semmelweis when the lights of understanding shone brightly in his mind.
Dr. Ignaz Semmelweis 1861
The Light of Understanding
It was Dr. Semmelweis who took note of the difference in mortality rates between the two wards, and the difference bothered him. He began to engage the midwives and enacted some of their superior hygienic practices with some success. Yet, the numbers persisted to be better on the midwives side of the hospital. The difference continued to perplex Semmelweis until a fateful incident occurred in the morgue one morning. Semmelweis and his close friend, Dr. Jakob Kolletschka, were performing an autopsy when Kolletschka's scalpel slipped and cut his finger. Three days later he died of puerperal fever. It was at this point that Semmelweis put all the pieces together. The key was the midwives. It wasn't any one thing they did, but a combination of all they did, as well as the fact that the didn't perform autopsies. He realized that doctors had been the source of transmission all along. To his credit he immediately instituted preventative measures to ensure the infections would stop, and stop they did...for a while.
Semmelweis insisted that all medical staff wash their hands between patient contacts and that linens be changed daily or upon becoming soiled. These measures were nothing new to the midwives, but the other doctors took great offense at being told they must wash their hands, wear clean smocks, etc. They resisted Semmelweis's rules, resistance that Semmelweis met with what can only be described as a righteous fury. On one occasion he took a bin full of linen that had not been properly laundered, reeking of death, and dumped it on the hospital administrators death. This action did not have the intended effect. Semmelweis was disciplined and the new standards he had implemented began to be ignored. When mortality rates again began to rise other physicians and administrators ignored it saying it was "a coincidence" or attributing the rise to other things; weather, construction, and the old fall back- miasma.
Outraged, Semmelweis fought back with angry letters to European physicians and hospital administrators. He called all who would not accept his doctrine "murderers" and worse. He wrote to Joseph Spath, professor of obstetrics at the University of Vienna's Joseph's Academy:
"You, herr Professor, have been a partner in this massacre. The murder must cease, and in order that the murder ceases, I will keep watch, and anyone who dares to propagate dangerous errors about childbed fever (puerperal fever) will find in me an eager adversary."
Though his anger was justified, its expression in such ways only served to alienate the Hungarian obstetrician from his peers. In his anger and outrage he was unable to see the fact that the main reason for the mass rejection of his doctrine did not stem from murderous hearts, but ignorant minds. If only Semmelweis had taken a more humble approach perhaps his doctrine would have found greater acceptance. Such an approach would be taken some 20 years later by British Surgeon Dr. Joseph Lister with great success. Lister, a more gentle minded and persuasive man, was able to convince his contemporaries of the reality of Semmelweis's findings and then see their world wide implementation.
The End of Dr. Ignaz Semmelweis
Eventually Dr. Semmelweis succumbed to mental illness and was institutionalized. It is believed by some that it was a combination of all the years of fighting, frustration, rejection, grief, and even guilt that brought dementia to a man not yet 50 years of age. In realization of the role he himself had played in the spread of disease prior to his understanding of the contagion he wrote:
"Because of my convictions, I must here confess that God only knows the number of patients who have gone to their graves prematurely by my fault. I have handled cadavers extensively, more than most accoucheurs. If I say the same of another physician, it is only to bring to light a truth, which was unknown for many centuries with direful results for the human race. As painful and depressing, indeed, as such an acknowledgement is, still the remedy does not lie in concealment and this misfortune should not persist forever, for the truth must be made known to all concerned."
With his mental status decreasing rapidly, he was tricked by family members into going to visit a new sanitarium in Vienna. Shortly after arriving it became clear to Semmelweis, even in his befuddled state, that he was not there to visit, but rather to be admitted. He resisted, but his protests were met by strong and forceful orderlies that escorted him to his new living quarters. Two weeks later, on August 14, 1865, Dr. Semmelweis was pronounced dead. The cause of death is not completely certain although there is significant evidence showing him to have been beaten severely, even to the point of death. Beatings were routine in those days as it was the only known way to subdue resistant mental patients. An autopsy declared Semmelweis to have died, not directly from the beating, but from wounds associated with it, wounds that contracted septicemia (aka puerperal fever). And so it would be that the man who had found the preventative cure to that dastardly disease would die from the disease itself. Dr. Nuland said it this way in his biographical work on Semmelweis:
"His death was the death of a martyred hero, a victim of the very disease he had been fighting with such unalloyed courage and selfless beneficence throughout his career. It provided the narrative of his life's journey with the final dramatic moment that would make of it an epic saga."
The Algemein Krankenhaus in Vienna, Austria
The Algemein Krankenhaus is the hospital where Dr. Semmelweis made his great discovery regarding the transmission of pathogens/contagions.
His death was the death of a martyred hero, a victim of the very disease he had been fighting with such unalloyed courage and selfless beneficence throughout his career.— Dr. Sherwin B. Nuland- The Doctor's Plague p.171
Bullet Points in the Life of Dr. Semmelweis
Paying Tribute to Dr. Semmelweis
Every time we wash our hands before dinner, clean up a soiled child or patient, or wash up just to feel clean; we pay tribute to Dr. Ignaz Semmelweis.
Questions & Answers
© 2018 Leland Johnson