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The Fool of Pest

The life of Ignác Semmelweis (1818– 1865) is a puzzle that admits no solution. Here was a man whose painstaking investigations, while he was still only in his twenties, led him to devise a means to control the devastating epidemic of childbed fever then sweeping Europe. Semmelweis saved the lives of countless women and their newborn children. He showed how a statistical approach to the problems of medicine could demolish popular but mystical theories of disease. His work prepared the way for Pasteur’s elucidation of germ theory. He turned obstetrics into a respectable science. And he revealed how professional eminence and authority could breed crass stupidity and bitter jealousy.

Yet this Hungarian émigré died in Vienna broken and alone, abandoned by his family and his colleagues in a Viennese lunatic asylum. It took forty years for him to be commemorated in Pest, his home city. The controversy circling his life continued into the 1960s, when his remains were exhumed, reexamined, and finally returned to his homeland. Even today, Semmelweis scholars are partisan. Was Semmelweis the author of his own destruction, the Fool of Pest, as he was called? Or was he the victim of a deliberate character assassination by a racist, anti-Semitic, anti-scientific, decadent, and murderous medical establishment reigning in nineteenth-century Austria?

1.

Semmelweis was the fourth son of a successful Jewish grocer. His schooling, in both Hungarian and German, left him with a hatred of writing, which was to cost him dearly in later years. He began studying law but quickly switched to medicine, completing his degree in 1844 and becoming accredited in midwifery, or the delivery of newborn babies, the same year. At that time, Vienna’s Allgemeines Krankenhaus was the world’s largest and most famous hospital. It housed two obstetric clinics, the first for teaching medical students, the second for training midwives. By 1846, Semmelweis had been appointed assistant to the director of the First Obstetrical Clinic.

Childbed (or puerperal) fever is an acute illness that affects women during labor. It can be aggressively infectious. During a twenty-month epidemic beginning in 1821, for example, childbed fever killed one in six women admit-ted to Viennese hospitals in labor. No one knew the cause. A commonly believed theory blamed noxious airs; as a result there was much drilling of holes through hospital walls and doors in the desperate attempt to improve ventilation. Even in 1864 an expensive ventilation system was being installed in the Viennese maternity clinic. Air ducts were piped through ceilings; iron gratings were laid across corridors. All to no avail.

Semmelweis was quick to notice that the women’s mortality rate in the clinic for medical students was exactly three times that in the clinic for midwives. Between 1841 and 1846, he calculated that 1,989 women died in the company of medical students, out of 20,042 admissions—9.9 percent. The comparable figures for midwives were 691 deaths out of 17,791 hospital confinements—3.3 percent. Women entering the Allgemeines Krankenhaus were only too well aware of these differences. Those admitted to the first clinic begged—“wringing their hands,” according to Semmelweis—to be transferred to the second. Giving birth on the streets of Vienna was safer than within the walls of the city’s most prestigious medical center.

Semmelweis correlated the soaring incidence of childbed fever with the introduction of autopsies into the hospital during the 1820s. When his friend Jakob Kolletschka, a professor of forensic medicine, died from a disease indistinguishable from that of women with fatal puerperal fever, Semmelweis became convinced that somehow cleanliness was at the root of the problem. Kolletschka had cut himself with a knife while conducting an autopsy. Semmelweis suggested that particles from the cadaver must have been transferred into Kolletschka’s bloodstream, thereby causing his death. Medical students were exposed to the same particles from cadavers while performing autopsies. The students could have been a source for the disease that soon overtook the women they went on to care for.

Semmelweis tested his idea by introducing new rules for hygiene in May 1847. He made it mandatory for doctors and students to wash their hands with warm soap and water, to scrub their nails, and to rinse their hands with a chlorine solution until they were slippery. By June, death rates had plummeted to only a few percent. They fell still further when Semmelweis realized that transmission of particles from cadavers could take place from one woman to another. He could stop the fever in its tracks as it moved through a ward by simply insisting on chlorine disinfection of a doctor’s hands after the examination of each woman. His terrifying conclusion was that doctors and their medical students had caused an entirely unnecessary epidemic of deaths. The uterus after birth had to be seen as a huge fresh wound. Only obsessional hygiene could prevent it from becoming a portal for fatal particles introduced through contaminated vaginal examinations.

These were striking and convincing results. But Semmelweis, for reasons that are still a matter of dispute, did not write up his findings for publication. Instead, he left it to colleagues and friends to circulate his discovery. Ferdinand von Hebra was editor of the Journal of the Medical Society of Vienna and he published accounts of Semmelweis’s work in December 1847 and April 1848, inviting others to try out his chlorine disinfection technique. And Charles Routh, who had been a student of Semmelweis’s at the time of his discovery, gave a report of events in Vienna to the Royal Medical and Chirurgical Society on November 21, 1848,1 writing that

the real cause of the mortality from puerperal fever there, was the “uncleanliness of medical men and students in attendance”; their hands being impregnated with cadaveric matter through dissecting, making autopsies, and performing obstetric operations on dead bodies. Dr. Semelweiss recommended all students attending his division of the Lying-in Hospital not to handle dead matter, or, if they did so, forbad them to make any examinations of the patients till the following day. And he directed every student to wash his hands in a solution of chlorine prior to and after every examination made on the living subject. The result was, that the number of deaths was reduced from thirty per month, to seven per month, the usual average mortality of the division for midwives only.2

While his remarkable observations were known to a small circle of close colleagues, Semmelweis’s reputation suffered in the salons of Viennese medicine. Europe had plunged into a period of mid-century chaos, and the revolutions of 1848 divided the Viennese academy as they divided the city’s streets. In March, Prince Clemens von Metternich, a leading advocate of the rights of kings and emperors, threw out democratic reform proposals, enraging students and younger faculty members who were sympathetic to change. This scholarly group of dissidents created an Academic Legion to exert further pressure on the government. Semmelweis was an enthusiastic supporter of the legion, wearing its uniform of plumed hat, gray trousers, and black jacket while giving lectures. Such revolutionary zeal angered the hospital’s old guard, and especially the reactionary head of Semmelweis’s department.

Johann Klein was one man among many who, as the German surgeon Theodor Billroth once noted, had “been reared in an intellectual strait-jacket with dark spectacles before their eyes and cotton wool in their ears.” He rejected Semmelweis’s arguments concerning cleanliness. Along with his colleagues, he probably felt angry that this precocious Hungarian was making orthodox practices—and practitioners—look not only ridiculous, but also dangerous. Indeed, as Sherwin Nuland points out in The Doctors’ Plague, it was Klein who had insisted that medical students examine cadavers in the first place, and it was he who had relaxed constraints on conducting vaginal examinations during labor. Semmelweis seemed to be saying that Klein’s policies were the direct cause of the epidemic.

When Semmelweis’s temporary appointment came up for renewal in March 1849, Klein blocked his application, despite appeals from senior medical colleagues, such as the celebrated pathologist Karl von Rokitansky and the skilled diagnostician Josef Skoda. Semmelweis was even unable to establish himself as an independent physician with the right to admit patients to a hospital. Eventually, and rather grudgingly, he was granted the status of a Privatdozent; but he was unpaid and had to accept the ludicrous understanding that he could only teach students by using a mannequin. Hurt and insulted, he left Vienna for Hungary without even telling his friends or supporters.

Pest was little better. His parents were dead, most of his family were refugees, and he returned to find only his sister and one brother, a Catholic priest, who had converted from Judaism. The academic standards at the University of Pest were low. In May 1851, he was given a second chance. He took an unpaid position in the obstetric division of St. Rochus Hospital in Pest, where he once again introduced chlorine disinfection—with dramatically successful results. His work earned him the chair in theoretical and practical midwifery in 1855, when he was thirty-seven. His life seemed to be settling at last. He married the twenty-one-year-old Maria Wiedenhoffer and, in 1858, published his first paper describing his work in a Hungarian medical journal.

But again he aroused conflict. Opposition to his work seemed to be growing stronger. For reasons that still remain obscure, the great Viennese pathologist Rudolf Virchow denounced Semmelweis. And amid these unpleasant arguments, Semmelweis began writing the book that would finally destroy as well as make his reputation.

The Aetiology, the Concept, and the Prophylaxis of Childbed Fever was published in 1861. It is divided into two parts. In the first, Semmelweis assembles a vast collection of data, presented in sixty-three detailed tables, to construct a theory for the transmission of puerperal fever. In addition to his observations among women, he included results from experiments on rabbits, which lent support to his view that particles deriving from autopsies provided the source of disease. It is a dense treatise, but one that bears witness to the remarkable thoroughness with which he conducted his investigations. The second part attacks his critics. He wrote that the medical students under his care knew enough about modern obstetrics to “laugh Virchow to scorn.” He criticizes Carl Braun—who succeeded Semmelweis at the Allgemeines Krankenhaus and then went on to take up Johann Klein’s professorship upon Klein’s retirement—for his lack of basic logic. And he called Friedrich Scanzoni, the professor of obstetrics in Würzburg who had been skeptical about his theories, a “wretched observer” of his discoveries.

The book, while it collected all of Semmelweis’s investigations for the first time in one volume, met with harsh reviews—and with dreadful results for medical care. For even in 1861, puerperal fever was an ever-present threat. At a meeting of the Obstetrical Society of London, for example, Dr. W. Tilbury Fox reported the “very high death rate” from puerperal fever between 1833 and 1858, over 3 percent.3 In the debate that followed, even the greatest obstetricians of London had to admit they “did not know what puerperal fever really was.” Standard treatment at the time included bleeding, leeching, and mercury. The president of the society proclaimed that “the obstetrist could put before him no nobler object than the diminution of this mortality.”

  1. 1

    See C.H.F. Routh, “On the Causes of the Endemic Puerperal Fever of Vienna,” The Lancet, December 9, 1848, pp. 642–643.

  2. 2

    The reaction to this paper was skeptical. One respondent from the audience criticized Routh for paying insufficient attention to the circumstances in Vienna: “It was well known that Vienna was the most unhealthy place in Europe. Fever of a low type was very prevalent there. The hospital was situated in a damp position, and was ill-ventilated, and unclean. The students, also, were anything but cleanly,” said one D. Webster.

  3. 3

    See W. Tilbury Fox, “On Puerperal Fever,” The Lancet, November 23, 1861, pp. 500–501.

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