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Unacknowledged and deadly truth

After the Lovable forgery and The Great Impostor posts – where the pleasant side of impostors and their hoaxes is presented, it makes sense to show the reverse situations – i.e. when somebody guesses a particular tricky truth but nobody believes him. It is no surprise that misbelief evenly shares the spotlight with forgeries…. One might argue that there is a plethora of examples for this: everybody’s day-to-day life would have enough working material for that! True; however, this story is a bit special, because of its environment (hospital), its seriousness (life and death) and its simplicity.
The unrewarded hero of this story is Ignaz Semmelweis

Who is Ignaz Semmelweis?

Ignaz Philipp Semmelweis was a Hungarian physician, who actually started his career studying law at the Vienna University in 1837. For still unknown reasons, he switched to medicine the following year and achieved his degree in 1844. He was then after an appointment for internal medicine but he failed to obtain it, so he specialised in obstetrics.
On July 1st 1946, Semmelweis was appointed assistant to Professor Johann Klein in the First Obstetrical Clinic of the Vienna General Hospital.

The problem

Puerperal fever – also known as Childbed fever – is a bacterial infection contracted by women during childbirth. It was common in the mid XIX century maternity hospitals and often fatal (with mortality between 10% and 35%) but quite rare in home births or in “street births” – i.e. while going to the hospital. And the situations were even quite different between maternity wards.
The case of the Vienna General Hospital was extreme: the First Obstetrical Clinical had a mortality rate almost triple than the Second Clinic one, despite the Second one being always more crowded. Its reputation was so bad that, in his Etiology, Concept and Prophylaxis of Childbed Fever, Semmelweis even mentioned women desperately begging not to be admitted to the First Clinic! In all of this, Semmelweis’s words are as simple and rational as they could be:

“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?”

So, following a very basic principle of scientific investigation, Semmelweis started comparing people and practices between the two Clinics, in order to narrow the investigation field only to what was different between the two. The only major difference was the people working there: teaching service for medical students in the First Clinic and for midwives in the Second one.
The explanation he was given by experienced workers in the ward was that the women were victims of a “poisonous gas”, an invisible “miasma” that had got into the ward and that was fatal for some. This explanation was far from convincing: why would only patients die from the “poisonous gas” that everybody was breathing? Plus, Semmelweis would not accept that somehow the “miasma” that was so destructive in the First Clinic did not get to the corridor of the Second one that was close by and more crowded.

The sparkle

In 1847, Semmelweis’s close friend, Jakob Kolletschka, cut his finger while he was performing an autopsy. Kolletschka died pretty soon of what would be later called septicaemia. While he was attending his friend’s postmortem, Semmelweis noticed that the lesions on his body were very similar to those of puerperal fever. This aspect got his attention: he started to believe that there had to be a connection between corpses and puerperal fever and that it had been the autopsy scalpel was the key.
His theory was that medical students in the First Clinic would carried an der Hand klebende Cadavertheile (German for cadaveric particles on their hands) from the autopsy cadavers to the patients they examined in the First Clinic. This was also consistent with the fact that the Second Clinic mortality rate was much lower because midwives didn’t participate to autopsies.

Seeing the truth ahead

Now these are trivial elements of knowledge. But the so-called germ theory of disease – though first guessed by Italian scientist Girolamo Fracastoro in the XV century, then better elaborated by Italian entomologist Agostino Bassi in the early XIX century – was indeed scientifically and definitively proved by Louis Pasteur some twenty years later. Semmelweis would definitely be an important part of this long and uneasy journey towards the truth.

The obvious solution

So far, Semmelweis’s theory was just a hypothesis that needed to be proved to become truth. If these “cadaveric particles” were the cause, removing them would somehow be the cure.
Semmelweis had previously observed that a solution of chlorinated lime (we would now call it calcium hypochlorite) was effective in removing the smell of rotting tissues from autopsies: maybe it was “removing” the cadaveric particles….
So, in mid May 1847, he implemented a policy of hand washing with chlorinated lime between autopsies and patient examinations.
The result was that the mortality rate in the First Clinic dropped by 90% to a comparable rate with that in the Second Clinic: from 18.3% in April 1847 to 2.2% in June, 1.2% in July and 1.9% in August. After extending the policy to all instruments used in the morgue, in 1848, the mortality rate was fundamentally reduced to zero!

Experimental truth can be manipulated or ignored

Such important results started to circulate around Europe because Semmelweis’s students and
assistants wrote letters, delivered lectures and published in prestigious medical journals.
The news was not well received: for some the contagiousness of puerperal fever was not “breaking news”, for others the accepted theories on humours imbalance were still not affected by this work.
The fundamental point in Semmelweis’s theory was that physicians contaminated their hands with cadaveric particles in the morgue while conducting autopsies. He pointed out that ordinary washings with soap did not remove these particles, because the hands could retain a stench for several days in spite of such washings. Semmelweis’s theories were much more favoured in England than on the rest of Europe: the English consistently regarded Semmelweis because he was supporting their theory of contagion, not so much because they understood him. Elsewhere in Europe – including his own country – he was strongly opposed: nobody could accept that the only cause of puerperal fever was the cadaveric particles that were introduced in the mothers’ bodies by the doctors themselves.
The best summary of the reaction is given by Semmelweis himself in his 1861 book:

“Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. (….) The medical literature for the last twelve years continues to swell with reports of puerperal epidemics, and in 1854 in Vienna, the birthplace of my theory, 400 maternity patients died from childbed fever. 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”.

Outraged by the indifference of the medical profession, Semmelweis started writing open and more and more angry letters in response to the reactions, up to denouncing the obstetrical community as irresponsible murderers. The people surrounding him, including his wife, started to believe that he was losing his mind. In 1865, he was confined in an asylum. He died there of septicaemia only two weeks later, possibly as the result of being severely beaten by guards.

Any learning?

Semmelweis’s story has been the subject of quite a few books, such as the biography by Sherwin Nuland. Semmelweis discoveries are often used in universities to provide an historical example of which types of knowledge are considered as scientific (and thus accepted), and which are not. The Semmelweis effect is a metaphor for the tendency to reject new evidence or new knowledge because it contradicts established norms, beliefs or paradigms.
It has to be retrospectively noted that (poor) communication played quite a role. The fundamental aspect Semmelweis was warning against was actually the decaying matter from the corpses, not just contagion. This and other misunderstandings are partly due to the fact that Semmelweis’s work was known only through his colleagues and students: at a crucial stage of the debate, Semmelweis himself had published nothing. Misinterpretations would continue to cloud his work throughout the XIX century. Some also emphasise that Semmelweis refused to make official communication of his method to the learned circles of Vienna, nor was he eager to describe it in writing….
One can perhaps understand the debate on the (lack of) theoretical explanation of the approach that Semmelweis was proposing. However, nobody could dispute Semmelweis’s practical results; so why not adopting an approach that had been – and could anytime be – proven useful and, more importantly, was simple and cheap? More subtle aspects might have played a role. It shouldn’t be a surprise if some doctors ended up being offended by the fact that they should wash their hands: their social status as gentlemen was deemed inconsistent with the suspect that their hands could be unclean…. Scientific and technical incontrovertible evidence and human lives being at stake fundamentally were erased by the simplest, lowest and worst of human sins: vanity. Does this ring a bell?

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{ 3 comments… add one }
  • Moiz Mehmood 11-Nov-2013, 16:21

    Medical science is a very conservative science which takes a long time to adopt new practices and rightly so. The burden of proof is very high in this branch of science as it deals with life and death. Also, it seems like Semmelweis lacked the statistical tools that are today used quite commonly by the medical industry.

  • Armando Gherardi 11-Nov-2013, 18:31

    I agree: Semmelweis didn’t do a good job at communicating his approach and his results. And, definitely, I agree that new practices shouldn’t be adopted just because someone “shouts that they’re good”!
    But the other doctors just debated…. Even if they didn’t understand if and/or why Semmelweis’s approach was working, wasn’t it easier to verify it – instead of just talking about it? Medicine is a technique, not a science: you don’t have to know why it works – as long as it works! If you know a cure that save lives, you have to apply it – whether you know why it’s working or not!
    Tens of thousands died throughout Europe while the debate was on, and we know now that they all could be saved.
    To be honest, there is a record of some doctors that didn’t apply Semmelweis’s procedures and infected members of their own families; the relatives died and the doctors committed suicide once they understood their responsibilities. But they were a minority.
    Most of them were definitely moved by other interests – not by the preservation of their patients’ lives.

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