In 1818 in Hungary, a man was born who would influence the development of public health. Throughout the course of his life, which ended abruptly in 1865, Ignaz Philipp Semmelweis led a dramatic discovery in antisepsis, before full development of the germ theory. Semmelweis would come to be known as ‘savior of mothers’ when, by mandating hand washing with a chloride of lime solution after performing post-mortem examinations and prior to examining obstetrics patients, he caused significant reductions in maternal mortality rates in Vienna and Budapest in the mid-19th century.
Having learned of Semmelweis’ historical significance in my studies of public health, I knew that his discovery of hand antisepsis as a method of reducing disease transmission was not met with widespread acceptance and he was faced by many in the medical community with tremendous adversity. Although his work had the potential to instantly prevent numerous deaths within hospitals, circumstances and beliefs of the time led to a drawn out period of opposition and therefore unnecessary deaths of mothers and children. For Semmelweis, the grief of this knowledge was difficult to bear. Late in his life he was stricken with depression and psychological disease that consequently led to his death.
I have invited Ignaz Semmelweis to join me for dinner. I have selected this man for several reasons. First, I would like to gain an understanding of his perspective through the course of his discovery, especially as he was met with opposition from the medical community in Vienna. Second, I would like to give him the opportunity to speak with someone, who, over 150 years later has a basic understanding of germ theory and modern medicine and can validate his concept of puerperal fever. He is deserving of recognition for his discovery and an understanding of his own credibility. Finally, I would like to share with Semmelweis modern views on his contributions to medicine and public health and the steps many have taken to recognize him.
Semmelweis arrived at my home at six o’clock in the evening. Prior to beginning our meal, Semmelweis inquired as to whether I had washed my hands. I smiled and nodded, I had. I informed him of our modern antiseptic methods of antibacterial hand soap, and could see that he was impressed. As dinner began, I told Semmelweis about myself and my pursuit of a Master of Public Health, a concept that he was intrigued by. I told him that I was most interested in hearing his story, and he began.
My career in medicine began when I moved from Budapest to Vienna to pursue law. I quickly changed course, as you know, to study medicine. After one year studying in Vienna and two at the University of Pest, I completed my degrees in Doctor of Medicine and Master of Obstetrics at the University of Vienna. I became acquainted with three physicians by the names of Joseph Skoda, a teacher of general medicine and statistics, Ferdinand Hebra, a dermatologist, and Carl Rokitansky, a professor of pathologic anatomy. These men would later become close friends and colleagues.
I nodded my head, listening closely. He continued.
In 1846 at the age of 28 I was appointed assistant to Dr. Johann Klein, professor of obstetrics. I began assisting with child births in the First Maternity Division of the Vienna General Hospital. Almost immediately, I noticed a disturbing rate of maternal mortality in the First Division. It was devastating to watch a healthy new mother transform to a helpless victim of childbed, or puerperal, fever. It was a terrible sickness: the patient was seized by a shivering fit and a great degree of heat resulting in perspiration, accompanied by severe, consistent pain in the abdomen. Death usually resulted within a matter of days. I was told by my predecessor and others that the women were being killed by an invisible miasm, an unknown epidemic influence of an atmospheric-cosmic-teluric nature.
What struck me most about all of this was the fact that in my first year, 459 women died in the First Maternity Division. Next door, however, in the Second Maternity Division, only 105 deaths occurred: nearly five times fewer. I found other trends in mortality. The women who delivered outside of the hospital, on the street, were not dying of childbed fever. Alternatively, the women who experienced longer period of labor were nearly always victimized by the disease. These inconsistencies consumed me, and I investigated every possible explanation that I could conceive. I spent a great deal of time in the deadhouse performing post-mortem examinations; back and forth between autopsies and deliveries. It was not until the day when I learned of the death of my friend from a knife cut during an autopsy that I realized the cause: physicians, myself included, were carrying decomposed animal organic matter from the corpses to the mothers. This explained the difference in number of deaths between divisions: in the First Division, patients were examined by physicians who also performed autopsies, in the Second Division, patients were examined by mid-wives and nurses who did not. It also explained why the women who did not deliver in hospital did not contract the disease: they were never examined by a physician. The women who experienced longer laboring were examined many times by physicians, hence their higher mortality rates. This was a difficult reality to learn, that I, the doctor who should be providing care for my patients, was actually carrying to them the disease that was killing them.
He went on.
Immediately, I mandated hand washing by every medical student and physician with a chloride of lime solution. Within months, the number of puerperal fever deaths in the First Maternity Division fell to the levels of the Second Maternity Division. From what I understood about childbed fever, and as I described in my publication later on, there were three sources. The first, from a dead body. The second, from a sick person who is afflicted by puerperal fever. The third, any decomposing matter. This was identified when the sheets of an afflicted patient were transferred to a healthy patient who subsequently acquired puerperal fever. The blood that had contaminated the sheets carried the disease. I found that the disease was transmitted by the hands of the examiners, the hands of the operators, surgical instruments, bed clothes, atmospheric air, sponges, and the hands of midwives and nurses who came in contact with the excrement of afflicted patients. Subsequently, we began washing medical instruments in the solution between patients as well.
At this juncture I was compelled to interject. I explained to him that his discovery was quite remarkable considering the fact that germ theory was yet to be fully uncovered, and also that he was almost completely accurate. Today, we know puerperal fever to be caused by bacteria called Group A streptococcus. We also discussed that fact that hand washing was not a completely new concept at the time of his discovery. The unique aspect of his discovery was that he recognized the cause of puerperal fever was being directly transmitted from one individual to another on the hands, and he understood the concept that there was one cause for the disease. He was ahead of his time. I told him that today his innovations represent the basis of infection control practice. In hospitals, where we still face the danger of bacterial infection transmission from patient to patient by way of health care providers, physicians are required to wash there hands frequently, and always before contact with a new patient. Hospital acquired infections continue to be one of the major preventable, iatrogenic complications of hospitalization. What I find so fascinating about his compulsory hand washing is that appropriate action was taken to avoid infection based on inadequate information about the infection.
Semmelweis stated that he is pleased to hear what I have told him, but that it was an extremely difficult time in the mid-1800s when he was attempted to change the ways of physicians. Dr. Klein was the first to denounce Semmelweis’ findings. Others stated that ‘the mere suggestion the puerperal fever might be transmitted by medical attendants was abhorrent, would damage the trusting physician-patient relationship, and that fear engendered in the laboring woman by such a suggestion might in itself cause her to be afflicted by the disease’. He described the frustration and anger he felt with the medical community. Differing opinions with Klein led to his dismissal, and he left Vienna for Budapest. When invited to speak on his findings in Vienna, he initially refused. His methods of communication seemed, to me, inadequate to accomplish the change in physician behavior he was seeking.
Listening to Semmelweis, I could sense the frustration and turmoil that he felt during this time in his career. He went on to explain that when he did publish his work, which he had put off for several years, he could not help the angry tone that came across. As the end of his life neared, he was not the same doctor he had once been. He alluded to the final days when he was admitted to the asylum, where he died from an infection that entered through a cut on his hand.
It was late then, and I thanked Semmelweis for spending this time with me, that it was an honor. I also told him of the recognition he has been given. Within 40 years of his discovery, his hand washing technique was adopted by most in the medical community. I told him that Budapest Medical School is now named Semmelweis University of Medicine. I told him that although the type of innovation he was attempting was initially accompanied by resistance and hostility, ultimately he is known for making a landmark contribution in the prevention of puerperal fever. He smiled and thanked me, and I hoped that our conversation had given him a small glimpse into his success as a physician. We then said good bye.
After Semmelweis left, I had time to process all that we discussed and all that I have learned from my research on his work and life. His experience offers many lessons in public health: around discovery and innovation, communicating information, and implementing changes necessary for improvement. Semmelweis made a significant discovery at a time when he lacked complete information about the disease he was studying. The set up of the First and Second Maternity Divisions played an extremely important role in his discovery, as he was able to use them as a case-control study. Epidemiology played a role through his comparisons of the two divisions and the resulting tables he created. Semmelweis faced unique challenges in his time. A majority of the medical community was resistant to his discovery. They felt that hand washing before each patient would be time consuming. In some journals, the profession was referred to as believing it was divinely blessed, and therefore it would be unreasonable to think the physicians themselves could be causing the disease. The germ theory was not clearly developed at this time. These circumstances presented challenges for the acceptance of Semmelweis’ discovery.
Semmelweis lacked important skills to implement change. He presented his work but did not publicize his discoveries for several years. When he did communicate his work, he did so in what is described as an angry, resentful, and, at times, threatening tone. He refused offers to address medical colleagues. Some viewed him as ‘tactless, volatile, single-minded, with a pompous’ personality. His responses to requests for proof were often rude. He clearly lacked patience and tolerance that is required when presenting a new concept to a group with established beliefs. Often success relies on one’s personal attributes and ability to communicate a new idea. Semmelweis had one half of the requirements needed to improve public health but lacked the other half – the ‘change agent’ skills. Spending time with Semmelweis helped me to realize some of the challenges I will face in the field of public health and some of the methods that can be utilized to overcome these challenges. It is apparent that historical figures in public health, like Ignaz Philipp Semmelweis, continue to make contributions to our learning years after they are gone.
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