In conversation with Donald Gillies
In the early 19th century, maternity hospitals around the world had a problem. Shortly after giving birth, as the womb was returning to its natural shape, a worrying amount of women were contracting, and dying from, a sudden and horrible disease; now known as puerperal fever. “A woman could be delivered on Monday, happy and well with her newborn baby on Tuesday, feverish and ill by Wednesday evening, delirious and in agony with peritonitis on Thursday, and dead on Friday or Saturday.”
On July 1st, 1846, a young Hungarian physician accepted the underwhelming post of “Assistant” at the maternity wards of Vienna General Hospital. Ignaz Philipp Semmelweis had come from a prosperous Budapest family. He had intended to study law but soon transferred to medicine in hopes of making a more profound difference – as he saw it – to the Austrian empire. He graduated in 1844, and Vienna General became his first full time position.
There could not have been a worse place to begin a medical internship. In Semmelweis’ own words, he walked into a "dreadful puzzle”. The two wards at Vienna General catered for between 7000 and 8000 women per year, which made it one of the largest hospitals in the world. The dreadful puzzle that Semmelweis found wasn’t just the high rates of puerperal fever, but the extreme difference in infection rates between the two wards.
In 1846, 11.4 percent of all mothers in the First Division contracted and died from the disease. In the adjacent Second Division, it was only 2.7 percent. Following a very “Popperian model of conjectures and refutations”, Semmelweis began considering various possible explanations; rejecting the ones which proved incompatible with the evidence at hand, and subjecting the rest to rigorous testing.
His first hypothesis was the widely held view that puerperal fever was due to “epidemic influences”. There was significant evidence to support this, as many diseases – malaria and cholera for example – were known to spread as epidemics. But this couldn’t explain the discrepancy between the two wards, nor the extraordinary fact that the death rate for “street births” was itself considerably lower than that of the First Division.
The next hypothesis was overcrowding. Again, another reasonable guess considering what was known about the higher prevalence of puerperal fever within the city’s “slums, barracks, ships, and workhouses.” But as it turned out, the reputation of the First Division had leaked out to Viennese society. Meaning that new patients regularly insisted on being treated in the Second Division, which made it – and not the First – the more crowded of the two wards.
Along similar lines, Semmelweis conjectured and then rejected the impact of diet, as well as other markers of overall health.
Next, the focus was on the medical staff, and a fear that students and nurses were dealing with patients in a “rough manner.” A large degree of this was xenophobia about “foreigners” not having the proper care, training, or compassion. To test this, Semmelweis moved staff around between the wards. He discovered no change in the rate of infections.
Psychological factors were then considered, such as the daily routine of the hospital priest. The First Division was set-up in such a way that the Priest would have to pass through five or so sub-wards to reach the “sickroom.” The concern was that seeing the priest, and knowing why he was there, might be a terrifying enough experience to affect the health of the watching patients. Semmelweis tested this hypothesis by persuading the priest to use a “roundabout route” instead, and to avoid announcing his presence with the customary tolling of a bell. For weeks the priest came and went unseen and in silence. Infection and mortality rates remained unchanged.
Another hypothesis had to do with delivery position. It was standard practice for women in the First Division to give birth on their backs, while in the Second Division they gave birth on their sides. At this stage Semmelweis was testing increasingly unlikely ideas, describing himself as “like a drowning man clutching at straw”; still, he continued to test. He introduced the practice of side births at the First Division; the rates of puerperal fever remained unaffected.
Then, in 1847, while struggling to find a new, plausible hypothesis to examine and test, one of Semmelweis’ colleagues cut his finger on a scalpel that was being used for an autopsy. Soon enough, this colleague became sick with fever and died a few agonising days later as a patient. For Semmelweis the similarities between his colleague’s sharply declining illness and the women with puerperal fever was hard to ignore. The scalpel seemed to have done more than simply puncture the skin. It might have carried with it “cadaveric matter.”
The role of micro-organisms in causing infection had not yet been discovered, but from this series of events Semmelweis had formed a crude theory about “blood poisoning”, and its path from dead to living bodies. He began to pay closer attention to the behaviour of his colleagues as they moved from the autopsy room and through the various sub-wards of the First Division. They all washed their hands, but only ever “superficially”, to the degree most would often retain a “characteristic foul odor”.
Semmelweis had a new theory to test. He issued new handwashing regulations, instructing all staff leaving the autopsy room to clean themselves with a stringent solution of chlorinated lime. For the first year that this procedure was tested, 1848, the mortality rate for puerperal fever in the First Division dropped suddenly to only 1.27 percent, outperforming even the Second Division which had a rate of 1.33 percent in the same year.
The reasons for the Second Division having lower rates than the First for all those previous years? By sheer chance, the Second Division’s patients were only attended to by midwives, whose training and hospital duties did not include the dissection of cadavers. This new theory also explained why “street births” didn’t suffer from higher rates of puerperal fever.
Soon Semmelweis had to broaden this thesis to capture new evidence. On one occasion, while still fighting with the details of his discovery, Semmelweis and some of his colleagues were doing the rounds of twelve women in a single maternity sub-ward. The first patient was suffering from “festering cervical cancer.” The doctors all thoroughly disinfected their hands before examining her, but only followed the “routine washing” before moving on to each new patient. Eleven of the twelve soon contracted and died from puerperal fever. Semmelweis had to amend his theory about “cadaveric material” being the problem, to also include “putrid matter derived from living organisms.”
He couldn’t possibly have understood at the time the full implications of his theory, nor how good of a Popperian he was being. But quite soon, Semmelweis was all too aware that he was on the verge of ushering-in a revolution in the history of medical science. And revolutions, as they are, tend to end badly for those in the vanguard.
If he was correct, then Semmelweis was effectively also saying that his fellow doctors – the people he needed to take his theory most seriously – were not just failing to save countless women from early deaths, but were, in fact, directly causing many of those deaths themselves. Instead of helping their patients, they were killing them, and all due to poor hygiene. Semmelweis was of course also implicating himself, but this small piece of self-effacement was cold comfort for the people he needed to convince.
It was a task he ultimately failed at, with the medical profession turning its back on him. When his contract at Vienna General came to its end in 1849, Semmelweis applied for an extension and was denied. Around the large medical institutions of Europe, Semmelweis went desperately to knock on doors and to apply for open positions. His reputation preceded him – he was rejected by every single one. Frozen out of medical practice, he eventually had little choice but to return to Hungary, where in 1865 he collapsed into madness and was committed to an asylum.
Grand, new ideas are often hard things to handle when they first arrive. Rather than building upon existing knowledge, they shatter it. Old paradigms and comfortable truths are not things to easily abandon, nor should they be. There are more reasons than just self-preservation for Semmelweis’ failure: he was slow to publish, there was a national prejudice towards his Hungarian heritage, and most significantly his theory was still young, it had criticism to still answer, explanations to flesh out, and boundaries still to be drawn.
Revolutionary science takes time to settle into the mind – people are accustomed to the world looking a certain way, and not another. But truth has the remarkable quality of not needing to be defended: it simply works! People who rely upon it will succeed, and those who don’t won’t! Whereas Semmelweis failed and felt “disgusted with his treatment”, his germ theory of disease did not. It succeeded without him, and it survives today, because, and only because, it remains true.
*** The Popperian Podcast #25 – Donald Gillies – ‘The Philosophy of Medical Discovery’ The Popperian Podcast: The Popperian Podcast #25 – Donald Gillies – ‘The Philosophy of Medical Discovery’ (libsyn.com)