2018 marks the 200th anniversary of the birth of Ignaz Semmelweis, a legendary figure in both Hungarian and international medicine, known as one of the forefathers of medical hygiene.
In the final part of his essay (you can read the first section in its entirety here, and the second portion here), Dr. László Rosivall, former Rector of Budapest’s Semmelweis University and President of the Semmelweis Memorial Committee, continues his reflections on the life, work, and legacy of the Hungarian medical giant.
This essay has been translated from the original Hungarian.
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In Budapest at St. Rókus Hospital and at the University
Semmelweis’ discovery was not understood by many, or was found to be too simple, not only in Vienna, but also in Hungary. After his return, on one of his first evenings home, colleagues from a populous group of doctors attacked him with the following:
Puerperal fever prevails every year at the St. Rókus Hospital, as it does right now, even though there are no medical students taking tests, whose hands were infected with decomposed organic matter.
Semmelweis responds thusly in his book:
All this was not in contrast to, but was actually in line with my views on the treatment of puerperal fever. Through closer examination, I was able to successfully determine that the St. Rókus Hospital Department of Obstetrics is not an independent class, but subordinated to the surgery; the chief physician of obstetrics is also the chief surgeon and a forensic physician. In addition, in the absence of a pathologist, autopsies are carried out by the department’s main doctors.
From 1851 until the summer of 1857 Semmelweis led St. Rókus Hospital’s maternity wards as the honorary chief doctor. During this time, of the 933 births they recorded, a total of eight (!) cases of death were caused by Puerperal fever, which is 0.85%!. In 1855, he was appointed professor of theoretical and practical obstetrics at the University of Pest. Here are a few lines from a letter written to the relevant authorities analyzing his clinic’s impossible material conditions.
Among other issues, this request notes:
“… the Obstetrics Clinic premises being unsanitary can be seen in the following as well.
The highest provisions regarding hospital equipment meeting a child’s bed is determined to be four square fathoms. Because the Obstetrics Clinic has 26 beds it should possess 104 square fathoms, making it the highest in accordance with the provisions of the Obstetrics Clinic, but only 41 are at its disposal; moreover, it is still missing the room, where a large number of students and midwives could be placed. Three rooms are so small that they can accommodate only half of the students and midwives, and the remaining two rooms are only so big that they could only hold each student and midwife if they were pressed together; from the point of view of the ones lying in the birthing bed, the air inside is harmfully stale, and every unbiased person can easily see this.
Near the windows of two rooms are the three chimneys of the chemical laboratory, which make these rooms’ temperatures increase unbearably, if specific kilns are fired.
The Obstetrics Clinic premises are such that not one single room can be designated exclusively as an infirmary. Due to the fact that patients lie scattered, puerperal fever – which is not a contagious disease, but in some circumstances can be spread to another individual- easily spreads to the healthy.
The Obstetrics Clinic premises is as follows: two windows look north, and six windows overlook the west courtyard. The northern air shaft is two fathoms and five feet wide; the height of the Obstetrics’ windows are surrounded by neighboring buildings’ fire walls. In this air shaft on the ground floor, the first and second floor are privies.
On the ground level, connected to the privy is the building’s cesspit, which wafts a penetrating stench of rotting contents. The ground floor is occupied by the elementary anatomy and pathology premises, and just below the windows of the Obstetrics clinic is the drainage channel, that contains all the fluids that the pathology department pours out. The first building is ruled by the Chemistry premises. In that the corner, where the north and west airshafts connect, the clinics’ morgue is found. The western airshaft is one fathom wide, and a three-meter-tall wall surrounds it, behind which lies a vacant lot. In the yard is a part of the morgue, on the ground floor again is the elementary and pathological anatomy premises, and the chemistry premises are located on the first floor.
It is not possible to explain the development of puerperal fever expounded by the made-up opinions of a subservient supplicant by quite simply saying: he is convinced that puerperal fever – always, without exception – is caused by decaying organic animal material.
The Honorable teaching staff can easily imagine the miserable position, if his conviction is upheld, an obstetrics professor is in if he can only close the window tightly, leaving those in birthing beds in an unsuitable place to be consumed by the same used air of a large number of medical students and future midwives, or he opens the windows, and allows, through them, the air from the two lightwells containing the infected, decaying organic animal substances into the delivery room.
No matter how dark the Obstetrics Clinic is in the present, if these premises are forced to continue in the way they are, then the future prospects are even darker …
“The situation is not any better in terms of presentation either. Since the Obstetrics Clinic does not have a separate presentation room, a lecturing professor of obstetrics, there in a guest role, presents where they currently let him: that is, in winter on the ground floor classroom of pharmacology, and in the surgery department in the summer. The fact that the presentation room in winter at seven o’clock in the morning – often by candlelight- is not too visited, is not in itself a great misfortune, because the theoretical obstetrics education is well-known to not be worth much among the faculty’s third year students, and the current system will be replaced soon by a far more simple one anyways …. My bold question is: are we entitled to condemn a village doctor who does not recognize a uterine rupture and who, in his naïveté, ligates an intestinal segment? Did he have any possibility during his studies, besides his best intentions, to learn the most difficult practical programs and make the knowledge of them absolutely his own? … Surgical education courses are irreplaceable nowadays in obstetrics …
Finally, there isn’t even the slightest opportunity to continue gynecological studies. However, this deficiency is often seen in other obstetric clinics. To avoid this, they usually establish a separate gynecology department in house. Shortly before this, for six years straight, the obstetrics professor of St. Rókus Hospital operated a small gynecological department – completely free – so the opportunity opened up for other hardworking students to be introduced to this important curriculum, and so an unspeakable amount of good was done on behalf of thousands of patients. However, the professor of obstetrics – against his will – was banned from continuing this practice. Tragic mistakes, such as putting a piece of intestine into your pocket, do not happen every day, but every day they treat hyperaemia rather than lashing down a polyp, and daily, they order rheumatism to be treated with aloe, instead of acknowledging the existing ulceration. The young doctor in the field of gynecology is essentially being sent without knowledge into the practice, which is really a concern to the maintaining of the fairer half of humanity, which constitutes the greater part of it. ”
The quote reveals not only the sad situation and reality of healthcare in nineteenth century Pest, but is also a good indicator of Semmelweis’ enlightened, progressive approach, medical and teaching commitments, and organizational readiness.
Forgetting and Rediscovering Semmelweis’ Personality and Teachings
Ignoring values, fate sometimes measures the lives of geniuses, the benefactors of humanity, with a tight-fist. This is what happened in the case of Semmelweis, who, at the age of only 47, died in the Landes Irrrenanstalt in Vienna, on August 13th, 1865. Uncovering the circumstances of his illness an death caused a great deal of problems not only for his family and colleagues, but apparently for the Viennese as well, who denied the existence of an autopsy report up until 1977, when finally they sent it by post, with a 112 year delay, to a researcher requesting it at the time.
Today it is clear from the records, what previously could only be assumed, that he suffered from a fatal disease: chronic and acute neurological impairment (progressive supranuclear palsy) caused by syphilis. The immediate cause of his death was an infection, spreading from an abscess, originating from a stab wound on his right hand he suffered in Hungary, which resulted in blood poisoning.
Problems with his neurological ssystem had already manifested in the last 5 years of his life, in his behavior, thinking, movement and gait. Although he was able to fulfill his routine work expertly, his scientific research work came to a halt, he experienced difficulties in his private life, he noticeably aged suddenly, suffered from sleep disorder and from bursts of anger.
It is unknown whether his numerous and neglected injuries and wounds, which were reported in his autopsy records, are the results of the harsh nursing practices of the psychiatric clinic and/or his outbreak of temper, but we know that his days were numbered even without the injuries and sepsis.
His original illness may have stemmed from the gynecological examination of Vienna’s poor maids without gloves, or from his school days prior to his marriage.
Neither the facts of this disease, nor the behavioral changes due to his illness were reasons for his long-lasting anonymity after his death – almost denial – the family name changes, and the silence around him.
When the famous Lister lectured in Hungary in 1875 about the surgical asepsis, he did not even mention the undisputed predecessor; no one from the audience- really nobody, not even his friends- stood up and mentioned that this theory’s successful and ground-breaking predecessor, Ignaz Semmelweis, had even existed.
Since then, experts have noted numerous factors of Hungarian and international resistance to Semmelweis and his ideas. Beyond the personal antagonisms and the researcher’s provocative youth, the era itself was not favorable to Semmelweis’ theory. After all, even the knowledge of bacteria had not spread yet, and doctors were looking for anatomical changes as the cause of the illness; at the time, only this explanation was acceptable. Virchow, the proposer of cytopathology also attacked Semmelweis’ theory persistently and in 1858 even gave a lecture explaining that the causes of puerperal fever are the simultaneous occurrence of weather conditions, diseases (erysipelas, purulence, etc.), lactation disorders and neurological excitement. Numerous obstetricians contended that Semmelweis’ experiences did not justify his teachings, or argued that his proposed doctrines are so simple, they could not be true.
A generation had to pass for the shackles of incomprehensible feelings of shame to be removed, for the great intellectual achievements of Semmelweis, which influenced the fate of the world, to receive their much-deserved celebration both at home and abroad. In 1891, his ashes were brought back to Hungary, and the Semmelweis Memorial Committee was established. In 1903, Alajos Strobl was commissioned to create a sculpture of the great doctor, which stands to this day in front of St. Rókus Hospital. In 1906, his collected works were published in German, and Tibor Győry’s Hungarian translation appeared in that same year as well. In 1941, his works published in English in the United States. George Sticker, a renowned historian, evaluated the book in the following way:
…due to the truth of the substance and the clarity of the presentation, it belongs among the best papers of medical literature, to be ranked with Robert Koch’s “Studies related to wound infection pathology”, and Pasteur’s “The cholera of chicken.
Slowly but surely, Semmelweis’ personality and discoveries are taking their rightful place, a fact reflected in their recognition by UNESCO.
An Old/New Work of Art Dedicated to the Preservation of Semmelweis’ Memory
The Budapest Medical Casino ruled in 1906 that once a year they would invite an outstanding physician for their Semmelweis Cup speech. For this, they had the Semmelweis cup created as well. Although the talks appeared in book form, the cup and the custom are almost forgotten.
Recently, I came across an interesting document at a flea market: a 14-page, small-format 1925 release of Emil Grosz’s cup speech, published by the Royal Hungarian University Press:
SEMMELWEIS – said university professor Dr. Emil Grosz during the Budapest Medical Casino’s Semmelweis-cup festivity held on the 30th of January 1925
The cup itself probably disappeared during the Second World War. It’s creator and an accurate description of the work are unknown, but an original photograph was found.
Per my request, the experienced and renowned John Szabo, a goldsmith and restorer, undertook the task of preparing a copy of the art piece, reflecting the era’s taste and outstanding quality, based on the photograph. The copy of the cup (we will call it a chalice to differentiate it from the original) was completed, and on behalf of living rectors of Semmelweis University, during the opening ceremony of the university’s 2014/15 semester, I handed it over to the University, saying
We wish the chalice’s pure silver material to symbolize it’s namesake’s nobility, the 86 pieces of mountain crystal and the amethyst his glorious spirit! The chalice, as the symbol of ancient covenants, shall express our fellowship! We hope that the Semmelweis-chalice contributes to keeping alive the memory of the world-renowned researcher and doctor. Alongside our University’s flag and scepter, it will become a new symbol of pioneering original traditions.
Conclusion
Semmelweis’ persistent research, scientific analysis of clinical statistical data, and animal experiments have borne fruit: the detection of the cause of the dreaded puerperal fever and preventative possibilities. “Not only did he discover the real cause of puerperal fever, but he also created and established the obstetric practice of antiseptic prophylaxis. In the meantime, he also laid the basis of today’s surgical and aseptic practices, whose principles and practices were developed in discovery of the puerperal fever pathogenesis and are rooted in the brilliant idea of Semmelweis. The discoveries of bacteriology and the work of Lister, Pasteur and Koch were only scientific evidence of Semmelweis’ intuitive findings.“
Semmelweis, who was undoubtedly the pioneer of clinical pathophysiological research, is now given a well-deserved, worthy respect by posterity, as atonement for the attacks by his contemporaries, and for bitterness based on misunderstanding.
‘The saviour of mothers’ is one of the prides of our nation, a role model for all of us. His work is recognized not only in our own country, but all over the world as well. The fruits and message of his short, tragic, but successful life, are eternal. Ignaz Semmelweis’ figure is on display in Chicago as well, amongst one of the world’s ten most important doctors, in the company of statues of Louis Pasteur and Wilhelm Conrad Röntgen.
In recent times, particularly in Anglo-Saxon areas, the new term “Semmelweis Reflex” appeared and has started to spread. It does not describe a medical phenomenon, but is rather an expression used to describe situations in which professionals or society reject significant discoveries and facts automatically, without enquiry and justification, almost reflexively. The phenomenon is not uncommon even today!
By Dr. László Rosivall
Translated by Gergely Edward Nagy and Tom Szigeti
Image via PBS
