B O V I N E SThe Ironies of Misplaced Assumptions in Biology
| B O V I N E S The Ironies of Misplaced Assumptions in Biology |
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The Tragic Hero of Childbed Fever* by Douglas Allchin The situation in the Vienna hospital in the mid-1840s was certainly grim. The hospital offered medical care to indigent mothers, but in one maternity ward a woman faced a ghastly one-in-ten chance of dying from childbed fever (today's puerperal sepsis, a bacterial infection). Could nothing be done? Enter Ignaz Semmelweis who, so popular stories typically tell us, "notices that [the attending medical] students move between the dissection room and the delivery room without washing their hands.". The students offering care are themselves infecting the patients with putrid matter from cadavers! Semmelweis institutes handwashing and the mortality rate soon drops by an impressive 90 percent. However, "despite the dramatic reduction in the mortality rate in Semmelweis' ward, his colleagues and the greater medical community greeted his findings with hostility or dismissal." Semmelweis's hypothesis "was largely ignored, rejected or ridiculed. He was dismissed from the hospital and harassed by the medical community in Vienna, which eventually forced him to move to Budapest." "Despite various publications of results where hand-washing reduced mortality to below 1%, Semmelweis's observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. Some doctors were offended at the suggestion that they should wash their hands and Semmelweis could offer no acceptable scientific explanation for his findings." "The years of controversy and repeated rejection of his work by the medical community caused him to suffer a mental breakdown. Semmelweis died in 1865 in an Austrian mental institution. Some believe that his own death was ironically caused by puerperal sepsis," the very disease he had tried to prevent. "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." Such is the apparently tragic tale of Ignaz Semmelweis, "savior of mothers" and "an unrewarded hero of medicine." The common story is a morality tale, where science offers prospective salvation, but fails. The sense of tragedy is poignant. And the emotion seems integral to the implicit lesson about the value of science, evidence, and open-mindedness—versus prejudice and disdain. By evoking a sense of unjustified loss, the stories render a set of unmet (as well as unstated) expectations. Others should have accepted Semmelweis's claims because, ultimately, he was right. Others should have listened to him and honored him because his scientific understanding could save lives. Heroic science, it seems, must have heroes, even if tragic ones. And villains. The heroes require ideal virtues, the villains the opposite. Yet these assumptions—these sacred bovines—can distort our understanding of the nature of science, by shaping how the very history is told. By delving a bit more fully into the history, behind the standard tropes of heroic tragedy, one can gain a deeper, less mythic, more authentic understanding of scientific practice.
First, if Semmelweis was right about handwashing, why was his work rejected? In conventional stories, the critics of Semmelweis were unreasonable. That is part of the genre. Anything less would diminish Semmelweis's heroic stature. In a sharp dichotomy, the evidence favors Semmelweis exclusively, while his critics were biased by "unscientific" factors. Their criticism apparently betrays personal interests and social ideology. Some stories say that Semmelweis was Hungarian and portray him as a victim of Austrian prejudice against foreigners. At the time, however, Vienna was viewed as "the Mecca of Medicine." In an effort to reform the earlier excesses of bloodletting, purgatives, and other questionable treatments, doctors endorsed a doctrine of therapeutic nihilism. "For fear of distorting symptoms, doctors refused to prescribe any remedies." They were cautious in their conclusions. This was a valuable corrective. Doctors discarded artificial aids during childbirth, trusting nature to do its part. As such, the approach embodied the Hippocratic motto, "first do no harm." Our modern practices of diagnostics and loose bandaging of wounds began here. All this reflected a major advance in medicine. Semmelweis's claim about an ill-defined cause of childbed fever could justly prompt skepticism (even now, a hallmark of good science). Without knowing a disease's cause, one could easily err—and be diverted from finding the real cause. Indeed, the stories often fail to mention that Semmelweis was not universally rejected. Many colleagues immediately adopted handwashing practice and advocated his views as far away as Paris and London. One journal editor compared the importance of the discovery to Jenner's smallpox inoculations. Semmelweis's results appeared in medical journals across Europe—in Austria, England, France, and Denmark. The practice of handwashing was adopted in England and much of Germany, at least. Semmelweis did help widely transform practice, lowering the incidence of childbed fever. Yet Semmelweis also stridently expounded an explanation that went beyond the available evidence. He attributed all cases of the disease to decaying matter, even where none was evident or seemed plausible. While we may readily accept his view as championing our modern concept of a single common cause, observations at the time did not support this bold claim. Accordingly, most took exception to just this aspect of Semmelweis's ideas. One sympathetic reviewer noted that his claims: go too far and are too one-sided. In any case, Semmelweis owes us a proof that only the one etiological condition that he identifies is responsible. Nearly every obstetrician is still of the opinion that a large number of cases of illness remain that originate from a different cause, a cause admittedly yet unknown.Doctors rejected Semmelweis's overstated theory even while adopting handwashing. In historical context, their selective judgment was based on evidence. The need for washing hands seems obvious to us today because the concept of disease-causing germs is so familiar. That sense of ordinariness did not exist in the mid-nineteenth century. Physicians were certainly trying to isolate causes of diseases. They especially looked to anatomy for clues, correlating damaged structures with functional losses and symptoms. Yet the anatomical aspects of childbed fever were hardly uniform: why, with such diversity of effect, would one assume a single cause? Other theories looked at environmental factors, and how diseases might spread via foul air, or miasmas. In Boston, Oliver Wendell Holmes similarly tracked the contagion of childbed fever to physicians' handling of patients. But even he acknowledged a possible role for miasmas. In London, John Snow was facing similar challenges in persuading peers that cholera might be caused just by isolated sources of sewage-contaminated water. Semmelweis's explanation might fit, but in historical context the evidence was not complete or absolutely conclusive. Calling the evidence "unequivocal" thus misportrays real, historically situated science. But it does enhance the drama. Adversaries who deny "unequivocal" evidence generate emotional conflict. They amplify the hero's struggle. Such literary embellishments help transform ordinary history into a larger-than-life myth. A portrayal of authentic science is traded for emotional engagement. The case of childbed fever is indeed tragic, but perhaps only because truths do not announce themselves. Discovery is a historical process. And science's institutional norms for reliability foster caution. Handwashing practice could be adopted at the same time Semmelweis's theory was not because, ironically, evidence emerges piecemeal and science is inherently conservative. Nor did Semmelweis always seem to help his own cause. One finds historical hints of a rather prickly and irascible personality. Semmelweis was not able to renew his temporary position at the Vienna hospital. One could blame the hospital director. He could have retaliated against Semmelweis for faulting programs he introduced, including adding dissections to the medical training and promoting the care of destitute patients for educational purposes. But documents indicate larger institutional power struggles. Furthermore, Semmelweis was obsessed with childbed fever. His passion may have eclipsed his other responsibilities. Neglect of some of his duties could easily have justified not extending his appointment. His zealous theoretical proclamations did not engender respect. Semmelweis ultimately decided to leave Vienna, but mysteriously without even consulting or informing supportive friends. Semmelweis also seemed reluctant to publish his findings, while expecting others to heed them. He acknowledged his dislike for writing, possibly rooted in unpleasant experiences in early schooling. His book appeared finally in 1861. Afterwards he became increasingly intolerant of others who did not agree with him. He seems not to have tried resolving disagreements with critics or seeking aid from supporters. Rather, his unsolicited letters to critics were, as characterized modestly by one historian, "highly polemical and superlatively offensive." For example, to one German doctor he wrote: I declare before God and the world that you are a murderer and the "History of Childbed Fever" would not be unjust to you if it memorialized you as a medical Nero, in payment for having been the first to set himself against my life-saving theory.To another he alleged: You, Herr Professor, have been a partner in this massacre.Ultimately, few popular stories mention Semmelweis's often dismissive tone. That does not align with the heroic ideal. Instead, his critics, as implicit villains, receive all the blame. They are portrayed negatively, as biased by nationalism, hostility, pride, and pettiness. The asymmetry sharpens the sense of conflict—or of moralistic melodrama. It invites the reader to sympathize with the main character's struggle. But one cannot justly blame the critics for Semmewleis's own antagonism. Scientific consensus is inevitably social. Persuading peers is one of the challenges. Individual personality and demeanor matter. In retrospect, one can only note sadly the psychology that seemed to increasingly isolate Semmelweis as he aged: describing a tragic hero of another sort entirely. Ironically, many of the stories about Semmelweis do not profile very well how he made his noteworthy discovery—what may contribute most to understanding the nature of science. The problem of childbed fever was well known, even internationally. In some stories, however, one gets the impression that only Semmelweis-as-bold-hero tried to remedy the problem. The mortality rate in the Viennese maternity ward was also well known, especially when contrasted with the lower rate in the hospital's other ward. Nor was the difference between the wards—midwives in one and medical students in the other—a subtle secret awaiting notice. Yet this observation alone was hardly enough to indicate the source of the problem or its solution. Semmelweis earns credit in part for his systematic investigation. He addressed multiple possible explanations in turn, subjecting each to rigorous scrutiny or testing. He considered birth delivery postures, the roughness of handling patients, overcrowding, ventilation, diet, the unlikely effect of clergy attending the dying, localized miasmas, and other possibilities. Semmelweis persisted, gradually discounting each as unsupported by evidence. He argued strongly from exceptions and statistics. His later test of handwashing, in fact, was meaningful in part because he could rule out these many alternatives. A story in which Semmelweis considers only his final hypothesis fosters an impression of immediate insight, or genius. That may endow the hero with exceptional intellect. But it misrepresents the process of science. Here, Semmelweis's sheer perseverance through mundane trial and error was significant. Ultimately Semmelweis was clued through happenstance. As with the case of Fleming and penicillin (essay 21), it might seem like a monumental insight if one disregards the many details that naturally threaded the thought process together. In this case, a colleague of Semmelweis died unexpectedly. One can imagine the puzzle when an autopsy revealed pathologies resembling those he already knew from the awful deaths of his maternity patients. Semmelweis inferred that similar effects would be due to a similar cause, even though childbed fever was considered related to the uterus and thus to occur exclusively among women. Had his friend contracted the disease from a patient? With regular but harmless exposure to such cases, that would seem unlikely. Semmelweis also learned that his friend had cut himself during an autopsy days before he died. He concurred with others that cadaverous material entering the wound had undoubtedly led to the illness. These particular facts, taken together, indicated that childbed fever, too, probably originated with the cadavers. That would explain the well known difference between the two wards, since only the medical students (not midwives in the second ward) participated in dissecting corpses. Following his methodical approach, Semmelweis then subjected the notion to further testing through handwashing. A fortunate, unplanned convergence of events showed Semmelweis—as for any of us—the key connection. No brute deduction. No rare insight of genius. Just a fortuitous combination of individual circumstances. Semmelweis did not know or speculate how putrid matter from corpses could cause disease. When he sought a way to rid the hands of the disease material, he relied on smell only. Washing hands in water, even with soap, was not enough. The odor remained. Only chlorinated lime solution seemed strong enough. While it proved effective, he could not say why. There was a limit to Semmelweis's understanding. That became clearer later when germ theory emerged. There had been no hint of microorganisms behind the practice of handwashing. So implying, as some stories do, that Semmelweis anticipated or contributed to that very theory, misportrays the historical context. Not even scientific heroes can transcend the limits of their time. But again, that impression would contribute further to a sense that Semmelweis was "ahead of his time," and tragically unappreciated. The final element in most stories about Semmelweis are the circumstances of his death. Semmelweis's outlook sadly deteriorated and developed into anti-social behavior that even his wife could not tolerate. Many stories try to relate this to the scientific tale by making the critics-as-villains directly responsible for the psychological decline. Whatever Semmelweis's own view—and his antipathies and anxieties have been noted above—this attribution is historically unwarranted. Eventually, his family and friends contrived to commit him to an asylum. But he resisted, was beaten, and died soon thereafter of a septic infection. An unfortunate end for anyone. But in this case, the downfall and ironic closure, although not really relevant to the science, seems to many too tragic not to mention. Is it not sufficient to note merely that Semmelweis suffered a personal sense of neglect, never fully appreciating the value of his own impact? Or does the rhetorical allure of the tragic hero demand more? Throughout, this essay has made clear, I hope, that the story of the case of childbed fever has been shaped and widely retold, trimmed and falsely elaborated, all to cast Ignaz Semmelweis in the genre of a tragic hero. The history is sacrificed to achieve a more standardized drama. But when the history is misleading, so too is the portrayal of the nature of science. Yet the real story is just as compelling. From the Semmelweis case one may reflect more generally about historical stories in science. Heroes need not be perfect to be heroes. Indeed, how much more human and accessible they seem if we understand their flaws and limits, as well as their triumphs. The primary tragedy of this case may be failing to recognize that science can often be effective without, ironically, always exhibiting what we imagine to be essential ideals.
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