Editing Ignaz Semmelweis (section)

==Efforts to reduce childbed fever==
Semmelweis's hypothesis, that there was only one cause, that all that mattered was cleanliness, was extreme at the time and was largely ignored, rejected, or ridiculed. He was dismissed from the hospital for political reasons and harassed by the medical community in Vienna, being eventually forced to move to Budapest.

Semmelweis was outraged by the indifference of the medical profession and began writing open and increasingly angry letters to prominent European obstetricians, at times denouncing them as irresponsible murderers. His contemporaries, including his wife, believed he was losing his mind, and in 1865, nearly 20 years after his breakthrough, he was committed to the ''Landesirrenanstalt [[Döbling]]'' (provincial lunatic asylum). He died there of [[Sepsis|septic shock]] only 14 days later, possibly as the result of being severely beaten by guards. Semmelweis's practice earned widespread acceptance only years after his death when [[Louis Pasteur]] further developed the germ theory of disease, offering a theoretical explanation for Semmelweis's findings. He is considered a pioneer of antiseptic procedures.

===Conflict with established medical opinion===
{{Main|Contemporary reaction to Ignaz Semmelweis}}
[[File:Monthly mortality rates 1841-1849.png|thumb|500px|[[Puerperal fever]] monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841–1849. Rates drop markedly when Semmelweis implemented chlorine [[hand washing]] mid-May 1847 [[Historical mortality rates of puerperal fever#Monthly mortality rates for birthgiving women 1841–1849|(see rates)]].]]

Semmelweis's observations conflicted with the established scientific and medical opinions of the time. The theory of diseases was highly influenced by ideas of an imbalance of the basic "[[Humorism|four humours]]" in the body, a theory known as [[dyscrasia]], for which the main treatment was [[bloodletting]]s. Medical texts at the time emphasized that each case of disease was unique, the result of a personal imbalance, and the main difficulty of the medical profession was to establish precisely each patient's unique situation, case by case.

The findings from autopsies of deceased women also showed a confusing multitude of physical signs, which emphasized the belief that puerperal fever was not one, but many different, yet unidentified, diseases.

The rejection of Semmelweis's empirical observations is often traced to [[belief perseverance]], the psychological tendency of clinging to discredited beliefs. Also, some historians of science{{sfn|Nissani|1995|pp=165–183}} argue that resistance to path-breaking contributions of obscure scientists is common and "constitutes the single most formidable block to scientific advances."

As a result, his ideas were rejected by the medical community. Other, more subtle, factors may also have played a role. Some doctors, for instance, were offended at the suggestion that they should wash their hands, feeling that their social status as gentlemen was inconsistent with the idea that their hands could be unclean.{{sfn|Carter|Carter|2005|p=9}}{{efn-ua|See for instance [[Charles Delucena Meigs]], in which there is a link to an original source document.}}

Semmelweis's results lacked scientific explanation at the time. That became possible only in the 1860s and 1870s, when [[Louis Pasteur]], [[Joseph Lister]], and others further developed the germ theory of disease.

During 1848, Semmelweis widened the scope of his washing protocol, to include all instruments coming in contact with patients in labour, and used mortality rates [[time series]] to document his success in virtually eliminating puerperal fever from the hospital ward.

===Hesitant publication of results and first signs of trouble===
[[File:Streptococcus pyogenes.jpg|right|thumb|''[[Streptococcus pyogenes]]'' (red-stained spheres) is responsible for most cases of severe [[puerperal fever]]. It is commonly found in the throat and [[nasopharynx]] of otherwise healthy carriers.]]
Toward the end of 1847, accounts of the work of Semmelweis (as well as the similar conclusions of [[Oliver Wendell Holmes Sr.]], working in the United States of America){{sfn|Lane|Blum|Fee|2010}} began to spread around Europe. Semmelweis and his students wrote letters to the directors of several prominent maternity clinics describing their recent observations. [[Ferdinand Ritter von Hebra|Ferdinand von Hebra]], the editor of a leading Austrian medical journal, announced Semmelweis's discovery in the December 1847{{sfn|Hebra|1847}} and April 1848{{sfn|Hebra|1848}} issues of the medical journal. Hebra claimed that Semmelweis's work had a practical significance comparable to that of [[Edward Jenner]]'s introduction of cowpox inoculations to prevent smallpox.{{sfn|Carter|Carter|2005|pp=54–55}}

In late 1848, one of Semmelweis's former students wrote a lecture explaining Semmelweis's work. The lecture was presented before the [[Royal Medical and Surgical Society]] in London and a review published in ''[[The Lancet]]'', a prominent medical journal.{{efn-ua|The author of the lecture was Charles Henry Felix Routh, but it was delivered by Edward William Murphy since Routh was not a Fellow of the Royal Medical and Surgical Society. (Lecture: ''On the Causes of the Endemic Puerperal Fever of Vienna'', Medico-chirurgical Transactions 32(1849): 27–40. Review: Lancet 2(1848): 642f.) For a list of some other reviews, see Frank P. Murphy, "Ignaz Philipp Semmelweis (1818–1865): An Annotated Bibliography," Bulletin of the History of Medicine 20 (1946), 653–707: 654f.{{sfn|Semmelweis|1983|p=175}}}} A few months later, another of Semmelweis's former students published a similar essay in a French periodical.{{sfn|Wieger|1849}}

As accounts of the dramatic reduction in mortality rates in Vienna were being circulated throughout Europe, Semmelweis had reason to expect that the chlorine washings would be widely adopted, saving tens of thousands of lives. Early responses to his work also gave clear signs of coming trouble, however. Some physicians had clearly misinterpreted his claims.{{Who|Simpson is not an example|date=January 2021}} Additionally, initial responses to Semmelweis's findings tended to downplay their significance by arguing that ''he had said nothing new''.{{sfn|Semmelweis|1983|p=31}} [[James Young Simpson]], for instance, saw no difference between Semmelweis's groundbreaking findings and the idea presented in an 1843 paper by Oliver Wendell Holmes Sr.{{sfn|Holmes|1842}} that childbed fever was contagious (''i.e''. that infected persons could pass the infection to others).{{sfn|Semmelweis|1983|pp=10–12}}

In fact, Semmelweis was warning against all decaying organic matter, not just against a specific contagion that originated from victims of childbed fever themselves. This misunderstanding, and others like it, occurred partly because Semmelweis's work was known only through secondhand reports written by his colleagues and students. At this crucial stage, Semmelweis himself had published nothing. These and similar misinterpretations continued to cloud discussions of his work throughout the century.{{sfn|Carter|Carter|2005|p=56}}

Some accounts emphasize that Semmelweis refused to communicate his method officially to the learned circles of Vienna,{{sfn|Reid|1975|p=37}} nor was he eager to explain it on paper.

===Political turmoil and dismissal from the Vienna hospital===
In 1848, [[Revolutions of 1848|a series of tumultuous revolutions]] swept across Europe. The resulting political turmoil would affect Semmelweis's career. In Vienna on 13 March 1848, students demonstrated in favor of increased [[civil rights]], including trial by jury and [[freedom of expression]]. The demonstrations were led by medical students and young faculty members and were joined by workers from the suburbs. Two days later in Hungary, demonstrations and uprisings led to the [[Hungarian Revolution of 1848]] and a full-scale war against the ruling [[House of Habsburg|Habsburgs]] of the [[Austrian Empire]]. In Vienna, the March demonstration was followed by months of general unrest.{{sfn|Carter|Carter|2005|p=57}}

No evidence indicates Semmelweis was personally involved in the events of 1848. Some of his brothers were punished for active participation in the Hungarian independence movement, and the Hungarian-born Semmelweis likely was sympathetic to the cause. Semmelweis's superior, professor [[Johann Klein]], was a conservative Austrian, likely uneasy with the independence movements and alarmed by the other [[revolutions of 1848 in the Habsburg areas]]. Klein probably mistrusted Semmelweis.{{sfn|Carter|Carter|2005|p=59}}

When Semmelweis's term was about to expire, [[Carl Braun (obstetrician)|Carl Braun]] also applied for the position of "assistant" in the First Clinic, possibly at Klein's own invitation. Semmelweis and Braun were the only two applicants for the post. Semmelweis's predecessor, [[Franz Breit (obstetrician)|Franz Breit]], had been granted a two-year extension.{{sfn|Semmelweis|1983|pp=61, 105}} Semmelweis's application for an extension was supported by [[Joseph Škoda]] and [[Carl Freiherr von Rokitansky|Carl von Rokitansky]] and by most of the medical faculty, but Klein chose Braun for the position. Semmelweis was obliged to leave the obstetrical clinic when his term expired on 20 March 1849.{{sfn|Carter|Carter|2005|p=61}}

The day his term expired, Semmelweis petitioned the Viennese authorities to be made [[Privatdozent|docent]] of obstetrics. A docent was a private lecturer who taught students and who had access to some university facilities. At first, because of Klein's opposition, Semmelweis's petition was denied. He reapplied, but had to wait until 10 October 1850 (more than 18 months), before finally being appointed docent of 'theoretical' obstetrics.{{sfn|Semmelweis|1983|p=105}} The terms refused him access to cadavers and limited him to teaching students by using leather-fabricated [[mannequin]]s only. A few days after being notified of his appointment, Semmelweis left Vienna abruptly and returned to [[Pest, Hungary|Pest]]. He apparently left without so much as saying goodbye to his former friends and colleagues, a move that might have offended them.{{sfn|Semmelweis|1983|p=52}} According to his own account, he left Vienna because he was "unable to endure further frustrations in dealing with the Viennese medical establishment".{{sfn|Carter|Carter|2005|p=67}}

===Life in Budapest===
[[File:Semmelweis Ignác és felesége 1857 Canzi Ágost.jpg|thumb|300px|Wedding portraits of Semmelweis and Mária Weidenhofer by [[:de:August Canzi|Ágost Canzi]] (1857)]]
During 1848–1849, some {{nowrap|70,000}} troops from the [[Habsburg]]-ruled [[Austrian Empire]] thwarted the [[Hungarian Revolution of 1848|Hungarian independence movement]], executed or imprisoned its leaders and in the process destroyed parts of [[Pest, Hungary|Pest]]. Semmelweis, upon arriving from the Habsburg Vienna in 1850, likely was not warmly welcomed in Pest.

On 20 May 1851, Semmelweis took the relatively insignificant, unpaid, honorary head-physician position of the obstetric ward of Pest's small [[Saint Roch|Szent Rókus]] Hospital. He held that position for six years, until June 1857.{{sfnm|1a1=Semmelweis|1y=1983|p=107|2a1=Carter|2a2=Carter|2y=2005|2p=68}} Childbed fever was rampant at the clinic; at a visit in 1850, just after returning to Pest, Semmelweis found one fresh corpse, another patient in severe agony, and four others seriously ill with the disease. After taking over in 1851, Semmelweis virtually eliminated the disease. During 1851–1855, only eight patients died from childbed fever out of 933 births (0.85%).{{sfn|Semmelweis|1983|pp=106–108}}

Despite the impressive results, Semmelweis's ideas were not accepted by the other obstetricians in Budapest.{{sfn|Carter|Carter|2005|p=69}} The professor of obstetrics at the [[University of Pest]], [[Ede Flórián Birly]], never adopted Semmelweis's methods. He continued to believe that puerperal fever was due to uncleanliness of the bowel.{{sfn|Semmelweis|1983|p=24}} Therefore, extensive purging was the preferred treatment.

After Birly died in 1854, Semmelweis applied for the position. So did Carl Braun—Semmelweis's nemesis and successor as [[Johann Klein]]'s assistant in Vienna—and Braun received more votes from his Hungarian colleagues than Semmelweis did. Semmelweis was eventually appointed in 1855, but only because the Viennese authorities overruled the wishes of the Hungarians, as Braun did not speak Hungarian. As professor of obstetrics, Semmelweis instituted chlorine washings at the University of Pest [[Maternity hospital|maternity clinic]]. Once again, the results were impressive.{{sfn|Carter|Carter|2005|p=69}}

Semmelweis declined an offer in 1857 to become professor of obstetrics at the [[University of Zurich]].{{sfn|Semmelweis|1983|p=56}} The same year, Semmelweis married Mária Weidenhofer (1837–1910), 19 years his junior and the daughter of a successful merchant in Pest. They had five children.

===Response by the medical community===
{{Main|Contemporary reaction to Ignaz Semmelweis|}}
[[File:Ignaz Semmelweis 1861 Etiology front page.jpg|thumb|right|Semmelweis's main work: ''Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers'', 1861 (front page)]]
[[File:Yearly mortality rates 1784-1849.png|thumb|500px|In his 1861 book, Semmelweis presented evidence to demonstrate that the advent of [[pathological anatomy]] in Wien (Vienna) in 1823 (vertical line) was accompanied by the increased incidence of fatal childbed fever. The second vertical line marks introduction of chlorine [[hand washing]] in 1847. Rates for the Dublin [[Rotunda Hospital|Rotunda maternity hospital]], which had no pathological anatomy, are shown for comparison ([[Historical mortality rates of puerperal fever#Yearly mortality rates for birthgiving women 1784–1849|view rates]]).]]
Semmelweis's views were much more favorably received in the [[United Kingdom]] than on the continent, but he was more often cited than understood. The British consistently regarded Semmelweis as having supported their theory of contagion. A typical example was W. Tyler Smith, who claimed that Semmelweis "made out very conclusively" that "[[Homeopathy|miasms]] derived from the dissecting room will excite puerperal disease."{{sfnm|1a1=Semmelweis|1y=1983|1p=176|2a1=Tyler Smith|2y=1856|2p=504}} One of the first to respond to Semmelweis's 1848 communications was [[James Young Simpson]], who wrote a stinging letter. Simpson surmised that the British obstetrical literature must be totally unknown in Vienna, or Semmelweis would have known that the British had long regarded childbed fever as contagious and would have employed chlorine washing to protect against it.{{sfn|Semmelweis|1983|p=174}}

In 1856, Semmelweis's assistant Josef Fleischer reported the successful results of hand washing activities at St. Rochus and Pest maternity institutions in the'' Viennese Medical Weekly ''(''[[Wiener Medizinische Wochenschrift]]'').{{sfn|Carter|Carter|2005|p=69}} The editor remarked sarcastically that it was time people stopped being misled about the theory of chlorine washings.{{sfnm|1a1=Semmelweis|1y=1983|1p=24|2a1=Fleischer|2y=1856|2p=536}} Two years later, Semmelweis published his own account of his work in an essay entitled "The Etiology of Childbed Fever".{{efn-ua|The report was "''A gyermekágyi láz kóroktana''" ("The Etiology of Childbed Fever") published in ''Orvosi hetilap'' '''2''' (1858); a translation into German is included in Tiberius von Györy's, ''Semmelweis's gesammelte Werke'' (Jena: Gustav Fischer, 1905), 61–83. This was Semmelweis's first publication on the subject of puerperal fever. According to Győry, the substance of the report was contained in lectures delivered before the ''Budapester Königliche Ârzteverein'' in the spring of 1858.{{sfn|Semmelweis|1983|p=112}}}} Two years after that, he published a second essay, "The Difference in Opinion between Myself and the English Physicians regarding Childbed Fever".{{efn-ua|The article was originally published as: Ignaz Philipp Semmelweis, "A gyermekágyi láz fölötti véleménykülönbség köztem s az angol orvosok közt" Orvosi hetilap '''4''' (1860), 849–851, 873–876, 889–893, 913–915.{{sfn|Semmelweis|1983|p=24}}}} In 1861, Semmelweis published his main work ''Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers'' (German for "The Etiology, Concept and Prophylaxis of Childbed Fever").{{efn-ua|[http://real-eod.mtak.hu/2450/ Digital copy of Semmelweis' book]}} In his 1861 book, Semmelweis lamented the slow adoption of his ideas: "Most medical lecture halls continue to resound with lectures on epidemic childbed fever and with discourses against my theories. [...] 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".{{sfn|Semmelweis|1983|p=169}}{{efn-ua|The monograph to which Semmelweis refers was a work by Heinrich Silberschmidt, "Historisch-kritische Darstellung der Pathologie des Kindbettfiebers von den ältesten Zeiten bis auf die unserige", published 1859 in [[Erlangen]], which mentions Semmelweis only incidentally and without dealing at all with the transfer of toxic materials by the hands of physicians and midwives. The book was awarded a prize by the medical faculty of Würzburg at the instigation of [[Friedrich Wilhelm Scanzoni von Lichtenfels]]{{sfnm|1a1=Hauzman|1y=2006|2a1=Semmelweis|2y=1983|2p=212}}}}

In a textbook, Carl Braun, Semmelweis's successor as assistant in the first clinic, identified 30 causes of childbed fever; only the 28th of these was cadaverous infection. Other supposed causes included conception and pregnancy, uremia, pressure exerted on adjacent organs by the shrinking uterus, emotional traumata, mistakes in diet, chilling, and atmospheric epidemic influences.{{sfn|Braun|1857}}{{efn-ua|Carl Braun's thirty causes appear in his ''Lehrbuch der Geburtshülfe''. In the first of these, published in 1855, he mentions Semmelweis in connection with his discussion of cause number 28, cadaverous poisoning. In the later version, however, although he discusses the same cause in the same terms, all references to Semmelweis have been dropped.{{sfn|Semmelweis|1983|p=34}}}}

Despite this opposition, Braun, who was Assistant in the First Division in the period April 1849 to summer 1853, maintained a relatively low mortality rate in the First Division, roughly consistent with the rate Semmelweis himself achieved, as [[Historical mortality rates of puerperal fever#Mortality rates at the Vienna General Hospital|mortality rates]] in the period April 1849 to end 1853 show. These results suggest that Braun continued, assiduously, to require the chlorine washings.{{sfn|Jadraque|Carter|2017}}

At a conference of German physicians and [[natural scientist]]s, most of the speakers rejected his doctrine, including the celebrated [[Rudolf Virchow]], who was a scientist of the highest authority of his time. Virchow's great authority in medical circles contributed potently to Semmelweis' lack of recognition.{{sfn|Hauzman|2006}} [[Ede Flórián Birly]], Semmelweis's predecessor as Professor of Obstetrics at the University of Pest, never accepted Semmelweis's teachings; he continued to believe that puerperal fever was due to uncleanliness of the bowel.{{sfn|Semmelweis|1983|p=4}} [[August Breisky]], an obstetrician in Prague, rejected Semmelweis's book as "naïve" and he referred to it as "the Koran of puerperal theology". Breisky objected that Semmelweis had not proved that puerperal fever and [[pyemia]] are identical, and he insisted that other factors beyond decaying organic matter certainly had to be included in the [[etiology]] of the disease.{{sfnm|1a1=Semmelweis|1y=1983|1p=41|2a1=Breisky|2y=1861|2p=1}} [[Carl Edvard Marius Levy]], head of the Copenhagen maternity hospital and an outspoken critic of Semmelweis's ideas, had reservations concerning the unspecific nature of cadaverous particles and that the supposed quantities were unreasonably small.{{sfnm|Semmelweis|1983|pp=180–181|Levy|1848}} In fact, [[Robert Koch]] later used precisely this fact to prove that various infecting materials contained living organisms which could reproduce in the human body; that is, since the poison could be neither chemical nor physical in operation, it must be biological.{{sfn|Semmelweis|1983|p=183}}

It has been contended that Semmelweis could have had an even greater impact if he had managed to communicate his findings more effectively and avoid antagonising the medical establishment, even given the opposition from entrenched viewpoints.{{sfn|Nuland|2003}}