- Email: [email protected]
Historical perspective
Phillip A. Dumesic and Daniel A. Dumesic, MD
T
cosmic-telluric nature, challenged Semmelweis’ logic, which sought a more rational explanation of the disease.* In July 1846, Semmelweis finally became Assistant Director in the First Division, where he soon initiated measures to combat the rate of puerpetal fever. Not believing that infectious vapors existed in the atmo-
hroughout history, a few courahave fought geous clinicians against the medical profession for the sake of humanity. One such clinician, Ignaz Philipp Semmelweis, identified puerperal fever as a contagious disease, challenging the popular belief of the time that disease resulted from atmospheric vapors.’ In voicing his opinion, Semmelweis received criticism from the medical profession and died fighting its prominent physicians, never seeing his scientific contributions revolutionize medicine. Ignaz Philipp Semmelweis was born in Buda, Hungary on July 1, 1818. After studying philosophy at the University of Pest, he traveled to Vienna in 1837.2 Initially, Semmelweis was a law student at the University ofvienna, but soon found his true calling in life when a friend invited him to an anatomy class at the Vienna Medical School. Realizing that medicine suited him better than law, Semmelweis enrolled in medical school and graduated in March 1844, with a strong interest in obstetrics.’ Semmelweis immediately applied for a position as Assistant Director of the Maternity Clinics at Vienna’s General Hospital, the Allgemeines Krakenhaus. While waiting for his appointment, he toured the hospital, noting that it contained two separate obstetrical divisions: obstetrical medical students received their training in its First Division, while midwives conducted their own deliveries in its Second Division. Other than personnel, all other conditions of the divisions were the same. Yet, puerperal fever had routinely killed threefold more women in the First Division than the Second Division, increasing to tenfold in 1846.3 The discrepancy between divisions in maternal mortality, which was commonly attributed to an unknown epidemic influence of an atmospheric-
[Kolletschka] received a punctured wound of the finger from the knife of one of the pupils Professor Kolletschka thereupon became affected with lymphangitis, phlebitis in the same upper extremity, and he died from pleurisy, pericarditis, peritonitis, and meningitis it rushed to my mind with irresistible clearness that the disease from which Kolletschka had died was identical with that from which I had seen so many hundreds of lying-in women die.
From the Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology, Mayo Clmx, Rochester, Minnesota.
Semmelweis further concluded that the disease was transmitted to patients by “cadaveric particles” that adhered to the examining hands of phy-
sphere,
he stated*:
Now, if the atmospheric-cosmic-telluric conditions of the City of Vienna are so disposed that they cause puerperal fever in individuals susceptible thereto as puerperae, how does it happen that these atmospheric-cosmic-telluric conditions over such a long period yearshave carried off individuals disposed thereto as puerperae in the first clinic while they have so strikingly spared others also in Vienna, even in the same building in the Second Division and similarly vulnerable as puer-
of
perae? Semmelweis tested many causes of fever in the First Division, even forbidding the priest to walk through the area en route to a patient’s bed.’ But before he fully recognized the infectious nature ofthe fever, his harsh criticism of the hospital director, Johann Klein, for the high maternal mortality rate caused his dismissal for 5 months.2 It was during this time that Semmelweis learned that his close friend and colleague, Jakob Kolletschka, had died from an infected scalpel cut received during an autopsy. As he recalled’:
sicians.’ After transmission by physician to patient, the particles traveled into the blood and then infected the patient in a manner similar to that of Kolletschka’s infected scalpel cut. Based on this logic Semmelweis soon realized that medical students dissecting cadavers before working in the First Division carried particles on their hands, which “were never completely removed, despite hand-washing in soap water, a fact demonstrated by the cadaveric odor which the hands retained.“5 Meanwhile, midwives who worked in the Second Division, but were unexposed to autopsies, did not carry such cadaveric particles. To stop the spread of cadaveric particles, Semmelweis instiruted prophylactic hand-washing in chlorinated lime solution, a policy loathed by medical students who were forced to scrub their hands until slippery. Nevertheless, his strategy was effective immediately: before hand-washing with chlorinated lime solution began in May 1847, 12.24O/i, of the First Division’s patients died of puerperal fever, whereas 3 months after the handwashing policy was instituted, maternal mortality had decreased to 1.82%’ Such a remarkable success in decreasing maternal mortality soon made Semmelweis critical of other phvsicians, whom he blamed for their parients’ deaths. Initially, Semmelweis limited chlorinated lime hand-washing to medical students performing autopsies, but he soon discovered that cadaveric particles were not alone in their infectious nature. In October 1847, a woman was admitted to the hospital, suffering from “foul-smelling medullary cancer of the cervix uteri.“’ When she was placed in the first bed of the ward, physicians would initially examine her and then proceed to other patients, washing between patients with soap and water alone. When 11 women in the ward died of puerperal fever, Semmclweis noted that ‘<. . not onlv cadaveric particles adhering to the’ hand, but [also] putrid matter derived from liv-
ing organisms produces puerperal fever.“3 One month later, another woman was admitted to the hospital, suffering from caries of the left knee joint. When all of the other patients sharing the same room with this woman acquired puerperal fever, Semmelweis realized that “. . . the foul exhalations from the carious joint were so strong, that the air of the labour-room in which she was confined, was so loaded that all the patients in the same room became infected. . . . The air of the labourroom, loaded with the putrid matter, found its way into the gaping genitals just at the completion of labour.“a Semmelweis immediately insisted upon chlorinated lime hand-washings between patient visits, cleanliness of linens, and isolation of sick patients. Unfortunately, Semmelweis delayed publishing his accomplishments despite the success of his prophylactic measures. His excuse: “an inborn loathing for everything that is called writing.“* Consequently, knowledge of his doctrine was spread only by visiting medical students and collegial letters. By 1848, one colleague, Ferdinand von Hebra, had published two articles in the Journal of the Vienna Society of Physicians concerning Semmelweis’ discovery, but mistakenly implicated cadaveric particles alone, not living materials, as the source of disease.2 One year later, Semmelweis, unpublished and rejected by the hospital, fled from Vienna to Budapest. In Budapest, Semmelweis supervised the obstetrical unit at St. Rochus Hospital without financial compensation. He improved departmental sanitation by instituting hand-washing prophylaxis, thereby reducing the maternal mortality to 0.85% over the next 6 years.2 By 1855, with the death of a faculty member, Semmelweis became Chairman of the Department of Obstetrics at the University of Pest. In this role, Semmelweis achieved one of his greatest victories: decreasing hospital mortality from puerperal fever to 0 .39% .2 Despite his innumerable accomplishments, Semmelweis never received praise or acceptance from his peers. Because Semmelweis never published his doctrine, many physicians turned to the erroneous publica(Continued onp. 16.7 02001 by theAmwcan College ofObstetricians and Gynecologists Pubbshedby ElsewrScience Inc 1085.6862/01/$6.00
EDITORIAL
erable if the data are from more than one group or center.
coniiflued hnl p. I may be subdivided into a cohort study, a case-controlled study, or a cross sectional study. Each of these studies has major flaws in their design so evaluation of the evidence must take these flaws into consideration. Examples of these flaws include selection bias, lack of knowledge of all related factors, time and exposure relationship unknowns, and unrecognized outside influences. These types of studies never reach the level of evidence that intervention studies attain. Interventional Studies: These studies are usually known as clinical trials. The investigator assigns groups to specific intervention or nonintervention (control or placebo) groups and monitors specific results of the intervention compared with nonintervention. The major subcategories in this type of investigation are whether or not the study includes randomization. Did the investigator assign subjects to specific groups or were they selected prospectively by a process over which the investigator had no control? Obviously, randomization is preferable. A further subcategory is whether the investigator knows prospectively which subject is assigned to each group even if the assignment is random. If they are unaware, then this is a blinded study. The study may also be a crossover study. One-half of the randomly assigned subjects have the intervention for part of the study and then become controls while the controls then receive the intervention. The best of all studies is a blinded, randomized, crossover evaluation. Unfortunately, this method is applicable only in a small number of studies. Based on these two types of evidence, the method of evaluation rating that is applied to each study is as follows:
11-3. Evidence is based on multiple observations with or without intervention. Uncontrolled studies are in this category. III.
Based on the opinion of authorities, usually as a result of clinical experience or committee opinions.
Once the evidence is rated, a recommendation can be provided. The recommendation is rated based on the following criteria: A. Recommendation based on good and consistent scientific evidence. B. Recommendation based on limited or inconsistent scientific evidence. C. Recommendation based on consensus and expert opinion. As with every rating system, this one is not perfect. It is easy to see that Level I and possibly II-1 allow Level A recommendations. Likewise, Level C recommendations occur with Level III and possible II-3 evidence. Level 11-3, however, as well as Level 11-l and II-2 may also be the basis of a Level B recommendation. Therefore, the reader must make subjective judgments in many instances. I hope this brief explanation has not been confusing. As you read the medical literature, you can apply these principles to assess the studies in a more discerning way. To assist in this process, the editors ofACOG Clinical Review will, whenever possible, establish a level of evidence for the articles reviewed.
I. Evidence is based on one randomized controlled trial. II-l.
Evidence is based on a nonrandomized controlled trial.
11-2. Evidence is based on a cohort or case-controlled study. It is prefJanuary/February
2001
l
ACOG CLINICAL REVIEW
l
15
P
Continuedfrom p. I5 tions of Van Hebra, which failed to discuss the infectious nature of living material. Others practiced handwashing techniques half-heartedly, becoming skeptical of Semmelweis when their maternal mortality remained high. Sensing professional discredit, in 1857 Semmelweis began writing his book, Die Aetiologie, der Begrzf und die (The
Prophylaxis Etiology,
des KindbettJiebers Concept,
Iaxis of Puerperal
Fever).
arzd PropbyBy
1860,
13 years
after his monumental discovery, the book was published. It was long and redundant, yet logical, with its latter pages filled with letters between Semmelwcis and other physicians. Despite its insights, however, the book was not accepted by the medical community. Semmelweis soon became frustrated and began several personal attacks against his colleagues. To his formidable enemy, Wilhelm Scanzoni, one of Europe’s leading obstetricians, Semmelweis wrote on June 25, 18613: Your teaching, Herr Hofrath,
is based on the dead bodies oflying-in women slaughtered through ignorance; and because I have formed the unshakable resolution to put an end to this murderous work as far as lies in my power so to do I denounce you before God and the world as a murderer, and the History of Puerperal Fever will not do you an injustice when, for the service of having been the first to oppose my life-saving Lehre it perpetuates your name as a medical Nero. And
when
Scanzoni
later
experi-
enced an outbreak of puerperal fever at Wurzburg, Semmelweis again scolded: “You have demonstrated, Herr Hofrath, that in spite of a new hospital provided with the most modern furnishings and appliances, a good deal of homicide can be perpetrated where the required talent in that way exists.“l In 1862 Semmelweis addressed his patients through a letter published in a scientific periodical?
You, farher, do you know what it means to call to your wife’s bedside a doctor or a midwife when in labor she needs their help? It means you are endangering her life. If you don’t want to become a widow and if your children don’t want to lose their mother, then buy yourself some bleaching powder, pour water on it, and don’t let the doctors or midwives examine your wife before, in your presence, they have washed their hands in that bleach, and don’t ler them examine till you’ve convinced yourself rhat rhey have washed them long enough so that they are slippery.
Unfortunately, as the medical community was slowly beginning to accept his doctrine, Semmelweis lapsed into a maniacal state. At dinners, he often leapt to his feet and raved passionate, incoherent words. At one faculty meeting, when it was his turn to speak, Semmelweis turned pale and recited the same oath that midwives recite when they assume their professional duties. His friends and colleagues could no longer deny that he was mentally ill. In 1865, Semmelweis was convinced by Von Hebra to return to Vienna to visit the new sanatorium of the renowned Dr. Riedel. As Von Hebra left unnoticed, Semmelweis was forcibly restrained and admitted as a patient to the sanatorium. Less than 2 weeks later, Semmelweis fell ill and died on August 13, 1865, at the age of 47.6 His autopsy revealed that he had died from an infection, presumably caused by a scalpel cut received during a previous gynecological operation.’ Few mourners attended Semmelweis’ funeral; none were family members. Even 6 years after his death, the Pest Association of Physicians had not yet delivered a eulogy honoring Semmelweis.Yet, 14 years later, with his doctrine nearly forgotten, Louis Pasteur identified hemolytic streptococci within lochia and blood of dying patients as the cause of puerperal fever, thereby providing evidence of Semmelweis’ infectious agent. Semmelweis never lived to receive any professional recognition
from his peers. Yet his prophetic words, written in Die Aetiologie, continue to send a sardonic message: “But should it [the time in which I see my doctrine accepted] not he given to me, which God forbid, to behold with my own eyes, the conviction rhat this time &ill soon come without fail sooner or later after me, will still soothe my hour of death.“l In 1885, 20 years after his death, Semmelweis was eulogized by Profcssor W.A. Freund as follows: “when fate calls upon such natures to play the part of prophets, the performance is always a tragedy. Fortunate for mankind if the prophecy is not overwhelmed with the prophet.“:
REFERENCES 1. 2.
.3
4.
5. Sinclair WJ. Semmelweis: Hts LijinndHis
6.
Doctrim. hfanchrster. UK: University Press, 1909. Gortvay G, Z&an I. Semmelweis: His
Lzfi um/ Work. K&o,
Hungary:
Akademiai
1968.
7 /. Carrcr KC. Caner RR. CRiMbedFetvr: A ScirntifTc Riogmpby of Ipaz Sernmehei5. Wrsrporr. C onnecricur: (;reenwood Press / . 1994.
1065-6662(200101/02)6:1;1-3
T
cosmic-telluric nature, challenged Semmelweis’ logic, which sought a more rational explanation of the disease.* In July 1846, Semmelweis finally became Assistant Director in the First Division, where he soon initiated measures to combat the rate of puerpetal fever. Not believing that infectious vapors existed in the atmo-
hroughout history, a few courahave fought geous clinicians against the medical profession for the sake of humanity. One such clinician, Ignaz Philipp Semmelweis, identified puerperal fever as a contagious disease, challenging the popular belief of the time that disease resulted from atmospheric vapors.’ In voicing his opinion, Semmelweis received criticism from the medical profession and died fighting its prominent physicians, never seeing his scientific contributions revolutionize medicine. Ignaz Philipp Semmelweis was born in Buda, Hungary on July 1, 1818. After studying philosophy at the University of Pest, he traveled to Vienna in 1837.2 Initially, Semmelweis was a law student at the University ofvienna, but soon found his true calling in life when a friend invited him to an anatomy class at the Vienna Medical School. Realizing that medicine suited him better than law, Semmelweis enrolled in medical school and graduated in March 1844, with a strong interest in obstetrics.’ Semmelweis immediately applied for a position as Assistant Director of the Maternity Clinics at Vienna’s General Hospital, the Allgemeines Krakenhaus. While waiting for his appointment, he toured the hospital, noting that it contained two separate obstetrical divisions: obstetrical medical students received their training in its First Division, while midwives conducted their own deliveries in its Second Division. Other than personnel, all other conditions of the divisions were the same. Yet, puerperal fever had routinely killed threefold more women in the First Division than the Second Division, increasing to tenfold in 1846.3 The discrepancy between divisions in maternal mortality, which was commonly attributed to an unknown epidemic influence of an atmospheric-
[Kolletschka] received a punctured wound of the finger from the knife of one of the pupils Professor Kolletschka thereupon became affected with lymphangitis, phlebitis in the same upper extremity, and he died from pleurisy, pericarditis, peritonitis, and meningitis it rushed to my mind with irresistible clearness that the disease from which Kolletschka had died was identical with that from which I had seen so many hundreds of lying-in women die.
From the Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology, Mayo Clmx, Rochester, Minnesota.
Semmelweis further concluded that the disease was transmitted to patients by “cadaveric particles” that adhered to the examining hands of phy-
sphere,
he stated*:
Now, if the atmospheric-cosmic-telluric conditions of the City of Vienna are so disposed that they cause puerperal fever in individuals susceptible thereto as puerperae, how does it happen that these atmospheric-cosmic-telluric conditions over such a long period yearshave carried off individuals disposed thereto as puerperae in the first clinic while they have so strikingly spared others also in Vienna, even in the same building in the Second Division and similarly vulnerable as puer-
of
perae? Semmelweis tested many causes of fever in the First Division, even forbidding the priest to walk through the area en route to a patient’s bed.’ But before he fully recognized the infectious nature ofthe fever, his harsh criticism of the hospital director, Johann Klein, for the high maternal mortality rate caused his dismissal for 5 months.2 It was during this time that Semmelweis learned that his close friend and colleague, Jakob Kolletschka, had died from an infected scalpel cut received during an autopsy. As he recalled’:
sicians.’ After transmission by physician to patient, the particles traveled into the blood and then infected the patient in a manner similar to that of Kolletschka’s infected scalpel cut. Based on this logic Semmelweis soon realized that medical students dissecting cadavers before working in the First Division carried particles on their hands, which “were never completely removed, despite hand-washing in soap water, a fact demonstrated by the cadaveric odor which the hands retained.“5 Meanwhile, midwives who worked in the Second Division, but were unexposed to autopsies, did not carry such cadaveric particles. To stop the spread of cadaveric particles, Semmelweis instiruted prophylactic hand-washing in chlorinated lime solution, a policy loathed by medical students who were forced to scrub their hands until slippery. Nevertheless, his strategy was effective immediately: before hand-washing with chlorinated lime solution began in May 1847, 12.24O/i, of the First Division’s patients died of puerperal fever, whereas 3 months after the handwashing policy was instituted, maternal mortality had decreased to 1.82%’ Such a remarkable success in decreasing maternal mortality soon made Semmelweis critical of other phvsicians, whom he blamed for their parients’ deaths. Initially, Semmelweis limited chlorinated lime hand-washing to medical students performing autopsies, but he soon discovered that cadaveric particles were not alone in their infectious nature. In October 1847, a woman was admitted to the hospital, suffering from “foul-smelling medullary cancer of the cervix uteri.“’ When she was placed in the first bed of the ward, physicians would initially examine her and then proceed to other patients, washing between patients with soap and water alone. When 11 women in the ward died of puerperal fever, Semmclweis noted that ‘<. . not onlv cadaveric particles adhering to the’ hand, but [also] putrid matter derived from liv-
ing organisms produces puerperal fever.“3 One month later, another woman was admitted to the hospital, suffering from caries of the left knee joint. When all of the other patients sharing the same room with this woman acquired puerperal fever, Semmelweis realized that “. . . the foul exhalations from the carious joint were so strong, that the air of the labour-room in which she was confined, was so loaded that all the patients in the same room became infected. . . . The air of the labourroom, loaded with the putrid matter, found its way into the gaping genitals just at the completion of labour.“a Semmelweis immediately insisted upon chlorinated lime hand-washings between patient visits, cleanliness of linens, and isolation of sick patients. Unfortunately, Semmelweis delayed publishing his accomplishments despite the success of his prophylactic measures. His excuse: “an inborn loathing for everything that is called writing.“* Consequently, knowledge of his doctrine was spread only by visiting medical students and collegial letters. By 1848, one colleague, Ferdinand von Hebra, had published two articles in the Journal of the Vienna Society of Physicians concerning Semmelweis’ discovery, but mistakenly implicated cadaveric particles alone, not living materials, as the source of disease.2 One year later, Semmelweis, unpublished and rejected by the hospital, fled from Vienna to Budapest. In Budapest, Semmelweis supervised the obstetrical unit at St. Rochus Hospital without financial compensation. He improved departmental sanitation by instituting hand-washing prophylaxis, thereby reducing the maternal mortality to 0.85% over the next 6 years.2 By 1855, with the death of a faculty member, Semmelweis became Chairman of the Department of Obstetrics at the University of Pest. In this role, Semmelweis achieved one of his greatest victories: decreasing hospital mortality from puerperal fever to 0 .39% .2 Despite his innumerable accomplishments, Semmelweis never received praise or acceptance from his peers. Because Semmelweis never published his doctrine, many physicians turned to the erroneous publica(Continued onp. 16.7 02001 by theAmwcan College ofObstetricians and Gynecologists Pubbshedby ElsewrScience Inc 1085.6862/01/$6.00
EDITORIAL
erable if the data are from more than one group or center.
coniiflued hnl p. I may be subdivided into a cohort study, a case-controlled study, or a cross sectional study. Each of these studies has major flaws in their design so evaluation of the evidence must take these flaws into consideration. Examples of these flaws include selection bias, lack of knowledge of all related factors, time and exposure relationship unknowns, and unrecognized outside influences. These types of studies never reach the level of evidence that intervention studies attain. Interventional Studies: These studies are usually known as clinical trials. The investigator assigns groups to specific intervention or nonintervention (control or placebo) groups and monitors specific results of the intervention compared with nonintervention. The major subcategories in this type of investigation are whether or not the study includes randomization. Did the investigator assign subjects to specific groups or were they selected prospectively by a process over which the investigator had no control? Obviously, randomization is preferable. A further subcategory is whether the investigator knows prospectively which subject is assigned to each group even if the assignment is random. If they are unaware, then this is a blinded study. The study may also be a crossover study. One-half of the randomly assigned subjects have the intervention for part of the study and then become controls while the controls then receive the intervention. The best of all studies is a blinded, randomized, crossover evaluation. Unfortunately, this method is applicable only in a small number of studies. Based on these two types of evidence, the method of evaluation rating that is applied to each study is as follows:
11-3. Evidence is based on multiple observations with or without intervention. Uncontrolled studies are in this category. III.
Based on the opinion of authorities, usually as a result of clinical experience or committee opinions.
Once the evidence is rated, a recommendation can be provided. The recommendation is rated based on the following criteria: A. Recommendation based on good and consistent scientific evidence. B. Recommendation based on limited or inconsistent scientific evidence. C. Recommendation based on consensus and expert opinion. As with every rating system, this one is not perfect. It is easy to see that Level I and possibly II-1 allow Level A recommendations. Likewise, Level C recommendations occur with Level III and possible II-3 evidence. Level 11-3, however, as well as Level 11-l and II-2 may also be the basis of a Level B recommendation. Therefore, the reader must make subjective judgments in many instances. I hope this brief explanation has not been confusing. As you read the medical literature, you can apply these principles to assess the studies in a more discerning way. To assist in this process, the editors ofACOG Clinical Review will, whenever possible, establish a level of evidence for the articles reviewed.
I. Evidence is based on one randomized controlled trial. II-l.
Evidence is based on a nonrandomized controlled trial.
11-2. Evidence is based on a cohort or case-controlled study. It is prefJanuary/February
2001
l
ACOG CLINICAL REVIEW
l
15
P
Continuedfrom p. I5 tions of Van Hebra, which failed to discuss the infectious nature of living material. Others practiced handwashing techniques half-heartedly, becoming skeptical of Semmelweis when their maternal mortality remained high. Sensing professional discredit, in 1857 Semmelweis began writing his book, Die Aetiologie, der Begrzf und die (The
Prophylaxis Etiology,
des KindbettJiebers Concept,
Iaxis of Puerperal
Fever).
arzd PropbyBy
1860,
13 years
after his monumental discovery, the book was published. It was long and redundant, yet logical, with its latter pages filled with letters between Semmelwcis and other physicians. Despite its insights, however, the book was not accepted by the medical community. Semmelweis soon became frustrated and began several personal attacks against his colleagues. To his formidable enemy, Wilhelm Scanzoni, one of Europe’s leading obstetricians, Semmelweis wrote on June 25, 18613: Your teaching, Herr Hofrath,
is based on the dead bodies oflying-in women slaughtered through ignorance; and because I have formed the unshakable resolution to put an end to this murderous work as far as lies in my power so to do I denounce you before God and the world as a murderer, and the History of Puerperal Fever will not do you an injustice when, for the service of having been the first to oppose my life-saving Lehre it perpetuates your name as a medical Nero. And
when
Scanzoni
later
experi-
enced an outbreak of puerperal fever at Wurzburg, Semmelweis again scolded: “You have demonstrated, Herr Hofrath, that in spite of a new hospital provided with the most modern furnishings and appliances, a good deal of homicide can be perpetrated where the required talent in that way exists.“l In 1862 Semmelweis addressed his patients through a letter published in a scientific periodical?
You, farher, do you know what it means to call to your wife’s bedside a doctor or a midwife when in labor she needs their help? It means you are endangering her life. If you don’t want to become a widow and if your children don’t want to lose their mother, then buy yourself some bleaching powder, pour water on it, and don’t let the doctors or midwives examine your wife before, in your presence, they have washed their hands in that bleach, and don’t ler them examine till you’ve convinced yourself rhat rhey have washed them long enough so that they are slippery.
Unfortunately, as the medical community was slowly beginning to accept his doctrine, Semmelweis lapsed into a maniacal state. At dinners, he often leapt to his feet and raved passionate, incoherent words. At one faculty meeting, when it was his turn to speak, Semmelweis turned pale and recited the same oath that midwives recite when they assume their professional duties. His friends and colleagues could no longer deny that he was mentally ill. In 1865, Semmelweis was convinced by Von Hebra to return to Vienna to visit the new sanatorium of the renowned Dr. Riedel. As Von Hebra left unnoticed, Semmelweis was forcibly restrained and admitted as a patient to the sanatorium. Less than 2 weeks later, Semmelweis fell ill and died on August 13, 1865, at the age of 47.6 His autopsy revealed that he had died from an infection, presumably caused by a scalpel cut received during a previous gynecological operation.’ Few mourners attended Semmelweis’ funeral; none were family members. Even 6 years after his death, the Pest Association of Physicians had not yet delivered a eulogy honoring Semmelweis.Yet, 14 years later, with his doctrine nearly forgotten, Louis Pasteur identified hemolytic streptococci within lochia and blood of dying patients as the cause of puerperal fever, thereby providing evidence of Semmelweis’ infectious agent. Semmelweis never lived to receive any professional recognition
from his peers. Yet his prophetic words, written in Die Aetiologie, continue to send a sardonic message: “But should it [the time in which I see my doctrine accepted] not he given to me, which God forbid, to behold with my own eyes, the conviction rhat this time &ill soon come without fail sooner or later after me, will still soothe my hour of death.“l In 1885, 20 years after his death, Semmelweis was eulogized by Profcssor W.A. Freund as follows: “when fate calls upon such natures to play the part of prophets, the performance is always a tragedy. Fortunate for mankind if the prophecy is not overwhelmed with the prophet.“:
REFERENCES 1. 2.
.3
4.
5. Sinclair WJ. Semmelweis: Hts LijinndHis
6.
Doctrim. hfanchrster. UK: University Press, 1909. Gortvay G, Z&an I. Semmelweis: His
Lzfi um/ Work. K&o,
Hungary:
Akademiai
1968.
7 /. Carrcr KC. Caner RR. CRiMbedFetvr: A ScirntifTc Riogmpby of Ipaz Sernmehei5. Wrsrporr. C onnecricur: (;reenwood Press / . 1994.
1065-6662(200101/02)6:1;1-3