Lessons from the Experience of Ignac Semmelweis

Due to a temporary job that was difficult to pass up and quite time consuming, I haven't written here in a while. But I'm back now to help relieve some of the work that Marc and Co. have had to do. The site has held up quite well in my absence, which doesn't surprise me; my presence on the site is something of an accident, at this point.

I recently read a book entitled The Doctor's Plague, by Sherwin B. Nuland. It told the story of Ignac Semmelweis and his discovery of the cause of childbed fever.

Childbed fever was a disease that afflicted mothers in the immediate aftermath of childbith. While it had existed for many years, for some reason, it began to increase in frequency in the early 19th century. In some hospitals, it was claiming one-sixth of all mothers, most within 2-3 days of childbirth. That's a staggering figure. At about this time, modern medicine was really starting to emerge. In Vienna, doctors performed autopsies on just about every dead body that they could. These autopsies, along with the new idea of looking for WHERE the disease was, vastly increased the understanding of disease.

Childbed fever was a real mystery. In came Ignac Semmelweis, a young doctor who had wound up in the unglamorous field (at the time) of obstetrics. It wasn't his first choice. It wasn't his second. For whatever reason (possibly due to the death of his mother), Semmelweis attacked the problem of childbed fever with gusto. While many other doctors believed that it was simply an unsolvable mystery, Semmelweis would not accept that. In the mode of the renowed Dr. Karl Rokitansky, Semmelweis made copious observations and learned some things about childbed fever.

1. The hospital's division that employed midwives rather than doctors saw vastly fewer deaths from childbed fever.
   
2. The epidemic was local to the hospital; it was not a problem in the city, otherwise.
   
3. There was no correlation between the appearance of the disease and weather conditions.
   
4. Trauma during delivery increased the likelihood of the onset of childbed fever.
   
5. Closing the ward and reopening it always stopped the disease.
   
6. Infants were also susceptible to the disease.

Semmelweis stumbled upon the cause of the disease accidentally. It just so happened that a friend of his had accidentally stuck by a knife while leading an autopsy. The wound developed into a massive infection, and he died of it a few days afterwards. Semmelweis performed the autopsy on his friend, and, as Nuland put it on page 98, "when his body was dissected, its organs and tissues were permeated with pus and abnormalities exactly like those common in women who succumbed to [childbed fever], and sometimes in their infants."

Semmelweis made the connection: his friend had contracted the disease from the cadaver. He realized that "the transmitting source of those cadaver particles was to be found in the hands of the students and the attending physicians." Essentially, there was a vicious cycle that was causing the deaths of all those women. Doctors were perfoming autopsies on bodies that had succumbed to childbed fever. They were then performing deliveries on women, and these were sometimes quite invasive (as was the nature of the educational process that sometimes occurred). In the process, the doctors transmitted the infection to many women, and the women then died of the mysterious disease. They then performed more autopsies, and, as deaths increased, autopsies increased, and the process spiraled out of control. This truly was a "doctor's plague."

Semmelweis immediately began to insist that people use chloride to disinfect their hands before making contact with a woman in labor. The results were amazingly effective. Semmelweis' discovery was poised to end the suffering of thousands of women.

But it didn't. The old guard was intransigent and rejected his theories. He failed to publish his theory and discovery initially, and, when he finally did, it was in a manuscript that was, quite frankly, unreadable. It was long-winded, disorganized, and unclear. People often misunderstood the nature of his theory because of this, and they often attributed the disease solely to cadavers rather than to the particles that were being transmitted by contact with the cadavers. They would then reject the theory of cadaver infection (which was not a fair representation of Semmelweis' theory) b/c it was unable to explain some cases. Semmelweis also failed to exploit the emerging field of microscopy, which could have helped to prove that there were infectious particles that were causing disease. Finally, he did not perform rudimentary experiments/tests to verify the theory.

The bottom line is that Semmelweis dropped the ball on it. He was so convinced of his own theory that he was unable to help convince other people. He did not understand why people needed more proof, and thus, he was unable to provide it. He did not help to make his disarming and new theory to be more understandable. He thought that it was so self-evident that he stopped short of true medical heroism.

So, why did I just waste 4-5 minutes of your time on Ignac Semmelweis? I feel that there are some lessons that we in the analytical community can take out of the tragic story of Ignac Semmelweis and childbed fever.

1. Further testing/verification is a good thing. Semmelweis stopped his work too early. While his observations were useful, either adding in experimental data or delving in microscopy would have gone a LONG way towards making his theory more believable. The parallels to baseball make sense. More studies and research can serve to add to our levels of certainty about specific things (or it can correct our misunderstandings).
2. Writing must be clear and understandable. Semmelweis' biggest failure was to not immediately publish his findings. When he finally did publish, his writing was terrible. Technical writing is great, but it's often important to simplify it for people like me and others who aren't well aware of numerical terms. TangoTiger is great at this, I think. We should emulate that.
3. Myths and misunderstandings should be carefully debunked. The fact that people did not understand the nature of the cadaver in infections made Semmelweis' case much worse. It's a lot like popular misconceptions about "statheads" (mostly the ones that were misconstrued by readers of Moneyball). While you can never get everyone to give up certain ideas, it's certainly good to try.
4. Personally attacking your enemies is not the best way to get them to agree with you. As his health wore down, Semmelweis wrote some very, very nasty letters directed at his medical enemies. He accused them of being murderers; in one letter, he wrote, "And you, Herr Professor, have been a partner in this massacre." While it was true, to some extent (albeit unintentionally), that's not how you win friends and supporters.
5. Don't give in to frustration. Semmelweis became incredibly frustrated by people's intransigence. He didn't realize that people are almost always reluctant to accept new ideas, whether they're about the relative uselessness of the RBI or about DIPS theory.
6. Don't alienate your supporters. Semmelweis actually bailed on his major supporters and thus was completely isolated. It's tough to convince anyone of anything if you're completely isolated.

After reading this book, I realized that there were connections, and I felt like writing something a little different in my return to the site. Most of this isn't new information, but it's always good to see these things from different perspectives.

Oh, and Nuland's book is a great read, and I highly recommend it. His explanations are certainly more understandable and more detailed than mine.