Ignaz Semmelweis: a victim of harassment?

Summary Ignaz Semmelweis’ (1818–1865) discovery of the endemic causes of febris puerperalis is a striking example of the role of pathology in medicine. Transdisciplinarity encounters Semmelweis’ biography, which is neither linear nor totally focused on medicine. He completed the philosophicum (artisterium), studying the septem artes liberales (1835–1837) in Pest, comprising humanities and natural science. After moving to Vienna, he began to study law, but turned to medicine as early as 1838. In 1844, he graduated with a botanical doctoral thesis composed in Neo-Latin, showing linguistic and stylistic talent and a broad knowledge of gynecology and obstetrics. The style and topoi demonstrate the interchangeability of what he learnt during his propaedeuticum. Nowadays, hardly anyone is familiar with this booklet, for two main reasons: the language choice and the life-saving impact of the physician’s opus magnum on the reasons for puerperal fever (Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers). In later life, he became convinced that he had no talent as a (scientific) author—a fatal error that led him to become a victim of what we now call “publish or perish.” Semmelweis had felt rejected for years. This negative feeling was the reason for his decision not to publish his great book for 14 years. When it finally went to the printer in 1861, the scientific community did not accept it. This experience caused psychosomatic symptoms owing to his long-standing and deeply felt disappointment. Bad conscience tortured him. This permanent stress destroyed his health: in 1865, his relatives (including his wife) and friends took him from Budapest to Vienna. He thought he was going to spend some time relaxing, but in fact was led into a newly built asylum for the mentally ill, the Niederösterreichische Landesirrenanstalt. When he realized what was happening, he tried to escape. Badly abused, he died from sepsis caused by open wounds and a dirty straightjacket 2 weeks later. This article will show Semmelweis to be a multilingual author of scientific literature and (open) letters; it will present him as a researcher who became a victim of harassment and what is referred to as the “Semmelweis reflex” (“Semmelweis effect”); and it will focus on his afterlife in (children’s) literature, drama, and film.


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showing linguistic and stylistic talent and a broad knowledge of gynecology and obstetrics. Nowadays, hardly anyone is familiar with this booklet, for two main reasons: the language choice and the life-saving impact of the physician's opus magnum on the reasons for puerperal fever, meticulously described in more than 500 pages. The year 2018, one of historical jubilees, was also one dedicated to Semmelweis: commemorating his 200th birthday, articles were published 3 and symposia were held-without any focus on or analysis of his doctoral thesis. 4 Knowing what happened later, and how he personally changed in response to the harassment 5 he had to face, the first lines, i.e., a single sentence in his thesis (p. 3), are moving ones. He enthusiastically praises botanical plurality using metaphors taken from Pliny the Elder's ( †79AD) vast encyclopedia, the Naturalis historia: Qui oculis tam grate arridet amoenus foliorum viror, florum splendor et mira varietas; qui nares feriunt suavissimi odores, qui gustum demulcent dulcissimi succi, quae corpus nostrum restaurant, morbos profligant, sanitatem reducunt-substantiae plantarum, e quibus animum poetarum inspirat suavissimus Apollo [. . . ] quam vim naturae-vitam-dicimus. ("How brightly does the lovely green color of the leaves shine into the human eye. How delightful is the splendor of the flowers and their broad variety. How mild is their fragrance meeting the nose. How sweet is their taste-the substance of the plants restoring our bodies, fighting various illnesses, bringing back the healthy state, the ingredients out of which honeysweet Apollo inspires the poets' souls, the thing we call the force of nature, the thing we call life.") 6 At the end of his encyclopedia, comprising 37 books, Pliny composes a prayer to the personified Mother Nature ( §205). In analogy, Semmelweis presents the wide range of powers humankind can derive from flora. 7 The style and topoi demonstrate the interchangeability of what he learnt during his propaedeuticum. In later life, he became convinced that he had no talent as a (scientific) author-a fatal error that led him to become a victim of what we now call "publish or perish." Working at the traditional and catholic University of Vienna, while writing his thesis, he combined science and religion, a method professionalized decades earlier by the Jesuits, insisting on the driving force, the curiosity to find out the truth (p. 3): Mens humana tamen non acquiescit, donec phaenomenorum omnium rationem reddat sufficientem, laeti ideo sequimur ideam, quam naturae philosophi hoc modo exponunt. Omne, quod existit, ex divino omnipotentiae spiritu emanat [. . . ]. ("Nevertheless, the human mind does not rest until it finds a sufficient reason for all natural phenomena; that is why we happily follow the idea, the natural philosophers explain. Everything existing is a fruit of almighty god").
Furthermore, Semmelweis worked systematically and gradually developed his theories, probably copying the familiar modes of exposition in the classes he had taken at university. He would do the same 17 years later in his book on fighting childbed fever, managing without perfect style, but convincing with figures, tables, and statistics. Traditionally, scientific literature in Latin was successful owing to its easily comprehensible terminology. 8  Those are the powers: heath, light, air, electricity, and ground.") Semmelweis presents their necessity and distinguishes between solum (the ground as such) und humus (fertilizer). He shows the plants' orientation towards the light, explained by the heliotropium (sunflower), by trees in the middle of the woods and at their margins, and by potatoes in the cellar seeking the sun coming in by a tiny window and thereby referring to an experiment in the footsteps of Goethe and Blumenbach. 9 What follows is a lengthy chapter on reproduction, full of parallels to animals. Details close to embryology come in (p. 7): Nucleus embryone et albumine completur. Embryo rudimentum novae plantae repraesentat; est ideo maxime essentialis seminis pars. ("The nucleus consists of the embryo and the albumen. The embryo is the rudiment of the new plant, and at the same time the most essential part of the seed.") Bulbs are viviparae, in other words: they give birth to living plants. When he writes a passage on Organologia, Semmelweis positions himself as a physician, using anatomical terms: the plants' vasa spiralia, their vascular tissues, are equivalents to nerves (p. 12). Heaps of cells form organs, nutritional reservoirs are compared with fat cells in animals, and there are even male and female parts (pp.  ("Furthermore, to my belief, nature has given a place to hermaphroditism or gender in the reign of plants, since we observe that under certain influences of temperature, especially when light or humidity are extreme, one gender separates from the other, a male becomes a female one and the other way around.") Strikingly enough, Semmelweis does not focus on animals that can do something similar (e.g., clownfish).
Finally, referring to the Processus foecundationis, he compares plants to amphibia and fish (p. 27): ovula eum in modum foecundare, ut hoc in ranis, salamandris et piscibus noscimus. ("Eggs are fertilized in the same way as we know from frogs, salamanders, and fish.") Generally speaking, the elements and many species, including homo sapiens, help to reproduce plants (p. 30): Semina leviora venti subinde per notabile spatium ferunt, graviora aqua per longum iter vehit, alia volatilia coeli dissipant, mammalia diducunt v. g. mures; quae tandem, homo hac in re faciat, quis non noscit! ("Wind transports light seeds over a wide space, water delivers heavier ones over a considerable distance, the breeze of air brings flying ones from A to B, as do mammals, especially mice. And, last but not least, who does not recognize the important role of man in this respect?!")

Semmelweis' exam and broad medical horizon
The last page of the booklet offers 10 Theses defendendae ("Theses to defend"), making a reconstruction of Semmelweis' rigorosum possible. The starting point is the thesis itself: Botanicae Studium pro Medico practico summi momenti ("Botanical studies are very important for the practical physician"). What follows is based on Thomas Sydenham (Non dantur morbi intermittentes-"There are no intermittent diseases," and Causam hydropis melius principiis mechanicis quam dynamicis explicabis-"You will better explain the causes of dropsy by mechanical principles than by dynamic ones"). The next thematic fields are pharmaceutics (Sine Opio et Mercurio nollem esse Medicus-"I would not like to be a physician without opium and mercury"), psychology (Omnis Medicus sit Psychologus-"Each physician should have psychological skills"), and anatomy, a Viennese "specialty": Fons floritionis medicinae modernae in Anatomia pathologica quaerendus est ("The source of the flourishing modern medicine is to be searched for in pathological anatomy"). At the same time, here lay the roots of puerperal sepsis. Finally, Semmelweis had to discuss conservation (Viget in omnibus corporibus nisus conservationis-"In all bodies preservation is of high importance"), the importance of diagnostics (Prognosis non de aegri, verum de Medici sorte decernit-"Prognosis is decisive for the physician's fate, not for the patient's"), and pathognomony (Nullum datur signum morbi pathognomonicum-"There is no pathognomonic sign of illness"). Dangerous substances and venoms came at the very end: Nullum venenum in manu medici ("No venom in the doctor's hand"). This sentence would become intriguingly important and subtle, especially to him-the pioneer of hand hygiene.

The fatal effects of Semmelweis' surroundings and intransigent character
Ignaz Semmelweis' fate is inseparably tied to the "Second Vienna Medical School": 10 Carl Freiherr von Rokitansky, Ferdinand Ritter von Hebra, Josef von Škoda, and Jakob Kolletschka. When the latter died in 1847, Semmelweis was not in Vienna; but when he learned of the symptoms, he noticed the striking parallels to the women and their babies dying in childbed or in the first days of their young lives. 11 An incautious student had cut his professor during an autopsy, which caused deadly sepsis.
The General Hospital housed two clinics specializing in obstetrics. Where the training of midwives took place, a significantly smaller number of patients died. Where students and professors worked, a huge number succumbed to childbed fever: the men went from the morgue to the women giving birth-without disinfection, since they did not know about bacteria. However, living people too could be vectors, not only cadavers-a fact Semmelweis realized only somewhat later. Deeply disappointed by the harassment he had suffered, Semmelweis in the meantime sulked and refused to publish his findings. His friends and supporters nonetheless tried to help disseminate them by word of mouth on his behalf. But when they did so, they unfortunately failed to mention the fact that living subjects, not just cadavers, could be infectious. This permitted his critics and opponents not to pay attention and to claim that there were no new and substantive findings.
1860s, it was too late. 12 Nevertheless, he promptly (as early on as 1847) prescribed the washing of hands with chlorinated lime solution, a method that saved countless lives, but was unpleasant for the skin and seen as a waste of time by many. The established physicians of high reputation and not accustomed to new ideas could not accept that a young assistant (and a foreigner to boot) declared their hands to be unsanitary. Instead of respecting the convincing results and scientific progress, they exhibited a symptom called "Semmelweis reflex" ("Semmelweis effect"), 13 a reaction that denotes denying new results out of principle. They preferred the old-fashioned genius epidemicus, atmospheric influence, climate theories, and the miasma, erroneous views going back to antiquity, followed and propagated by famous physicians of Semmelweis' day. He criticizes this disturbing fact in his last publication of 1862, citing the Danish physician Thomas Bartholin who (in 1672) believed that childbed fever was more dangerous in autumn and winter owing to the climate influencing the uterus. 14 It was Semmelweis' fault that he attacked his "colleagues" in an inappropriate way: 15 He called them murderers-even "efficient" ones-and Friedrich Wilhelm Scanzoni von Lichtenfels a "medical Nero." 16 It is no wonder that this wording caused enmity, even if it is understandable from the psychological point of view. Semmelweis had felt rejected for years. This negative feeling was the reason for his decision not to publish his great book for 14 years. In the meantime, he felt, and was in effect, relegated from Vienna to Budapest, where he continued his evidence-based methods with success. From an empirical point of view, he was definitely right. One has to add that he had left Vienna, since he refused to be reduced to demonstrations using the so-called phantom rather than real women. 17 Semmelweis declared that he had been successfully fighting (for 14 years and in three hospitals) against Pseudo-Puerperalfieber-Epidemien, 18 that statistics were on his side, and that his survival rates spoke a very clear language. Furthermore, he showed great familiarity with the scientific literature of the time by precisely citing and finding arguments against false theories and assertions, but to no avail. Having read all his works, one has to confess that Semmelweis' sarcasm and bitterness might have been responsible for that: e.g., he calls the professors who do not follow his ideas "infectors" who should be "impeached" immediately: there is no hope that mankind will be freed from the scourge of childbed fever earlier, for all believers in epidemics will have died. Countless puerperae will die. And if I had the power and the choice between the death of innumerable women in childbed who could have been saved, or the removal from their posts of all professors of obstetrics who believe in epidemics and who do not want to follow my way or cannot even follow it, I would choose their removal, for I am deeply convinced that some dozens of professors are a quantité négligeable in comparison to thousands and thousands of murdered women and suckling infants.") Semmelweis frankly informs Siebold 20 that he doubts his knowledge, that his pupils are not the 19  guilty ones, since they have to trust their teacher, who unfortunately does not accept the truth. On the other hand, he begs him for respect and tells him that he knows him as a positive-minded, warm-hearted man who wants the best for his patients. To Scanzoni he writes that he was "right" for 13 years only because he remained silent. 21 When Semmelweis' book finally went to the printer in 1861, the scientific community did not accept it. This experience caused psychosomatic symptoms owing to his long-standing and deeply felt disappointment: bad conscience tortured him. The same had been true for Gustav Adolph Michaelis, 22 who committed suicide in 1848 after having understood that he was responsible for the deaths of many women, including that of his own cousin.
In the case of Semmelweis, it was even more complicated: he wanted to save all patients, and he had clear results proving his theory, but was hindered by conservative traditionalists, who openly opposed and-what made the affair even more unbearable-privately used his methods. 23  ("Because Professor Rokitansky had been the head of the pathological-anatomical institute from 1828 on, out of his memory, due to section protocols, and talking to other physicians, those assistants and students who worked with dead bodies could be found. It would have become evident if there had been a connection between the number of diseases in the maternity hospital and the use of assistants and students in the morgue. The commission was not allowed-because of higher order-to continue its work. Following my persuasion, I have to confess that only God knows the number of those who had to step much too early into their graves-because of me . . . I worked with dead bodies to such an extent as only a few of obstetricians did.") 23 Maisel [ cluding his wife) and friends took him from Budapest to Vienna. He thought he would be spending some time relaxing, but in fact was led into a newly built asylum for the mentally ill, the Niederösterreichische Landesirrenanstalt, in Lazarettgasse. When he realized what was going on, he tried to escape. Badly abused, he died from sepsis caused by open wounds and a dirty straightjacket 2 weeks later. It is unlikely that he was suffering from neurosyphilis, a risk to which gynecologists of the time were exposed. 24 The same is true for presenile Alzheimer's disease. Silló-Seidl seems to have found a more probable option based on documents and eyewitnesses: 25 Semmelweis may have suffered from burnout, an illness unknown in the 19th century, combined with diabetes, a reasonable explanation for his insatiable thirst and his potency problems. Furthermore, his wife felt ashamed by her husband's (rather rude) behavior. The combination of these factors and symptoms finally killed him, left alone in a cell, abandoned to indignity and dying from a secondary illness whose causes he had discovered.
At nearly the same time in the British Isles, Joseph Lister, the "father of antiseptic surgery," had achieved his first successful results inspired by Louis Pasteur, and he admired Semmelweis. 26 As early as in 1843, the American physician Oliver Wendell Holmes had success with disinfection and had to face the same enmity as Semmelweis. 27 Evidently, there was no transatlantic exchange between the two men. Decades went by before the scientific community paid tribute to him. Until then, the majority slandered him as someone who fouled his own nest (Nestbeschmutzer). It was only after his death (quite a typical Austrian fate) that people called him "savior of the mothers" (Retter der Mütter).
One scene shows the prejudice he had to contend with: when he quoted the oath of the midwives in a medical meeting, the majority of those present did not understand the deeper sense of his choice of this text, but expected a scientific paper and thought he had gone mad. However, Semmelweis-with all his subtlety-wanted to show the ethical principle governing midwives and physicians.

Semmelweis' multilingual correspondence as a sign of individuality
Whatever the case may be, Semmelweis had always been somehow different-even in his doctoral thesis, which opened the gates to clinical practice for him, after having demonstrated his broad intellectual knowledge in a field that was not primarily medical.
Furthermore, he was multilingual. His first biographer 28  Credisne novos casus, qui in hospitio ex tempore mei abitus admissi sunt, opinionem tuam confirmant? Febris ne puerperalis rarior est quam antea? Si morbus sic periculosus in cubilibus obstetriciis non adsit ut ante, certe effectus magni momenti denuo firmatus. In Praga quoque, ubi febris puerperalis tum frequenter obvenire solebat, eisdem causis consecuta fuit ingenerari!' ("In the meeting that took place in the last week of November, the paper in which I presented your discovery and showing greatest respect to you-what a sign of justice!-was read in public. I can even say that the whole discourse was accepted in the very best way, and so many of the most learned men attested that your argumentation was really convincing-especially Webster, Copeland and Murphy, most learned men and doctors, spoke in a very positive way. In the 'Lancet' of November 1848 you can read everything on the controversy. Do you think that new cases happening in the hospital after I left confirm your opinion? Isn't the childbed fever 28 Schürer [21, p. 43-4] & Obituary. Charles Henry Felix Routh [22]. rarer than before? If the so dangerous malady in maternity units is less present than before, the effect of high importance is proved again. Even in Prague, where so many cases of childbed fever occurred, it consequently arose from the same reasons!") Next follows a letter dated [. These documents clearly show that (from the early stage of the discovery until its propagation and spreading) not everybody was against Semmelweis, but as a result of his personality, he was unable to see the positive side-neither in the late 1840s nor in the (early) 1860s, nor in between. 29 Instead, he focused on the negative elements. Even an encouraging letter from his colleague Louis Kugelmann failed to console him (10.08.1861): Nur sehr wenigen war es vergönnt, der Menschheit wirkliche, große und dauernde Dienste zu erweisen, und mit wenigen Ausnahmen hat die Welt ihre Wohltäter gekreuzigt und verbannt. Ich hoffe also, Sie werden in dem ehrenvollen Kampfe nicht ermüden, der Ihnen noch übrig bleibt. 30 ("To give real, great, and everlasting things to mankind was granted to very few, and except for a very small number the world crucified and banned its benefactors. I hope you will not tire during the remainder of your honorable fight.") 29 Semmelweis [14, p. 27]: Von der großen Anzahl der Professoren der Geburtshilfe haben innerhalb fünfzehn Jahren nur zwei die von mir entdeckte Wahrheit erkannt, selbe mit Erfolg beobachtet, und nur diese zwei waren zugleich auch redlich genug, das auch öffentlich anzuerkennen; Einer dieser Professoren der Geburtshilfe war Michaelis in Kiel, der andere ist der Geh. Hofrath Prof. Dr. Lange in Heidelberg. ("Out of the huge number of professors of obstetrics in 15 years only two have seen the truth discovered by me and observed it with success, and only the two of them were honest and of sufficient integrity to acknowledge it in public. One was Michaelis in Kiel, the other is the Geheime Hofrath Prof Dr Lange in Heidelberg.") 30 Ibid.:V.

Semmelweis' afterlife or: an insight into reception studies concerning a tragic hero
This personal tragedy is the reason why he is so inspiring for authors, directors and artists: in the final scene of Hans José Rehfisch's drama Doktor Semmelweis (1934), the protagonist cuts himself with a contaminated scalpel and utters his final words, his ultima verba: 31 Meine Damen und Herren! Wenn Sie Ihr Augenmerk auf den weitern Verlauf wenden wollen, werden Sie den etwa zwei Wochen dauernden Zerfall meiner körperlichen Existenz beobachten. Wenn ich Glück habe, lernt ihr daraus. ("Ladies and Gentlemen! If you would pay attention to what happens next, you will observe the decline of my bodily existence over a period of approximately two weeks. If I am lucky, you will learn from it.") Curtain. This invented literary moment has its roots in the theory that Semmelweis suffered his lethal sepsis during an operation: he was also a pioneer in gynecological surgery. 32  . ] I beg you, be more careful and master your immoderate fury. If you are acting furiously and offensively, kicking, hissing, and spitting, it will be so easy to call you a lunatic and to find many sharing this opinion. You cannot behave like a coachman if you want to get respect as a professor. In addition, your opponents are no shabby nags that shall follow you forced by a whip. You should better work on gaining the friendship of these gentlemen. Try to be charming-nobody dislikes that. Everybody loves the mirror showing and reflecting his brightness-so, everybody will be-quick and easy-on your side. And if you manage to find the right words, they will accept your doctrine.") In both plays, the dialogues are based on Semmelweis' writings, which make them vivid and realistic. 32 Lesky [25, p. 93-5].
Rehfisch's tragic hero is a real person, not a fictional character.
Fred Zinnemann directed the short film That Mothers Might Live (1938), which won an Oscar. Retter der Mütter (1950), starring Karl Paryla, was produced in the German Democratic Republic, and Michael Verhoeven was responsible for Arzt der Frauen (1987)(1988), starring Heiner Lauterbach. These movies show the fate of a man who was in the wrong place (the dangerous, conservative, nationalistic and anti-Semitic academic community of Vienna) at the "wrong" time (around the revolutionary year 1848), with the "wrong" political orientation (democratic and open-minded), the "wrong" roots (Hungarian born), and a Jewish-sounding name. He had mentors, but no chance-never.
Even as the hero of a children's book, poor Semmelweis is a victim. In 1967, Willy Miksch, who also published on the Viennese Laboratoriumspest of 1898, 33 portrays him as follows: Götter, sprich Professoren der Gynäkologie, waren nicht schuld, sondern der Held selbst. ("Many biographers depict him as a tragic hero à la Aischylos, destroyed by evil gods. However, he fits better into a Sophoclean tragedy, where the hero's fate is not determined by the gods, but by a tragic flaw in his own character. After having found his mission, Ignaz Semmelweis inevitably headed towards his tragic destiny. Precisely like this would Sophocles have written the plot-including a choir of dying women in the background: a great hero, a great truth, a great mission, insanity, and hybris causing ruin. The gods, i.e., the professors of gynecology, were not guilty, but the hero himself.") Or, as Durnova  And this seemed to be true for his fight for the truth as well.") Nevertheless, the stubborn gynecologist would have been very pleased that, in 1967, the rebellious sculptor Alfred Hrdlicka created a lasting monument to him-in the courtyard of the University of Vienna, the place of his enduring triumph and personal ruin.
However, even this belated honor did not work as planned: the monument was intended to be unveiled in 1965, when the university was 600 years old and Semmelweis dead for a century; however, those in charge failed to take into consideration the amount of time Hrdlicka would need to realize his project. 36 Funding Open access funding provided by University of Vienna.
Conflict of interest S. Schreiner declares that she has no competing interests.
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