‘The Fool of Pest’: An Exchange

To the Editors:

In his unrestrained zeal to refute my thesis that Ignác Semmelweis was a major contributor to his own personal and scientific downfall, Richard Horton has concocted a review of my book, The Doctors’ Plague: Germs, Childbed Fever, and the Strange Story of Ignác Semmelweis [NYR, February 26], that is a tissue of misapprehensions, error, and distortions.

Most egregiously misleading is Horton’s fabricated assertion—several times repeated—that Semmelweis was a Jew and therefore “the victim of a deliberate character assassination by a racist, anti-Semitic, anti-scientific, decadent, and murderous medical establishment.” Horton has either conveniently invented the myth of a Jewish Semmelweis or been taken in by our mutual protagonist’s name. The name itself is Swabian, and most assuredly not Jewish. Traceable through parish registers, the identities of Semmelweis’s direct forebears are known, beginning with the birth and baptism of his great-great-grandfather, Gyorgy Semmelweis, in 1670. Like his ancestors, Semmelweis was born and died a Roman Catholic. All of this is described in detail in my book, which Dr. Horton quite obviously chose either not to believe or not to read.

Having begun his attack with an error which in itself is sufficient to cast grave doubt on his credibility, Horton then adds a series of similar inaccuracies that undermine his argument at one point after another, beginning with two consecutive ones. Semmelweis’s work in no sense “prepared the way for Pasteur’s elucidation of germ theory. He turned obstetrics into a respectable science.” In fact, Semmelweis did neither. He was largely forgotten or ignored during much of the entire period of two to three decades during which the germ theory was being promulgated by Pasteur and Lister. There is no verifiable evidence that either of them had so much as heard of his name or his theory until long after they had accomplished their mission of educating doctors about microbes. As is well known, his work had to be rediscovered more than twenty years after his tragic death. As for the unsupported generalization that Semmelweis “turned obstetrics into a respectable science,” I cannot imagine what Horton might mean by that, since it was not until many decades after his death that the specialty began the slow intellectual and technological ascent that only gradually made it truly scientific and attractive as a career to young doctors in much the same way as surgery or internal medicine.

Horton seeks to paint his subject as a lone, ingenuous outsider with “no advanced scientific training, and no mentor who was close to him…. There was nobody to advise him day-to-day in the subtleties of scientific etiquette.” Worse yet, claims Horton, “Semmelweis was not an academic like Rokitansky and Scanzoni. He was a medical practitioner who specialized in obstetrics.” Except that Semmelweis did specialize in obstetrics, none of this is true. Semmelweis was never an ordinary medical practitioner, having embarked on his specialty training in obstetrics almost immediately after receiving his diploma from the most scientifically advanced medical school in the world. Two years later, he became assistant to the chairman of its obstetrics department after spending eighteen months of the intervening period working in the well-appointed laboratory of Europe’s leading pathological anatomist, Carl von Rokitansky. Far from having “no mentor who was close to him,” he was brought by his discovery even further under Rokitansky’s nurturing wings. At the same time, he became the standard- bearer for the younger scientifically minded faculty in their conflicts with the aging conservatives whose authority they were in the midst of successfully undermining.

Semmelweis did not lack for mentors or for supportive colleagues who urged him to carry out well-designed experiments to prove his hypothesis, and then submit monographs to scientific journals. Had he but accepted the help of several medical school associates skilled in the use of the newly refined microscopes of the day, he would have seen that the pus of his dead patients was teeming with microbes, and thus proven his thesis beyond question. That he did none of this does not attest to the validity of Horton’s baseless claim that “Nuland seems to judge his subject according to commonly accepted twenty-first-century rules of medical science,” but to my subject’s continued stubborn refusal to take advice or use the sufficient contemporary science so readily available to him.

To say of a man with Semmelweis’s premier medical education, graduate training, and university surroundings; a man who started his post-training career as assistant to the professor of obstetrics at such a distinguished institution; a man who was for ten years of his eighteen-year career the professor and chairman of a university department—to say of such a man that he was merely “a medical practitioner” and “not an academic” is beyond reason.

I was astonished to read that “Nuland is dismissive of the claim that Semmelweis had a ‘bruised soul.'” Having already quoted from my 1979 article in The Journal of the History of Medicine and Allied Sciences, how could Horton have failed to see the following sentence appearing there: “When he was offered a minor clinical appointment that somewhat restricted his teaching prerogatives, his bruised soul considered it the final insult”? It is obvious from the context in which the statement appears in the 1979 paper that neither sarcasm nor harshness is meant by it, unlike the ample quantities of both—directed at me—that permeate Dr. Horton’s review. It is difficult to fathom how anyone who has read my book or in the past twenty-five years heard me lecture on that tortured genius of childbed fever could respond this way. In one particularly nasty passage, Horton all but accuses me of succumbing to the same monomaniacal madness that afflicted poor Semmelweis.

Like so many others who realize that their arguments are not substantiated by the facts, Horton repeatedly invokes authority to prop up his case, but he does so by putting more than a bit of spin on it. One eye-catching example that is particularly disappointing—coming as it does from the editor of The Lancet, one of the most well regarded of medical journals—is the reference to a paper by Professor Codell Carter of Brigham Young University. Carter, asserts Horton, “demonstrates that the view that Semmelweis made little effort to communicate his discoveries [as claimed by Nuland] is quite wrong. In 1847, together with his students, Semmelweis wrote letters to leading obstetricians describing his findings and inviting replies.” Carter, a far more reliable reader of texts than Horton, does not, in fact, say this. What he does say (p. 253) is only that Semmelweis claimed (italics mine) that he and his students wrote such letters. That letters were sent is certainly true, but no evidence has ever been found that Semmelweis himself wrote any of them. As I note in The Doctors’ Plague (p. 117), Semmelweis “is said to have written a few of these letters, but there is no documentation of this.”

There are other glaring errors in Richard Horton’s mean-spirited critique of The Doctors’ Plague, though space constraints do not allow their inclusion here. But even adding to the list would not add to the message of this letter, which is that my book has been savaged by a reviewer who is either misinformed or mischievous, or both.

Sherwin B. Nuland
Clinical Professor of Surgery
Fellow of the Institution for Social and Policy Studies
Yale University
New Haven, Connecticut

Richard Horton replies:

Sherwin Nuland is upset about my implication—I meant it to be a firm proposition—that he is monomaniacal in his critical assessment of Ignác Semmelweis. There is nothing wrong with being monomaniacal. As the respected medical historian Owsei Temkin has written,

The vision of a genius needs a certain single-mindedness to cut through the bewildering, contradictory evidence of contemporary life; it needs a compulsion to follow the vision and thus comes perilously close to the monomania of the crackpot. Semmelweis called the obstetricians who disregarded his work murderers. To them in turn his zeal must have appeared that of a fanatic.

And so these bitter divisions continue. To summarize, Nuland not only denies Semmelweis’s enormous contribution to women’s health (he rejects my claim, for example, that Semmelweis injected science into the then lethal art of obstetrics), but also refuses to admit one shred of compassion for a man ruined by an illness that gradually destroyed his mind. To be sympathetic to a person undergoing a catastrophic mental breakdown is not to distort, but merely to be appreciative of the evidence history has bestowed upon us. To seek a more balanced account of a life is not to be mischievous, but to wish to recognize a compelling discovery that has been largely forgotten.¹ Nuland welcomes neither objective and instead entangles himself in arguments about the meaning of his own words in order to justify his sometimes cruel adjudications about Semmelweis. I would simply invite readers of The New York Review to go back to Nuland’s writing and judge for themselves the tone and style of his appraisal, an indication of which can be found in his letter.

Semmelweis’s central achievement was to use careful and precise analytic methods to prove that puerperal (or childbed) fever was transmitted by the hands of medical students and physicians. He also proved that the usually fatal transmission of this disease could be prevented by hand-washing in chlorinated water. The sheer scale of these findings is perhaps difficult to understand in modern times. Puerperal fever was a major and gruesome cause of death among women in 1847, the year that Semmelweis made his discovery. His remarkable observations and experiments stunned the Viennese medical academic elite, which had itself created the very conditions that were accelerating the spread of infection. They also ricocheted around Europe, thanks to the documented efforts of his students (which I cited) and against Nuland’s assertion that Semmelweis and his allies did little to communicate their findings.

It is worth reflecting on the character of scientific communication in 1847. Although scientific journals had existed since the seventeenth century, the link between respectable science and journal publication was only established much later. For example, the proceedings of the Vienna Academy of Science, which was formed in 1847, contained Academy news and secondary reports of scientific findings. There was almost no original research. The decision by Semmelweis not to publish his observations was therefore not so surprising. The use of letters to disseminate a new discovery was entirely in keeping with the period. It is an exaggeration to say that his results were “largely forgotten or ignored.” Oliver Wendell Holmes, then dean of medicine at Harvard, referred to Semmelweis in his own 1855 publication on puerperal fever. This historical context is vital if one is to reach a fair verdict on Semmelweis. It is omitted by Nuland.

Time and again, Nuland interprets the evidence one way—against Semmelweis. Carter, for example, writes that

as Semmelweis explained in his major book, The Etiology, Concept, and Prophylaxis of Childbed Fever, near the end of 1847 he and his students wrote letters to several prominent obstetricians in which they described their experiences and invited responses. Most of the letters were ignored. In The Etiology, Semmelweis quoted and discussed the few responses he had received. Hebra also referred to the letters in both of his announcements.

Fact: Letters were sent. Fact: Responses were received and documented, unless Nuland is seriously proposing that this evidence was fabricated by Semmelweis, his students, and Hebra (there is no evidence that this is so). Conclusion: It is reasonable to claim that Semmelweis sought to communicate his ideas to others. It is wholly unreasonable to imagine that Semmelweis took no part in sending out these letters, given that they—and certainly the one letter cited by Carter—came from his student collaborators.

Nuland objects to my deliberately extreme characterization of the Viennese medical establishment in the early nineteenth century. Yet there is considerable evidence to support this description. To take just one example, Nuland himself has shown that the city was “hostile to certain kinds of foreigners,” and that “Poor Semmelweis, a Hungarian with a Germanic name, may have felt that he was, in some quarters, suspected of being a crypto-Jew.” Nuland is certain that we know all there is to know about Semmelweis’s background. Yet the question of whether Semmelweis’s family were Jewish or retained a strong Jewish cultural identity remains contested. In Hal Helman’s study of Semmelweis, for example, he quotes medical historian Constance Putnam, who “suspects that [Semmelweis’s] forebears may well have been Jewish.” Where I see this issue as open to debate, Nuland sees it as closed. This difference underlies much of our disagreement.

He also implies that Semmelweis was quick to take up his training in obstetrics soon after qualifying in medicine. He uses this supposition to suggest that Semmelweis was anxious to enter the academic world of obstetric research. But his decision to enter obstetrics, as Nuland has pointed out elsewhere, followed two devastating rejections, one to embark on a career in forensic pathology, the other to become an assistant to Josef Skoda, then the Vienna medical school’s leading physician. These disappointments, Nuland argues, especially the first, “must have been great.” Obstetrics was very much Semmelweis’s third choice, hardly an auspicious start to what Nuland wants us now to believe was an early and ardent commitment to his chosen specialty.

Semmelweis, Nuland goes on to argue, was part of a close-knit group of mentors and academics, a scientific network by any standards. But to be a professor and chairman of a university department in the 1850s was not the same as it is today. Not until well into the twentieth century did scientific research become the defining quality of the clinical professoriate. Teaching and clinical acumen were the greater hallmarks of a university position in the mid-nineteenth century, and in these Semmelweis excelled. Moreover, as I noted in my review, Semmelweis did have one close friend, mentor, and colleague in Jakob Kolletschka. But when Kolletschka died from the illness that sparked Semmelweis’s own insight into the cause of puerperal fever, the Hungarian “outsider” (Nuland’s word) lost his principal adviser. Astonishingly, Nuland now claims that Semmelweis was a well-trained scientist and not, as I suggest, educated primarily as a skilled clinician. This is a dramatic, bizarre, and opaque reversal by Nuland. For in his book, he makes a great deal of the fact that Semmelweis was a “reluctant” investigator, and that his laboratory experiments were “haphazard” and “feeble.” So much, according to Nuland’s own conclusions, for Semmelweis’s scientific credentials.

Amid this sea of inconsistency and elision, Nuland’s most serious misjudgment, one that even he does not truly believe, is that Semmelweis contributed nothing to our understanding of germ theory. In fact, his discovery was a vital part of the cumulative understanding of infectious disease during the nineteenth century. Nuland accepts this view, but, perversely, would now have us think otherwise. In a long interview dated March 9, 2003, Nuland said, “I just finished a biography of Ignatz Semmelweis who was a 19th century obstetrician who essentially found germ theory before Pasteur.”² At last, we agree!