Ignaz Semmelweis (1818-1865) was a Hungarian doctor who, during his tenure as an assistant professor at the Obstetrics clinic in the Vienna General Hospital, became interested in learning why so many women were dying from puerperal fever, which was colloquially called childbed fever.1
Semmelweis studied two of the hospital’s maternity wards; one was staffed by female midwives while male doctors and medical students worked in the other. The statistics he gathered demonstrated that women who were treated in the doctor-run clinic were five times more likely to die following childbirth than those who visited the ward that was run by the midwives.2 Women knew of the differing mortality rates as well. Semmelweis recorded that the female patients were so scared of the male-staffed clinic that when they found out that they had entered this clinic by mistake, they would, “kneeling and wringing their hands, beg to be released in order to seek admission to the second clinic [female-run clinic].”3 In this same work, published in 1861, Semmelweis describes his approach to resolving this discrepancy, the translated version of the text reads:
I was convinced that the greater mortality rate at the first clinic was due to an endemic but as yet unknown cause. That the newborn, whether female or male, also contracted childbed fever convinced me that the disease was misconceived. I was aware of many facts for which I had no explanation… Patients who delivered prematurely or on the street almost never became ill, and this contradicted my conviction that the deaths were due to endemic causes. The disease appeared sequentially among patients in the first clinic. Patients in the second clinic were healthier, although individuals working there were no more skillful or conscientious in their duties… Everything was in question; everything seemed inexplicable; everything was doubtful. Only the large number of deaths was an unquestionable reality.4Ignaz Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, trans. K. Codell Carter (Wisconsin: The University of Wisconsin Press, 1983), 70.
Semmelweis attempted to uncover the root of these drastically different mortality rates by observing the differing practices that were used in the two wards. First, he found that women in the female-run clinic gave birth on their sides whereas those who visited the doctor’s ward lay on their back. Semmelweis asked the male doctors to implement this technique but the mortality rates remained the same. Next, Semmelweis noticed that after a woman succumbed to childbed fever in the doctor’s clinic a priest would walk through the space while ringing a bell. He proposed that women in the ward were falling sick and dying of fear in response to this practice, but even after the priest discontinued his use of the bell there was no improvement in the clinic’s statistics.
On 20 March 1847, Semmelweis learned that his friend, Professor Jakob Kolletschka (1803-1847) had died shortly after one of his students had accidentally cut Kolletschka’s finger while they were performing an autopsy. In his book Semmelweis writes that he was “haunted by the image of Kolletschka’s disease and was forced to recognize, even more decisively, that the disease from which Kolletshka died was identical to that from which so many maternity patients died.” This hypothesis was confirmed by the results of the professor’s autopsy, after which Semmelweis concluded that Kolletschka’s death was caused by ‘cadaverous particles’ that entered his injured finger, rather than the wound itself. Semmelweis writes: “I was compelled to ask whether cadaverous particles had been introduced into the vascular systems of those patients whom I had seen die of this identical disease. I was forced to answer affirmatively.”
Semmelweis had finally discovered why there was a staggering difference in maternal mortality rates between the two clinics: the male staff at the Vienna General Hospital frequently performed autopsies before examining a pregnant woman or delivering her baby. Since the doctors were not properly sanitizing their hands before working in the obstetrics ward, the women they treated were being exposed to, and dying from the ‘cadaverous particles’ on their hands.’5 The midwives did not have occasion to come in contact with ‘cadaverous particles’ during their medical training, and thus, did not contaminate their patients, which explained why the mortality statistics at the female-run clinic were fairly low.
In May 1847 Semmelweis instituted a rule which stated that all employees of the male-run obstetrics clinic must wash their hands with a chlorinated lime chemical solution before beginning their shift. By October, the staff were also instructed to wash their hands with the chemical in between examining each of their patients. Semmelweis believed that the use of chlorinated lime would drastically reduce maternal mortality rate, and he was correct. In 1848, the first year that doctors utilized the chemicals, the mortality rate for the male-run ward fell to 1.27 percent, a number lower than the midwife clinic which sat at 1.33 percent.6
Despite Semmelweis’s demonstrable success, his superior, Professor Johann Klein (1788-1856) did not accept Semmelweis’s understanding of childbed fever. Instead, he believed that the reduced mortality rate in the male-run clinic was caused by a new ventilation system that had been installed at the hospital, despite, as Semmelweis notes, both clinics utilizing the same ventilation system.7,8 Klein was part of the old guard and resented Semmelweis and his young peers both for their liberal views, and for the implications that hospital policies were to blame for the high maternal mortality rate at the male-run clinic. As a result of this rivalry Klein did not renew Semmelweis’s assistant professorship when his two-year term expired in March 1849. After applying for a clinical faculty appointment (Privatdozent) in February 1850, Semmelweis received word that he could teach midwifery but would not be permitted access to patients or cadavers. Stunned by these harsh provisions, and feeling betrayed, Semmelweis fled Vienna without warning and returned home to Pest.
In 1851, Semmelweis was made honourary head physician in the maternity ward of Rókus Hospital in Pest, where he immediately instituted his chlorine solution handwashing routine. Indeed, as Sherwin B. Nuland notes, Semmelweis often stood near the chemical basin and “never hesitated to harangue a physician or aide who tried to circumvent his procedures.”9 As a result of Semmelweis’s strict adherence to his handwashing directive, the mortality rate from childbed fever dropped to .85%.10 Despite his success at Rókus, Semmelweis’s theory of the origin of puerperal fever was largely disregarded by members of the medical community. In 1861, Semmelweis published his research in a book titled The Etiology, the Concept, and the Prophylaxis of Childbed Fever, copies of which he sent to leading obstetricians around Europe, but still, his theories were ignored and criticized. Semmelweis felt it was his responsibility to save women from childbed fever, as is notable from a letter he sent to Joseph Späth, a professor of obstetrics at the University of Vienna. Semmelweis writes:
…within myself, I bear the knowledge that since the year 1847 thousands and thousands of puerperal women and infants who have died would not have died had I not kept silent, instead of providing the necessary correction to every error which has been spread about puerperal fever…And you, Herr Professor, have been a partner in this massacre. The murder must cease, and in order that the murder ceases, I will keep watch, and anyone who dares to propagate dangerous errors about childbed fever will find in me an eager adversary.11Ignaz Semmelweis, Letter to Joseph Späth, quoted in Sherwin B. Nuland, The Doctor’s Plague: Germs, Childbed Fever, and the Strange Story of Ignaz Semmelweis (New York: W.W. Norton, 2003), 161.
In July 1865, just four years after the publication of his research, Semmelweis experienced a state a mental decline. For instance, when he was called upon to give a report in a faculty meeting, he pulled the Midwives’ Oath from his pants and read it, without any indication that he understood where he was or what he was meant to be doing.12 Some scholars believe that his illness may have been caused by the constant criticism of his theories and his belief that his actions (before he knew that handwashing could prevent puerperal fever) had sent a number of his patients “prematurely to their graves.”13 Semmelweis was admitted to a psychiatric institution in Dòbling on July 31st, and passed two weeks later on August 13th 1865 at 47 years of age. Although historians have long debated the mechanism for Semmelweis’s death, it is clear that he died of general sepsis, the same blood infection that Semmelweis had spent much of his life trying to prevent.
Dr. Ignaz Semmelweis was the first healthcare worker to demonstrate that handwashing could prevent the spread of infections. His theories became more respected in the 1860s when Louis Pasteur’s (1822-1895) experiments helped him formulate germ theory and Joseph Lister (1827-1912) made great strides in antiseptic techniques. We continue to regard Semmelweis’ work quite favourably. The University of Pest, where Semmelweis worked in the years before his death changed its name to Semmelweis University in 1969. In 2018, the Hungarian government declared that the year, the 200th anniversary of Semmelweis’s birth, would be dedicated to celebrate the ‘saviour of mothers’. More recently, on March 20th, 2020, near the beginning of the pandemic, the Google homepage recognized Semmelweis and the importance of handwashing.
- We now believe that puerperal fever was caused by the Betta haemolytic streptococcus, Lancefield Group A. For more information about the specific bacteria that caused this illness please read Hallett, Christina. “The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory.” Medical History 49, no. 1 (2005): 1-28.
- Women whose babies were delivered at the doctor-staffed clinic had a 13-18% mortality rate whereas women who were treated by midwives had a 2% mortality rate. M. Best, and D. Neuhauser. “Ignaz Semmelweis and the birth of infection control.” BMJ Quality and Safety 13, no.3 (2014): 233.
- Ignaz Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, trans. K. Codell Carter (Wisconsin: The University of Wisconsin Press, 1983), 70.
- Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, 86.
- Germ Theory had not yet been formulated in the late 1840s. Doctors did not understand that bacteria caused illness, so they did not wear gloves while working at the clinic, nor did they properly sanitize their hands between patients.
- Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, 89.
- Professor Klein subscribed to the miasma theory of contagion, as did most doctors during this period. Miasmatists believed that illness was caused by bad or polluted air, which likely explains why Klein attributed the lower rate of infection to the improved air flow.
- Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, 75.
- Sherwin B. Nuland, The Doctor’s Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis (New York: W.W. Norton, 2003), 139.
- Puerperal fever mortality records from the years prior to the use of Semmelweis’s handwashing procedures were lost during the uprisings of 1848. It is clear, however that mortality rates from this infection were much higher than the .85% achieved during Semmelweis’s tenure. Nuland, The Doctor’s Plague, 140.
- Ignaz Semmelweis, Letter to Joseph Späth, quoted in Sherwin B. Nuland, The Doctor’s Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis (New York: W.W. Norton, 2003), 161.
- Robert P. Gaynes, Germ Theory: Medical Pioneers in Infectious Diseases (Washington: ASM Press, 2020), 140.
- Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, 98.
Bibliography (click to expand)
Hallett, Christina. “The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory.” Medical History 49, no. 1 (2005): 1-28.
Best, M. and Neuhauser. D. “Ignaz Semmelweis and the birth of infection control.” BMJ Quality and Safety 13, no.3 (2014): 233-234.
Semmelweis, Ignaz. The Etiology, Concept, and Prophylaxis of Childbed Fever. Translated by K. Codell Carter. Wisconsin: The University of Wisconsin Press, 1983.
Nuland, Sherwin B. The Doctor’s Plague: Germs, Childbed Fever, and the Strange Story of Ignac Semmelweis. New York: W.W. Norton, 2003.
Gaynes, Sherwin B. Germ Theory: Medical Pioneers in Infectious Diseases. Washington: ASM Press, 2020.
Haggard, Howard W. From Medicine Man to Doctor: The Story of the Science of Healing. New York: Dover Publications, 2004.
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