By: Susan-Marie Cronkite, PhD.
Ignaz Semmelweis 1818 – 1865
Dr. Ignaz Semmelweis is called the “savior of mothers” because he discovered that the incidence of puerperal sepsis, or childbed fever, could be drastically reduced if attending physicians washed their hands with disinfectant prior to helping mothers in the birthing process [1]. Sadly, the medical system at the time was highly resistant to change, so his assertions were ridiculed and he soon became an outcast. Semmelweis is actually one of the better known heroes of Environmental Health as his tragic life is often taught in classes on the history of medicine, epidemiology and environmental/public health.
Cases of childbed fever have been recorded throughout history [2], but it did not become a serious wide-spread problem until the 17th century and the invention of lying-in or childbirth hospitals. The first epidemic of puerperal fever was recorded in 1646 in the lying-in hospital Hôtel-Dieu de Paris but epidemics were soon recorded all across Europe and the US with death rates as high as 25% [3]. This was the situation when Dr. Semmelweis started his first medical job in 1846 as an assistant head to Dr. Klein in the Obstetric Clinic at Allgemeines Krankenhaus (Vienna’s General Hospital). He was assigned to the First Clinic, one of two lying-in clinics in the hospital. The First Clinic was a teaching site for new doctors and had a mortality rate of 25%, while the Second Clinic was a teaching site for midwives and had a mortality rate of 3%. This huge difference in the mortality rates, and the fact that women who gave birth on the street, or at home, also had a mortality rate of 3%, haunted the young doctor. From that point, Dr. Semmelweis dedicated himself to discovering why so many new mothers had to die.
The medical community at the time believed the mortality rate was due to any number of factors, including: miasmas, fear, constipation, delayed lactation, crowding and the season [4]. Semmelweis, not convinced by these theories, began to study the differences between the two obstetrical clinics. The patients in the two clinics were basically identical in their makeup – they faced the same crowding, the same fears and the same ‘miasmas’– and their admission was random. The women who came to the hospital were not assigned to a specific clinic, instead their admission simply depended upon the day of the week as each clinic took admissions on alternating days [5]. The clinics themselves were also basically the same, both used as teaching sites; Clinic One focused on training new doctors while Clinic Two focused on training midwives. Semmelweis was baffled until the sudden death of his best friend and colleague, Dr. Jakob Kolletschka who died from pyemia (blood poisoning) after an accidental injury acquired during an autopsy [6]…
“Totally shattered [by the death of Kolletschka], I brooded over the case with intense emotion until suddenly a thought crossed my mind; at once it became clear to me that childbed fever and the death of Professor Kolletschka were one and the same because they both consist pathologically of the same anatomic changes. If, therefore, in the case of Professor Kolletschka…. septic changes…. arose from the inoculation of cadaver particles, then puerperal fever must originate from the same source….. [7]”
Following up on his assumption, Semmelweis discovered that the educational focus of each clinic was at the base of the problem; in Clinic One, the teaching was dedicated to young doctors, physician professors and students. It was common morning practice in this clinic to dissect the bodies of women who had died the previous day. The afternoon was then spent in the lying-in wards performing internal examinations “with hands that smelled of cadavers” [8]. In Clinic Two, however, the midwifery students were not involved in dissection studies, but only in the care of women in labor. Semmelweis concluded that “the fingers and hands of students and doctors, soiled by recent dissections, carry those death-dealing cadavers’ poisons into the genital organs of women in childbirth…..” [9]. He was so convinced that the lack of hand hygiene in Clinic One was a direct cause of the high mortality rate seen in new mothers that, from May 1847 onwards, he instituted a program of hand-washing, requiring all students and doctors to wash in a chlorinated lime solution (calcium hypochlorite, the component used in household bleach, see: Mini Bio # 17) after dissections of cadavers as well as between each female patient requiring an internal examination. The results were instantaneous and dramatic – the mortality rate from puerperal sepsis fell, in just one month, from 18% in May 1847 to 3% by June [10].
Despite the clinical evidence, the medical community rejected his findings. How dare he suggest that the hands of gentlemen of good social standing could be so unclean as to cause death! Semmelweis was ridiculed, and when his position of assistant in the First Clinic came up for renewal 20 March 1849, another candidate also applied. The position was given to the second applicant, Carl Braun, so Semmelweis was obligated to leave. Immediately Semmelweis was removed from the Allgemeines Krankenhaus, the hand-washing practice was dropped and the mortality rate in Clinic One quickly began to climb again. Semmelweis presented his findings at a conference in 1850, but his conclusions were rejected. He then began to write a series of open letters to the medical fraternity, accusing them of being murderers. One of his most vitriolic open letters was addressed to Friedrich Scanzoni, Professor of Obstetrics as Würzburg…
“If, Sir, without having refuted my doctrine, you continue to teach the students and midwives that you train that puerperal fever is an ordinary epidemic disease, I proclaim you before God and the world to be an assassin and the history of puerperal fever would not do you an injustice were it, on opposition to my life-saving discovery, to immortalize you as a medical Nero [11].”
These letters did not gain him any support and actually greatly tarnished his reputation, making his claims even more unlikely to be examined, let alone accepted. He finally published his work in 1861 [12], presenting graphs and other clinical data to support his conclusions, but again his findings were dismissed [13].
The last few years of Semmelweis’ life were increasingly troubled. He suffered from bouts of depression and he fixated on childbed fever turning every conversation to that topic. He then began to age rapidly, lose his memory and eventually to display serious bouts of psychosis. Today it is postulated he may have suffered a nervous breakdown, suffered from third-stage syphilis which was common among obstetricians at the time or from Alzheimer’s [14]. Semmelweis’ wife and good friend admitted him to a private insane asylum. The doctor tried to leave, whereupon he was beaten severely by the asylum guards, put in a straitjacket and placed in a cell. Two weeks later, on August 13, 1865, at age 47, Semmelweis died. An autopsy revealed that he died from pyemia — blood poisoning. The exact cause of the blood poisoning is not known, but it is likely due to an injury obtained during the beating. The autopsy also revealed extensive injuries to his internal organs. Semmelweis died slowly, and in great pain, in the same way the new mothers with childbed fever had died.
Semmelweis had some followers and individual contemporary doctors experimented with washing with a chlorinated lime solution. His work was not fully accepted, however, until the accumulated the work of such men as Agostini Bassi (1835), John Snow (1854), Louis Pasteur (1860), Joseph Lister (1870) and Robert Koch (1890) proved the germ theory of disease transition. Today, Semmelweis is recognized as a great humanitarian and a pioneer in antiseptic policy [15].
Annotated References:
[1] Hanninen, O., M. Farago, E. Monos, 1983, Ignaz Semmelweis, the prophet of bacteriology. Infect Control, vol. 4(5), pp.367-370. Available on-line at: http://web.archive.org/web/20080404214853/http://www.general-anaesthesia.com/semmelweis.htm. Cited January 11, 2010.
[2] One of the most famous victims of puerperal fever is Lady Jane Seymour, third wife of King Henry VIII. She died on 24 October 1537 soon after giving birth to Edward VI of England.
[3] Puerperal fever, Wikipedia, the free encyclopedia. Available on-line at: http://en.wikipedia.org/wiki/Puerperal_fever. Cited January 11, 2010.
[4] Tan S.Y, MD, JD and Brown, J, 2006, Medicine in Stamps Ignac Philipp Semmelweis (1818-1865): handwashing saves lives. Singapore Med J., vol. 47(1), pp.6-7. Available on-line at: http://www.sma.org.sg/smj/4701/4701ms1.pdf. Cited January 11, 2010.
[5] The differences in the mortality rates in the two clinics was well known by the women of Vienna. If at all possible, women held off entering the hospital until they could enter Clinic Two or delayed journeying to the hospital so they had the birth “on the street on the way to the hospital” as they were then still eligible for free medical care.
Nuland, Sherwin B. 2003. The Doctors’ Plague: germs, childbed fever and the strange story of Ignac Semmelweis. Norton and Company. New York.
Loudon, Irvine ((March 9, 2000)). The Tragedy of Childbed Fever. Oxford University Press, USA;. ISBN 019820499X. page 6. First chapter available on http://fds.oup.com/www.oup.co.uk/pdf/0-19-820499-X.pdf
[6] Dr. Kolletschka was cut by a student’s scalpel during an autopsy and died a few days later.
[7] Tan S.Y, MD, JD and Brown, J, 2006, Medicine in Stamps Ignac Philipp Semmelweis (1818-1865): handwashing saves lives. Singapore Med J., vol. 47(1), pp.6-7. Available on-line at: http://www.sma.org.sg/smj/4701/4701ms1.pdf. Cited January 11, 2010.
[8] Ibid. Cited January 13, 2010.
[9] Ibid. Cited January 13, 2010.
[10] De Costa, Caroline M, 2001, The contagiousness of childbed fever: a short history of puerperal sepsis and its treatment. eMJA (Medical Journal of Australia), vol. 177 (11/12), pp. 668-671. Available on-line at: http://www.mja.com.au/public/issues/177_11_021202/dec10354_fm.html. Cited January 12, 2010.
[11] Tan S.Y, MD, JD and Brown, J, 2006, Medicine in Stamps Ignac Philipp Semmelweis (1818-1865): handwashing saves lives. Singapore Med J., vol. 47(1), pp.6-7. Available on-line at: http://www.sma.org.sg/smj/4701/4701ms1.pdf. Cited January 11, 2010.
[12] The Etiology, Concept and Prophylaxis of Childbed Fever.
[13] The main reason his findings were rejected is because the ‘germ theory’ of infection had not yet either wide publication or wide belief. Similar work in the US by Oliver Wendall Holmes (1843) was also ridiculed and resulted in public retorts, including one from Dr. Charles Meigs, the most prominent US obstetrician at the time. Meigs was incensed at the idea that doctors were the cause of puerperal sepsis and commented that “Doctors are gentlemen, and gentlemen’s hands are clean.”
De Costa, Caroline M, 2001, The contagiousness of childbed fever: a short history of puerperal sepsis and its treatment. eMJA (Medical Journal of Australia), vol. 177 (11/12), pp. 668-671.
[14] Ignaz Semmelweis, From Wikipedia, the free encyclopedia. Available on-line at: http://en.wikipedia.org/wiki/Ignaz_Semmelweis. Cited January 13, 2010.
[15] Ibid. Cited January 13, 2010.
