The realization he made — before the germ theory and critical to the founding of infection control — must be unraveled like a detective story.
Pregnant women had very high rates of mortality caused by a kind of sepsis known as “childbed” or puerperal fever at the Vienna Maternity Hospital where Semmelweis worked for several years in the 1840s. One biographer gave a sense what this horrific infection was like, describing Semmelweis standing over a patient who had just given birth but was deteriorating rapidly.
“As he stood over her supine figure, Semmelweis noted a sudden onset of uncontrollable shaking throughout her body, accompanied by a chattering of teeth that persisted for several minutes,” the author notes.1 “It would take decades of full elucidation of the germ theory before physicians recognized the shaking and chattering for what it truly represented — a sudden invasion of massive numbers of bacteria into the bloodstream. Her uncontrollable rigors signaled the onset of fulminating disease, her calamitous descent over the medical precipice. In this era before antibiotics, her death was a foregone conclusion.”
There were two maternity clinics at the Vienna hospital: clinic 1 for the training of male obstetricians and clinic 2 staffed by midwives. The mortality rate in clinic 1 was sometimes six times higher than the other clinic, and over a six-year period, pregnant women were three times more likely to die in the physician clinic. Over this period, the mortality rate at clinic 1 was 9.9% compared to 3.3% in clinic 2, Semmelweis wrote in his 1861 book on the subject.2
Concerns and Clues
This difference greatly troubled Semmelweis and set him into deep thought and careful observation. In the end, the explanation made perfect sense. He began picking up clues, such as noticing that even women who gave birth in the streets of Vienna had a lower puerperal fever mortality rate than those delivering in the hospital.
“To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic,” Semmelweis wrote. “What protected those who delivered outside the clinic from these destructive unknown endemic influences?”
A friend and colleague, Jokob Kolletschka, died after he incurred a scalpel wound while instructing a student on performing an autopsy on a patient who had died of childbed fever. The Vienna physicians commonly performed autopsies, which then were sometimes followed by an examination of their pregnant patients. The midwives in clinic 2 did not perform autopsies. Kolletschka’s rapid progression toward death struck Semmelweis with the thought that he had seen this before.
“I could see clearly that the disease from which Kolletschka died was identical to that from which so many hundred maternity patients had also died,” Semmelweis wrote. “The maternity patients also had lymphangitis, peritonitis, pericarditis, pleurisy, and meningitis, and metastases also formed in many of them.”
This insight led to the eureka moment, as Semmelweis reached a conclusion that would save an inestimable number of lives.
“Not the wound, but contamination of the wound by the cadaverous particles caused his death,” Semmelweis realized. “I was forced to admit that if his disease was identical with the disease that killed so many maternity patients, then it must have originated from the same cause … [T]he specific causal factor was the cadaverous particles that were introduced into his vascular system. 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.”
Realizing that soap and water — which apparently was sometimes used — would not be strong enough to decontaminate the contaminated hands, Semmelweis used a solution of chlorinated lime. In May 1847, Semmelweis began washing his hands in chlorinated lime and had his students do so before seeing maternity patients.
“In 1848, chlorine washings were employed throughout the year and of 3,556 patients, 45 (1.2%) died,” he found.
Suggesting a look-back study to an investigating commission, Semmelweis reasoned that specific maternal deaths could be linked to the pattern of doctors and students who performed autopsies prior to patient examinations. “[H]igher authorities prevented the commission from carrying out this assignment,” he wrote.
Recognition After Death
It was a remarkable process in reasoning, but Semmelweis also came to the realization of how many lives had been lost because of his own contaminated hands. “In consequence of my conviction I must affirm that only God knows the number of patients who went prematurely to their graves because of me. I have examined corpses to an extent equaled by few other obstetricians,” he wrote. “If I say this also of another physician, my intention is only to bring to consciousness a truth that, to humanity’s great misfortune, has remained unknown through so many centuries. No matter how painful and oppressive such a recognition may be, the remedy does not lie in suppression. … None of us knew that we were causing the numerous deaths.”
Despite his own admission of ignorant complicity, rejection by his physician peers was rapid and vitriolic. He gave back in kind, and eventually lost his professorship in Vienna, now widely criticized and dismissed for “unscientific” methods at medical conferences. Without the knowledge of microscopic pathogens, some physicians thought disease was caused by vapors and contaminated air. On a societal note, some found it offensive as gentlemen that they should be accused of unclean hands.3 The abject denial that Semmelweis faced could be compared with how some viewed the COVID-19 pandemic, both about the disease and the vaccines to prevent it.
It warrants emphasis that Semmelweis’ findings essentially were iatrogenic: He was reporting provider-to-patient fatal infections to some of the very physicians who were culpable. Such a conclusion was roundly rejected, perhaps in part because accepting Semmelweis’ findings amounted on some level as an admission of guilt.
Berating his colleagues for dismissing his findings, Semmelweis grew more shrill and eventually was driven into exile as a medical pariah. Isolated and depressed, he declined mentally until he was confined in an asylum in Budapest under harsh conditions in 1865. He died shortly thereafter at age 47, having never been recognized for his achievements in his lifetime.
The growing implications of Pasteur’s discovery of the germ theory in 1861 contributed to the long image rehabilitation that followed. Thereafter, he was called the “savior of mothers” or the father of infection control. There also is this widely used metaphor in his name that attests to his courage while serving as a cautionary tale: “Semmelweis Reflex: The tendency to reject new evidence or new knowledge because it contradicts established norms, benefits, and paradigms.”
Semmelweis was not the only one who saw the benefit of hand hygiene. Florence Nightingale recommended in 1860 that nurses should wash their hands frequently throughout the day, but the first formal guidelines on handwashing in hospitals by the Centers for Disease Control and Prevention were not issued until the 1970s, when the field of infection control was emerging.
REFERENCES
- Obenchain TG. Genius Belabored: Childbed Fever and the Tragic Life of Ignaz Semmelweis. University of Alabama Press; 2021.
- Semmelweis I. Etiology, Concept and Prophylaxis of Childbed Fever (1861). English translation. University of Wisconsin Press; 1983.
- Carter KC, Carter BR. Childbed Fever: A Scientific Biography of Ignaz Semmelweis. Transaction Publishers; 2005.
Ignaz Semmelweis, the 19th century Hungarian obstetrician who made the lifesaving connection between unwashed hands and patient infections, is widely known to have had his findings soundly rejected by his physician peers. But that is only part of the story.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content