Ignaz Philipp Semmelweis (1818–1865): herald of hygienic medicine

Commemorating the bicentenary of the doctor who championed aseptic practice in obstetric medicine

Asepsis and antiseptic technique are fundamental to modern medicine, a fact evident on any Australian hospital ward with its diverse array of sanitisers, soaps, and antiseptic sprays. Infection control staff regularly scurry about our workplaces, hand hygiene is encouraged in every corridor, and few medical procedures are possible without removing at least one item from a sterile plastic wrapper. Less than 200 years ago, however, medicine was performed without any effective antisepsis. One of the pioneers in this area was Ignaz Semmelweis (1818–1865), the Hungarian obstetrician who dedicated his career to reducing maternal mortality by strict insistence on hand washing, facilitating what William Osler (1849–1919) described as “one of the most striking of all victories of preventive medicine … the almost total abolition of so-called child-bed fever from the maternity hospitals.”1

“The dark side of obstetrics”: the Vienna General Hospital, 1846

Ignaz Philipp Semmelweis (Box 1) was born 200 years ago in the Tabán district of Buda (now part of Budapest). He initially studied law at the University of Vienna, but quickly switched to medicine, graduating in 1844.2 After failing to secure a position in either pathology or internal medicine, Semmelweis accepted in 1846 the role of assistant obstetrician under Johann Klein (1788–1856) in the obstetric department of the Vienna General Hospital. His daily responsibilities included examining patients, teaching medical students, and supervising deliveries.3

As a public institution that predominantly served Vienna’s poor, the General Hospital offered physicians and medical students many learning opportunities throughout the 19th century and had a strong emphasis on the teaching of pathological anatomy.4 Each morning, under the instruction of Professor Klein, doctors and medical students in the obstetric department performed dissections in the hospital morgues before attending the clinic. This was long before American surgeon William Halsted (1852–1922) introduced rubber gloves into surgical practice, and both the dissections and the internal examinations of patients were performed barehanded.

There were two maternity clinics at the General Hospital. Since 1840, obstetricians and medical students had attended the patients in the First Clinic, where by 1846 the mortality rate was more than five times that of the Second Clinic, in which midwives attended the women.3 The high mortality was generally associated with “childbed fever” (puerperal fever), a disease that had been recognised since Hippocrates (“erysipelas of the womb”: Aphorisms V, 43).5 Now known to be caused by staphylococcal or streptococcal septicaemia,6 it was attributed in the 19th century to unhealthy miasmas arising from the mixture of blood, pus and excrement that filled the air of these overcrowded wards.7 The first signs of the infection — fever, tachycardia and diarrhoea — developed soon after labour, followed by a broad range of sepsis-related symptoms, including uterine or perineal pain, peritonitis, pleural effusion, pericarditis, seizures, and violet macules on the limbs.4 Death was often drawn out and painful. Such was the reputation of the First Clinic that women often preferred to deliver at home or even on the street than to be admitted to the dreaded General Hospital. Semmelweis watched helplessly as hundreds of previously healthy women died of puerperal fever on his ward; by his own admission, this was “the dark side of obstetrics”.3

The Austrian government established several commissions to investigate the causes of puerperal fever but failed to implement any meaningful reforms.3 Semmelweis, however, closely studied the disease and, on the basis of a series of careful observations, concluded that in Vienna it was unique to the First Clinic:

• in 1846, the mortality rate among women in the First Clinic was five times as high as in the Second Clinic;

• puerperal fever affected entire rows of patients in the First Clinic, but occurred only sporadically in the Second Clinic;

• when labour lasted more than 24 hours, women in the First Clinic almost invariably fell ill, but this did not apply to women in the Second Clinic;

• the risk of puerperal fever among women who gave birth on the street was significantly lower than for women who delivered in hospital.3

Semmelweis’ insight: asepsis is imperative

Semmelweis’ epiphany came in 1847 when he learned of the death of his close friend and professor of forensic medicine, Jakob Kolletschka (1803–1847). During an autopsy, a medical student had accidently pricked Kolletschka’s finger with his knife; Kolletschka quickly fell ill with symptoms identical to those of patients who had died of puerperal fever. As Kolletschka’s death was clearly caused by his inoculation with “cadaverous particles” from the contaminated knife, Semmelweis hypothesised that the same particles could be introduced into the uterus during an internal examination by a doctor with contaminated hands.3

Semmelweis’ hypothesis explained each of his observations. As doctors and medical students performed autopsies, but midwives did not, only patients in the First Clinic were exposed to cadaverous particles. Further, as doctors examined the patients each day, proceeding from one woman to the next, it was apparent why entire rows of patients suddenly became ill at the same time. The hypothesis also explained why the risk of puerperal fever was particularly high when labour lasted more than 24 hours: in these cases, the women were examined several times, increasing the opportunity for infection. Finally, women who gave birth on the street were not examined by doctors and were therefore not exposed to cadaverous particles.3

Spurred on by this revelation, Semmelweis introduced mandatory hand washing in a chlorinated lime solution to remove cadaverous particles before any internal examination by his staff members. Later, he also washed any instruments to be employed during deliveries. Following these initiatives, the annual mortality rate in the First Clinic plummeted from 11.4% in 1846 to 1.3% in 1848 (Box 2).3 Semmelweis’ elation at his success was tempered by the sobering realisation that he and his colleagues had acted as vectors for the spread of a fatal disease among young women; he sorely confessed that “only God knows the number of patients who went prematurely to their graves because of me.”3

The muted response to Semmelweis’ solution

Despite the marked reduction in maternal mortality in the First Clinic and the overall support he received from the Vienna General Hospital, Semmelweis’ hypothesis was not widely accepted, largely because he was reluctant to publish a formal report on his work.2 It was not until 1850 that Semmelweis presented his findings to the Association of Physicians in Vienna, but even then he did not publish his lectures. Consequently, very few doctors had access to his data and relied on what was reported by his supporters, the professors Ferdinand von Hebra (1816–1880) and Joseph Škoda (1805–1881).2

Like his pioneering predecessors Alexander Gordon (1752–1799) in Scotland8,9 and Oliver Wendell Holmes (1809–1894) in the United States,10,11 Semmelweis encountered strong opposition to his revolutionary views on the iatrogenic aetiology of puerperal fever. Even Klein, despite witnessing his achievements firsthand, never accepted Semmelweis’ theory, and in 1849 refused to extend his contract. In 1850, unemployed and frustrated by the lack of recognition, Semmelweis left Vienna and accepted an unpaid position at the small Szent Rókus (St Rochus) Hospital in Pest, Hungary,12 where his Viennese hand-washing and sterilisation techniques reduced maternal mortality to 0.85%. In 1855, he was appointed professor of obstetrics at the University of Pest.2

It was not until 1861 that Semmelweis published his major work, The aetiology, concept, and prophylaxis of childbed fever (Box 3). It was, however, largely dismissed by the medical community as overly repetitive.12 Semmelweis took each criticism personally and responded angrily by dictating abusive letters to those who opposed his views, further alienating him from his peers.2 Semmelweis’ mental health began to deteriorate; he suffered amnesia and developed severe depression and anxiety.12 By 1865, still professor of obstetrics, his behaviour had become unmanageable, forcing his wife, Maria Weidenhoffer (1837–1910), and life-long friend Hebra to admit him to the Lower Austrian Mental Asylum, where he was restrained and beaten shortly after his arrival. Two weeks later, Semmelweis died, aged 47: in a sad irony, of septicaemia secondary to an infected wound probably sustained during his beating.12

Semmelweis’ legacy

Semmelweis did not live to see the broader impact of his work on modern medicine. Indeed, it was not until decades after his death that the germ theory of disease was firmly established, and it took the combined efforts of Louis Pasteur (1822–1895), Joseph Lister (1827–1912) and Robert Koch (1843–1910) to convince sceptics of the value of Semmelweis’ insights. Some historians have blamed the contemporary medical establishment for being dismissive of Semmelweis’ work, while others have regarded him as bringing misery upon himself. Whichever version of events one prefers, we can still read with solemn serenity the 200-year-old obstetrician’s dream of a world free of puerperal fever:

Box 1 – Ignaz Philipp Semmelweis (1818–1865), 1861

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Source: United States National Library of Medicine, Digital Collections.

Box 2 – Maternal deaths attributed to puerperal fever in the First Clinic of the General Hospital in Vienna, 1846–1849

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Source: Based on data reported by Semmelweis.3

Box 3 – The title page of Semmelweis’ major publication, The aetiology, concept and prophylaxis of childbed fever (1861)

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Source: With the kind permission of the Royal College of Obstetricians and Gynaecologists, London.