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Semmelweis: A Lesson in Epidemiology

King-Thom Chung and Christine L. Case
SIM News 47(5):234-237, 1997

During the 19th century, women and their protested Josephine Baker’s program to teach
babies were dying in childbirth at alarming hygiene to child care providers. Thirty physi-
rates in Europe and the United States. In cians sent a petition to the Mayor complain-
some years, as many as one in every four ing that “was ruining medical practice by
women who delivered their babies in hospi- keeping babies well.” (1) Concern for the
tals died from puerperal fever. In 1795, Al- health of mothers and babies has been of
exander Gordon, a Scottish physician, wrote concern to many—but perhaps no one was as
that puerperal fever was transmitted “…by a passionate, or as consumed, as Ignaz
practitioner who had previously attended pa- Semmelweis.
tients affected with the v
disease.” He recom- Ignaz Philipp
mended that doctors “The thing that kills women with
Semmelweis was born
and nurses wash their [puerperal fever]…is you doctors that on July 1, 1818 in either
hands after attending carry deadly microbes from sick Buda or Pest, Hungary.
infected patients. The women to healthy ones.” After completing
American physician, schooling at the Gymna-
Oliver Wendell sium of Buda and the
Holmes in 1843 advocated handwashing to University of Pest in 1837, he enrolled at the
prevent puerperal fever. Holmes was University of Vienna Law School. Bored by
horrified by the prevalence of the disease in his law studies, he was fascinated by what he
American hospitals, which he believed to be saw when he visited the anatomy lab and he
an infectious disease passed to pregnant transferred to the Medical School the
women by the hands of doctors. He following fall. The next year, he transferred
recommended that a physician finding two to the University of Pest Medical School to
cases of the disease in his practice within a be close to his family. His parents had eight
short time should remove himself from children to support and the savings incurred
obstetrical duty for a month. Holmes’s ideas living at home may have been important. The
were greeted with disdain by obstetricians in facilities at Pest were out-dated and
the United States. The medical community inadequate, however, and in the Fall of 1840,
was not ready to accept the recommendations Semmelweis returned to the University of
of Gordon and Holmes. Vienna Medical School where he received
Why were physicians reluctant to accept both Doctor of Medicine and Master of
the important of handwashing? Perhaps be- Midwifery degrees in 1844.
cause they didn’t understand the nature of Following his graduation, Semmelweis
infectious diseases. Robert Koch’s work on obtained a position at the Lying-in (obstet-
the Germ Theory of Disease would not come rics) Hospital of Vienna General Hospital.
for another 30 years. Or, perhaps the answer Vienna General Hospital was a teaching hos-
was more pragmatic: The lack of indoor pital that accepted patients who were too poor
plumbing made it difficult to get water. In to have private physicians. In 1840, Johann
order to make the water comfortably warm, it Klein, the new director of the Lying-in Hos-
would have to be heated over a fire. Addi- pital had made procedural changes. The hos-
tionally, contact with water sources was as- pital consisted of two clinics: formerly medi-
sociated with diseases such as malaria and cal students and midwives were instructed in
typhoid fever. A different motive was stated both clinics. Subsequently, medical students
in 1910 by physicians in New York who were instructed in the First Clinic and Mid-
Semmelweis—p. 2

wives, in the Second. Medical students no Semmelweis collected information from

longer used a model to learn their practice, both clinics. One particular fact caught his
now they used adult female and newborn ca- attention, wealthy women and street births
davers. The First Clinic became a source of were not examined by the medical students
gossip throughout Vienna because the death who had spent their mornings dissecting ca-
rate due to puerperal fever in the First Clinic davers. The death of his good friend, Jakob
ranged between 13 and 18%, four times that Kolletschka, a professor of forensic pathol-
of the Second Clinic. Poor women had ogy, in 1847 was a horrible shock to
learned they had a better chance of surviving Semmelweis but also provided him a needed
childbirth if they gave birth before going to insight. Kolletschka had sustained an acci-
the hospital. (These were called street births.) dental laceration during an autopsy. He de-
On arriving at the hospital, the women veloped lymphangitis in his arm, pleuritis,
begged to be assigned to the Second Clinic, pericarditis, and peritonitis. Five days later he
although the Second Clinic had more patients died. Kolletschka died with identical symp-
and was overcrowded.. toms and pathology as seen in the puerperal
Semmelweis studied with exceptional zeal. fever patients. An earlier event had stayed on
He spent each morning doing dissections in Semmelweis’s mind. In 1844, Semmelweis
the pathology lab and each afternoon attend- watched the obstetrician Johann Chiari re-
ing patients in the Clinic. Here, he observed move a tumor from a patient’s cervix. The
the disease which would become his obses- operation was considered simple and
sion. He was keenly aware that his patients Semmelweis had seen it done many times. A
were terrified and suffering. few days later the women died of puerperal
There were several hypotheses on the fever. Neither patient had given birth and
cause of puerperal fever including suppres- Kolletschka had not been in the First Clinic.
sion of lochial discharge and internal fibrin Semmelweis had found his explanation, “the
deposits. Unfortunately, no one realized that transmission of cadaveric particles clinging to
these were the result, not the cause of the dis- the hand, [and] also by ichorous discharges
ease. On autopsy, the pus in Puerperal fever is a nosocomial originating in living organisms.”
the cadavers led to the no- infection that frequently leads (2)
tion that milk accumulated to peritonitis and septicemia. In May 1847, he ordered all
in the body to cause the dis- The disease begins as an medical students to wash their
ease. Some physicians cited infection of the uterus resulting hands with chlorinated lime before
from childbirth or abortion.
the nebulous “influences” Streptococcus pyogenes, a entering the delivery room. The
of the obstetric hospitals as group A ß-hemolytic mortality rate dropped to under
the cause of the disease. Streptococcus, is the most 2%. In October, 12 women in a
It is unlikely that frequent cause. Penicillin and row of beds became ill and 11
Semmelweis had read aseptic techniques have made died. Semmelweis logically
Holmes’s paper on puer- puerperal disease.
sepsis an uncommon
looked at the first patient exam-
peral sepsis published the ined that day, a woman admitted
previous year. Semmelweis was probably at not for childbirth but because she had a uter-
as much of a loss as anyone else to explain ine infection. Semmelweis modified the
the occurrence. washing procedure to require everyone to
Klein saw that Semmelweis was an in- wash their hands with chlorinated lime after
dustrious student and, in 1846, appointed examining each patient. The staff and stu-
Semmelweis to Assistant in the First Clinic. dents objected because the chlorine irritated
The young Assistant’s duties included their skin and washing took too much time,
teaching the 44 medical students and per- but generally they complied with the new
forming all clinical examinations. rule. Semmelweis’s success annoyed Klein
who had seen the death rate rise under his
Semmelweis—p. 3

administration and his ire caused him to de- different. When new mothers were infected
mote Semmelweis. at parturition, the child was almost always
Semmelweis had used techniques that infected as well; this time the children were
would later be called the science of epidemi- fine. Semmelweis concluded that the infec-
ology. This was likely construed as unsound tion was occurring after birth. The women
because biological science was discovering languished for nine days prior to discharge,
the value of controlled experiments during lying on sheets still soiled from patients who
the 19th century. During 1849, Semmelweis had lain on them before. The cause was not
let himself be convinced by friends that ani- nurses failing to change sheets. The laundry
mal tests would convince the skeptics. He had been taking away bags of sheets and re-
conducted nine experiments that clearly turning bags of unwashed sheets. Semmel-
showed puerperal fever in rabbits that were weis gathered the smelly bags and barged
contaminated with cadaver material. Then he into the office of the hospital administrator.
abruptly stopped; it was obvious to him that Dumping the sheets on Statthaltereirat von
using clinical statistics was a better way to Tandler’s desk, Semmelweis announced that
prove the method of transmission and this was the cause of the new outbreak of
prevention of the disease. puerperal fever.
Semmelweis was averse to writing and
stubbornly refused to publish his findings. In 1901, the Hungarian Academy of Sciences
His medical students and associates were offered a prize for the best monographs “On
promoting his doctrine, however. At one the History of Asepsis and Antisepsis, With
point in 1850, the Board of Studies of the Vi- Special Reference to the Teaching of
Semmelweis.” The United Nations declared
enna Medical School voted to study the 1965 as Semmelweis year. And, two hundred
correlation between puerperal-fever mortality years after its founding, on November 7,
in institutions that did not perform cadaver 1969, the Medical School in Budapest was
dissection and those that did. Somehow, the renamed the Semmelweis University of
powerful Klein scuttled this move and Medicine.
Semmelweis was not reappointed as Assis- Another puerperal fever outbreak occurred
tant in the First Clinic. His new job as a clini- in the 1857–1858 academic year. This time
cal professor for Theoretic Midwifery should the cause was a nurse who had not changed
have been a good position but it came with a sheets after infected patients. Semmelweis
degrading and embarrassing restriction to the reported this event in the new Hungarian
use of the model for teaching. Later, it was medical journal, Orvosi Hetilap. The
learned that malicious tampering had changed publication achieved the desired results—the
the wording from practice on the model and nurse no longer worked in the hospital—and
the cadaver. It was too late; Semmelweis had Semmelweis became a regular contributor to
left Vienna. the journal. Semmelweis’s doctrine was
In 1850, Semmelweis accepted a position being promoted in England by James
at the University of Pest, where he reduced Simpson, and, in the United States Holmes
the incidence of puerperal fever to less than had republished his paper on the cause of
1%. That same year, Semmelweis’s succes- puerperal fever.
sor in the First Clinic, Karl Braun reported to In 1861, Semmelweis published his only
the Vienna Society of physicians that the report on his findings concerning puerperal
handwashing did not prevent puerperal fever. fever. The rambling, 543-page monograph
Semmelweis responded in his typical entitled Die Ætiologie included all of his data
brusque manner that Braun was incompetent and tables but didn’t reflect the brilliant logic
or, at best, negligent. he had shown in discovering the method of
The disease reappeared under Semmel- transmission of the disease. His book was
weis’s watch in 1856, but this time it was largely ignored. In frustration, he began to
Semmelweis—p. 4

publish Open Letters to opponents of his ria to other organs. Ignaz Semmelweis died
doctrine. One such opponent was Rudolf of puerperal fever on August 13, 1865.
Virchow, a German physiologist, who told v
Berlin obstetricians that puerperal fever was Twenty-four years later, a speaker at the
the result of weather conditions. Semmelweis Academy of Medicine in Paris expressed his
had charts showing that the mortality from skepticism that disease could be spread by
puerperal fever varied widely during any sin- hands. An outraged member of the audience
gle month and could not be due to weather. shouted at the speaker “The thing that kills
Instead of using his data, Semmelweis re- women with [puerperal fever]…is you doc-
sponded in an Open Letter to Virchow that tors that carry deadly microbes from sick
“823 of my pupil midwives…know better women to healthy ones.” (4) The man who
than Virchow [and are] more enlightened shouted was Louis Pasteur who had, that
than the members of the Berlin Obstetrical year, observed Streptococcus pyogenes in the
Society…”(3) blood of puerperal fever patients.
Semmelweis had a wife and three children In 1995, Stole and Lanky (5) stated that
to provide happy diversions from the tribula- “iatrogenic disease usually reveals not error,
tions of his professional life. He married 18- but ignorance.” This was undoubtedly true of
year old Marie Weidehofer in July 1857. Semmelweis’s colleagues. Antibiotics and
Eighteen months later, Semmelweis oversaw autoclaves have solved many of the early
the delivery of their first child. A physician problems of infection but, according to the
came to their home and a bowl of chlorinated Centers for Disease Control and Prevention
water was provided for him. The infant son, (CDC), “Handwashing is the single most
named Ignaz, died the next day. The diagno- important means of preventing the spread of
sis was hydrocephalus. His second child, a infection.”(6) Handwashing is taught at every
daughter, died at four-months of age from level of school, advocated in the work place,
peritonitis. Their next three children born in and emphasized during medical training. Yet,
1861, 1862, and 1864 were all healthy. recent studies indicate that lack of or im-
Semmelweis could not separate his belief proper handwashing still contributes signifi-
in handwashing from himself. When physi- cantly to disease transmission. In 1997, a re-
cians disagreed with the practice of hand- port published by researchers at the CDC re-
washing, Semmelweis took it as personal vealed that hands were washed before an in-
abuse. In the course of his family tragedies teraction 27% of the time in a long-term care
and controversies with unbelieving col- facility. (7) A 1996 study by researchers at
leagues, Semmelweis’s behavior became in- Ohio State University College of Medicine
creasingly erratic. He was tormented by the identified handwashing rates as low as 31%
continuing outbreaks of puerperal fever. The in an emergency department. (8) Approxi-
rate of infection at the Paris Maternité was mately two million nosocomial infections
12% in 1861. Perhaps he thought about his occur each year in the United States. $500
own role in spreading the disease through his million would be saved if just 17% of the
many mornings spent in dissections. His nosocomial infections were prevented. (9)
wife, embarrassed by his bitter and emotional This money could be saved for such things
displays, contacted his medical associates for as cancer or AIDS research.
assistance. He was persuaded to have himself Semmelweis might feel vindicated by the
committed to a sanitarium in Vienna. In the acceptance of his idea. Would he still feel the
sanitarium, a physician noticed that same frustration with the medical commu-
Semmelweis had a cut on one finger, proba- nity’s failure to adopt this behaviorial
bly the result of surgery. The wound became change?
gangrenous and septicemia spread the bacte-
Semmelweis—p. 5

References 7 B. L. Thompson et al. “Handwashing

1 E. M. O'Hern. Profiles of Women Scien- and glove us in a long-term-care facility.”
tists. Washington, D.C.: Acropolis Infection Control Hospital Epidemiology
Books, 1985, p. 27. 18:97–103, February 1997.
2 Quoted in F. G. Slaughter. Immortal 8 S. T. Dorsey, R. K. Cydulka, and C. L.
Magyar. New York: Schuman, 1950, p. Emerman. “Is handwashing teachable?”
78. Academic Emergency Medicine
3 Slaughter. Ibid. p. 174.. 3:360–365, April 1996.
4 P. DeKruif. Microbe Hunters. New 9 CDC. MMWR 41(42):783-787, October
York: Harbrace, 1953, pp. 133-134. 23, 1992.
5 P. Stolley and T. Lasky. Investigating
Disease Patterns. New York: Scientific General reference:
American Library, 1995, p. 140. Rich, J. The Doctor Who Saved Babies.
6 CDC. Guideline for Handwashing and New York: Messner, 1961.
Hospital Environmental Control, 1985.