Ingnaz Semmelweis: Pride and Tragedy

Ignaz Semmelweis's life was a story of pride and tragedy. In the 1840s, many thousands of women were dying of childbed fever in maternity wards across Europe. Semmelweis discovered that simple handwashing could save their lives, but he failed to convince the medical establishment. What makes his case stand out is how easily the medical establishment could have avoided its mistake. All they had to do was run a simple clinical trial to decide the truth of Semmelweis's claims. There was no risk, and it was cheap and easy to implement. However, their pride got in the way, and tragedy followed.

Semmelweis's story starts in what was then the small provincial town of Buda. His father, József Semmelweis, was an ethnic German born in Kismarton (then part of Hungary and now Austria). In 1806 József established a wholesale business selling spices and general consumer goods and opened a shop in Buda. His businesses prospered, and in 1810 József married Teréz Müller, the daughter of coachbuilder Fülöp Müller. The couple had ten children. Ignác Fülöp Semmelweis was born on July 1, 1818, and he was their fifth child. He had a comfortable, uneventful childhood. However, it did give him one trait that would be important in his adult life. He developed an unusual German accent. Ignaz was self-conscious about his accent. As a result, he was reticent to talk publicly, and this characteristic stayed with him for the rest of his life.

Semmelweis was a good student, and in 1837, he went to the University of Vienna to study law. During his first year, Ignaz decided he wanted to become a doctor. So he switched courses, and in 1844 graduated with a degree in medicine. At this point, he needed to find a job that would allow him to continue studying. After applying for various roles, Semmelweis accepted a post as Professor Johann Klein's assistant in the Vienna General Hospital's obstetrics department.

By the 1840s, the medical profession knew hospitals had a problem with childbed fever: data showed that delivering a baby at home was much safer than in a hospital. One study between 1831 and 1843 found that having a baby in London's General Lying-In Hospital increased mortality sixtyfold compared to home delivery. Other studies from Paris, Dresden, Austria, and America showed the same. Ignaz started his new role in 1846, and from his first day, he kept careful records. The data showed his hospital suffered the same maternal death rates as other hospitals across Europe. However, there was a difference. The Vienna General had two maternity Divisions. One to train doctors and the other to train midwives. Ignaz's figures showed that there were far fewer deaths in the Division run by the midwives. This result was surprising. At the time, most people would have expected the doctor's wards to provide better care. After all, the doctors were much better qualified than the midwives. So, Why were the Division's death rates so different?

Semmelweis became obsessed with finding an explanation for the difference and making childbirth safer. There were several generally accepted theories. The most popular was that miasma caused infections. Many doctors believed particles from putrefying carcasses, rotting vegetation molds, etc., could make people unwell. They thought these infective particles traveled in the air, and when they entered the body, they caused illness. However, this explanation did not make sense to Semmelweis because the two wards in the hospital were close to each other and had the same air. Ignaz reasoned that if miasma was causing the childbed fever, then both Divisions should suffer equally. But his data did not show this. Some people argued that overcrowding caused the high maternity death rate. However, the clinic run by the midwives was far more crowded and had far fewer deaths. Ignaz also eliminated diet and general practices. Both sides had the same diet and the same general medical care practices. Even the way the babies were delivered was the same.

Soon Semmelweis had eliminated the more obvious explanations, but he was no closer to understanding what was happening. In desperation, he turned to increasingly unlikely theories. For instance, when a woman died in the doctor's ward, there was a religious ritual. A priest would slowly walk through the clinic, followed by an attendant ringing a bell before reaching the sickroom containing the body. In the midwives' Division, the priest had direct access to the sickroom and did not have to walk through the wards. Semmelweis speculated that the ceremony might be terrorizing the women, and their horror caused fever and death. To check, he asked the priest to change his route and to silence the bell: it made no difference—the death rate stayed the same.

Ignaz's breakthrough finally came as the result of a tragic accident. Professor Jakob Kolletschka was injured and died while Semmelweis was away on holiday. When Ignaz returned, his colleagues told him what had happened. During an autopsy, a student accidentally cut one of Kolletschka's fingers. The wound became infected, and Kolletschka died a few days later. Semmelweis was devastated by the news. How could this have happened? To find an answer, Semmelweis read Kolletschka's autopsy report. By chance, what he read in the grim document answered two questions: it told him what had killed Kolletschka and what caused childbed fever. Later Semmelweis described the moment of insight, saying, "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, the fatal sickness of the newborn and the disease of Professor Kolletschka were one and the same, because they all consist pathologically of the same anatomic changes. If, therefore, in the case of Professor Kolletschka general sepsis arose from the inoculation of cadaver particles, then puerperal fever must originate from the same source. Now it was only necessary to decide from where and by what means the putrid cadaver particles were introduced into the delivery cases. The fact of the matter is that the transmitting source of those cadaver particles was to be found in the hands of the students and attending physicians."

This explanation fitted what Semmelweis saw in the hospital. Each day started with the doctors and their students autopsying the women who had died the previous day. They then moved onto general medical patients and ended their day in the delivery ward. Semmelweis realized that the doctor's daily routine could transport cadaverous material to the maternity wards. Things were different in the midwives' Division. They did not do autopsies, and therefore, there was no path for autopsy material to get to their maternity wards.

Semmelweis also knew from experience that the doctors' and students' hands smelt putrid. It was a small step to speculate that perhaps cadaverous material caused the smell. Semmelweis experimented and found that washing his hands in a solution of chlorinated lime (calcium hypochlorite) removed the putrid smell. At last, he had a possible solution to prevent childbed fever. Semmelweis implemented a handwashing protocol. So that, at the end of their autopsy work, his students washed their hands in chlorinated lime. The results were spectacular. The mortality rate in the doctors' wards "dropped from 18.27 to 1.27 percent, and in March and August of 1848 no woman died in childbirth in his division."

Semmelweis's discovery should have made him famous and saved countless thousands of lives. Instead, it was the beginning of a series of events that led to his early death. The initial problem was that Semmelweis was a poor communicator. He did not like writing academic papers, and since his childhood, he had been self-conscious about his unusual German accent. As a result, he relied on his students to tell people about his discovery. They did the best they could. However, it was never going to be effective. They did not even have Semmelweis's account of his discovery—it was many years before he published his results. In desperation, his students wrote their own accounts, but it was not enough. They could not convince others to adopt the handwashing protocol.

Senior doctors in the Austrian medical hierarchy instinctively resisted ideas from young junior doctors because they were young and junior. When Semmelweis told his boss, Professor Klein, about his discovery, Klein reputedly said, "Keep yourself to what is old, for that is good. If our ancestors have proven it to be good, why should we not do as they did? Mistrust new ideas. I have no need of learned men. I need faithful and obedient subjects. He who would serve me must do what I command. He who cannot do this or who comes full of new ideas may go his way. If he does not, I shall send him. Do you understand, Dr. Semmelweis?"

The second obstacle Semmelweis and his students faced was the miasma theory. Up to at least the 1860s, medical universities taught the miasma theory. It was the preeminent explanation of infectious diseases, and many doctors had built their careers on it. By doing so, they tied their reputations to this explanation. To accept that it was wrong would have been painful. Yet, this is what Semmelweis and his students were trying to get them to do.

They had a third emotional hurdle to overcome. Senior doctors were insulted by the suggestion that their hands were dirty. In the 19th century, doctors were gentlemen and came from the top ranks of society. They viewed themselves as clean. It was the lower orders which were dirty. You can imagine how the doctors would react to being told their hands were dirty, and they needed to wash them.

As if this was not enough, Semmelweis's data showed that the doctors and their students were directly harming their patients. Unknowingly, the doctors' actions were killing mothers and their babies. This truth was another difficult pill to swallow for men whose goal was to save their patients' lives. The easier option was to ignore Semmelweis and his data.

European doctors lost an opportunity to save the lives of thousands of women and babies. Who you might blame for that depends on your viewpoint. What is clear is that there were faults on both sides. Semmelweis was undoubtedly a poor communicator, and the conservative medical establishment resisted change. The senior doctors had an additional responsibility because they could have easily put Semmelweis's discovery to the test. After all, lives were at stake. All it would have taken was for one or two senior doctors to have put their pride to one side and run a clinical trial. There was no risk or cost. All they had to do was implement Semmelweis's hygiene policy, provide the chlorinated lime, and record the results. Over the following weeks and months, they would have seen the death rate fall, and their experience would have convinced other hospitals to do the same. Instead, their pride stopped them.

Professor Klein had employed Semmelweis on a three-year contract, and at the end of the period, he did not renew it. As a result, Semmelweis needed to find a new post, and 1849 was not a good time to be job-hunting. People in Vienna were still nervous. In the previous year, the Hungarian independence revolution had nearly split the Austrian Empire in two. Even in Vienna, there had been political unrest. Students had demonstrated in the streets for civil rights such as trial by jury and freedom of the press. In this environment, Semmelweis's Hungarian birth might have counted against him. Whatever the reason, he could not find a new post in Vienna and decided to return to Buda. However, his prospects were not much better in his hometown. Obstetric jobs were few and far between. Eventually, a post came up, and, on May 20, 1851, he took an unpaid honorary position as head of the obstetric ward at the St. Rókus Hospital. This role was probably not the next step in his career that Semmelweis wanted. However, it did present a familiar challenge. Too many women were dying of childbed fever. Again Semmelweis implemented his hygiene procedures, and immediately the death rate started to decline. Between 1851 and 1855, there were 933 births, and only eight patients died of childbed fever (0.85%).

In 1855 a new opportunity opened for Semmelweis. Professor Birly, the head of Theoretical and Practical Midwifery at Pest University and a strident critic of Semmelweis, died. As a result, the University had a vacancy to fill. Despite opposition, Semmelweis's qualifications and ability to speak Hungarian won him the post. This role marked a new stage in his career. Significantly, he now had the income and stability to support a family. Within two years of starting his new position, he married Mária Weidenhofer, and the couple went on to have five children. However, the role also brought professional challenges. Semmelweis found that the University's Maternity Clinic had many problems, only one of which was rampant childbed fever. Birly believed that childbed fever originated in the bowels and treated it with purgatives. He refused even to try chlorinated lime handwashing. The clinic had for years implemented its former head's views. As a result, Semmelweis had a lot to change, and it was not easy. Many people in the University's administration shared Birly's beliefs. They tried to block Semmelweis every step of the way. Despite the obstruction, Ignaz slowly prevailed. For a third time, Semmelweis demonstrated that his hygiene protocols worked. He reduced "maternal mortality from childbed fever to 0.39% during his first year as Professor, and the rate remained at 0.9% during 1859 to 1860, the last year before the clinic was moved to a new facility."

Semmelweis was not the only doctor to link childbed fever and handwashing. Doctors in America and the UK were making the same connection. Unfortunately, they did not conduct trials and only published their ideas and advice. In 1842, Thomas Watson, a British Professor of Medicine at King's College Hospital, London, wrote: "Wherever puerperal (childbed) fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent ablution." He went on to recommend handwashing with chlorine solution and that attendants change their clothing, saying that this was "to prevent the practitioner becoming a vehicle of contagion and death between one patient and another." Watson's advice was not enough to persuade other doctors to change. Semmelweis was effectively in the same position. Although he had conducted a medical trial, he still had not written about it in a medical journal ten years later. However, this was about to change.

In 1857, Lajos Markusovszky established the Hungarian Medical Weekly and needed content. He encouraged Semmelweis to write an account of his discovery. At last, doctors could read about Semmelweis's work and see his data. In London, doctors welcomed the paper because it echoed and supported Dr. Watson's advice. Semmelweis did not like this response. He thought they had ignored the novel features of his ideas. To defend himself, Semmelweis published another article explaining the difference between his ideas and the English "contagionists." It was not enough. Semmelweis still felt people did not understand what he was trying to say. He resolved to consolidate and strengthen his argument. The result was a book, The Aetiology, Concept, and Prophylaxis of Childbed Fever, which Semmelweis had published in 1861 (Kay Codell Carter completed an English translation in 1983). However, it did not get good reviews, and the medical world ignored it. Yet again, Semmelweis had failed to convince those he needed to. In desperation, he sent copies to leading obstetricians across Europe. It made no difference. Semmelweis had run out of positive options. The only thing left for Semmelweis to do was criticize. He did this in a series of open letters. In them, he called his fellow doctors murderers and ignoramuses. These letters were professional suicide and showed how desperate Semmelweis had become.

By 1861, Ignaz was depressed, absentminded, and obsessed with talking about childbed fever. It is difficult to know if his breakdown caused his increasingly vitriolic attacks on the medical establishment or whether their rejection of his discovery triggered his mental health problems. Either way, by mid-1865, his behavior was so extreme that his family had to act. On July 30, they committed Ignaz to a mental asylum. Tragically just two weeks later, he was dead (aged 47). His autopsy report indicated that "in all likelihood, Semmelweis was beaten by his attendants when struggling to escape, and died of generalized sepsis caused by his infected injuries." It was a shocking end to his life.

Semmelweis died a forgotten man, except by his family and a few friends. The medical press announced his death. But, only a handful of people attended his funeral service. This low point could have been the end of his story, but it was not. Although Semmelweis failed to convince the medical establishment, he did convince his students. They had seen with their own eyes what a difference his handwashing and other hygiene measures had made. So when Semmelweis left Vienna, they continued his hygiene protocols. As a result, the death rate stayed low. However, it was Louis Pasteur's work that changed everything. Since the 17th century, people had suggested that micro-organisms might cause disease. In a series of experiments between 1803 and 1813, Agostino Bassi demonstrated that a fungal organism (Bassi called it a "vegetable parasite") caused disease in silkworms. Despite this progress, germ theory remained on the fringes of medicine until Louis Pasteur's work on fermentation. In a series of compelling experiments conducted between 1860 and 1864, he showed that micro-organisms cause fermentation. Later, he found the actual organism that caused childbed fever. In 1879 he took samples from the uterus and blood of women with childbed fever, and from these samples, Pasteur isolated the streptococcus micro-organism. He then proved that streptococcus caused childbed fever.

Pasteur was not alone. Other researchers were making similar discoveries, and soon a new field of medical research was underway. The evidence for germ theory rapidly piled up. However, it was not just a question of more evidence. As people started to understand how germs caused infectious diseases, they also began to see how to prevent infections. Germ theory explained why Semmelweis's hygiene protocols worked. Despite the new knowledge, many hospitals did not immediately introduce good hygiene practices. That change had to wait for the next generation of doctors before it became common. However, at last, Semmelweis's hygiene protocols were being used and improved.

After Pasteur's work, Semmelweis's reputation slowly grew. People realized that he was one of the first to show that good hygiene could prevent infectious diseases. They also started to appreciate Semmelweis's goal and his struggles. As a result, he became known as "The Savior of Mothers," a Hungarian university was named after him, and in 2018, Hungary celebrated the 200th anniversary of Ignaz's birth by issuing a commemorative stamp and coin.

Over the last 50 years, Semmelweis's life story has become a modern myth. Searching the web, you will find many versions. Writers like telling the story because it includes discovery, struggle, tragedy, and redemption. It gives them a lot of material and possibilities. They can choose what to emphasize and what to omit depending on the points they want to make. My account focused on how senior doctors could have put their pride aside and let the results of a simple, easy, and cheap clinical trial decide if Semmelweis was correct.

What do you think? Did pride stop doctors from putting Semmelweis's handwashing protocol to the test?