by Imre Zoltán

Whenever the question of obstetric infection arises, the first name to be mentioned is that of Semmelweis.

In 1954 the World Federation of Surgeons established in Chicago a Medical Memorial Museum. There, in the Hall of Fame among the ten most outstanding figures of medicine, stands the statue of Semmelweis.

Ignace Philip Semmelweis has been called by posterity the "Saviour of Mothers". Indeed, his discovery of the most disastrous disease of his time, puerperal fever, and the simple prophylactic method he suggested, make him one of the most prominent personalities in medical history.

He was born in Buda, then the capital of Hungary, on 1st July 1818. Educated at the universities of Pest and Vienna, he received his doctor's degree in Vienna on 21st May 1844.

After taking his degree, he started his career at the obstetric clinic of the General Hospital. He also visited the Institute for Pathological Anatomy, where in the early morning hours he regularly did autopsy work, mainly on the cadavers from the obstetric clinic.

At that time the high death rate of women during labour and lying in was a constant concern of medical science, so it could not escape the attention of the young doctor. He was deeply moved by the ravages of this form of death. There had been months when as many as 30% of all recently delivered women died of childbed fever.

The shock produced by his first experience in clinical work, gave him determination to devote his energy and knowledge to save women from this dreadful end.

The problem of puerperal fever had existed long before the time of Semmelweis. The feverish condition connected with childbirth had been known in all ages, beginning with ancient times. Hippocrates, Galenus, Avicenna had all made observations concerning the disease.

Nevertheless it was not before the 17th and 18th century that it was recognised as affecting so many. This was at a time when social progress and humane considerations had produced special environments. The first childbed fever epidemics are known to have occurred in France between 1662 and 1664, then again in 1770 and 1776, in London 1760, in Dublin 1767 and in Vienna 1770-1771.

Different ideas prevailed regarding the origin of the illness. The majority of these theories were baseless, superstitious, and lacking observation. All the same, at the end of the 18th and in the first half of the 19th century, some approaches had been made towards the truth concerning the essence of puerperal fever. It would be unjust not to mention the names of White in Manchester; Gordon in Aberdeen; Cederskjšld in Sweden; Denman, Kneeland and Watson in England; Eisenmann in Germany and last but not least Holmes in Boston.

Before Semmelweis' discovery, a medley of doctrines, superstition and ignorance had prevailed. Doctors believed in cosmic, telluric and atmospheric influences. They believed that puerperal fever was inevitable and could find no better means of defeating it, than to close the doors of lying-in hospitals from time to time.

Nobody before Semmelweis had clearly recognised that the immediate cause of puerperal fever was unclean, manual intrusion, and that the disease itself was only another kind of pyaemia.

The first thing that had struck Semmelweis was the remarkable difference in puerperal fever mortality between two neighbouring clinics. In 1846, in the first obstetric clinic where he worked, out of 4010 labouring patients 459 died of puerperal fever, a total of 11.4%, while during the same period in the second clinic only 15 out of 3754 labouring women died, that is 2.7%.

Semmelweis soon became convinced that the solution to the problem of puerperal fever lay in the difference between these figures and he was determined to find the reason for this discrepancy. He set himself to the study of all the case histories from 1789, the year of foundation of the clinic.

He found that the average puerperal mortality was low, (1.25%) up until 1822, when the newly appointed professor, Klein, introduced regular post mortem examinations in the clinic. At the end of this year the mortality figure had risen from 2.84% to 7.45% (Fig.1.).

Fig. 1
up to 1822 1.25 - 2.84%
beginning of 1822 2.84%
end of 1822 7.45%

The second clinic was founded in 1833 after the division of the lying-in hospital into two clinics.

Between 1833 and 1839 mortality had been equally high in both clinics. A definite change was noticeable from 1840 onwards when the first clinic was available to medical students only, and the second clinic to midwifery students only. From that time the difference in mortality rate in the two clinics became obvious (Fig.2).

Fig. 2
  1st Clinic 2nd clinic
1839 5.5% 4.5%
1840 9.5% 2.6 %
1841 7.8% 3.52%
1842 15.8% 7.5%
1843 8.95% 5.38%
1844 8.23% 3.30%
1845 6.9% 2.03%
1846 11.44% 2.79%

Semmelweis was consumed by a determination to solve the mystery of puerperal fever. He wrote: "A feeling of discouragement has taken possession of me; really and truly I would have preferred to die. Puerperal disease remains a mystery, only the number of the dead is a palpable fact."

Semmelweis observed that the pathological findings in the cadavers of the mothers and in their babies were identical. The same changes were seen on the peritoneum and viscera and they had the same signs of inflammation. He had of course come to the conclusion that the babies had died of the same disease as their mothers - pyaemia. Since others, other than recently delivered women, could contract puerperal fever and die as a result, puerperal fever could not be considered a disease of puerperal patients only.

Semmelweis had reached this point in his observations when doctor Kolletschka, professor of forensic medicine, died. During an autopsy he had cut his finger. The wound became septic and Kolletschka died.

Reading the report of Kolletschka's post mortem, Semmelweis was deeply shocked; the findings were identical with the symptoms of those who died in puerperal fever; peritonitis, phlebitis, multiple abscesses, that is to say; pyaemia.

The fact that after his injury Kolletschka had developed symptoms and pathological changes identical to those seen in the cadavers of puerperal patients, convinced Semmelweis that there must be some connection between the doctors who examined corpses by dissection and puerperal fever itself. Now he saw the explanation: puerperal fever is caused by the examining physician himself, by the manual introduction of cadaveric particles into the bruised and torn genitalia.

Suddenly, it was all so very clear!

Since 1839 the second clinic had been engaged in the instruction of midwifery students only. The midwives did not attend post mortem examinations, as did the medical students of the first clinic. Hence the discrepancy in the mortality of childbed patients after 1840.

Semmelweis himself was perfectly aware of the importance of his discovery. It was a sign of his greatness that instead of being proud of his findings, he was filled with remorse and reproached himself for causing the deaths of so many women.

He wrote: "My conscience tells me that I must reprove myself, as God only knows the number of those who had died as a result of my activity. Few of the obstetricians have had more dealings with cadavers than myself. However painful and distressing this fact is, there would be no sense to deny it. No, there is one remedy only: to publish the truth to all those who are concerned."

The course to be taken was obvious to him: as it was the doctors' hands which carried the cadaverous matter, they should be properly cleaned, that is, washed, before an examination. After the morning dissections he began to experiment with various liquids for handwashing. Finally he decided on the chlorine solution.

At the end of May 1847 he made it compulsory for everybody performing dissection to disinfect their hands using chlorine before examining patients.

The introduction of chlorine handwash gave rise to protests. Even the medical students tried to refuse to comply. Professor Klein himself was not convinced of the importance of the discovery, remaining uninterested, nevertheless he permitted the introduction of the handwash.

The use of the chlorine handwash produced amazing results. The mortality rate was greatly reduced, decreasing from month to month, in April being 18.27%, in May 12.24%, in June 2.36%, and by the end of the year 0.19% (Fig.3).

Fig. 3
1847 April May June December
1839  18.27% 12.24% 2.36% 0.19%

In 1848 the mortality rate was 1.27%, for the first time since 1840 lower than in the second clinic.

The statistical data he published in his book on puerperal fever - mortality before and after his discovery - is shown below (Fig.4).

Fig. 4
  in the 1st clinic in the 2nd clinic
1833-1839 62.2 57.3
1840-1846 97.6 38.3
1847-1861 33.1 29.2

The difference in mortality in the two clinics became negligible after his discovery.

However, after August when there had been no deaths, the mortality unexpectedly rose in September and in October to 5.2% and 3.9% respectively. It was discovered that two patients, one suffering from purulent uterine cancer, the other from a carious knee-joint, were responsible for the new epidemic by infecting the other patients through their exudates.

Following this incident Semmelweis proposed that not only cadaverous particles could produce puerperal fever but so could any putrid organic material, any putrid exudate if introduced into the genital organs of labouring women by the hand of the examining doctor, and so into the blood stream.

The scientific explanation came much later, when Pasteur identified bacteria as the real cause of puerperal fever having found streptococci in the blood of the affected. It was left to him, and other bacteriologists, to produce the final evidence in support of Semmelweis' theory of a definite infecting agent, substituting "putrid organic material" by bacteria. Without knowledge of the latter Semmelweis formulated his doctrine of exogenous and endogenous infection when constructing his theory concerning the etiology of puerperal fever.

During his time in Vienna the leading personalities of the new medical generation, like Skoda and Hebra, recognised the importance of Semmelweis' discovery and gave him all possible assistance. Professor Klein, his superior, on the other hand was critical, not to say hostile, because he failed to understand him.

In 1849 Semmelweis was dismissed from his post at the clinic. He gave a successful lecture at the Medical Society of Vienna, entitled "The origin of puerperal fever". Soon after that he left Vienna. He returned to Pest in 1850 and worked for the next six years at the St. Rochus Hospital, where before his arrival an epidemic of puerperal fever had broken out. His measures amazingly reduced the mortality rate, which averaged 0.85% when he was in charge, while - as far as it is known - in Vienna and in Prague during the same period the rate was still between 10 and 15%.

In 1855 Semmelweis was appointed professor of obstetrics at the University of Pest. His ideas were accepted in Hungary. The government addressed a circular to all authorities ordering the introduction of prophylactic handwashing.

Vienna still remained hostile toward him. The editor of the Wiener Medizinische Wochenschrift wrote that it was time to stop the nonsense about the chlorine handwash.

In 1861 Semmelweis published his principal work "Die Aetjiologie, der Begriff und die Prophylaxis der Kindbettfieber". He sent it to all the prominent obstetricians abroad, but the general reaction was adverse. The weight of authority, the leading personalities of the European obstetrics, like Scanzoni, Kiwisch, Siebold opposed his teaching. He wrote his ill-famed open letters addressing them to all the professors of obstetrics in Europe - without effect.

At the Conference of German Physicians and Natural Scientists most of the speakers, including Virchow himself, rejected his doctrine.

The years of controversy and struggle to get his work accepted gradually undermined his spirit and perhaps were the cause of his breakdown in 1865. He was taken to a mental hospital where he died on 13th August 1865.

The tragic irony of his fate was that his death was caused by the infection of a wound on his right hand, apparently the result of an accident during an operation he had performed before being taken ill. So he died eventually of the same disease against which he had struggled all his professional life.

His full life which was so rich in struggle, so tragic as a human destiny, serves as an example for every member of the medical profession. His heritage is not only surgical cleanliness, but moral chastity. He left us a faith unshaken, an optimism, which can best be expressed in his own words which he wrote at the end of his book:

"Compared with the vast figures of the past and future, the number of those saved by me or by my students following my doctrine may be small. Should it not be my fate to see with my own eyes the happy future, the firm belief that this time will come and must come, will cheer my dying days."

This time has come. The problem of puerperal fever, the problem of obstetric infection is solved, and the first step toward this solution was made by Ignace Philip Semmelweis.

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