Ignaz Semmelweis was a Hungarian obstetrician. He was born on July 1, 1818, in what is now Budapest. He was the son of a wealthy grocer and grew up in a bustling enclave of German-descendant merchants, where he attended Catholic schools.
In the early 19th century, childbed fever was a major cause of death among women shortly after childbirth, with mortality rates from childbed fever as high as 25%. Many theories of the cause of childbed fever were popular at the time, including atmospheric toxins, “epidemic constitutions” of some women, putrid air, or solar and magnetic influences. This period was a time of growing interest in pathologic anatomy. Because the cause of childbed fever remained a mystery, great interest arose in associating the findings at autopsies of women who had died of the disease with the clinical manifestations that characterized them while ill after childbirth.
Semmelweis was placed in charge of the First Obstetrical Clinic of the Allgemeine Krankenhaus (General Hospital) in Vienna in July 1846. At that time there were two obstetrical clinics, the First and the Second. Pregnant women were admitted for childbirth to the First Clinic or to the Second Clinic on an alternating 24-hour basis. The First Clinic was staffed by physicians and medical students and the Second Clinic by midwives. Physicians and medical students began their days performing autopsies on women who had died from childbed fever; they then proceeded to provide clinical care for women hospitalized in the First Clinic for childbirth. The midwives staffing the Second Clinic did not perform autopsies. Semmelweis had been impressed by mortality rates in the two clinics in 1842 (Fig. 1.11). Mortality in the First Clinic was more than twice as high as in the Second Clinic—16% compared with 7%.
Semmelweis surmised that mortality was higher in the First Clinic than in the Second because the physicians and medical students went directly from the autopsies to their patients. Many of the women in labor had multiple examinations by physicians and by medical students learning obstetrics. Often these manual examinations traumatized the tissues of the vagina and uterus. Semmelweis suggested that the hands of physicians and medical students were transmitting disease causing particles from the cadavers to the women who were about to deliver. His suspicions were confirmed in 1847 when his friend and colleague Jakob Kolletschka died from an infection contracted when he was accidentally punctured with a medical student’s knife while performing an autopsy. The autopsy on Kolletschka showed pathology very similar to that of the women who were dying from childbed fever. Semmelweis concluded that physicians and medical students were carrying the infection from the autopsy room to the patients in the First Clinic and that this accounted for the high mortality rates from childbed fever in the First Clinic. Mortality rates in the Second Clinic remained low because the midwives who staffed the Second Clinic had no contact with the autopsy room.
Semmelweis then developed and implemented a policy for the physicians and medical students in the First Clinic, a policy designed to prevent childbed fever. He required the physicians and medical students in the First Clinic to wash their hands and to brush under their fingernails after they had finished the autopsies and before they came in contact with any of the patients. As seen in Fig. 1.12, in 1848, mortality in the First Clinic dropped from 12.2% to 2.4%, a rate comparable to that seen in the Second Clinic for the same year. When Semmelweis was later replaced by an obstetrician who did not subscribe to Semmelweis’s theories, and who therefore eliminated the policy of required handwashing, mortality rates from childbed fever rose again in the First Clinic—further evidence supporting a causal relationship.
Unfortunately, for many years Semmelweis refused to present his findings at major meetings or to submit written reports of his studies to medical journals. His failure to provide supporting scientific evidence was at least partially responsible for the failure of the medical community to accept his hypothesis of causation of childbed fever and his further proposed intervention of handwashing before examining each patient. Among other factors that fostered resistance to his proposal was the reluctance of physicians to accept the conclusion that by transmitting the agent responsible for childbed fever, they had been inadvertently responsible for the deaths of large numbers of women. In addition, physicians claimed that washing their hands before seeing each patient would be too time consuming. Another major factor is that Semmelweis was, to say the least, undiplomatic and had alienated many senior figures in medicine. As a consequence of all of these factors, many years passed before a policy of handwashing was broadly adopted. An excellent biography of Semmelweis by Sherwin Nuland was published in 2003.3 The lessons of this story for successful policy making are still relevant today to the challenge of enhancing both public and professional acceptance of evidence-based prevention policies. These lessons include the need for clearly presenting supporting scientific evidence for a proposed intervention, the need for implementation of the proposed intervention to be perceived as feasible and cost-effective, and the need to lay the necessary groundwork for the policy, including garnering professional as well as community and political support. Years later, the major cause of childbed fever was recognized to be a streptococcal infection. Semmelweis’s major findings and recommendations ultimately had worldwide effects on the practice of medicine. Amazingly, his observations and suggested interventions preceded any knowledge of germ theory and thus proved that it is possible to implement a prevention strategy even when the exact cause of the disease is not known. However, it is also of interest that, although the need for hand washing has now been universally accepted, recent studies have reported that many physicians in hospitals in the United States and in other developed countries still fail to wash their hands as prescribed.
References
- Kadar N, Romero R, Papp Z. Ignaz Semmelweis: the “Savior of Mothers”: On the 200th anniversary of his birth. Am J Obstet Gynecol. 2018;219(6):519-522. doi:10.1016/j.ajog.2018.10.036
- David D. Celentano, Moyses Szklo, The Epidemiologic Approach to Disease and Intervention; Gordis Epidemiology Sixth Edition, Elsevier.