Ignaz Philipp Semmelweis

Ignaz Philipp Semmelweis was one of the most prominent medical figures of his time. His discovery concerning the aetiology and prevention of puerperal fever was a brilliant example of fact-finding, meaningful statistical analysis, and keen inductive reasoning. The highly successful prophylactic hand washings made him a pioneer in antisepsis during the pre-bacteriological era in spite of deliberate opposition and uninformed resistance.

Semmelweis was born in Tabán, an old commercial sector of Buda. He was the fifth child of a prosperous shopkeeper of German origin whose family can be traced back to the 17. century. He received his elementary education at the Catholic Gymnasium of Buda, then completed his schooling at the University of Pest between 1835 and 1837.

In the fall of 1837, Semmelweis travelled to Vienna, ostensibly to enrol in its law school in order to comply with his father’s wish that he become a military advocate in the service of the Austrian bureaucracy. Soon after his arrival, however, he was attracted to medicine; and seemingly without parental opposition he matriculated in the medical school.

After completing his first year of studies at Vienna, Semmelweis returned to Pest and continued at the local university during the academic years 1839-1841. The backward conditions in the school, however, caused his return to Vienna in 1841 for further studies at what is known as the Second Vienna Medical School. This school became one of the leading centres for almost a century with its combination of laboratory and bedside medicine. During the last two years of the study, Semmelweis came in close contact with three of the most promising figures of the new school, Karl von Rokitansky (1804-1878), Josef Skoda (1805-1881), and Ferdinand von Hebra (1816-1880).

After voluntarily attending seminars led by these teachers, Semmelweis completed his botanically oriented dissertation early in 1844. He remained in Vienna after graduation, repeating a two-month course in practical midwifery and receiving a master’s – Magister - degree in the subject. He also completed some surgical training and spent almost fifteen months (October 1844 – February 1846) with Skoda learning diagnostic and statistical methods. Finally Semmelweis applied for the position of assistant in the First Obstetrical Clinic of the university’s teaching institution, The Vienna General Hospital (Wien Allgemeines Krankenhaus).

Semmelweis soon concerned himself with the problem of puerperal fever, the scourge of 19th century European birth clinics. Most women at the time delivered at home, but those who had to take to the hospitals, due to poverty, illegitimacy, or birth complications, suffered a mortality of 25-30 percent.

Some physicians believed the infection to be caused by crowdedness, poor ventilation, or beginning lactation. Despite strong resistance from his superior, who had the accepted the disease as non-preventable, Semmelweis commenced his work on finding the causes of the misery.

In July 1846 Semmelweis became the titular house officer of the First Clinic, which was then under the direction of professor Johann Klein (1788-1856). Among his numerous duties were the instruction of medical students, assistance at surgical procedures, and the regular performance of all clinical examinations. One of the most pressing problems facing him was the high maternal and neonatal mortality due to puerperal fever, 13.10 percent. Curiously, however, the Second Obstetrical Clinic in the same hospital exhibited a much lower mortality rate, 2.03 percent. The only difference between them lay in their function. The first was the teaching service for medical students, while the Second had been selected in 1839 for the instruction of midwives. Although everyone was baffled by the contrasting mortality figures, no clear explanation for the differences was forthcoming. The disease was considered to be an inevitable aspect of contemporary hospital-based obstetrics, a product of unknown agents operating in conjunction with elusive atmospheric conditions.

After a temporary demotion to allow the reinstatement of his predecessor, who soon left Vienna for a professorship at Tübingen, Semmelweis resumed his post in March 1847. During his short vacation in Venice, the tragic death of his friend Jakob Kolletschka (1803-1847), professor of forensic medicine at Vienna, occurred after his finger was accidentally punctured with a knife during a post-mortem examination. Interestingly, Kolletschka’s own autopsy revealed a pathological situation akin to that of the women who were dying from puerperal fever.

Prepared through his intensive pathological training with Rokitansky, who had placed all cadavers from the gynecology ward at his disposal for dissection, Semmelweis made a crucial association. He promptly connected the idea of cadaveric contamination with puerperal fever, and made a detailed study of the mortality statistics of both obstetrical clinics. He concluded that he and the students carried the infecting particles on their hands from the autopsy room to the patients they examined during labour. This startling hypothesis led Semmelweis to devise a novel system of prophylaxis in May 1847.

Realizing that the cadaveric smell emanating from the hands of the dissectors reflected the presence of the incriminated poisonous matter, he instituted the use of a solution of chlorinated lime for washing hands between autopsy work and examination of patients. Despite early protests, especially from the medical students and hospital staff, Semmelweis was able to enforce the new procedure vigorously; and in barely one month the mortality from puerperal fever declined in his clinic from 12.24 percent to 2.38 percent. A subsequent temporary resurgence of the dreaded ailment was traced to contamination with putrid material from a patient suffering from uterine cancer and another with a knee infection.

In March and August no women died of puerperal fever in Semmelweis’ department. The younger physicians of Vienna understood the importance of his discovery and supported him. His superior however, was critical, and probably so simply because he did not understand Semmelweis.

In spite of the dramatic practical results of his washings, Semmelweis refused to communicate his method officially to the learned circles of Vienna, nor was he eager to explain it on paper. Hence, Ferdinand von Hebra finally wrote two articles in his behalf, explaining the aetiology of puerperal fever and strongly recommending use of chlorinated lime as a preventive. Although foreign physicians and the leading members of the Viennese school were impressed by Semmelweis’ apparent discovery, the papers failed to generate widespread support.

During 1848 Semmelweis gradually widened his prophylaxis to include all instruments coming in contact with patients in labour. He statistically documented success in virtually eliminating puerperal fever from the hospital ward led to efforts by Skoda to create an official commission to investigate the results. The proposal was ultimately rejected by the Ministry of Education, however, a casualty of the political struggle between the defeated liberals of the 1848 movement and the newly empowered conservatives in both the university and the government bureaucracy.

Angered by favourable reports concerning the new methods that indirectly represented an indictment of his own beliefs and actions, Klein refused to reappoint Semmelweis in March 1849. Undaunted, Semmelweis applied for an unpaid instructorship in midwifery. In the meantime he began to carry out animal experiments to prove his clinical conclusions with the aid of the physiologist Ernst Brücke and a grant from the Vienna Academy of Sciences.

In 1848 a liberal revolution swept Europe, and Semmelweis took part in the events in Vienna. After the revolution had been defeated, Semmelweis found that his political activities had created further obstacles for his profession work. In 1849 he was fired from his position in the clinic. He then applied for a position at the school of midwifery, but was rejected.

The first account of Semmelweis discovery was published by professor Ferdinand Hebra in December 1847, in the Zeitschrift der kaiserlich-königlichen Gesellschaft der Ärzte zu Wien (December 1847) followed by a supplementary statement from the same physician in April 1848. In October 1849, Professor Josef Skoda delivered an address upon the same subject in the Imperial and Royal Academy of Sciences. Unfortunately, Semmelweis had neglected to correct the papers of these friends of his, and thus failed to make known their mistakes, so that the interference might be drawn that only infection from septic virus caused puerperal fever.

At last, however, Semmelweis was persuaded to present his findings “On the Origin of Puerperal Fever” personally to the local medical community. On May 15, 1850, he delivered a lecture to the Association of Physicians in Vienna, meeting under the presidency of Rokitansky; this address was followed by a second on June 18, 1850. The following October he received the long-awaited appointment as a Privatdozent in midwifery, but the routine governmental decree stipulated that he could teach obstetrics on a mannequin, a rather humiliating condition. Faced with financial difficulties in supporting his family, and perhaps discouraged, Semmelweis in 1850 abruptly left the Austrian capital, returning to Pest without notifying even his closest friends. Such a hasty decision jeopardized forever his chances to overcome the Viennese sceptics gradually with the dedicated help of Rokitansky, Skoda, Hebra, and other colleagues.

In Hungary, Semmelweis found a backward and depressed political and scientific atmosphere following the crushing defeat of the liberals in the revolution of 1848. Despite the unfavourable circumstances, he managed to receive an honorary appointment and took charge of the maternity ward of Pest’s St.-Rochus Hospital in May 1851, remaining there until 1857. When he came to this hospital an epidemic of puerperal fever had broken out in the birth clinic. Semmelweis, at his own request, took charge of the department, where his prophylactic measures soon reduced mortality to a mere 0.85 percent. At his time, mortality in Prague and Vienna was still between 10 and 15 percent.

Semmelweis married, had five children, and built a large private practice. His ideas were soon accepted in Hungary, and in a letter to all local authorities the government ordered that his profylactic methods were to be introduced. In 1857 he turned down an invitation to the chair of obstetrics in Zurich. Vienna was still hostile towards him, and the editor of the Wiener medizinische Wochenzeitschrift wrote that it was time to stop the nonsense of hand washing with chloride.

Following the death of the incumbent, Semmelweis was appointed by the Austrian Ministry of Education to the chair of theoretical and practical midwifery at the University of Pest in July 1855, although he had been only the second choice of the local medical faculty. He subsequently devoted his efforts to improving the appalling conditions of the university’s lying-in hospital, a difficult task in the face of severe economic restrictions. In 1855 Semmelweis instituted his chlorine hand washings in the clinic, and he gradually achieved good results despite initial carelessness by the hospital staff. His lectures, delivered in Hungarian by decree of the Austrian authorities, attracted large audiences. Semmelweis also became active in university affairs, serving on committees dealing with medical education, clinical services, and library organizations.

In 1861 Semmelweis finally published his momentous discovery in book form Die Ätiologie, der Begriff und die Prophylaxis des Kindbettfiebers. The work was written in German and discussed, at length, the historical circumstances surrounding his discovery of the cause and prevention of puerperal fever. A number of unfavourable foreign reviews of the book prompted Semmelweis to lash out against his critics in series of open letters written in 1861-1862, which did little to advance his ideas.

At a conference of German physicians and natural scientists, most of the speakers rejected his doctrine. One of them was Rudolf Virchow.

In 1861 Semmelweis’ increasing bitterness and frustration at the lack of acceptance of his method finally broke his hitherto indomitable spirit. He became alternately apathetic and pathologically enraged about his mission as a saviour of mothers. In July 1865 Semmelweis suffered what appeared to be a form of mental illness; and after a journey to Vienna imposed by friends and relatives, he was committed to an asylum, the Niederösterreichische Landesirrenanstalt in Wien Döbling. He died there only two weeks later. Traditionally, he is said to have died the victim of a generalized sepsis ironically similar to that of puerperal fever, which had ensued from a surgically infected finger. According to an article in Journal of Medical Biography, by H. O. Lancaster, however, this is not true:

“Much biographical material has been written on Semmelweis, yet the true story of his death on 13 August 1865 was not confirmed until 1979, by S. B. Nuland. After some years of mental deterioration, Semmelweis was committed to a private asylum in Vienna. There he became violent and was beaten by asylum personnel; from the injuries received he died within a fortnight. Thus some dramatic theories have been destroyed, including that he was injured and infected at an autopsy, which if true would have been a wonderful case of Greek irony.”

Semmelweis’ achievement must be considered against the medical milieu of his time. The ontological concept of disease insisted on specific disease entities that could be distinctly correlated both clinically and pathologically. Puerperal fever, however, exhibited multiple and varying anatomical localizations and a baffling symptomatology closely related to the evolution of generalized sepsis. The apparent connection between this fever and erysipelas further clouded the issue. Moreover, the idea of a specific contagion causing the disease was not borne out by the clinical experience. In the face of such theoretical uncertainties and the profusion of causes attributable to the disease, Semmelweis displayed a brilliant methodology borrowed from his teachers at the Second Vienna Medical School.

The Medical University of Budapest where he worked is named after him.

It is not chance that accounts for a single practitioner having 16 fatal cases in a single month.
Oliver Wendell Holmes

When I look back upon the past, I can only dispel the sadness which falls upon me by gazing into that happy future when the infection will be banished . . . The conviction that such a time must inevitably sooner or later arrive will cheer my dying hour.
Semmelweis, Aetiology, Foreword.

We thank Frederick Sweet for correcting errors on the original entry. Frederick Sweet is Professor, Washington University School of Medicine, St. Louis, Missouri.

• Fall von sackartiger Ausbuchtung des schwangeren Gebärmutterhalses.
  Wiener medizinische Wochenschrift, 1857.
• A gyermekagyi láz koroktana (“The Atiology of Childbed Fevers”), Orvosi hétilap, 1858; no. 1: 1-5; no. 2: 17-21; no. 5, 65-69; no. 6: 81-84; no. 21: 321-326; no. 22: 337-342; no. 23: 353-359. Semmelweis’ first first publications on his ideas.
• Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers. Pest-Wien-Leipzig, 1861.
  Reprinted with a new introduction by A. F. Guttmacher. New York-London, 1966.
  Translated into English by F. R. Murphy as The Etiology, the Concept and Prophylaxis of Childbed Fever, in Medical Classics, 1941; 5: 350-773.
• Zwei offene Briefe an Dr. Ed. Casp. Jac. von Siebold und an Dr. F. W. Scanzoni, Professoren der Geburtshilde.< Vienna, 1861.
  Rferring to Eduard Kaspar Jakob von Siebold (1801-1866) and Friedrich Wilhelm Scanzoni von Lichtenfels (1821-1891).
• Zwei offene Briefe an Dr. J. Späth, Professor der Geburtshilfe an der k. k. Josephs-Akademie in Wien und an Hofrath Dr. F. W. Scanzoni, Professor der Geburtshilfe zu Würzburg.
  Vienna, 1861. Referring to Joseph Späth (1823-1896).
• On the Origin and Prevention of Puerperal Fever.
  Medical Times and Gazette, London, 1862; 1: 601-602.
• Gesammelte Werke.
  Jena, Gustav Fischer, 1905. Edited and partially translated from the Hungarian by T. Von Györi. Also contains papers and articles on Semmelweis by Hebra and Skoda.
  In 1903 the Hungarian Society for the Publication of Medical Works collected and published Semmelweis’ works in Hungarian while the Hungarian Academy simultaneously arranged for an edition of the collected writings in German: Semmelweis writings are listed in:
  
• Medical Classics, 1941; 5: 340-341.
  
• Bulletin of the History of Medicine, 1946; 20: 653-707. On Semmelweis and his work:
• J. Magyary-Kossa:
  Ungarische Medizinische Erinnerungen. Budapest, 1935, pp. 284-194.
• Viktor Robinson:
  Pathfinders in Medicine.
  1st edition, 1912, pp. 249-273; 2nd edition, 1929, pp. 623-647.
  Medical Review of Reviews, 1912, 18: 232-246.
• H. O. Lancaster (Sydney, Australia):
  Semmelweis: a rereading of Die Aetiologie . . .
  Part I: Puerperal sepsis before 1845; Die Aetiologie.
  Journal of Medical Biography, London, February 1994; volume 2, No 1, pp 12-21.
  Part II: Medical historians and Semmelweis.
  Journal of Medical Biography, London, May 1994; volume 2, No. 2, pp 84-88.
• S. B. Nuland:
  The enigma of Semmelweis – an interpretation.
  Journal of the History of Medicine and Allied Sciences, Oxford, 1979; 34: 255-272.
• Alfred Hegar:
  Ignaz Philipp Semmelweis. Sein Leben und Seine Lehre, Zugleich ein Beitrag zur Lehre der fieberhaften Wundkrankheiten.
  Freiburg-Tübingen, 1882. 18: Freiburg im Breisgau.
• Fritz Schürer von Waldheim:
  Ignaz Philipp Semmelweis, sein Leben und Wirken.
  Wien.Leipzig, 1905.
• William J. Sinclair:
  Semmelweis, His Life and Doctrines. Manchester, 1909.
• György Gortvay, Imre Zoltán:
  Semmelweis – His Life and Work.
  Originally published in Hungarian in 1965. Translated by E. Róna. Budapest, 1968.
• E. Podach:
  Ignaz Philipp Semmelweis. Berlin-Leipzig, 1947.
• Henry E. Sigerist, in:
  The Great Doctors.
  Translated by Eden and Cedar Paul. Baltimore, 1933; chapter 41: 338-343.
• Regöy-Mérei:
  The Pathological Reconstruction of Semmelweis’ Disease on the Basis of the Catamnestic Analysis of Paleopathological Examination.
  In: Orvostörteneti közlemények, 1970; no. 55-56: 65-92.
• Benedek:
  The Illness and Death of Semmelweis. In: Orvostörteneti közlemények, 1970; no. 55-56: 103-113.
• L. Madai:
  Semmelweis and Statistical Science. In: Orvostörteneti közlemények, 1970; no. 55-56: 157-174.
• Erna Lesky:
  Ignaz Philipp Semmelweis und die Wiener medizinische Schule.
  Sitzungsberichte der phil.-hist. Klasse der Österreichischen Akademie der Wissenschaften,
  Vienna, 1964; volume 245, 3. Abhandlung: 1-93.
  Summarized in:
  Ignaz Philipp Semmelweis, Legende und Historie.
  Deutsche medizinische Wochenschrift, Stuttgart, 1972; 97: 627-632.
• S. Fekete:
  Die Geburtsfilhe zur Zeit Semmelweis.
  Clio Medica, Amsterdam, 1970; 5: 35-44.