In the Vienna General Hospital in the 1840s there were two maternity clinics, and women admitted to the hospital knew which one they wanted. Admission alternated by day of the week, and it was not unusual for a woman in labour to beg on her knees to be sent to the second clinic, or, failing that, to give birth in the street outside and present herself afterwards.
They were not being superstitious. In the First Clinic, staffed by doctors and medical students, the death rate from puerperal fever ran at around 10 percent and in bad months reached 18. In the Second Clinic, staffed by midwives, it was about 4. Women who delivered on the pavement and then came in did better than either.
Ignaz Semmelweis, a Hungarian obstetrician appointed assistant in the First Clinic in 1846, found this unbearable and set out to explain it.
Eliminating the Explanations
The accepted causes of childbed fever were atmospheric, cosmic and telluric influences, overcrowding, and the general constitution of the patients. Semmelweis went through the candidates one by one and threw them out.
Both clinics were in the same building and breathed the same air, so it was not miasma. The Second Clinic was more crowded, not less. The social class of the women was identical, since admission was by rota. Diet and ventilation were the same. A theory that the priest walking through the ward with a bell to administer last rites frightened the women into illness was tested by rerouting the priest and silencing the bell, which changed nothing.
The one difference he could find was who did the work, and what those people did before they arrived.
The Autopsy That Answered It
In March 1847 a colleague and friend, the forensic pathologist Jakob Kolletschka, was cut on the finger by a student’s scalpel during a post mortem. He fell ill and died, and Semmelweis read the autopsy report.
The pathology was the same as that of the women in his ward. The same inflammation, the same spread, the same appearance in the tissues. Kolletschka had died of childbed fever, and he was a middle aged man.
The link followed at once. The medical students of the First Clinic spent the morning dissecting corpses in the mortuary and then walked upstairs to examine women in labour, rinsing their hands in soap and water at most. The midwives of the Second Clinic did no autopsies at all. Something Semmelweis called cadaverous particles was being carried on the hands of the men who were supposed to be helping.
In May 1847 he ordered every doctor and student to scrub their hands in a solution of chlorinated lime before entering the ward, chosen because it was the only thing he knew of that removed the smell of the dissecting room. He reasoned that if it destroyed the smell it might destroy whatever carried it.
The mortality in the First Clinic fell from 18.3 percent in April to 2.2 percent in June, and for one month in the following year to zero. He extended the rule to instruments after an incident in which twelve women in a row died following the examination of a patient with a discharging cancer, which told him the material need not come from a corpse at all.
Why It Was Rejected
The result was published by supportive colleagues, discussed in Vienna, tried in a few places, and then largely dropped. The reasons are worth listing plainly, because none of them is stupidity.
- It had no mechanism. Semmelweis could describe what the particles did but not what they were. Germ theory did not yet exist, and asking physicians to change their practice for an invisible agent with no known nature was asking a lot
- It contradicted the dominant theory. Disease was understood as an imbalance in an individual patient, so each case had its own causes. A single external cause for every case was a different kind of claim altogether
- It was an accusation. The finding was not that childbed fever is preventable. It was that the doctors were carrying it in on their hands and killing their patients. Gentlemen’s hands were held to be clean by definition, and the professional insult was immediate
- He argued badly. This part is genuinely his own fault. He refused for years to write a proper account, delegated the defence to friends, and when he finally published The Etiology, Concept and Prophylaxis of Childbed Fever in 1861, he followed it with open letters calling named European obstetricians murderers and their teaching a massacre
He was not helped by hospital politics. Vienna after the 1848 revolutions was suspicious of Hungarians, his appointment was not renewed, and he left for Pest without telling his supporters, which they took as desertion. At the St Rochus hospital there he reduced maternal mortality below 1 percent, and almost nobody outside Hungary noticed.
He Was Not the Only One
In Boston in 1843, four years before Vienna, Oliver Wendell Holmes had published an essay arguing from case series that puerperal fever was carried from patient to patient by physicians, and recommending that a doctor who attended a case should not deliver another woman for weeks. He was answered by Charles Meigs of Philadelphia with the line that doctors are gentlemen, and gentlemen’s hands are clean.
Two men on two continents reached the same conclusion from different evidence, and both were dismissed with the same argument.
The Ending
Semmelweis deteriorated through the early 1860s. He became obsessive, publicly abusive, and possibly ill in a way that had nothing to do with the dispute, though the dispute was clearly consuming him. In July 1865 his wife and colleagues took him to an asylum in Vienna under the pretence of visiting a new institute. He realised what was happening, tried to leave, and was beaten by the guards and confined in a straitjacket.
He died two weeks later at the age of 47, of sepsis, from an infected wound sustained during that beating. The mechanism was the one he had spent his life describing.
Vindication, and What It Cost
Within twenty years the explanation arrived from elsewhere. Pasteur’s demonstration that specific organisms cause specific diseases supplied exactly the mechanism Semmelweis had lacked, and identified the streptococcus responsible for childbed fever in 1879. Joseph Lister, working from Pasteur rather than from Semmelweis, made antisepsis routine in surgery.
By then the delay had a cost that can be estimated: the maternity wards of Europe and North America continued at their old rates for a further two decades, which puts the toll in the hundreds of thousands.
The pattern is not unique to him. John Snow was making a parallel argument in London at exactly the same period, with better presentation and better statistics, and was also rejected in his lifetime. The difference is that Snow was a well connected London physician with a public reputation in anaesthesia, and Semmelweis was a foreigner in a hostile institution who eventually started calling his opponents murderers in print.
The lesson usually drawn is that science resists new ideas, which is true and not very useful. The more specific one is that a correct result without a mechanism is extremely fragile, and that its survival depends almost entirely on whether the person holding it can keep the argument civil for long enough. Semmelweis could not, and the ward records that proved him right sat unread while women went on dying in them.
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