As individuals in society, we live by structure and regimes that are either taught or acquired through our environments. The practice of hand-washing and the sterilization of surgical equipment in hospitals are procedures that we expect and universally accepted as best practices. The recent Coronavirus (COVID-19) pandemic has reminded us of the importance of sanitation and cleanliness to prevent disease and ultimately save lives. However, the importance of hand-washing was not common practice throughout many hospitals before the nineteenth century. Here, Amy Chandler explains Ignaz Semmelweis’ important discovery about hand-washing in the nineteenth century.
An 1860 copper plate picture of Ignaz Semmelweis.
Physician and gynaecologist Ignaz Semmelweis discovered the importance and life-saving impact of hand-washing within maternity wards in the 1850s. Semmelweis’ “discovery exceeded the forces of his genius. It was, perhaps, the root cause of all his misfortunes”, and in an ironic tragedy, Semmelweis died of the same illness that he devoted his career to preventing.[1]This article will explore Semmelweis’ contribution to medical practice in the nineteenth century and analyze how he failed to achieve public and international support for his discovery. Many contributing factors failed to propel Semmelweis into the sphere of revolutionizing and respecting theories in science and medicine, such as failing to publish his hand-washing theory and methodology, fleeing Vienna and the lack of support from his contemporary doctors. How did Ignaz Semmelweis simultaneously revolutionize surgical procedures and fail to convince his contemporary physicians?
17th century
During the seventeenth century, many hospitals in Europe became overwhelmed with cases of childbed fever (also known as 'puerperal fever') that women contracted during childbirth and suffered from days after birth.[2] Symptoms of puerperal fever included severe abdominal pain, fever and debility, and the result was commonly death for many women.[3] By the start of the nineteenth century, puerperal fever was a common and deadly disease that many women feared when entering maternity wards. The cause of this disease was bacteria infecting women during childbirth, but the understanding of how bacteria and disease spread was non-existent until the 1870s. Throughout history, there have been many different attempts to identify the cause of illness and disease, for example, the widely recognized theory of miasma. Miasma was considered “poisonous emanations, from putrefying carcasses, rotting vegetation or molds, and invisible dust particles inside dwellings” that was understood to be within the air that we breathe.[4] Therefore disease and illnesses were thought to be caused by ‘bad air’ or foul smells. By the end of the nineteenth century, the work of Louis Pasteur and his discovery of Germ theory replaced and progressed thinking around the cause of disease. The lack of knowledge around the causation of disease and the spread of infection made Semmelweis’ discovery imperative to progressing medical and scientific ideology. Semmelweis' ideas were often ignored, apart from support from close colleagues, which eventually led to his professional and personal demise.
Semmelweis’ discovery
In 1846, Semmelweis was appointed as an assistant professor in the maternity ward at Vienna General Hospital. Semmelweis undertook the challenge to understand and answer why mortality rates were so high within the Vienna General Hospital. The high mortality rates in the maternity ward of Vienna General hospital represented a widespread problem across Europe. Therefore, the cause of the disease was a universal substance and not specific to Vienna medical practice but widespread malpractice of the nineteenth century.
During Semmelweis’ employment in Vienna, mortality cases continued to increase, and so did Semmelweis’ concern and desire to discover the causation of illness. The maternal ward offered two divisions of maternity clinics; male physicians controlled one division, and female midwives staffed the other clinic.[5] In 1846 both of these divisions included similar patients demographics, but the statistics present that the male-staffed clinics had 13.10% of maternal deaths from puerperal fever, while the second division only suffered 2.03% of puerperal fever deaths.[6] From these statistics, it is evident that the cause of the illness originated and increased with the medical professionals within the first division that increased mortality rates. Semmelweis undertook a methodological approach to identify and inevitably reduce mortality rates and, as a result, to improve the lives of his patients, professional practice and contribute to disease theory. Semmelweis’ position as a gynaecologist and physician placed him in an advantageous position to discover the root cause of the mortality rates and implement policies to improve practice. Semmelweis had the opportunity to conduct research, medical knowledge and resources to identify the cause of puerperal fever. Historically, midwifery was recognized as a female role that expanded in the eighteenth century, with an increased number of male physicians and surgeons becoming involved within midwifery.[7]
A turning point in Semmelweis’ thinking was when his friend and colleague, Jacob Kolletschka, died from a puerperal fever after wounding himself during a dissection.[8] The autopsy results confirmed that Kolletschka contracted the same illness that many women suffered in the maternity wards. The contemporary theory of miasma formed the foundations of Semmelweis’ theory by speculating that “decaying animal-organic matter” caused the puerperal fever.[9] The causation of infections became evident to Semmelweis after he observed that student physicians worked in the dissection rooms and then directly, without changing their clothes or sanitizing their hands, entered the maternity wards.[10] The correlation between the two clinic divisions and the student's behavior emphasized that the male physicians were the carriers, to a point, of puerperal fever on their unwashed hands and clothes.
What did Semmelweis do with his newfound knowledge?
During this period, disinfectants that we are familiar with in contemporary society did not exist, nor was the knowledge of using chemicals to remove bacteria from surfaces. The concept of bacteria was not known or explored until many years after Semmelweis’ death. Therefore, methods to combat the unpleasant odors from miasmas included fire, sunlight, strong aromas and chemicals.[11] Semmelweis utilized his knowledge of miasma theory by attempting to eliminate foul odors transferred between the dissection room and the maternity ward by the physicians. For Semmelweis, the most potent smelling chemical available at the Vienna General Hospital was a solution of chlorinated lime. Under the supervision and authority of Semmelweis, physicians were ordered to wash their hands with this solution before entering the maternity wards. Inevitably, mortality rates in the maternity wards began to decrease, which supported Semmelweis’ theory. However, Semmelweis only understood that the solution reduced the number of cases and was unable to explain why hand-washing was so effective.
Semmelweis’ hand-washing policy was unpopular and faced opposition within the hospital, with individuals complaining of the burning sensations on their hands from vigorously washing and exposing their skin to the chlorinated lime solution.[12]Despite declining mortality rates, Semmelweis could not explain why the chlorinated solution was so effective as he did not realize hand-washing removed the bacteria causing disease. Furthermore, Semmelweis did not publish his findings or share his work for many years, which contributed to the lack of support amongst contemporary physicians for adopting the sanitation procedure. For some physicians, Semmelweis’ discovery lacked evidence to be understood fully, and in 1849 Semmelweis’ position within Vienna General Hospital was terminated. The Ministry of Education also declined the proposal to investigate Semmelweis’ theories further and gain evidence to support using chlorinated lime within medical practice.[13]
By 1851, Semmelweis left Vienna and returned to Hungary to continue his work by implementing his chlorinated lime regime and enforcing good ventilation, sterile linen, bandages and surgical equipment for his patients.[14] Eventually, in 1861, Semmelweis published his findings in The Etiology, Concept, and Prophylaxis of Childbed Fever. However, towards the end of Semmelweis’ career, his mental health began to decline, resulting in a mental breakdown in 1865, and his wife admitted Semmelweis into a mental hospital in Lazarettgasse. Unfortunately, Semmelweis died from blood poisoning after appropriate anti-septic methods were not enforced.
Conclusion
Semmelweis’ tragic death in some way proved that his theory of using a chlorinated lime solution to avoid puerperal fever was effective in preventing severe infection. Semmelweis’ lack of willingness to share his findings with his contemporaries reduced his hand-washing theory's credibility, while also lack of evidence and widespread enforcement of hand-washing isolated his results to be limited and circumstantial. In some ways, Semmelweis’ courage to challenge popular and pre-established views placed him in a difficult and unfavorable position because he was directly criticizing the work of his contemporaries by insinuating that their practice caused the deaths of many patients. This idea in itself was that doctors who dedicated their professional careers to saving lives and being seen as saviors against diseases were also the cause and carrier of such diseases they treated. Hindsight is a valuable asset we possess after years of scientific discoveries, but we have to praise Semmelweis for his work within the boundaries of knowledge of the time. The knowledge of bacteria was non-existent therefore working within the realms of miasma theory and Semmelweis’ methodologically eliminating factors in his study was to some extent revolutionary given the circumstances and knowledge of the time. Semmelweis’ ideas were brushed aside as unsupported ramblings, which contributed to the decline of his professional career. However, Semmelweis has now gained the status that his work deserves as a pioneer of modern medicine and sanitation procedures within medical environments. Semmelweis' work continues to help save lives today.
What do you think of Ignaz Semmelweis? Let us know below.
1. D. Pittet and B. Allegranzi, ‘Preventing sepsis in healthcare - 200 years after the birth of Ignac Semmelweis'. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin, vol .23 (2018), p.2.
[2] J. Simmons, Doctors & Discoveries: Lives that created today’s medicine (New York, Houghton Miffin Company,2002),p.167.
[3] C. Hallett, ‘The attempt to understand puerperal fever in the eighteenth and early nineteenth centuries: the influence of inflammation theory’. Med Hist. vol. 49 (2005), p. 1.
[4] A. Kannadan,’History of the Miasma Theory of Disease’. Essai, vol. 16 (2018),p. 41.
[5] Simmons, op.cit.,p.166.
[6] Ibid.,p.166.
[7] Hallett,op.cit.,p.4.
[8] Simmons, op.cit.,p.166.
[9] Ibid.,p.166.
[10] Ibid.,p.166.
[11] G. Risse. ‘Before Germs: Decay, Smell, and Contagion in the Work of Ignaz Semmelweis on Puerperal Fever’,unpublished,(2015),p.3.
[12] Ibid.,p.3.
[13] Ibid.,pp.3-4.
[14] Simmons, op.cit.,p.167.
Bibliography
Hallett, C, ‘The attempt to understand puerperal fever in the eighteenth and early nineteenth centuries: the influence of inflammation theory’. Med Hist, vol.49, no.1, January 2005, pp. 1-28.
Kannadan, A, ’History of the Miasma Theory of Disease’. Essai, vol. 16, no. 18, 2018, pp.41-43.
Persson, J, ‘Semmelweis’s methodology from the modern stand-point: intervention studies and causal ontology’, Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences,vol.40, no.3, 2009, pp.204-209.
Pittet, D and Allegranzi, B, ‘Preventing sepsis in healthcare - 200 years after the birth of Ignac Semmelweis'. Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin, vol. 23, no. 18, May 2018, pp.1-5.
Risse, G. ‘Before Germs: Decay, Smell, and Contagion in the Work of Ignaz Semmelweis on Puerperal Fever’, unpublished, 2015,pp.1-8.
Simmons, J. Doctors & Discoveries: Lives that created today’s medicine (New York, Houghton Miffin Company,2002).
