Historical Vignette - The Sad Case of Ignaz Semmelweiz, Part I

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By Paul D Maher

In Vienna in the summer of 1846 a young Hungarian physician by the name of Ignaz Semmelweis had just been appointed to the post of assistant professor of Obstetrics at the Vienna General Hospital. There the young doctor found an appalling situation. His hospital ran two obstetric clinics which provided free perinatal care to the poor of the city. However, the clinic he was in charge of had a maternal mortality rate nearly 3 times that of the other hospital clinic and one which often exceeded 10% in any given month. Mind you this was not an infant mortality of 10%, rather one in ten mothers who entered this hospital to deliver a baby did not leave alive. It was so bad, the poor and the prostitutes of Vienna would often look to give birth on the street on the way to the hospital, in order to retain their child care benefits but not subject themselves to the potential health horrors of his clinic.

To Semmelweis' dismay, these "street births" as they were called did not suffer from the same risk of "child bed" or puerperal fever, the main cause of maternal death in his clinic, as those who were actually admitted to the clinic.

Being a contentious physician he sought the answer to this mystery stating the situation, "made me so miserable that life seemed worthless". One by one he eliminated various possible causes to account for the deaths of so many expectant mothers in his clinic, overcrowding, climate, medical technique and so forth were all examined and dismissed. The only difference he noted was that his clinic was used to instruct medical students while the clinic with much lower mortality was used to teach midwives. The mystery continued until somewhat later in 1847 when a good friend, Jakob Kolletchka, was pricked by a student's scalpel during an anatomy lesson with a cadaver. Over the ensuing days Kolletchka went on to suffer and die of an illness which very closely resembled the childbed fever so prevalent in the Vienna hospital. As Semmelweis stated,

"Day and night I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died."
Puerperal fever in modern terminology would be recognized as a type of sepsis, an infection by bacteria seeded in the bloodstream. It began, as might be expected, with a high fever which usually came on quite suddenly and was accompanied by violent shaking chills. The infection was sometimes fought off and recovered from, however, if not, a condition of overwhelming sepsis ensued. The abdomen would often become unbearably tender to the touch. Only improving with a sometimes false sense of recovery when the abdominal tissue had become so gangrenous and necrotic as to be less painful. Over days or weeks, the bacteria and their toxins would attack every major organ system in the body. Even in modern times such a situation of overwhelming sepsis will quite often lead to death from multi organ system failure, the shutdown of kidneys, liver, lungs and/or endocrine system from the overwhelming infection. Without antibiotics the situation was generally a death sentence. And child bed fever sentenced women to die with a vengeance. Author Irving Louden in his "The Tragedy of Childbed Fever" estimates that in Europe of the 18th and 19th centuries, out of 1000 women in childbirth, 6-9 would contract the disease and 2-3 die of it. This background endemic rate was often punctuated by epidemic outbreaks where maternal mortality could exceed 50%. It was an ever present part of the fabric of society and described by a medical practitioner of the day as a "sort of desecration" that the relief and joy of successful childbearing would be followed so cruelly some days later by the onset of the disease.

Following the death of his friend, Kolletchka, Semmelweis observed that many of the medical students serving his clinic would go straight from their anatomy lessons with the cadavers to the maternity ward. Midwives, however, were not instructed in anatomy through the dissection of cadavers. In 1847, one year after being put in charge of the clinic, Semmelweis instituted a policy that we would only consider commonsense today, that of antiseptic handwashing before each delivery. The results he achieved using a solution of chlorinated lime as an antiseptic were dramatic to say the least. In April of 1847 the maternal mortality rate was 18.7%, hand washing was instituted in the middle of May. In June the mortality rate was 2.2%, in 1848, there would be two months with a zero death rate.

Perhaps at least, or even more, astonishing then the results Semmelweis achieved with his antiseptic approach was the response of the medical community of his time to his findings. Unfortunately his findings did not fit the prevailing wisdom of the day, which prescribed disease to an imbalance of humors often best treated through blood letting. Indeed, nearly a century before Semmelweis, noted Scottish obstetrician, Alexander Gordon, had correctly concluded that puerperal fever was spread by physicians and midwives, and that it had some relation to skin infections. In fact the staphylococcal and streptococcal bacteria responsible for the deadly childbed fever could sometimes be seen as a mild dermatological infection on the skin, a condition known as erysipelas. Despite his clear headed analysis of the etiology of the disease, Gordon then unfortunately concluded that puerperal fever should thus be treated by aggressive bloodletting; over a pint for an initial measure.

Semmelweis' findings were publicized initially by his students who wrote the heads of respected maternity clinics throughout Europe with news of their success. They detailed their findings in the well known English Medical journal the Lancet as well as other medical journals throughout Europe. A few individuals recognized the significance of the findings, Ferdinand Von Hebra who edited a prominent Austrian medical journal and would establish the modern discipline of dermatology, commented publicly in his journal that Semmelweis' findings had a significance comparable to that of Edward Jenner's work in developing the small pox vaccine. For the most part however, tragically, Semmelweis' findings were not merely dismissed they were ridiculed.

In time, of course, Semmelweis would go on to be called the "father of antisepsis" and the "savior of mothers". However, his research was still some decades before Louis Pasteur's groundbreaking microbiological work would lead to the "germ theory" of disease. The idea that minuscule infectious cadaveric particles on the hands could account for disease was rejected as irrational by some and offensive by others. As Charles Meigs the respected Philadelphia Obstetrician commented at the time, "Physicians are gentleman... and gentleman's hands are clean". Other noted medical authorities of the day likewise criticized the findings with vehemence and declared them unscientific.

The ensuing controversy with all of its political uproar soon cost Semmelweis his position in Vienna and he was forced to take an unpaid honorary position as head of Obstetrics at a small hospital in Pest, Hungary. There he again initiated his antiseptic regime, subsequently only eight patients would die of childbed fever in his clinic in the next five years. Eventually, he was able to obtain a more respectable position as professor of obstetrics at the University of Pest. Once again maternal mortality declined dramatically. Despite this and despite finally publishing himself at this time his findings he was dismissed by the obstetrical community of Europe, his ideas described by one respected obstetrician as "naive" and the "Koran of puerperal theology".

Over time Semmelweis' railings against the established medical doctrine grew more strident, he became obsessed with puerperal fever, and increasingly depressed at the rejection of his work. His behavior also began to become erratic and inappropriate. It is unclear to what extent his rapid decline was a result of stress from the rejection of his ideas. Some speculate that he was evincing signs of the neurologic sequela of tertiary syphilis, acquired either from a prostitute he was reported to have been frequently seen with or as an occupational hazard, often seen at that time, from his work. Be that as it may, as his condition worsened his friend and former professor, Ferdinand von Hebra, arranged, without Semmelweis' knowledge, to have him involuntarily committed to an insane asylum. When Semmelweis realized, too late, what was occurring he attempted to resist his commitment. In the process he was severely beaten by the hospital guards. In a painfully ironic twist of fate, he died two weeks later when an infection from his wounds seeded his blood leading to overwhelming sepsis, the same condition, from which he protected so many of his patients. Ignaz Semmelweiz was 46 years old.

A physician who spent nearly ten years at the US Food and Drug Administration, Dr. Maher, has authored peer-reviewed articles for the medical literature, authored a chapter on the genomics of rare diseases for a text book of rare disease therapy and writes on his website on neglected questions of medical importance as well as pointing out historical medical fallacies. You may find more of his work at The Skeptic's Health Journal Club,