Ignác Semmelweis—celebrating a flawed pioneer of patient safety

There was presumably a moment when everything changed for Ignác Philipp Semmelweis (1818—65)—a moment of awful clarity in which he realised the truth about the cause of childbed fever. His later descriptions suggest that any initial sense of achievement was soon overshadowed by a sinking, overwhelming guilt. It must have quickly dawned on him that while he had diligently been keeping precise records of maternal mortality rates—rates that he found disturbingly high, and inadequately investigated—the devastating “contagion” was being carried to his patients on his own hands and those of the medical students under his direct supervision. Perhaps he never fully recovered, and the zeal with which he later stripped layers of skin from his hands with chlorinated lime solution recalls the words of Shakespeare's Lady Macbeth when she despaired, “What, will these hand ne'er be clean?”

From this moment, we think that hand hygiene became the central motivation in Semmelweis's career. A decade earlier, Danish theologian and philosopher Søren Kierkegaard had written, “the crucial thing is to find a truth which is truth for me, to find the idea for which I am willing to live and die”. In the cause and prevention of childbed fever, Semmelweis found this truth. His life until that point had not been characterised by single-minded focus. Graduating second in his school class in Buda—then a part of the Austrian Empire—Semmelweis began studying law in Vienna in accordance with his father's desire for him to become a military judge. After a year, however, he transferred to medicine, and graduated in 1844 with a botanical thesis, Tractatus de Vita Plantarum. Failing in his attempts to enter the renowned pathology department, Semmelweis settled on a post as professor's assistant in the obstetrics department. While awaiting this position, he spent 2 years mentored by anatomical pathologist Carl von Rokitansky and internist Joseph Škoda. But it was not until his next move that Semmelweis found himself, by chance, in the midst of a problem for which he was willing to live and die.

When he gained the position as assistant in obstetrics at the Vienna General Hospital in 1846, Semmelweis was appalled by the “horrible devastations” caused by childbed fever. This very human reaction is the first lesson we can take from him. At the time, childbed fever was endemic in Europe and elsewhere and was widely attributed to miasma (an illness-carrying vapour) or intrinsic factors related to the patient. Seemingly beyond human control, these theories fostered a resigned acceptance and allowed their proponents, in Semmelweis' unforgiving opinion, to “escape all responsibility for the devastations of the disease”. But Semmelweis was not content to succumb to contemporary lassitude, and launched a careful inquiry that led him to develop, as he later described, the “unshakable conviction [that childbed fever] consists entirely of instances of infection from external sources which could have been prevented”.

Semmelweis was faced with four key facts. First, of the two clinics (or wards) in the maternity hospital, ward one had a consistently higher maternal mortality rate compared with ward two. Second, women in labour were allocated to one of the two wards on the basis of the day of the week of their presentation to the hospital (what we might regard today as quasi-randomisation). To Semmelweis, this method of ward allocation made factors related to individual patients—emotional disturbance of the patient was sometimes blamed—an unlikely culprit. “I was convinced that the greater mortality rate at the first clinic was due to an endemic but as yet unknown cause”, he wrote. Third, both wards were essentially identical with regard to layout and infrastructure, and were “separated”, as Semmelweis observed, “only by a common anteroom”. Semmelweis did not believe that miasma could distinguish between two such proximal and similar wards. Finally, ward one was staffed by doctors and medical students, whereas ward two was run by midwives. Semmelweis began to suspect that it was in this major difference that the answer must be found.

But while his careful approach was able to refute—at least in his own mind—other current explanations, it was the death of his friend, pathologist Jakob Kolletschka that allowed Semmelweis to connect the dots leading to the true cause of the disease. While supervising an autopsy, Kolletschka sustained a laceration from a stray scalpel wielded by a medical student. He subsequently succumbed to a febrile illness that resembled childbed fever. “Suppose cadaverous particles adhering to hands”, wrote Semmelweis, aware that the medical staff of ward one participated in autopsies while the midwives of ward two did not, “cause the same disease among maternity patients that cadaverous particles adhering to the knife caused in Kolletschka”. Indeed, mortality rates had first increased when Johann Klein introduced student participation in autopsies as a flagship initiative of his professorship on gaining the position in 1823.

Thinking himself armed with the unbeatable backing of truth, Semmelweis set out to diffuse his theory and institute change in 1847. “Do you dare to claim that human beings, in a crowd”, wrote Kierkegaard in the same year that Semmelweis introduced mandatory hand washing with chlorinated lime, “are just as quick to reach for truth, which is not always palatable, as for untruth, which is always deliciously prepared, when in addition this must be combined with an admission that one has let oneself be deceived!” Semmelweis was the bearer of an inconvenient truth. Did Semmelweis hesitate before setting off with this burden down the path that would end, after years of struggle with his death in an asylum? We suspect not. As he later wrote “the facts cannot be changed, and denying the truth only increases guilt”. As is well known, the path of least resistance for many of his colleagues was to dismiss the legitimacy of his ideas.

Despite a dramatic reduction in mortality, Semmelweis and his theory were met with tolerance at best and, at worst, with derision. His contract did not survive the renewal process in 1849. Truth, it might have seemed to him, does not always triumph after all. In one sense, this was predictable. He was a young and fairly inexperienced physician whose idea challenged the views of his colleagues. Much has been written about the extent to which Semmelweis's intemperate personality may have influenced the way his contemporaries reacted to his work. Yet despite the controversy that surrounds his personal conduct, medical history provides examples of such stories being overcome. Only a decade earlier, for example, Škoda's clinical responsibilities had been transferred to the ward for the “insane” in an expression of the medical faculty's disapproval of his unconventional and invasive new methods of examination: percussion and auscultation. After 9 years of increasingly influential publications, however, not only was this slap on the wrist forgotten, Škoda was elected professor of medicine. Semmelweis was not so fortunate.

Semmelweis was seen to be pointing an uncomfortable finger of blame at his colleagues at a time of wider sociopolitical tensions. As a Hungarian belonging to a German-speaking ethnic minority in Vienna, Semmelweis witnessed his nation's dissatisfaction towards the Austrian Empire result in the Hungarian War of Independence of 1848—49. Against this historical backdrop, Semmelweis also faced other obstacles. He lacked an explanatory model on which to base his claims. While bacteria had first been observed some 200 years earlier, Louis Pasteur—who cultured Streptococcus pyogenes from the blood of a woman with childbed fever in 1879—had not yet proposed the germ theory of disease, and Robert Koch's postulates were 30 years away. Rather than pathological, Semmelweis's proof was epidemiological, a perceived failing in a medical school leading a revolution in anatomical pathology. Another problem in our view is that his intervention wasn't exactly benign. According to Semmelweis's protocol, a hand hygiene action took an interminable 5 minutes. Worse still, chlorinated lime caused much irritation to hands. Moreover, when Semmelweis's magnum opus, The Aetiology, Concept and Prophylaxis of Childbed Fever, finally appeared in 1861, it was a formidable tome of more than 500 pages. Within its pages, Semmelweis oscillates between measured epidemiological discourse and bitter, caustic ranting. With almost evangelical fervour, he still invokes truth as his unconquerable ally. Take this, for example, “the ground, the unshakable rock, in which I erect my teaching is the fact that from May 1847 until the present day, 19 April 1859, that is for over twelve years, in three different institutions, I succeeded in limiting childbed fever to isolated cases.” Nevertheless, given that this work provides evidence that adequate hand hygiene can lower inpatient mortality from healthcare-associated infections, we regard it as a groundbreaking publication, and its sesquicentenary deserves celebration.

Our interpretation is that Semmelweis's monograph—the ultimate product of his fanaticism—sought to recreate in others his own moment of realisation by sheer weight of evidence. According to him, the facts should speak for themselves. But he overplayed his hand. Despite strong evidence of a clearly lifesaving intervention, his uncompromising message generated anger and rejection rather than behaviour change. In 2011, 150 years after this milestone publication, his unsuccessful attempt to implement a patient safety initiative remains as instructive as his great achievements.

AS and DP received partial financial support for hand hygiene research activities from the Swiss National Science Foundation (Subside 3200B0-122324/1) and WHO's Patient Safety Programme. WHO takes no responsibility for the information provided or the views expressed in this report.