Dr. Ignaz Semmelweis worked at the Vienna General Hospital's maternity clinic on a 3-year contract from 1846-1849. There, as elsewhere in European and North American hospitals, puerperal fever, or childbed fever, was rampant, sometimes climbing to 40 percent of admitted patients. He was disturbed by these mortality rates, and eventually developed a theory of infection, in which he theorized that decaying matter on the hands of doctors, who had recently conducted autopsies, was brought into contact with the genitals of birthgiving women during the medical examinations at the maternity clinic. He proposed a radical hand washing theory using chlorinated lime, now a known disinfectant.
At the time however, the germ theory of infection had not been developed and Semmelweis' ideas ran contrary to key medical beliefs and practices at the time. His ideas were rejected and ridiculed. Quite unusually, his contract was not renewed, effectively expelling him from the medical community in Vienna. He died as an outcast in a mental institution.
An 1841 account of epidemic childbed fever states that insofar as existing historical documents permit one to judge, childbed fever is a modern disease. The cases reported by Hippocrates that are generally identified as such are not puerperal fever. There are only examples of bilious fever, then common, which among maternity patients was no different from its appearance among non-maternity patients or men; Hippocrates himself never identified it as a separate and distinguishable disease.[1]
We encounter the first, as yet unclear indication of childbed fever in the second half of the 17th century at the Hôtel-Dieu in Paris. Phillipe Peu relates that mortality among the newly delivered was very great and greater in certain seasons than others. The year 1664 was particularly devastating.[1]
Another account states that the lower abdominal infection, la fièvre puerpérale, had raged every winter since 1774 among the maternity patients of the Hôtel-Dieu, and that often as many as 7 of every 12 patients suffered from it.[2]
For the relatively small maternity clinic at Würzburg in Germany, Franz Kiwisch von Rotterau reported 27 deaths from 102 patients (26.5 %) cared for during one year, much higher than the Viennese hospital. Semmelweis explained this from the need in small hospitals to use every patient as teaching material. In contrast, "in Vienna there is such an excess of teaching material that hundreds of individuals are not used for teaching and thus are not infected".[3]
There are various inconsistencies in the datasets reported by Semmelweis and provided below. Inconsistencies exist for instance in reported yearly rates, and monthly rates (if aggregated to yearly basis). One of the causes may be that Semmelweis used different sources. He points out several times that actual mortality rates were higher than reported ones, because during childbed fever epidemics, the maternity ward was overwhelmed with dying women, who were then transferred to the general hospital, and therefore not registered at the maternity ward, when dying.[4] Some women were also released from the maternity ward, either healthy or not so healthy, only to be readmitted to the general hospital when symptoms appeared or worsened. See also a similar underreporting practice at the Charité in Berlin, Joseph Hermann Schmidt.
There were two maternity clinics at the Vienna General Hospital. Semmelweis is not always specific, if the numbers are for both clinics, or for his own clinic only. The figures presented below are exactly as reported in (the 1983 translation by Carter of) Semmelweis' 1861 publication.
There are also at times minor arithmetical errors in his computed rates; for this reason all rates on this page are computed.
The table below shows monthly incidence rates from 1841–1849, in particular the remarkable decline in mortality rates from June 1847 to February 1849, when Semmelweis' handwashing policy was implemented.
Year | Month | Births | Deaths | Rate (%) | Sort restore | |
1841 | Jan | 254 | 37 | 14.6 | 1 | |
Feb | 239 | 18 | 7.5 | 2 | ||
Mar | 277 | 12 | 4.3 | 3 | ||
Apr | 255 | 4 | 1.6 | 4 | ||
Maj | 255 | 2 | 0.8 | 5 | ||
Jun | 200 | 10 | 5.0 | 6 | ||
Jul | 190 | 16 | 8.4 | 7 | ||
Aug | 222 | 3 | 1.4 | 8 | ||
Sep | 213 | 4 | 1.9 | 9 | ||
Okt | 236 | 26 | 11.0 | 10 | ||
Nov | 235 | 53 | 22.6 | 11 | ||
Dec | na | na | na | 12 | ||
1842 | Jan | 307 | 64 | 20.8 | 13 | |
Feb | 311 | 38 | 12.2 | 14 | ||
Mar | 264 | 27 | 10.2 | 15 | ||
Apr | 242 | 26 | 10.7 | 16 | ||
Maj | 310 | 10 | 3.2 | 17 | ||
Jun | 273 | 18 | 6.6 | 18 | ||
Jul | 231 | 48 | 20.8 | 19 | ||
Aug | 216 | 55 | 25.5 | 20 | ||
Sep | 223 | 41 | 18.4 | 21 | ||
Okt | 242 | 71 | 29.3 | 22 | ||
Nov | 209 | 48 | 23.0 | 23 | ||
Dec | 239 | 75 | 31.4 | 24 | ||
1843 | Jan | 272 | 52 | 19.1 | 25 | |
Feb | 263 | 42 | 16.0 | 26 | ||
Mar | 266 | 33 | 12.4 | 27 | ||
Apr | 285 | 34 | 11.9 | 28 | ||
Maj | 246 | 15 | 6.1 | 29 | ||
Jun | 196 | 8 | 4.1 | 30 | ||
Jul | 191 | 1 | 0.5 | 31 | ||
Aug | 193 | 3 | 1.6 | 32 | ||
Sep | 221 | 5 | 2.3 | 33 | ||
Okt | 250 | 44 | 17.6 | 34 | ||
Nov | 252 | 18 | 7.1 | 35 | ||
Dec | 236 | 19 | 8.1 | 36 | ||
1844 | Jan | 244 | 37 | 15.2 | 37 | |
Feb | 257 | 29 | 11.3 | 38 | ||
Mar | 276 | 47 | 17.0 | 39 | ||
Apr | 208 | 36 | 17.3 | 40 | ||
Maj | 240 | 14 | 5.8 | 41 | ||
Jun | 224 | 6 | 2.7 | 42 | ||
Jul | 206 | 9 | 4.4 | 43 | ||
Aug | 269 | 17 | 6.3 | 44 | ||
Sep | 245 | 3 | 1.2 | 45 | ||
Okt | 248 | 8 | 3.2 | 46 | ||
Nov | 245 | 27 | 11.0 | 47 | ||
Dec | 256 | 27 | 10.5 | 48 | ||
1845 | Jan | 303 | 23 | 7.6 | 49 | |
Feb | 274 | 13 | 4.7 | 50 | ||
Mar | 292 | 13 | 4.5 | 51 | ||
Apr | 260 | 11 | 4.2 | 52 | ||
Maj | 296 | 13 | 4.4 | 53 | ||
Jun | 280 | 20 | 7.1 | 54 | ||
Jul | 245 | 15 | 6.1 | 55 | ||
Aug | 251 | 9 | 3.6 | 56 | ||
Sep | 237 | 25 | 10.5 | 57 | ||
Okt | 283 | 42 | 14.8 | 58 | ||
Nov | 265 | 29 | 10.9 | 59 | ||
Dec | 267 | 28 | 10.5 | 60 | ||
1846 | Jan | 336 | 45 | 13.4 | 61 | |
Feb | 293 | 53 | 18.1 | 62 | ||
Mar | 311 | 48 | 15.4 | 63 | ||
Apr | 253 | 48 | 19.0 | 64 | ||
Maj | 305 | 41 | 13.4 | 65 | ||
Jun | 266 | 27 | 10.2 | 66 | ||
Jul | 252 | 33 | 13.1 | 67 | ||
Aug | 216 | 39 | 18.1 | 68 | ||
Sep | 271 | 39 | 14.4 | 69 | ||
Okt | 254 | 38 | 15.0 | 70 | ||
Nov | 297 | 32 | 10.8 | 71 | ||
Dec | 298 | 16 | 5.4 | 72 | ||
1847 | Jan | 311 | 10 | 3.2 | 73 | |
Feb | 312 | 6 | 1.9 | 74 | ||
Mar | 305 | 11 | 3.6 | 75 | ||
Apr | 312 | 57 | 18.3 | 76 | ||
Maj | 294 | 36 | 12.2 | 77 | Handwashing policy instituted mid-May | |
Jun | 268 | 6 | 2.2 | 78 | ||
Jul | 250 | 3 | 1.2 | 79 | ||
Aug | 264 | 5 | 1.9 | 80 | ||
Sep | 262 | 12 | 4.6 | 81 | ||
Okt | 278 | 11 | 4.0 | 82 | ||
Nov | 246 | 11 | 4.5 | 83 | ||
Dec | 273 | 8 | 2.9 | 84 | ||
1848 | Jan | 283 | 10 | 3.5 | 85 | strict controls enforced on students' negligent hand-wash |
Feb | 291 | 2 | 0.7 | 86 | ||
Mar | 276 | 0 | 0.0 | 87 | ||
Apr | 305 | 2 | 0.7 | 88 | ||
Maj | 313 | 3 | 1.0 | 89 | ||
Jun | 264 | 3 | 1.1 | 90 | ||
Jul | 269 | 1 | 0.4 | 91 | ||
Aug | 261 | 0 | 0.0 | 92 | ||
Sep | 312 | 3 | 1.0 | 93 | ||
Okt | 299 | 7 | 2.3 | 94 | ||
Nov | 310 | 9 | 2.9 | 95 | ||
Dec | 373 | 5 | 1.3 | 96 | ||
1849 | Jan | 403 | 9 | 2.2 | 97 | |
Feb | 389 | 12 | 3.1 | 98 | ||
Mar | 406 | 20 | 4.9 | 99 | Semmelweis' employment terminated |
From his theory of decaying matter on the hands of examining physicians as a cause for childbed fever he was able to explain other features in the dataset, for instance why mortality rates were remarkably higher during winter than summer, because of increased student activity and scheduled autopsies immediately before the rounds at the maternity clinic. He writes:
He was able to explain additional features:
A second clinic was started in 1833 because of the large number of women being admitted to the maternity ward . Medical students and midwife students undertook their studies at both clinics. In 1841 however, these two groups were separated. Thereafter, medical students attended the first clinic only, and midwife students attended the second clinic only. Joseph Späth was professor at the second clinic.
First clinic | Second clinic | |||||||
Year | Births | Deaths | Rate (%) | Births | Deaths | Rate (%) | Note | |
1833 | 3,737 | 197 | 5.3 | 353 | 8 | 2.3 | Second clinic started | |
1834 | 2,657 | 205 | 7.7 | 1,744 | 150 | 8.6 | ||
1835 | 2,573 | 143 | 5.6 | 1,682 | 84 | 5.0 | ||
1836 | 2,677 | 200 | 7.5 | 1,670 | 131 | 7.8 | ||
1837 | 2,765 | 251 | 9.1 | 1,784 | 124 | 7.0 | ||
1838 | 2,987 | 91 | 3.0 | 1,779 | 88 | 4.9 | ||
1839 | 2,781 | 151 | 5.4 | 2,010 | 91 | 4.5 | ||
1840 | 2,889 | 267 | 9.2 | 2,073 | 55 | 2.7 | ||
1841 | 3,036 | 237 | 7.8 | 2,442 | 86 | 3.5 | Only midwives worked in the second clinic | |
1842 | 3,287 | 518 | 15.8 | 2,659 | 202 | 7.6 | ||
1843 | 3,060 | 274 | 9.0 | 2,739 | 164 | 6.0 | ||
1844 | 3,157 | 260 | 8.2 | 2,956 | 68 | 2.3 | ||
1845 | 3,492 | 241 | 6.9 | 3,241 | 66 | 2.0 | ||
1846 | 4,010 | 459 | 11.4 | 3,754 | 105 | 2.8 | ||
1847 | 3,490 | 176 | 5.0 | 3,306 | 32 | 1.0 | Handwashing in first clinic mid-May | |
1848 | 3,556 | 45 | 1.3 | 3,319 | 43 | 1.3 | ||
1849 | 3,858 | 103 | 2.7 | 3,371 | 87 | 2.6 | Semmelweis dismissed in March | |
1850 | 3,745 | 74 | 2.0 | 3,261 | 54 | 1.7 | ||
1851 | 4,194 | 75 | 1.8 | 3,395 | 121 | 3.6 | ||
1852 | 4,471 | 181 | 4.0 | 3,360 | 192 | 5.7 | ||
1853 | 4,221 | 94 | 2.2 | 3,480 | 67 | 1.9 | ||
1854 | 4,393 | 400 | 9.1 | 3,396 | 210 | 6.2 | ||
1855 | 3,659 | 198 | 5.4 | 2,938 | 174 | 5.9 | ||
1856 | 3,925 | 156 | 4.0 | 3,070 | 125 | 4.1 | ||
1857 | 4,220 | 124 | 2.9 | 3,795 | 83 | 2.2 | ||
1858 | 4,203 | 86 | 2.0 | 4,179 | 60 | 1.4 |
Semmelweis seeks to demonstrate that the advent of pathological anatomy, and consequently the increase in autopsies, is correlated to the incidence of childbed fever. From 1789-1822 professor Johann Lucas Boër was assigned the teaching post at the maternity ward, however he left the post discouraged of what was then regarded as an enormous mortality rate. He was succeeded by professor Johann Klein who reformed obstetrics to an anatomical orientation emphasizing the value of pathological autopsies. Mortality rates jump markedly.
Year | Births | Deaths | Rate (%) | Note |
1784 | 284 | 6 | 2.1 | No pathological anatomy |
1785 | 899 | 13 | 1.4 | |
1786 | 1,151 | 5 | 0.4 | |
1787 | 1,407 | 5 | 0.4 | |
1788 | 1,425 | 5 | 0.4 | |
1789 | 1,246 | 7 | 0.6 | |
1790 | 1,326 | 10 | 0.8 | |
1791 | 1,395 | 8 | 0.6 | |
1792 | 1,579 | 14 | 0.9 | |
1793 | 1,684 | 44 | 2.6 | |
1794 | 1,768 | 7 | 0.4 | |
1795 | 1,798 | 38 | 2.1 | |
1796 | 1,904 | 22 | 1.2 | |
1797 | 2,012 | 5 | 0.2 | |
1798 | 2,046 | 5 | 0.2 | |
1799 | 2,067 | 20 | 1.0 | |
1800 | 2,070 | 41 | 2.0 | |
1801 | 2,106 | 17 | 0.8 | |
1802 | 2,346 | 9 | 0.4 | |
1803 | 2,215 | 16 | 0.7 | |
1804 | 2,022 | 8 | 0.4 | |
1805 | 2,112 | 9 | 0.4 | |
1806 | 1,875 | 13 | 0.7 | |
1807 | 925 | 6 | 0.6 | |
1808 | 855 | 7 | 0.8 | |
1809 | 912 | 13 | 1.4 | |
1810 | 744 | 6 | 0.8 | |
1811 | 1,050 | 20 | 1.9 | |
1812 | 1,419 | 9 | 0.6 | |
1813 | 1,945 | 21 | 1.1 | |
1814 | 2,062 | 66 | 3.2 | |
1815 | 2,591 | 19 | 0.7 | |
1816 | 2,410 | 12 | 0.5 | |
1817 | 2,735 | 25 | 0.9 | |
1818 | 2,568 | 56 | 2.2 | |
1819 | 3,089 | 154 | 5.0 | |
1820 | 2,998 | 75 | 2.5 | |
1821 | 3,294 | 55 | 1.7 | |
1822 | 3,066 | 26 | 0.8 | |
1823 | 2,872 | 214 | 7.5 | Pathological anatomy begins |
1824 | 2,911 | 144 | 4.9 | |
1825 | 2,594 | 229 | 8.8 | |
1826 | 2,359 | 192 | 8.1 | |
1827 | 2,367 | 51 | 2.2 | |
1828 | 2,833 | 101 | 3.6 | |
1829 | 3,012 | 140 | 4.6 | |
1830 | 2,797 | 111 | 4.0 | |
1831 | 3,353 | 222 | 6.6 | |
1832 | 3,331 | 105 | 3.2 | |
1833 | 3,737 | 197 | 5.3 | |
1834 | 2,657 | 205 | 7.7 | |
1835 | 2,573 | 143 | 5.6 | |
1836 | 2,677 | 200 | 7.5 | |
1837 | 2,765 | 251 | 9.1 | |
1838 | 2,987 | 91 | 3.0 | |
1839 | 2,781 | 151 | 5.4 | |
1840 | 2,889 | 267 | 9.2 | |
1841 | 3,036 | 237 | 7.8 | Separation of clinics |
1842 | 3,287 | 518 | 15.8 | hereafter numbers refer to first clinic only |
1843 | 3,060 | 274 | 9.0 | |
1844 | 3,157 | 260 | 8.2 | |
1845 | 3,492 | 241 | 6.9 | |
1846 | 4,010 | 459 | 11.4 | |
1847 | 3,490 | 176 | 5.0 | Chlorine washings begin mid-May |
1848 | 3,556 | 45 | 1.3 | |
1849 | 3,858 | 103 | 2.7 | Semmelweis dismissed from hospital in March |
The mortality rate for newborn infants was also higher in the first clinic.
First clinic | Second clinic | ||||||
Year | Births | Deaths | Rate (%) | Births | Deaths | Rate (%) | |
1841 | 2,813 | 177 | 6.3 | 2,252 | 91 | 4.0 | |
1842 | 3,037 | 279 | 9.2 | 2,414 | 113 | 4.7 | |
1843 | 2,828 | 195 | 6.9 | 2,570 | 130 | 5.1 | |
1844 | 2,917 | 251 | 8.6 | 2,739 | 100 | 3.7 | |
1845 | 3,201 | 260 | 8.1 | 3,017 | 97 | 3.2 | |
1846 | 3,533 | 235 | 6.7 | 3,398 | 86 | 2.5 |
Semmelweis compared mortalilty rates in Vienna with maternity institutions in the United Kingdom where mortality rates were lower. He wished to show that childbed fever was related to pathological anatomy. His choice, Dublin Maternity Hospital, was like the Viennese hospital, a large teaching institution for physicians.
He argued that as a rule German and French maternity hospitals are associated with large general hospitals. Therefore their students occupy themselves in morgues, and in medical and surgical wards, as well as in maternity wards. In this way they become carriers of the decaying matter responsible for childbed fever.
Contrary hereto, maternity hospitals in the United Kingdom were independent institutions; removed from general hospitals. The students are forced to concern themselves exclusively with obstetrics, they do not carry out pathological autopsies.[13]
Year | Births | Deaths | Rate (%) |
1784 | 1261 | 11 | 0.9 |
1785 | 1292 | 8 | 0.6 |
1786 | 1351 | 8 | 0.6 |
1787 | 1347 | 10 | 0.7 |
1788 | 1469 | 23 | 1.6 |
1789 | 1435 | 25 | 1.7 |
1790 | 1546 | 12 | 0.8 |
1791 | 1602 | 25 | 1.6 |
1792 | 1631 | 10 | 0.6 |
1793 | 1747 | 19 | 1.1 |
1794 | 1543 | 20 | 1.3 |
1795 | 1503 | 7 | 0.5 |
1796 | 1621 | 10 | 0.6 |
1797 | 1712 | 13 | 0.8 |
1798 | 1604 | 8 | 0.5 |
1799 | 1537 | 10 | 0.7 |
1800 | 1837 | 18 | 1 |
1801 | 1725 | 30 | 1.7 |
1802 | 1985 | 26 | 1.3 |
1803 | 2028 | 44 | 2.2 |
1804 | 1915 | 16 | 0.8 |
1805 | 2220 | 12 | 0.5 |
1806 | 2406 | 23 | 1 |
1807 | 2511 | 12 | 0.5 |
1808 | 2665 | 13 | 0.5 |
1809 | 2889 | 21 | 0.7 |
1810 | 2854 | 29 | 1 |
1811 | 2561 | 24 | 0.9 |
1812 | 2676 | 43 | 1.6 |
1813 | 2484 | 62 | 2.5 |
1814 | 2508 | 25 | 1 |
1815 | 3075 | 17 | 0.6 |
1816 | 3314 | 18 | 0.5 |
1817 | 3473 | 32 | 0.9 |
1818 | 3539 | 56 | 1.6 |
1819 | 3197 | 94 | 2.9 |
1820 | 2458 | 70 | 2.8 |
1821 | 2849 | 22 | 0.8 |
1822 | 2675 | 12 | 0.4 |
1823 | 2584 | 59 | 2.3 |
1824 | 2446 | 20 | 0.8 |
1825 | 2740 | 26 | 0.9 |
1826 | 2440 | 81 | 3.3 |
1827 | 2550 | 33 | 1.3 |
1828 | 2856 | 43 | 1.5 |
1829 | 2141 | 34 | 1.6 |
1830 | 2288 | 12 | 0.5 |
1831 | 2176 | 12 | 0.6 |
1832 | 2242 | 12 | 0.5 |
1833 | 2138 | 12 | 0.6 |
1834 | 2024 | 34 | 1.7 |
1835 | 1902 | 34 | 1.8 |
1836 | 1810 | 36 | 2 |
1837 | 1833 | 24 | 1.3 |
1838 | 2126 | 45 | 2.1 |
1839 | 1951 | 25 | 1.3 |
1840 | 1521 | 26 | 1.7 |
1841 | 2003 | 23 | 1.1 |
1842 | 2171 | 21 | 1 |
1843 | 2210 | 22 | 1 |
1844 | 2288 | 14 | 0.6 |
1845 | 1411 | 35 | 2.5 |
1846 | 2025 | 17 | 0.8 |
1847 | 1703 | 47 | 2.8 |
1848 | 1816 | 35 | 1.9 |
1849 | 2063 | 38 | 1.8 |
The second obstetrical clinic at Vienna General Hospital that instructed midwife student evidently had a lower mortality rate than the first obstetrical clinic, where physicians were instructed.
While the midwife students in Vienna were not partaking in autopsies, there were still opportunities for them to contaminate their hands. In a lecture in 1846 Jakob Kolletschka is reputed to have said, "It is here no uncommon thing for midwives, especially in the commencement of their practice, to pull off legs and arms of infants, and even to pull away the entire body and leave the head in the uterus. Such occurrences are not altogether uncommon; they often happen.".[15]
The Maternité in Paris was an exception. It was exclusively for the education of midwives, but it had a mortality rate as great as Paul-Antoine Dubois's Paris Clinic for the education of physicians. In the Maternité, midwives participated in autopsies as frequently physicians would elsewhere.
The hospital midwives and some of their students accompanied the physician on his daily rounds through the infirmary for maternity patients. Each student was assigned a diseased patient for particular observation and was expected to prepare a short case history of the birth and of the physician's treatment. Autopsies were conducted in a building in the garden somewhat removed from the maternity hospital; these were usually attended by student midwives. I was often astonished to see the active part some of the young women took in the dissection of corpses. With bare and bloody arms, holding large knives in their hands, laughing and quarreling, they cut the pelvis apart, having received permission from the physician to prepare the corpse for him.[16]
Ignaz Semmelweis' Open Letter to all professors of obstetrics (1862) presents statistics from other European maternity institutions. The 1862 open letter is available at Austrian literature online, Österreichische Nationalbibliothek [1] (in German, Gothic print)
Semmelweis, Ignaz; K. Codell Carter (translator and extensive foreword) (1861). Etiology, Concept and Prophylaxis of Childbed Fever. University of Wisconsin Press, September 15, 1983. ISBN 0299093646.