The Cadaver Ward

How Handwashing Ended Childbed Fever in Vienna

Between 1841 and 1846 at the Vienna General Hospital (Allgemeines Krankenhaus), a pregnant woman admitted to the First Obstetrical Clinic on a Tuesday, Thursday, or Saturday faced a nearly fivefold higher risk of dying from childbed fever than a woman admitted twenty paces across the courtyard to the Second Obstetrical Clinic on a Monday, Wednesday, or Friday. Both clinics occupied the same wing, shared the same ventilation and kitchen, and admitted poor women free of charge as teaching subjects. Admissions rotated by the clock: the First Clinic received all mothers arriving during the twenty-four hours beginning Monday, Wednesday, and Friday at 4:00 PM, plus Sunday; the Second Clinic received everyone arriving on the alternate days.

In 1840, Professor Johann Klein had separated the two clinics by profession. The First Clinic trained exclusively male medical students and physicians; the Second Clinic trained exclusively female midwives. Over the next six years, out of 20,042 women delivered by physicians in the First Clinic, 1,989 died of puerperal fever—a mortality rate of 9.92 percent that regularly exceeded 15 percent in winter. Over the same six years in the Second Clinic, out of 17,791 women delivered by midwives, 691 died—a mortality rate of 3.38 percent.

Because charity patients could not choose their clinic once inside the hospital gates, women in labor waited in doorways around Vienna on alternate nights until the clock struck 4:00 PM on Tuesday or Saturday so they would be routed to the midwives. Stranger still, women who gave birth in carriages or on the cobblestones on their way to the hospital—recorded as "street births"—remained eligible for charity beds in the First Clinic, yet almost never contracted childbed fever.

The Viennese hierarchy, led by Klein and anatomist Carl von Rokitansky, blamed "cosmic-telluric-atmospheric influences," overcrowding, or maternal fear. In July 1846, Hungarian assistant physician Ignaz Philipp Semmelweis systematically falsified every official excuse. Overcrowding could not be the cause, because the safer Second Clinic was always more crowded. Miasmas could not stop at an interior wall to kill women in one ward while sparing those across the courtyard. When colleagues blamed psychological terror caused by the hospital priest walking through the First Clinic ringing a brass bell for last rites, Semmelweis persuaded the priest to take a silent route; mortality did not budge. Delivering women on their sides to match the midwives' posture also changed nothing.

In March 1847, returning from a brief leave in Venice, Semmelweis learned that his friend Jakob Kolletschka, Professor of Forensic Medicine, had died days earlier after a student's scalpel pricked Kolletschka's finger during an autopsy. Reading Kolletschka's post-mortem ledger, Semmelweis saw bilateral pleuritis, pericarditis, peritonitis, meningitis, and purulent abscesses—the exact pathology Semmelweis had seen in hundreds of mothers who died of childbed fever.

The causal chain snapped into focus. Under Klein's 1840 curriculum, male medical students performed morning dissections on cadavers in the morgue immediately before walking upstairs to conduct vaginal examinations on women in labor. Ordinary soap washed off blood, but left a putrid odor on the doctors' fingers—what Semmelweis termed "cadaveric particles." Midwives performed zero autopsies, and street-birth mothers arrived with closed cervixes, sparing them student examinations.

In mid-May 1847, after First Clinic mortality hit 18.27 percent in April (57 deaths among 312 births), Semmelweis mounted basins of chlorinated lime (calcium hypochlorite solution) at the ward entrance. Every physician and student entering from the morgue had to scrub their hands and fingernails until all cadaveric odor vanished.

In June 1847, First Clinic mortality fell to 2.38 percent; in July, to 1.20 percent. Across 1848, out of 3,556 women delivered in the First Clinic, 45 died (1.27 percent), matching the 1.33 percent rate of the Second Clinic, with zero deaths in March and August 1848.

Offended by the indictment of his curriculum, Klein refused to renew Semmelweis's post in March 1849. Forced back to Pest, Semmelweis published his 1861 treatise Die Ätiologie, only to have Rudolf Virchow and Carl Braun reject his contact protocol. Driven to fury by the ongoing deaths, Semmelweis published open letters calling European obstetricians "medical Neros." On July 31, 1865, lured to Vienna by Ferdinand von Hebra, Semmelweis was committed to the Döbling mental asylum, where six guards beat him when he tried to leave. A surgical cut on his right hand turned gangrenous during the beating, and on August 13, 1865, Semmelweis died of generalized pyemia—the exact bloodstream sepsis he had eradicated from the First Clinic.