Did Doctors in the 1800's really not wash their hands?

Spoiler: They washed their hands.

Earlier this year Google made a doodle for their main search page about Dr. Ignaz Semmelweis who practiced medicine in Vienna, and later in his native Hungary in Pest. Dr. Semmelweis is famous for advocating for hand washing before we even knew about the existence of germs. At his hospital in Vienna he was able to greatly reduce maternal mortality rates by simply having the doctors and medical students wash their hands. Supposedly there were doctors across Europe who resisted this idea and fought against the suggestion that they were killing their patients. Only later when doctors discovered the existence of germs and understood how they caused disease was Semmelweis vindicated. Countless lives could have been saved if people had just listened to Semmelweis, but doctors were obstinate and stubborn and refused to listen.

This version of the story is the one that gets repeated in numerous news stories from NPR to the Washington Post, along with other places. It makes for a dramatic story, which is why it gets repeated, but there is a problem with it. It isn't true.

To understand what happened we have to consider the context, and also look at what Semmelweis himself wrote about his own ideas and also what we wrote about his supporters and critics.

In 1847 Semmelweis started an experiment in national hospital in Vienna. In the maternity ward the mortality rate was terrible, to the point that it was reported that women would rather give birth in the street than go to the hospital. During some months one out of every seven women who entered the maternity ward died there. But for women who used midwives and not doctors, even in the hospital, the mortality rate was closer to one out of every hundred women. To Semmelweis this indicated that the problem was the doctors and the medical students.

Because the hospital was also a research institution, an autopsy was performed on every woman who died there. Usually the same doctors and students who performed the autopsies were the same doctors who later attended the births. You can probably see where this is going.

A woman dies after childbirth because of an infection. The doctor performs an autopsy on her, and later attends another birth and the woman also dies from an infection. Semmelweis noticed this and implemented strict handwashing procedures.

But here is where actual history diverges from the story that usually gets told. When people tell the story of Semmelweis they portray it like washing their hands was a new, unusual, and radical practice. But in reality the radical change Semmelweis started was to change what the doctors washed their hands with. The doctors routinely used soap and water to wash their hands. They weren't barbarians. If they did an autopsy they would always wash their hands with soap and water before doing anything else. They were doctors, and knew how to keep things clean, just not sanitized by our standards.

Semmelweis had the doctors wash their hands with a solution of chlorine (bleach) after an autopsy. In the months that followed the mortality rate dropped dramatically. After two years of collecting data the difference was so clear that Semmelweis's students began travelling across Europe to explain the new theory of how to prevent what they called "childbed fever". As reported in letters from his students the reception of his ideas was positive and enthusiastic. Much of this we know because Semmelweis later published a book entitled The Etiology, Concept, and Prophylaxis of Childbed Fever where he laid out his theories and data. At the end of his book he included a chapter on reactions to his theories with excerpts from personal letters and also formal published responses to his ideas. He took extra care to respond to all those he thought had unfairly criticized his work.

It is from his own book that we get the story that he was persecuted and rejected by doctors across Europe. He made sure to bitterly complain of his critics inability to understand what to him was very plain. But it turns out that while his data was compelling, it didn't actually support his conclusions.

Semmelweis thought that dead or decaying matter would get on the doctor's hands, which would then release its miasma (smell) causing the women to get sick and die. Other doctors responded that after washing their hands, because every doctor actually did wash their hands, there wouldn't be enough dead material left on their hands to cause the sickness.

Essentially Semmelweis was saying that the raw matter of a dead body was one of the most potent poisons known to man. But this poison could only kill women, and kill them when they were giving birth. Furthermore he insisted, without evidence, that this was the only cause of "childbed fever", and there could be no other cause. This last point was the source of most criticism.

Dr. Carl Levy from Denmark pointed out doctors at his hospital did not perform autopsies. They outsourced autopsies to other doctors who did not work directly with patients. Also in Dr. Levy's reply to Semmelweis's own response to Dr. Levy, he casually mentioned that the doctors in Denmark would regularly wash with soap and water, and in some cases would wash with a chloride solution, just as Semmelweis demanded that doctors do. This exchange is recorded in Semmelweis's book, and shows that doctors in Europe actually did wash their hands.

Also recorded in Semmelweis's book was a letter from Sir James Simpson (the "father of anesthesiology"). Semmelweis attributed most of the criticisms from Simpson to issues of translation (he assumed that when his letter was translated from German into English something must have been lost since Simpson was not ecstatic about his ideas). But based on what Simpson wrote it is clear that he actually had no issue with Semmelweis one way or the other.

Simpson was surprised to learn that in Vienna they treated up to 32 women in the same room, and noted that in the UK they only had one patient per room. Also Simpson was not particularly impressed with reports that in Vienna they failed to change the sheets between patients. Additionally Simpson was not moved by Semmelweis's insistence that the English adopt his theories since, as Simpson noted, in England they had already been using chlorine solution washes before attending patients for many years. 

In fact one medical textbook published in 1854, quoted by Semmelweis in his book, noted that in English hospitals they had already adopted the practice of chlorine washes. When Simpson responded to Semmelweis he was a bit dismissive because he didn't think much of the hygienic practices of the doctors in Vienna who had apparently just barely discovered hand washing.

So what about the hospital in Vienna? Some versions of the story mention that the hospital administrator opposed hand washing. But this is contradicted by what Semmelweis wrote in his own book. It is true that his superior in the hospital didn't agree with Semmelweis, but his disagreement was over Semmelweis's theory, not the actual hand washing. After Semmelweis left Vienna the doctor who replaced him continued the practice of handwashing and kept the mortality rate low.

Semmelweis's reason for departure from Vienna is frequently cited as proof that he was persecuted for his ideas. Semmelweis was not promoted to the equivalent of full professor, and was also given a lower position along the lines of adjunct faculty. Frustrated Semmelweis left Vienna and returned to Hungary where he ultimately ended up working in the hospital in Pest.

To understand this we need to look at the larger events at the time. Vienna was the capitol of Austria, which was at the time part of the Austro-Hungarian Empire. Austria-Hungary was an unstable collection of nations that would very quickly collapse in the aftermath of WW I. As a Hungarian Semmelweis was viewed with suspicion in Austria, especially since his siblings and other family members supported the Hungarian revolution in 1848 and 1849. It was precisely at the end of the revolution, with at least one of Semmelweis's brothers being executed for treason, that Semmelweis was passed over for promotion. Even though many of his colleagues recommended him, the hospital administration decided to hire an Austrian because of political considerations. He also had a contentious relationship with some of the doctors in the hospital, including his direct superior. So being passed over for promotion was more about politics and personal relationships than disrespect for his research.

But in his book Semmelweis maintains that it was because his superiors disapproved of his theories and wanted someone who would not promote them. But, as already noted, his replacement continued using a chloride solution for washing hands, and also wrote a textbook that included a section on Semmelweis's theory. 

So just based on the information included in Semmelweis's book, we learn that doctors commonly washed their hands with soap and water. The medical practices were not uniform across Europe, even down to how many patients were kept in a room and how often they changed the sheets. But in some countries, such as England, it was apparently routine for doctors performing surgery, or delivering a baby, to wash their hands with a chlorine solution. It was not the case that doctors all over the continent were repositories of unmitigated filthiness.

They did inadvertently spread disease because they did not know about germs, but there was nothing in Semmelweis's theory to imply the spread of germs. From the way he understood it he found a cure for a single, though deadly, disease. He never extended his ideas to other diseases such as dysentery, because he focused on a single problem. In his writing there is no indication that hand washing with a chloride solution could be a way of avoiding any other diseases. It was only later with the development of germ theory that doctors could recognize using a chloride solution (bleach) as a general way of controlling germs.

In retrospect Semmelweis is remembered for being correct about washing hands, but he was not correct about the core of his theory which assumed that miasma (vapor or gasses) emanating from decaying matter from a corpse was the primary source of the disease he was studying. A few of the articles written about him mention only in passing those things that made up the bulk of his theories. It was those things, that disease was caused by particles of decaying organic matter, that his contemporaries rejected. They were not opposed to hand washing, they did it anyway, they just didn't think that it was necessary to wash their hands to remove the minute traces of decaying organic matter.

Later because hand washing became such an important thing, that part of his writings were remembered and emphasized, and nothing else. He was only known for telling people to wash their hands, and not for ideas like self-infection through dead organic matter. Thus it was assumed that opposition to him was because of hand washing. And the only conceivable way someone could be opposed to hand washing was if they did not wash their hands. This is the unfortunate source of the idea that doctors in the 1800's did not wash their hands. But just using the writings of the man who is always cited for proof that doctors did not wash their hands, we can see that doctors did in fact wash their hands.