Ignaz Semmelweis: Figuring out the Cause of Puerperal Fever Edward Andrews, Biostatistics601, class of 2007

Setting: The Vienna General Hospital

Ignaz Semmelweis

What was the problem?  Puerperal Fever, (a.k.a. “childbed fever”)  From Wikipedia, “Puerperal fever (from the latin puer meaning boy), also called childbed fever, can develop into puerperal sepsis (a serious form of septicaemia contracted by a woman during or shortly after childbirth or abortion). “

The general theory of disease at the time  Disease is caused by miasms, or bad/poisonous air.  So how do you prevent/treat disease caused by bad air?

The setting  The Vienna General Hospital contained two “maternity divisions” which were relatively far from each other  In one, women were attended to by doctors, and in the other by midwives (post 1840)  In many instances the midwives were there to fulfill contractual obligations for free medical care. They also functioned as wet nurses and maintenance persons.

Setting, continued  Women were systematically assigned to a division based on the time of day they arrived, and the day of the week  However many women would roam the streets during labor, and then deliver on the street and show up at the hospital in order to guarantee admittance into the second division because it was policy to admit women to the 1 st division if they required special medical care.

Work of Lyle D Broemeling

Why the difference?  It was believed to be miasms (bad air)  Semmelweis said no, it can’t be because then the rates of death would be the same in both divisions  Overcrowding? No, Semmelweis routinely shut down admittance to the 2 nd division because it was too crowded; he never had to shut the 1 st division and force patients into the 2 nd division.

Other factors?  What about all of the medical reasons? (protracted labor, decreased weight, too much blood in the circulation)  Semmelweis also says no to these theories because the women in the 2 nd section were equally vulnerable to all of these factors and more.

Semmelweis after his appointment begins to investigate the cause  He uses epidemiological reasoning to determine the cause, and concentrates on creating equal groups for comparison.

How did he make the divisions equal?  All patients needed to eat the same food  All patients needed to have sheets from the same launderer  All deliveries had to be done in the lateral position because in the 2 nd section all were done in that position.  He Asked the priest to come quietly (he usually rang a bell) and without being seen (one section allowed direct access, one did not) in order to not affect the mental states of the patients when delivering Last Rites, which he did VERY often.

Why did he do this?  “I did this for no other reason than that the latter were customary in the second section. I did not believe that additional deaths could be attributed to its use. But in the second section deliveries were performed from a lateral position and the patients were healthier. Consequently we also delivered from the lateral position, so that everything would be exactly as in the second section.”

What were the results?  Semmelweis observed no differences between the groups after his attempts to make them equal for comparison. So he concluded that there must be another cause of puerperal fever.

The death of a colleague  Semmelweis’ friend and colleague, Jakob Kolletschka dies while experiencing “bilateral pleurisy, pericarditis, peritonitis, and meningitis” and later “a metastasis formed in one eye. During an autopsy, a student has pricked Kolletschka’s finger with a knife being used in the autopsy”

Semmelweis sees the connection between two deaths  It is obvious to him that Kolletschka died and had the same symptoms of puerperal fever.  It is also obvious to him that Kolletschka died as a result of his wound.  He now tries to see if the corpse matter could have been the infecting agent.

Semmelweis sees the connection between two deaths  He determines that yes, in fact the women are exposed to the morbid matter in the hospital through autopsies conducted by the doctors.  More women are exposed in the 1 st division than the 2 nd, hence the higher death rates.

The intervention  Semmelweis believes that merely washing the hands of the morbid matter will stop he disease.  Since the hands still smell of the corpse after a normal washing, he believes that they must be thoroughly cleaned with “chlorina liquida” but later switches to chlorinated lime due to cost issues.

The results

The Results of Intervention

Aftermath  Although Semmelweis had significant evidence to show his theory of the cause of puerperal fever, he faced wide criticism, due to the state of medicine at the time.  His theory suffered because persons claimed his intervention was ineffective, although they were washing improperly, or did not wash their hands.

Aftermath  Experiments “in which the genitals of newly delivered rabbits were brushed with blood and other fluids from human corpses” and in which “most of the rabbits died, and dissection revealed remains similar to those found in victims of childbed fever” failed to stop the “political” criticism he suffered from.  He nearly eliminated death due to childbed fever in two more hospitals.

Aftermath  He delayed the publishing of his results nearly 14 years  Most of the results published were by his students, whom did not understand his methods and thoroughness  Some persons accepted his theory, and it was widely used in practice in Germany

Aftermath  He was committed to a mental institution by colleagues whom failed to examine him before hand.  While there, he was severely beaten, and eventually died due to pyemia, or blood poisoning, which in maternity patients would be childbed fever.

Aftermath  Studies still show that “Cross- transmission of microorganisms by the hands of health care workers is considered the main route of spread of nosocomial infections.”  Nosocomial means due to being treated in the hospital, but not due to the original reason of admittance.  This was stated in 1999

What can you do?

According to the CDC  Wet hands with running water; place soap in palms; rub together to make a lather; scrub hands vigorously for 20 seconds; rinse soap off hands.  If possible, turn off the faucet by using a disposable paper towel.  Dry hands with a disposable paper towel. Do not dry hands on clothing.  Assist young children with washing their hands.