Ignaz Semmelweis Ignaz Semmelweis and the and the Determination of the Determination of the Cause of Puerperal Cause of Puerperal FeverFever

Setting: The Vienna Setting: The Vienna General HospitalGeneral Hospital

Ignaz SemmelweisIgnaz Semmelweis

What was the problem?What was the problem?

Puerperal Fever, also known as childbed Puerperal Fever, also known as childbed fever. fever.

From wikipedia, “From wikipedia, “Puerperal feverPuerperal fever (from (from the latin the latin puerpuer meaning meaning boyboy), also called ), also called childbed feverchildbed fever, can develop into , can develop into puerperal sepsispuerperal sepsis, which is a serious , which is a serious form of septicaemia contracted by a form of septicaemia contracted by a woman during or shortly after childbirth or woman during or shortly after childbirth or abortion. “abortion. “

More on Puerperal FeverMore on Puerperal Fever

Sepsis is the medical term for the Sepsis is the medical term for the inflammation of the whole body, as a inflammation of the whole body, as a result of infectionresult of infection

According to Semmelweis, symptoms According to Semmelweis, symptoms included lymphangitis, phlebitis, pleuritis, included lymphangitis, phlebitis, pleuritis, pericarditis, peritonitis, meningitis and pericarditis, peritonitis, meningitis and metastis. metastis.

And those symptoms And those symptoms mean what? mean what?

Acute lymphangitis is a bacterial infection in Acute lymphangitis is a bacterial infection in the lymphatic vessels which is characterized by the lymphatic vessels which is characterized by painful, red streaks below the skin surface. painful, red streaks below the skin surface. This is a potentially serious infection which can This is a potentially serious infection which can rapidly spread to the bloodstream and be fatal. rapidly spread to the bloodstream and be fatal.

Phelbitis is the inflammation or swelling of a Phelbitis is the inflammation or swelling of a vein and can cause blood clots which can vein and can cause blood clots which can reach the lungs, and end in pulmonary reach the lungs, and end in pulmonary embolism (blood clot in the lung).embolism (blood clot in the lung).

And those symptoms And those symptoms mean what?mean what?

Pleuritis is an inflammation of the lining of the Pleuritis is an inflammation of the lining of the lungs. lungs.

Pericarditis is the inflammation of the lining sac Pericarditis is the inflammation of the lining sac of the heart.of the heart.

Peritonitis is inflammation of the layer of cells Peritonitis is inflammation of the layer of cells lining the inner wall of the abdomen and pelvis. lining the inner wall of the abdomen and pelvis.

Meningitis is inflammation of the membranes Meningitis is inflammation of the membranes that cover the brain and spinal cord. that cover the brain and spinal cord.

And those symptoms And those symptoms mean what?mean what?

Metastis is the spread of disease from Metastis is the spread of disease from one body part to another. one body part to another.

So we see, this was a really horrible So we see, this was a really horrible horrible disease, and resulted in death. horrible disease, and resulted in death.

All definitions stolen from medterms.comAll definitions stolen from medterms.com

What were the believed What were the believed causes?causes?

In 1825 a British physician identified the In 1825 a British physician identified the causes of sporadic phtisis, including:causes of sporadic phtisis, including:

Exposing the body to cold air after exercise, Exposing the body to cold air after exercise, exposure to cold due to too quick change of exposure to cold due to too quick change of apparel, continuing to suckle too long under a apparel, continuing to suckle too long under a deliberated state, and playing much on wind deliberated state, and playing much on wind instrumentsinstruments

Some of the causes were relatively correct, Some of the causes were relatively correct, such as lying in damp beds, and environmental such as lying in damp beds, and environmental exposuresexposures

The general theory of The general theory of disease at the timedisease at the time

Disease is caused by miasms, or Disease is caused by miasms, or bad/poisonous air. bad/poisonous air.

So how do you treat disease caused by So how do you treat disease caused by bad air? bad air?

TreatmentTreatment

An American’s treatment for An American’s treatment for the disease in the 1850’sthe disease in the 1850’s

““prompt abstraction of the blood is called for; prompt abstraction of the blood is called for; take from the arm from twelve to thirty ounces of take from the arm from twelve to thirty ounces of blood[1-3 pints] depending, of course, on the blood[1-3 pints] depending, of course, on the urgency of the case”urgency of the case”

““bleed from a large orifice, let there be a bold bleed from a large orifice, let there be a bold and full stream; in one word, make your patient and full stream; in one word, make your patient faint; syncope [fainting] will be more readily faint; syncope [fainting] will be more readily accomplished by placing the patient in the sitting accomplished by placing the patient in the sitting position during the abstraction of blood… The position during the abstraction of blood… The next indication will be a free action of the next indication will be a free action of the bowels”bowels”

The Viennese treatment The Viennese treatment in the 1820’sin the 1820’s

““repeated venesection [opening of the repeated venesection [opening of the veins], the application of leeches, veins], the application of leeches, emollient cataplasms [medicated emollient cataplasms [medicated substances spread over the skin], substances spread over the skin], emollient clysters [enemas]... Emetics [to emollient clysters [enemas]... Emetics [to induce vomiting]”induce vomiting]”

An Explanation of the An Explanation of the settingsetting

The Viennese General Hospital contained two The Viennese General Hospital contained two “maternity wards” which were relatively far from “maternity wards” which were relatively far from each othereach other

In one women were attended to by doctors, In one women were attended to by doctors, and in the other by midwives (post 1840)and in the other by midwives (post 1840)

In many instances the midwives were there to In many instances the midwives were there to fulfill contractual obligations for free medical fulfill contractual obligations for free medical care. They also functioned as wet nurses and care. They also functioned as wet nurses and maintenance persons. maintenance persons.

An Explanation of the An Explanation of the settingsetting

Women were systematically assigned to a Women were systematically assigned to a section based on the time of day they arrived, section based on the time of day they arrived, and the day of the weekand the day of the week

However many women would roam the streets However many women would roam the streets during labor, and then deliver on the street and during labor, and then deliver on the street and show up at the hospital in order to guarantee show up at the hospital in order to guarantee admittance into the second ward because it admittance into the second ward because it was policy to admit women to the 1was policy to admit women to the 1stst section if section if they required special medical care. they required special medical care.

Work of Lyle D Work of Lyle D BroemelingBroemeling

So What Caused So What Caused Puerperal Fever?Puerperal Fever?

As stated before it was believed to be miasms As stated before it was believed to be miasms (bad air) (bad air)

Semmelweis says no, it can’t be because then Semmelweis says no, it can’t be because then the rates of death would be the same in both the rates of death would be the same in both sectionssections

Overcrowding? No, Semmelweis routinely shut Overcrowding? No, Semmelweis routinely shut down admittance to the 2down admittance to the 2ndnd section because it section because it was too crowded, he never had to do so with the was too crowded, he never had to do so with the 11stst section and force patients into the 2 section and force patients into the 2ndnd section. section.

So What Caused So What Caused Puerperal Fever?Puerperal Fever?

What about all of the medical reasons? What about all of the medical reasons? (protracted labor, decreased weight, too (protracted labor, decreased weight, too much blood in the circulation)much blood in the circulation)

Semmelweis also says no to these Semmelweis also says no to these theories because the women in the 2theories because the women in the 2ndnd section were equally vulnerable to all of section were equally vulnerable to all of these factors and more. these factors and more.

Semmelweis after his Semmelweis after his appointment begins to appointment begins to investigate the causeinvestigate the cause

He uses epidemiological reasoning to He uses epidemiological reasoning to determine the cause, and concentrates determine the cause, and concentrates on creating equal groups for comparison.on creating equal groups for comparison.

How did he make the How did he make the groups equal?groups equal?

All patients needed to eat the same foodAll patients needed to eat the same food All patients needed to have sheets from the same All patients needed to have sheets from the same

laundererlaunderer All deliveries had to be done in the lateral position All deliveries had to be done in the lateral position

because in the 2because in the 2ndnd section all were done in that section all were done in that position. position.

Asked the priest to come quietly (he usually rang a Asked the priest to come quietly (he usually rang a bell) and without being seen (one section allowed direct bell) and without being seen (one section allowed direct access, one did not) in order to not affect the mental access, one did not) in order to not affect the mental states of the patients when delivering Last Rites, which states of the patients when delivering Last Rites, which he did VERY often. he did VERY often.

Why did he do this? Why did he do this?

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

What were the results?What were the results?

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

Semmelweis sees the Semmelweis sees the connection between two connection between two deathsdeaths

While on vacation Semmelweis’ friend While on vacation Semmelweis’ friend and colleague, Jakob Kolletschka dies and colleague, Jakob Kolletschka dies while experiencing “bilateral pleurisy, while experiencing “bilateral pleurisy, pericarditis, peritonitis, and meningitis” pericarditis, peritonitis, and meningitis” and later “a metastasis formed in one and later “a metastasis formed in one eye.”eye.”

Semmelweis sees the Semmelweis sees the connection between two connection between two deathsdeaths

It is obvious to him that Kolletschka died It is obvious to him that Kolletschka died and had the same symptoms of and had the same symptoms of puerperal fever.puerperal fever.

It is also obvious to him that Kolletschka It is also obvious to him that Kolletschka died as a result of his wound. died as a result of his wound.

He now tries to see if the corpse matter He now tries to see if the corpse matter could have been the infecting agent.could have been the infecting agent.

Semmelweis sees the Semmelweis sees the connection between two connection between two deathsdeaths

He determines that yes, in fact the He determines that yes, in fact the women are exposed to the morbid matter women are exposed to the morbid matter in the hospital through autopsies in the hospital through autopsies conducted by the doctors.conducted by the doctors.

More women are exposed in the 1More women are exposed in the 1stst section than the 2section than the 2ndnd, hence the higher , hence the higher death rates.death rates.

The interventionThe intervention

Semmelweis believes that merely Semmelweis believes that merely washing the hands of the morbid matter washing the hands of the morbid matter will stop he disease. will stop he disease.

Since the hands still smell of the corpse Since the hands still smell of the corpse after a normal washing, he believes that after a normal washing, he believes that they must be thoroughly cleaned with they must be thoroughly cleaned with “chlorina liquida” but later switches to “chlorina liquida” but later switches to chlorinated lime due to cost issues. chlorinated lime due to cost issues.

The resultsThe results

The Results of The Results of InterventionIntervention

AftermathAftermath

Although Semmelweis had significant Although Semmelweis had significant evidence to show his theory of the cause evidence to show his theory of the cause of puerperal fever, he faced wide of puerperal fever, he faced wide criticism, due to the state of medicine at criticism, due to the state of medicine at the time. the time.

His theory suffered because persons His theory suffered because persons claimed his intervention was ineffective, claimed his intervention was ineffective, although they were washing improperly, although they were washing improperly, or did not wash their hands. or did not wash their hands.

AftermathAftermath

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

He nearly eliminated death due to childbed He nearly eliminated death due to childbed fever in two more hospitals. fever in two more hospitals.

AftermathAftermath

He delayed the publishing of his results He delayed the publishing of his results nearly 14 yearsnearly 14 years

Most of the results published were by his Most of the results published were by his students, whom did not understand his students, whom did not understand his methods and thoroughnessmethods and thoroughness

Some persons accepted his theory, and it Some persons accepted his theory, and it was widely used in practice in Germanywas widely used in practice in Germany

AftermathAftermath

He was committed to a mental institution He was committed to a mental institution by colleagues whom failed to examine by colleagues whom failed to examine him before hand. him before hand.

While there, he was severely beaten, and While there, he was severely beaten, and eventually died due to pyemia, or blood eventually died due to pyemia, or blood poisoning, which in maternity patients poisoning, which in maternity patients would be childbed fever.would be childbed fever.

AftermathAftermath

Studies still show that “Cross-transmission Studies still show that “Cross-transmission of microorganisms by the hands of health of microorganisms by the hands of health care workers is considered the main route care workers is considered the main route of spread of nosocomial infections.” of spread of nosocomial infections.”

Nosocomial means due to being treated in Nosocomial means due to being treated in the hospital, but not due to the original the hospital, but not due to the original reason of admittance. reason of admittance.

This was stated in 1999This was stated in 1999

What can you do? What can you do?

According to the CDCAccording to the CDC

Wet hands with running water; place soap in Wet hands with running water; place soap in palms; rub together to make a lather; scrub palms; rub together to make a lather; scrub hands vigorously for 20 seconds; rinse soap off hands vigorously for 20 seconds; rinse soap off hands. hands.

If possible, turn off the faucet by using a If possible, turn off the faucet by using a disposable paper towel. disposable paper towel.

Dry hands with a disposable paper towel. Do Dry hands with a disposable paper towel. Do not dry hands on clothing. not dry hands on clothing.

Assist young children with washing their hands. Assist young children with washing their hands.