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

Setting: The Vienna Setting: The Vienna General HospitalGeneral Hospital

Ignaz Ignaz SemmelweisSemmelweis

What was the problem?What was the problem? Puerperal Fever, (a.k.a. “childbed fever”) Puerperal Fever, (a.k.a. “childbed fever”)

From Wikipedia, From Wikipedia,

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

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

The settingThe setting The Vienna General Hospital contained two The Vienna General Hospital contained two

““maternity divisionsmaternity divisions”” which were relatively far which were relatively far from each otherfrom each 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.

Setting, continuedSetting, continued Women were systematically assigned to a Women were systematically assigned to a

division based on the time of day they arrived, division 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 division because it admittance into the second division because it was policy to admit women to the 1was policy to admit women to the 1stst division if division if they required special medical care. they required special medical care.

Work of Lyle D Work of Lyle D BroemelingBroemeling

Why the difference?Why the difference? It was believed to be miasms (bad air) It was believed to be miasms (bad air)

Semmelweis said no, it canSemmelweis said no, it can’’t be because then the t be because then the rates of death would be the same in both divisionsrates of death would be the same in both divisions

Overcrowding? No, Semmelweis routinely shut Overcrowding? No, Semmelweis routinely shut down admittance to the 2down admittance to the 2ndnd division because it was division because it was too crowded; he never had to shut the 1too crowded; he never had to shut the 1stst division division and force patients into the 2and force patients into the 2ndnd division. division.

Other factors?Other factors? 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 on creating equal groups for comparison.comparison.

How did he make the How did he make the divisions equal?divisions 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 laundererAll patients needed to have sheets from the same launderer

All deliveries had to be done in the lateral position because All deliveries had to be done in the lateral position because in the 2in the 2ndnd section all were done in that position. section all were done in that position.

He Asked the priest to come quietly (he usually rang a bell) He Asked the priest to come quietly (he usually rang a bell) and without being seen (one section allowed direct access, and without being seen (one section allowed direct access, one did not) in order to not affect the mental states of the one did not) in order to not affect the mental states of the patients when delivering Last Rites, which he did VERY patients when delivering Last Rites, which he did VERY often. 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 section. latter were customary in the second section. I did not believe that additional deaths could I did not believe that additional deaths could be attributed to its use. But in the second be attributed to its use. But in the second section deliveries were performed from a section deliveries were performed from a lateral position and the patients were lateral position and the patients were healthier. Consequently we also delivered healthier. Consequently we also delivered from the lateral position, so that everything from the lateral position, so that everything would be exactly as in the second section.would be exactly as in the 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.

The death of a colleagueThe death of a colleague

SemmelweisSemmelweis’’ friend and colleague, Jakob friend and colleague, Jakob Kolletschka dies while experiencing Kolletschka dies while experiencing ““bilateral bilateral pleurisy, pericarditis, peritonitis, and meningitipleurisy, pericarditis, peritonitis, and meningitiss”” and later and later ““a metastasis formed in one eye.a metastasis formed in one eye.

During an autopsy, a student has pricked During an autopsy, a student has pricked Kolletschka’s finger with a knife being used in Kolletschka’s finger with a knife being used in the autopsythe autopsy””

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 division than the 2division 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 liquidachlorina liquida”” but later switches to 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 Experiments ““in which the genitals of newly in which the genitals of newly

delivered rabbits were brushed with blood and delivered rabbits were brushed with blood and other fluids from human corpsesother fluids from human corpses”” and in which 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 fevervictims of childbed fever”” failed to stop the failed to stop the ““politicalpolitical”” criticism he suffered from. 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 Studies still show that ““Cross-transmission 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.