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Ignaz Semmelweis and the Determination of the Cause of Puerperal Fever. Setting: The Vienna General Hospital. Ignaz Semmelweis. What was the problem?. Puerperal Fever, also known as childbed fever.
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Ignaz Semmelweis and the Determination of the Cause of Puerperal Fever
What was the problem? • Puerperal Fever, also known as childbed fever. • From wikipedia, “Puerperal fever (from the latin puer meaning boy), also called childbed fever, can develop into puerperal sepsis, which is a serious form of septicaemia contracted by a woman during or shortly after childbirth or abortion. “
More on Puerperal Fever • Sepsis is the medical term for the inflammation of the whole body, as a result of infection • According to Semmelweis, symptoms included lymphangitis, phlebitis, pleuritis, pericarditis, peritonitis, meningitis and metastis.
And those symptoms mean what? • Acute lymphangitis is a bacterial infection in the lymphatic vessels which is characterized by painful, red streaks below the skin surface. This is a potentially serious infection which can rapidly spread to the bloodstream and be fatal. • Phelbitis is the inflammation or swelling of a vein and can cause blood clots which can reach the lungs, and end in pulmonary embolism (blood clot in the lung).
And those symptoms mean what? • Pleuritis is an inflammation of the lining of the lungs. • Pericarditis is the inflammation of the lining sac of the heart. • Peritonitis is inflammation of the layer of cells lining the inner wall of the abdomen and pelvis. • Meningitis is inflammation of the membranes that cover the brain and spinal cord.
And those symptoms mean what? • Metastis is the spread of disease from one body part to another. • So we see, this was a really horrible horrible disease, and resulted in death. • All definitions stolen from medterms.com
What were the believed causes? • In 1825 a British physician identified the causes of sporadic phtisis, including: • Exposing the body to cold air after exercise, exposure to cold due to too quick change of apparel, continuing to suckle too long under a deliberated state, and playing much on wind instruments • Some of the causes were relatively correct, such as lying in damp beds, and environmental exposures
The general theory of disease at the time • Disease is caused by miasms, or bad/poisonous air. • So how do you treat disease caused by bad air?
An American’s treatment for the disease in the 1850’s • “prompt abstraction of the blood is called for; take from the arm from twelve to thirty ounces of blood[1-3 pints] depending, of course, on the urgency of the case” • “bleed from a large orifice, let there be a bold and full stream; in one word, make your patient faint; syncope [fainting] will be more readily accomplished by placing the patient in the sitting position during the abstraction of blood… The next indication will be a free action of the bowels”
The Viennese treatment in the 1820’s • “repeated venesection [opening of the veins], the application of leeches, emollient cataplasms [medicated substances spread over the skin], emollient clysters [enemas]... Emetics [to induce vomiting]”
An Explanation of the setting • The Viennese General Hospital contained two “maternity wards” 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.
An Explanation of the setting • Women were systematically assigned to a section 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 ward because it was policy to admit women to the 1st section if they required special medical care.
So What Caused Puerperal Fever? • As stated before it was believed to be miasms (bad air) • Semmelweis says no, it can’t be because then the rates of death would be the same in both sections • Overcrowding? No, Semmelweis routinely shut down admittance to the 2nd section because it was too crowded, he never had to do so with the 1st section and force patients into the 2nd section.
So What Caused Puerperal Fever? • 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 2nd 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 groups 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 2nd section all were done in that position. • 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.
Semmelweis sees the connection between two deaths • While on vacation Semmelweis’ friend and colleague, Jakob Kolletschka dies while experiencing “bilateral pleurisy, pericarditis, peritonitis, and meningitis” and later “a metastasis formed in one eye.”
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 1st section than the 2nd, 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.
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
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.
