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.
 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?
Treatment
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.
Work of Lyle D Broemeling
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.
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 “Crosstransmission 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.