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Semmelweis 200, Part 2: Child-Bed Fever and the Great Discovery

By Hungary Today // 2018.02.15.

2018 marks the 200th anniversary of the birth of Ignaz Semmelweis, a legendary figure in both Hungarian and international medicine, known as one of the forefathers of medical hygiene.

In the second part of his essay (you can read the first section in its entirety here), Dr. László Rosivall, former Rector of Budapest’s Semmelweis University and President of the Semmelweis Memorial Committee, continues his reflections on the life, work, and legacy of the Hungarian medical giant.

This essay has been translated from the original Hungarian.

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Struggling to find the cause of Puerperal Fever at the University of Vienna

Semmelweis’ worry-free and happy years as a student passed, and he gradually became a doctor who lived for his patients and his field. He was a unique person, who disliked arguments and didn’t really care for writing, but who took care of and paid attention to every birthing mother with plenty of compassion, regardless of their background or affiliations, as was necessary. In 1858, he wrote in the Medical Weekly (Orvosi Hetilap) that,

The sheer number victims of puerperal fever have long stood as a challenge to the investigative drive of scientists and humanistic consciousness, that they might discover the causes of this unknown destruction; lest thousands of more individuals will be designated as death’s prey

Driven by the fear of puerperal fever spreading and through scientific thoroughness with detail-obsessed perseverance, he continuously fought to find the solution to this devastator of mothers and offspring, sparing neither himself, nor the prejudices, traditions, or ranks of the day. He examined all known ideas that could explain the cause of the disease, regardless of their apparent scientific value, and logically analyzed these findings, doing experiments to refute them in detail. He precisely documented parent and patient data, and studied the changes in the statistics to find hidden reasons behind the numbers, and relationships. Immediately at the beginning of the grand summary of his research (The Pathology of Puerperal Fever, Understanding and Prevention) he makes clear the almost unbearably oppressive burden of obstetricians:

… those times when the obstetrician could intervene effectively, are comparatively negligible in relation to the number of victims, that is, compared to the cases when the intervention was unsuccessful. The downside of obstetrics is puerperal fever … not only did I consider the treatment ineffective, but the doctrine is incomplete as well, because the current pathology of puerperal fever is not true … I found no explanation for its true cause. 

In Vienna, at the time, they believed and felt that puerperal fever was set it stone, that it had an unknown cause and an inevitable fate. The directors did not really like Semmelweis’ zeal, since they did not believe that statistics would lead to a successful solution; moreover, they feared that these would cast the institution in a bad light. This difference in approach, the clash and tension of the sycophantic past versus ambitious and talented future is well illustrated in the following events. When, in 1846 the tradition-oriented, or rather obstinate, Professor Klein, director of the Obstetrics Institute, explained to a committee that building new walls (as  the existing ones were too old) would help prevent the occurrence of puerperal fever, the young, “wild Hungarian” stood up to speak out. He proved that this new addition would be pointless, since there were maternity wards which were much older, where the death rate was nevertheless lower than that of the Department of Obstetrics.

In this age, in Vienna, there was a wide variety of pathological explanations of puerperal fever. Many considered it an infectious epidemic. Others thought that it was an irresistible atmospheric-cosmic-telluric effect that triggered the illness in expectant mothers. They also believed that a high level of congestion contaminated birthing rooms. Some blamed the disease on elevated levels of fear in women giving birth, while others felt it was caused by the ‘terrifying’ bells rung by Catholic priests when they performed last rites in the ward, as they often did due to high death rates.

Some people believed that the cause of the high mortality rate is due to the dire circumstances lived in by unmarried girls who strive to be breadwinners during pregnancy, existing in misery and need, with a gloomy state of mind; they may have even used substances to cause miscarriages, etc.

According to others, the rougher methods of students arriving for further training from other universities may have caused injuries leading to death.

Luckily for mothers and Semmelweis, the two parts of the University of Vienna’s Department of Obstetrics Institute, divisions I and II, worked side by side. Coincidence had created these unique conditions and circumstances to allow for clinical surveys, since the operation and statistics for the two classes were well tracked and comparable. Patient registration was controlled, and usually changed within 24-hour intervals between the classes. The two classes’ mortality rates caused by puerperal fever did not differ. In 1840, however, the management decided to reorganize the departments of education and, henceforth, the doctoral students would be in division I, while the midwives would be in division II. This move suddenly, and almost immediately, changed the mortality data. Semmelweis later reminisced on these events in the Medical Weekly, Reports of Foreign and Local Medicine, in which he wrote the following:

The rate of successful births in both divisions are about the same: namely three thousand and a few hundred in both clinics separately. For many years, the mortality rates were so unique and varying, that in the clinic where the midwives were studying the amount of deaths hadn’t surpassed 60, after over 3000 births, while in the obstetrics ward, after the same amount of deliveries, the number of deaths had fluctuated between 600-800.

The changes sparked great excitement in mothers, doctors and the program’s leaders alike, but the causes couldn’t be explained based on approaches of the time.

This was the period in Vienna when, in opposition to earlier, empirically-based theories of patient care, necrology-based (autopsy-based) thinking began to spread. The primary representative of this thinking was the Moravian-born Professor Rokitansky, a famous anatomist, who brought into practice Mograni’s theory that first one must seek the anatomical and morphological issues, and only then is it worthwhile or possible to find a causal therapy. The tragedy of this important and forward-thinking theory was that, in order to make any progress, the patient had to die first, and only then could an accurate diagnosis be established, and the disease be cured for others. Due to the popularity of this view, the number of autopsies in each field grew by leaps and bounds

Semmelweis obsessively searched for the cause of childbed fever by dissecting the dead. The more mothers died, the more he wanted to see the morphology, and its cause. He diligently prepared, processed, and compared the statistical data, trying to understand and interpret their meaning, the underlying secret, the real cause behind the disease. Besides anatomy, he deeply believed in statistics as a scientific research tool, even if he knew that numbers can often be misleading, and also brought attention to this fact multiple times. He knew that the department head of division I had some patients transported to other divisions so to not ruin the groups statistics, and in order to avoid the embarrassment of having to disclose the mortality rates, for reasons of vanity and material considerations. Aiding and abetting this decision, the legalizing committee tried to protect this process by moving the already ill mothers to divisions where effects of the disease could no longer reach them. However, this did not help save the mothers’ lives.

How great it would have been if the head of the department and the various committees – recognizing the excellent opportunity- would have worked together with the  relentlessly logical scientist Semmelweis and his indisputably objective methods to struggle on the behalf of mothers and toward understanding of the cause of puerperal fever as soon as possible! However, for this to be achievable, they would have had to overstep the spirit of the age, as Semmelweis did; this, however, is something that few can do.

Tinkering with statistics couldn’t improve Obstetrics’ bad reputation, and it could not be denied that about 10-20% of healthy young mothers and their children often died in the department; they were much worse off than the expectant mother who remained at home. The pregnant mothers trembled at Division I of the Department of Obstetrics, they tried everything and invented a variety of tricks to be admitted to the division II department (which was staffed by midwives).

It’s hard to imagine what the doctors who did their jobs ethically felt while carrying out their daily work in the division I department under such circumstances. Having to deal with an inexplicably high rate of cases of puerperal fever, even for the time, must have placed an almost incomprehensible psychological burden on their shoulders.

Semmelweis, a young, but thorough “scientist”, examined every thought and idea. He asked the priests not to ring their bells when they went to a dying patient, because there were some who blamed the sound as being fear-inducing. He was scrupulously careful to see to the patients in the same way as they would have done in another department, so as to not introduce any potential causes of variation. He paid attention to everybody and everything, followed the statistics, and kept an eye on any changes in the mortality rate, regardless of if a given explanation seemed believable or unbelievable. The analysis of data accumulated over the years from month to month; by analyzing the data he determined that “besides the slow decrease of congestion, the proportionate amount of dwindling deaths cannot be observed”, “in other words, congestion does not play a role.” Tough work showed that neither the changing of seasons, nor the climate, nor level of fear, nor poverty caused a statistical difference. After all, the climatic conditions did not differ between the two divisions, abandoning the bell-ringing did not help, and the mortality rate was not high for the poor mothers who lived in miserable conditions, gave birth in the street, and were subsequently admitted to the obstetric clinic. He noticed also that in the case of premature babies, when there was no vaginal examination by a physician due to the rapid and unexpected nature of the birth, the occurrence of puerperal fever was considerably lower, but he did not yet understand the reason for this, nor did he find an explanation.

Markusovszky, a surgical student friend of Semmelweis’ who lived with him at the time, wrote the following

“I was a witness to this man, who, knowing no rest, examining people and situations with a cautious eye, followed a method of investigating every facet of health and sickness. With this method, he worked to observe and capture his furious and underhanded murderous foe (child-bed fever), to find the causes of this illness. Nothing was left unstudied. Semmelweis diligently examined the incoming women for their past and present states of health, their way of life, their occupation; he conducted the surgeries and examinations with the utmost care: he separated the patients, he had the women giving birth on their sides, as was done in Clinic II as well, and they were carried to their rooms, so they did not need to get up after the birth, unlike before; he changed medications; by using a variety of methods he kept a teacher who was known for not examining the women in the most gentle way away from certain cases. He posted guards at the doors, preventing the midwives from transferring healthier, better-off patients to Clinic II. He made friends with the same clinic’s assistant professor, so he could monitor the situation better. He made sure that the entire hospital’s deaths and autopsies were supervised by Tudor Lautnerbey, who was the chief pathologist at the time. He made sure that the ventilation and cleaning was done with utmost care – All in vain! “

Still new, with a medical degree in his pocket that was barely two years old, Semmelweis got to the point in the autumn of 1846, that he announced that puerperal fever is not epidemic, not a general outbreak, but an endemic, that it is a local, problem. The cause should be searched for and found in the immediate vicinity of the patient. He was working more and more, autopsied, dissected, and surveyed reports, struggled and debated with himself, but he still could not find the exact cause. Meanwhile, the mortality rate was increasing, and by August 1846 had increased to over 18% on the ward. At this time, he wrote the following lines on a paper:

“Although I was convinced that in the First Obstetrics Department mortality is endemic, the cause is still unknown. I have so far unsuccessfully sought the reason for it, and I was disturbed by the fact that the newborns as well, boys or girls alike, got sick from puerperal fever. In addition, I observed phenomena which I was not able to explain – such as the fact that deaths almost inevitably occur during long dilation time, that premature street births are less likely to be affected, and that the First Obstetrics Department’s mortality- despite my earlier belief- can be traced back to epidemic causes. In other words, the serial occurrence of sickness among postpartum mothers in the 1st Obstetrics Clinic, as well as healthier conditions in the Second Obstetrics Clinic, led me to think that the employees of the Second Department were more skilled  or careful in  undertaking their responsibilities than we were. The lack of esteem that staff felt for employees of the 1st Obstetrics Clinic made me so unhappy that it truly soured my life. Everything seemed questionable, unexplained, doubtful; only the number of dead remained an undeniable reality. “

 

The discovery and its Consequences

In the spring of 1847, after a temporary dismissal, he returned to the Department in Vienna. Upon his return, Semmelweis received sad news about the respected and highly regarded Kolletschka, professor of Forensic Medicine. During an autopsy, one of his students accidentally pricked him with a scalpel. He passed away after falling ill of lymphadenitis and phlebitis, as well as bilateral pleuritis, carditis, peritonitis, and meningitis.

Semmelweis remembers the incident the following way in his book:

… in an emotional state due to Kolletschka’s death, realization rushed into my mind with invincible power: Kolletschka died from the same disease as the hundreds of postpartum women whom I saw die. These mothers, shortly after giving birth, also died of lymphadenitis, phlebitis, peritonitis, pleuritis, carditis, and meningitis.

Would this discovery have been missed if his colleague had not had an accident? This is unlikely. The discovery would inevitably have been made in short order regardless, because the enabling conditions, knowledge, data and experience that led to this discovery took shape as a result of his earlier, exacting research, as recorded in his book. The news of the death was rather just a memory, capturing the knowledge, and was used as a crystallization point, but even without this great moment of recognition the discovery eventually would have formulated itself in Semmelweis’ mind.

Microorganisms and bacteria were not completely unknown at this time, but at the University of Vienna they did not pay attention to them. Semmelweis believed that “pieces of the corpses” got into the wounds and that infection of the wound caused by the corpses’ toxins caused death.

In order to destroy the cadaverous matter on the hand- in mid-May of 1847, I do not remember the exact date – I used chlorina liquida. All my students and I had to wash our hands with this solution before examinations.

In the second half of May they started to use the less expensive chlorinated lime. Over the following seven months, the average mortality rate was 3.04% in the First Obstetrics Department. Over time, these figures improved even further: “In 1848, during the entire year, we strictly followed hand washing with chlorinated lime, and in the First Department, out of 3556 postpartum patients 45 died, namely 1.27%.” Semmelweis also recognized that not only particles from the corpse, but also disintegrating cancerous tissues, and the

rotting matter from the infected wounds can cause child-bed fever.

Could it be that the Viennese doctors and medical students had not washed their hands earlier, or just not properly, or did not think of its importance, or did not understand beyond the “visible” cleanliness? Semmelweis admits the following: “The excellent anatomical direction of the Medical University of Vienna makes the teachers and students perform autopsies on corpses on a daily basis; their hands get contaminated, and despite cleaning them with soap, the foul smell gives away the fact that this is not sufficient. Such invisible cadaveric particles, which can be recognized only by their putrid smell, will be introduced to the cervix, at the uterus, which was protected by the embryonic sac for months, and whose seal provides a great surface for absorption.

If this reasoning was true, then to eliminate the cause should result in the disappearance of mortality as well. Therefore, to remove and destroy the corpse particles, the hands must be washed with chlorinated lime.

The precise, consistent, well-prepared, nearly obsessive young Semmelweis, a constant follower and investigator of medical developments, barely three years after obtaining his medical diploma, barely two month after he became appointed assistant professor of First Obstetrics Department, at age 29, had not only recognized the cause of the childbed fever, but had found an effective and easy solution to for its prevention as well, ending the terrible suffering of the sad and long standing history of childbed fever. However, the actual liberation from these sufferings was not this easy!

Perhaps medical historians can calculate and estimate approximately how many patients died due to puerperal fever under doctors’ hands in Vienna before this discovery. In the meantime, it is almost certain that the most of the victims can be linked to Semmelweis’ own hands. He writes about this in his book: “Due to my belief, I must confess that God alone knows how many people died prematurely because of me as well. I had to deal with corpses more often than most obstetricians. “

Semmelweis did not stop his examinations at opportunities presented by chance and clinical events alone. He wanted to prove his theory. To confirm his views, he conducted animal testing with Lautner, his assistant professor friend who worked under Rokitansky. They conducted studies on nine rabbits, and conducted a varying degree of experiments on them.

In the first rabbit, after giving birth they introduced a brush into the vagina and uterus which was saturated with soiled endometritis exudate. The animal was well for a long time, but it died on day 31. In the second animal, the treatment was repeated every day. The animal perished on day 10. In the third animal, the treatment was started 10 hours after birth and continued each day. The animal died on the 6th day.

In the fourth rabbit, the experiment began an hour after giving birth and they repeated the treatment several times with a brush soaked with a dead man’s blood diluted with water who passed away because of marasmus. Following this, the treatment was continued with pleural and peritoneal exudate of a tuberculosis patient. The animal stayed seemingly healthy and gave birth again a month later.

In the fifth experiment, 12 hours after giving birth, they treated the animal with peritoneal exudate, and it remained healthy and gave birth again. They later killed the rabbit for another experiment, and could not detect any changes in the body.

In the subsequent four experiments, they treated the animals over periods of varying length, either with the peritoneal exudate of a man who had died of typhoid fever, or with the puss from the abscess of a man who had died of cholera.

These experiments, which were conducted in different animals, with different methods, are incomparable and difficult to interpret.

However, the results of the detailed autopsies basically confirmed Semmelweis’ idea, because the changes found in the dead animals were similar to each other, and to those people who had died of puerperal fever, without exception. Semmelweis evaluated the results of the autopsy in the following way:

 we found the same changes in the carcasses of the rabbits as in the people who died as a result of puerperal fever, respectively as an end result of pyemia.

 

Despite this landmark discovery that saved the lives of many mothers, or precisely because of this, in 1850 they did not extend Semmelweis’ position in Vienna. Therefore, in October, he moved to his hometown, Budapest, as a newly appointed private professor of gynecology.

 

By Dr. László Rosivall

Translated by Gergely Edward Nagy and Tom Szigeti

Images via NPR, PBS, and


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