Ignaz Semmelweis

Often referred to as "The Father of Infection Control," Ignaz Semmelweis (b. July 1,1818, d. August 13,1865) was a Hungarian physician who served in the Maternity Department of the Vienna Lying-in Hospital, where the poor and unwed came for obstetric care. He conducted clinical studies in puerperal sepsis (childbed fever), which was a common cause of mortality of young mothers. Our modern concept of infectious diseases was unknown then, and the prevailing belief was that puerperal fever and other epidemics were due to "miasma," a bad quality to the air. Semmelweis observed that women delivered by medical students (who did autopsies) had high mortality rates while those delivered by midwife trainees had low rates of childbed fever. After rejecting many proposed factors for the difference in mortality, he concluded that puerperal fever was a contagious disease spread by hands contaminated with cadaveric or necrotic material. He hypothesized that disinfection of hands could stop the transmission of disease from cadaver to pregnant women. When medical students were ordered to soak their hands in chlorinated lime after autopsies, before examining patients, the results of his intervention were dramatic: the mortality rates of women delivered by the medical students fell to the same level as those of women delivered by the midwife trainees. When he observed that puerperal fever could be spread from necrotic discharges from living patients, as well as autopsy material, he then required that students wash their hands between patient examinations. Although physicians had been recommending general hygiene and cleanliness for decades, Semmelweis' unique contribution was the recognition that the agent of puerperal fever was being spread by contaminated hands rather than some nebulous miasma. Despite his carefully documented findings and dramatic results, his findings unfortunately were not widely accepted among his medical peers until long after his death.

...Because Vienna is so large, women in labour often deliver on the street, on the earthwork, or in front of the gates of houses before they can reach the hospital. It is then necessary for the woman, carrying her infant in her skirts, and often in very bad weather, to walk to the maternity hospital. Such births are referred to as street births....

...Admission to the maternity clinic and to the foundling home is gratis, on the condition that those admitted be available for open instructional purposes, and that those fit to do so serve as wet nurses for the foundling home. Infants not born in the maternity clinic are not admitted gratis to the foundling home because their mothers have not been available for instruction. However, in order that those who had the intention of delivering in the maternity hospital but who delivered on the way would not innocently lose their privilege, street births were counted as hospital deliveries...

Don't Ask - Don't Tell: Austrian Style

...This, however, led to the following abuse: women in somewhat better circumstances, seeking to avoid the unpleasantness of open examination without losing the benefit of having their infants accepted gratis to the foundling home, would be delivered by midwives in the city and then be taken quickly by coach to the clinic where they claimed that the birth had occurred unexpectedly while they were on their way to the clinic....

...If the child had not been christened and if the umbilical cord was still fresh, these cases were treated as street births, and the mother received charity exactly like those who delivered at the hospital. The number of these cases was high; frequently in a single month between the two clinics there were as many as one hundred cases....

...As I have noted, women who delivered on the street contracted childbed fever at a significantly lower rate than those who delivered in the hospital. This was in spite of the less favourable conditions in which such births took place. Of course, in most of these cases delivery occurred in a bed with the assistance of a midwife. Moreover, after three hours, hospital patients were obliged to walk to their beds by way of the glass-enclosed passageway. However, such inconvenience is certainly less dangerous than being delivered by a midwife, then immediately having to arise, walk down many flights of stairs to the waiting carriage, travel it in all weather conditions and over horribly rough pavement to the maternity hospital, and there having to climb up another flight of stairs....

...For those who really gave birth on the street, the conditions would have been even more difficult....

...To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic. I have already expressed my firm conviction that the deaths in the first clinic were not caused by epidemic influences but by endemic and as yet unknown factors, that is, factors whose harmful influences were limited to the first clinic....

What protected those who delivered outside the clinic from these destructive unknown endemic influences?

....In the second clinic, the health of the patients who underwent street births was as good as in the first clinic, but there the difference was not so striking, since the health of the patients was generally much better....

...In addition to those who delivered on the street, those who delivered prematurely also became ill much less frequently than ordinary patients. Those who delivered prematurely were not only exposed to all the same endemic influences as patients who went full-term, they also suffered the additional harm of whatever caused the premature delivery....

...Under these circumstances, how could their superior health be explained?

...One explanation was that the earlier the birth, the less developed the puerperal condition and therefore the smaller the predisposition for the disease. Yet puerperal fever can begin during birth or even during pregnancy; indeed, even at these times it can be fatal....

North, South, East, West: Which Row was the Best?

...The better health of patients who delivered prematurely in the second clinic conformed to the general superior health of full-term patients in the clinic. Patients often became ill sporadically. One diseased patient would be surrounded by healthy patients. But very often whole rows would become ill without a single patient in the row remaining healthy....

...The beds in the maternity wards were arranged along the length of the rooms and were separated by equal spaces. Depending on their location, rooms in the clinic extended either north-south or east-west. If patients in beds along the north walls became ill we were often inclined to regard chilling as a significant factor. However, on the next occasion those along the south wall would become ill. Many times those on the east and west walls would become diseased. Often the disease spread from one side to the other, so that no one location seemed better or worse. How could these events be explained, given that the same patterns did not appear in the second clinic where one encountered the disease only sporadically?

...I was convinced that the greater mortality rate at the first clinic was due to an endemic but as yet unknown cause. That the newborn, whether female or male, also contracted childbed fever convinced me that the disease was misconceived....

Taking a Different Position on the Matter

...I was aware of many facts for which I had no explanation. Delivery with prolonged dilation almost inevitably led to death. Patients who delivered prematurely or on the street almost never became ill, and this contradicted my conviction that the deaths were due to endemic causes....

...The disease appeared sequentially among patients in the first clinic. Patients in the second clinic were healthier, although individuals working there were no more skillful or conscientious in their duties.... ...The disrespect displayed by the employees toward the personnel of the first clinic made me so miserable that life seemed worthless....

...Everything was in question; everything seemed inexplicable; everything was doubtful. Only the large number of deaths was an unquestionable reality. The reader can appreciate my perplexity during my first period of service when I, like a drowning person grasping at a straw, discontinued supine deliveries, which had been customary in the first clinic; in favour of deliveries from a lateral position. I did this for no other reason than that the latter were customary in the second clinic. I did not believe that the supine position was so detrimental that additional deaths could be attributed to its use. But in the second clinic 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 clinic....

Dr. Sammelweis Takes A Holiday

...At the end of February 1847, in the company of two friends, I departed for Venice on 2 March 1847. I hoped the Venetian art treasures would revive my mind and spirits, which had been so seriously affected by my experiences in the maternity hospital....

...On 20 March of the same year, a few hours after returning to Vienna, I resumed, with rejuvenated vigour, the position of assistant in the first clinic. I was immediately overwhelmed by the sad news that Professor Kolletschka, whom I greatly admired, had died in the interim. The case history went as follows: Kolletschka, Professor of Forensic Medicine, often conducted autopsies for legal purposes in the company of students. During one such exercise, his finger was pricked by a student with the same knife that was being used in the autopsy. I do not recall which finger was cut. Professor Kolletschka contracted lymphangitis and phlebitis in the upper extremity. Then, while I was still in Venice, he died of bilateral pleurisy, pericarditis, peritonitis, and meningitis. A few days before he died, a metastasis also formed in one eye....

...I was still animated by the art treasures of Venice, but the news of Kolletschka's death agitated me still more. In this excited condition I could see clearly that the disease from which Kolletschka died was identical to that from which so many hundred maternity patients had also died. The maternity patients also had lymphangitis, peritonitis, pericarditis, pleurisy, and meningitis, and metastases also formed in many of them....

Putting 2 and 2 Together

...Day and night I was haunted by the image of Kolletschka's disease and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died....

...Earlier, I pointed out that autopsies of the newborn disclosed results identical to those obtained in autopsies of patients dying from childbed fever. I concluded that the newborn died of childbed fever, or in other words, that they died from the same disease as the maternity patients. Since the identical results were found in Kolletschka's autopsy, the inference that Kolletschka died from the same disease was confirmed....

....The exciting cause of Professor Kolletschka's death was known; it was the wound by the autopsy knife that had been contaminated by cadaverous particles. Not the wound, but contamination of the wound by the cadaverous particles caused his death...

...Kolletschka was not the first to have died in this way. I was forced to admit that if his disease was identical with the disease that killed so many maternity patients, then it must have originated from the same cause that brought it on in Kolletschka...

...In Kolletschka, the specific causal factor was the cadaverous particles that were introduced into his vascular system. I was compelled to ask whether cadaverous particles had been introduced into the vascular systems of those patients whom I had seen die of this identical disease. I was forced to answer affirmatively...

Getting Awash in New Ideas

...Because of the anatomical orientation of the Viennese medical school, professors, assistants, and students have frequent opportunity to contact cadavers. Ordinary washing with soap is not sufficient to remove all adhering cadaverous particles. This is proven by the cadaverous smell that the hands retain for a longer or shorter time...

...In the examination of pregnant or delivering maternity patients, the hands, contaminated with cadaverous particles, are brought into contact with the genitals of these individuals, creating the possibility of resorption. With resorption, the cadaverous particles are introduced into the vascular system of the patient. In this way, maternity patients contract the same disease that was found in Kolletschka....

...Suppose cadaverous particles adhering to hands cause the same disease among maternity patients that cadaverous particles adhering to the knife caused in Kolletschka. Then if those particles are destroyed chemically, so that in examinations patients are touched by fingers but not by cadaverous particles, the disease must be reduced. This seemed all the more likely, since I knew that when decomposing organic material is brought into contact with living organisms it may bring on decomposition....

...To destroy cadaverous matter adhering to hands I used chlorina liquida. This practice began in the middle of May 1847; I no longer remember the specific day. Both the students and I were required to wash before examinations. After a time I ceased to use chlorina liquida because of its high price, and I adopted the less expensive chlorinated lime....

Hate to be an "I-Told-You-So", but ...

...In May 1847, during the second half of which chlorine washings were first introduced, 36 patients died - this was 12.24 percent of 294 deliveries. In the remaining seven months of 1847, the mortality rate was below that of the patients in the second clinic. . . .