Historically, puerperal fever was a devastating disease. It affected women within the first three days after childbirth and progressed rapidly, causing acute symptoms of severe abdominal pain, fever and debility.
The most common infection causing puerperal fever is genital tract sepsis caused by contaminated medical equipment or unhygienic medical staff who contaminate the mother's genital tract during the delivery. Other types of infection that can lead to sepsis after childbirth include urinary tract infection, breast infection (mastitis) and respiratory tract infection (more common after anaesthesia due to lesions in the trachea). Puerperal fever is now rare in the West due to improved hygiene during delivery, and the few infections that do occur are usually treatable with antibiotics.
The work of Dr. Ignaz Semmelweis
Dr. Ignaz Semmelweis worked at the Vienna General Hospital's maternity clinic on a 3-year contract from 1846–1849. There, as elsewhere in European and North American hospitals, puerperal fever, or childbed fever, was rampant, sometimes climbing to 40 percent of admitted patients. He was disturbed by these mortality rates, and eventually developed a theory of infection, in which he theorized that decaying matter on the hands of doctors, who had recently conducted autopsies, was brought into contact with the genitals of birthgiving women during the medical examinations at the maternity clinic. He proposed a radical hand washing theory using chlorinated lime, now a known disinfectant.[citation needed]
At the time however, the germ theory of infection had not been developed and Semmelweis' ideas ran contrary to key medical beliefs and practices. His ideas were rejected and ridiculed. Quite unusually, his contract was not renewed, effectively expelling him from the medical community in Vienna. He died as an outcast in a mental institution.
Puerperal fever – a modern disease
An 1841 account of epidemic childbed fever states that insofar as existing historical documents permit one to judge, childbed fever is a modern disease. The cases reported by Hippocrates that are generally identified as such are not puerperal fever. There are only examples of bilious fever, then common, which among maternity patients was no different from its appearance among non-maternity patients or men; Hippocrates himself never identified it as a separate and distinguishable disease.[1]
Hospital Hôtel-Dieu de Paris
Hôtel Dieu in Paris, about ad 1500. The priest on the right is issuing the last sacraments, while a nun administers to the patient on the left. Patients often slept two, three and even four to a bed
We encounter the first, as yet unclear indication of childbed fever in the second half of the 17th century at the Hôtel-Dieu in Paris. Phillipe Peu relates that mortality among the newly delivered was very great and greater in certain seasons than others. The year 1664 was particularly devastating.[1]
Another account states that the lower abdominal infection, la fièvre puerpérale, had raged every winter since 1774 among the maternity patients of the Hôtel-Dieu, and that often as many as 7 of every 12 patients suffered from it.[2]
The maternity clinic at Würzburg
For the relatively small maternity clinic at Würzburg in Germany, Franz Kiwisch von Rotterau reported 27 deaths from 102 patients (26.5%) cared for during one year, much higher than the Viennese hospital. Semmelweis explained this from the need in small hospitals to use every patient as teaching material. In contrast, "in Vienna there is such an excess of teaching material that hundreds of individuals are not used for teaching and thus are not infected".[3]
Inconsistencies in data
There are various inconsistencies in the datasets reported by Semmelweis and provided below.[citation needed] Inconsistencies exist for instance in reported yearly rates, and monthly rates (if aggregated to yearly basis). One of the causes may be that Semmelweis used different sources. He points out several times that actual mortality rates were higher than reported ones, because during childbed fever epidemics, the maternity ward was overwhelmed with dying women, who were then transferred to the general hospital, and therefore not registered at the maternity ward, when dying.[4] Some women were also released from the maternity ward, either healthy or not so healthy, only to be readmitted to the general hospital when symptoms appeared or worsened. See also a similar underreporting practice at the Charité in Berlin, Joseph Hermann Schmidt.
There were two maternity clinics at the Vienna General Hospital. Semmelweis is not always specific, if the numbers are for both clinics, or for his own clinic only. The figures presented below are exactly as reported in (the 1983 translation by Carter of) Semmelweis' 1861 publication.
There are also at times minor arithmetical errors in his computed rates; for this reason all rates on this page are computed.
Mortality rates at the Vienna General Hospital
Monthly mortality rates for birthgiving women 1841–49
The table below shows monthly incidence rates from 1841–1849, Semmelweis' handwashing policy was implemented from June 1847 to February 1849.
Puerperal fever monthly mortality rates at Vienna Maternity Institution 1841–1849. Rates drop when implementing handwash
Puerperal fever mortality rates for birthgiving women at the first clinic at the Vienna General Hospital 1841–1849 reported by Semmelweis.[5]
Year
Month
Births
Deaths
Rate (%)
Notes
1841
January 1841
254
37
14.6
February 1841
239
18
7.5
March 1841
277
12
4.3
April 1841
255
4
1.6
May 1841
255
2
0.8
June 1841
200
10
5.0
July 1841
190
16
8.4
August 1841
222
3
1.4
September 1841
213
4
1.9
October 1841
236
26
11.0
November 1841
235
53
22.6
December 1841
na
na
na
1842
January 1842
307
64
20.8
February 1842
311
38
12.2
March 1842
264
27
10.2
April 1842
242
26
10.7
May 1842
310
10
3.2
June 1842
273
18
6.6
July 1842
231
48
20.8
August 1842
216
55
25.5
September 1842
223
41
18.4
October 1842
242
71
29.3
November 1842
209
48
23.0
December 1842
239
75
31.4
1843
January 1843
272
52
19.1
February 1843
263
42
16.0
Mar 1843
266
33
12.4
April 1843
285
34
11.9
May 1843
246
15
6.1
June 1843
196
8
4.1
July 1843
191
1
0.5
August 1843
193
3
1.6
September 1843
221
5
2.3
October 1843
250
44
17.6
November 1843
252
18
7.1
December 1843
236
19
8.1
1844
January 1844
244
37
15.2
February 1844
257
29
11.3
March 1844
276
47
17.0
April 1844
208
36
17.3
May 1844
240
14
5.8
June 1844
224
6
2.7
July 1844
206
9
4.4
August 1844
269
17
6.3
September 1844
245
3
1.2
October 1844
248
8
3.2
November 1844
245
27
11.0
December 1844
256
27
10.5
1845
January 1845
303
23
7.6
February 1845
274
13
4.7
March 1845
292
13
4.5
April 1845
260
11
4.2
May 1845
296
13
4.4
June 1845
280
20
7.1
July 1845
245
15
6.1
August 1845
251
9
3.6
September 1845
237
25
10.5
October 1845
283
42
14.8
November 1845
265
29
10.9
December 1845
267
28
10.5
1846
January 1846
336
45
13.4
February 1846
293
53
18.1
March 1846
311
48
15.4
April 1846
253
48
19.0
May 1846
305
41
13.4
June 1846
266
27
10.2
July 1846
252
33
13.1
August 1846
216
39
18.1
September 1846
271
39
14.4
October 1846
254
38
15.0
November 1846
297
32
10.8
December 1846
298
16
5.4
1847
January 1847
311
10
3.2
February 1847
312
6
1.9
March 1847
305
11
3.6
April 1847
312
57
18.3
May 1847
294
36
12.2
Handwashing policy instituted mid-May
June 1847
268
6
2.2
July 1847
250
3
1.2
August 1847
264
5
1.9
September 1847
262
12
4.6
October 1847
278
11
4.0
November 1847
246
11
4.5
December 1847
273
8
2.9
1848
January 1848
283
10
3.5
strict controls enforced on students' negligent hand-wash
February 1848
291
2
0.7
March 1848
276
0
0.0
April 1848
305
2
0.7
May 1848
313
3
1.0
June 1848
264
3
1.1
July 1848
269
1
0.4
August 1848
261
0
0.0
September 1848
312
3
1.0
October 1848
299
7
2.3
November 1848
310
9
2.9
December 1848
373
5
1.3
1849
January 1849
403
9
2.2
February 1849
389
12
3.1
March 1849
406
20
4.9
Semmelweis' employment terminated
Explanatory power of his theory of cadaverous poisoning
From his theory of decaying matter on the hands of examining physicians as a cause for childbed fever he was able to explain other features in the dataset, for instance why mortality rates were remarkably higher during winter than summer, because of increased student activity and scheduled autopsies immediately before the rounds at the maternity clinic. He writes:
The prevailing opinion is that winter is the season most conducive to outbreaks of childbed fever. This is explained by the different activities of those who visit the maternity hospital. These activities are determined by the season. After the long vacation in August and September, students resume their studies, including obstetrics, with renewed diligence. In winter the influx of students into the maternity hospital is so great that individuals must wait weeks and even months for their turn to study. In summer, during vacation, half or even two-thirds of the places are vacant. In winter, the pathological and forensic autopsies and the medical and surgical wards are visited industriously by those who also visit the maternity hospital. In summer, the diligence is noticeably less. The charming surroundings of Vienna are more attractive than the reeking morgue or the sultry wards of the hospital.
In winter the assistant of obstetrics holds practical operative exercises on cadavers before the afternoon rounds at the maternity ward at four o'clock, because in the mornings students are otherwise engaged, and following the afternoon rounds, at five o'clock, it is already too dark. In summer the heat is too oppressive before the afternoon visit, and the operative exercises are held in the evening following afternoon rounds.[6]
He was able to explain additional features:
The assistant of the first clinic seldom visited the morgue in the months of December 1846 and January, February, and March 1847. The students followed his example. The opportunity for them to contaminate their hands with cadaverous particles was thereby greatly reduced. Restricting examinations to the minimum also reduced the opportunity for the genitals of patients to be touched by contaminated hands. For these reasons, mortality in the first clinic was reduced during these months.
I had Carl von Rokitansky's permission to dissect all female corpses, including those not already set aside for autopsy, in order to correlate the results of my examinations with autopsies. I devoted nearly every morning before the professor's rounds in the obstetrical clinic to these studies. On 20 March 1847, I reassumed the position of assistant in the first clinic. Early that morning I conducted my gynecological studies in the morgue. I then went to the labor room and began to examine all the patients, as my predecessors and I were obliged to do, so that I could report on each patient during the professor's morning rounds. My hands, contaminated by cadaverous particles, were thereby brought into contact with the genitals of so many women in labor that in April, from 312 deliveries, there were 57 deaths (18.3 percent).[7] Only God knows the number of patients who went prematurely to their graves because of me. I have examined corpses to an extent equaled by few other obstetricians.[8]
He was also able to explain why women with extended dilation invariably died: "Infection occurs most often during dilation. [...] ..it is frequently necessary to penetrate the uterus in manual examination to determine the location and position of the fetus. Thus, before chlorine washings, almost every patient whose period dilation was extended died of childbed fever."[9]
Yearly mortality rates for birthgiving women 1833–58 for first and second clinics
A second clinic was started in 1833 because of the large number of women being admitted to the maternity ward. Medical students and midwife students undertook their studies at both clinics. In 1841 however, these two groups were separated. Thereafter, medical students attended the first clinic only, and midwife students attended the second clinic only. Joseph Späth was professor at the second clinic.
Puerperal fever yearly mortality rates at Vienna Maternity Institution 1833–1858 for first and second obstetrical clinics. Period with Semmelweis' handwashing policy marked with red rectangle
Puerperal fever mortality rates for birthgiving women at the first and second clinic at the Vienna General Hospital 1833–1858 reported by Semmelweis. From 1841 only midwives worked in the second clinic, after which mortality rates were markedly lower than the first clinic. Semmelweis instituted a handwashing policy in the first clinic by mid-May 1847. His employment was terminated March 20, 1849[10]
First clinic
Second clinic
Year
Births
Deaths
Rate (%)
Births
Deaths
Rate (%)
Note
1833
3,737
197
5.3
353
8
2.3
Second clinic started
1834
2,657
205
7.7
1,744
150
8.6
1835
2,573
143
5.6
1,682
84
5.0
1836
2,677
200
7.5
1,670
131
7.8
1837
2,765
251
9.1
1,784
124
7.0
1838
2,987
91
3.0
1,779
88
4.9
1839
2,781
151
5.4
2,010
91
4.5
1840
2,889
267
9.2
2,073
55
2.7
1841
3,036
237
7.8
2,442
86
3.5
Only midwives worked in the second clinic
1842
3,287
518
15.8
2,659
202
7.6
1843
3,060
274
9.0
2,739
164
6.0
1844
3,157
260
8.2
2,956
68
2.3
1845
3,492
241
6.9
3,241
66
2.0
1846
4,010
459
11.4
3,754
105
2.8
1847
3,490
176
5.0
3,306
32
1.0
Handwashing in first clinic mid-May
1848
3,556
45
1.3
3,319
43
1.3
1849
3,858
103
2.7
3,371
87
2.6
Semmelweis dismissed in March
1850
3,745
74
2.0
3,261
54
1.7
1851
4,194
75
1.8
3,395
121
3.6
1852
4,471
181
4.0
3,360
192
5.7
1853
4,221
94
2.2
3,480
67
1.9
1854
4,393
400
9.1
3,396
210
6.2
1855
3,659
198
5.4
2,938
174
5.9
1856
3,925
156
4.0
3,070
125
4.1
1857
4,220
124
2.9
3,795
83
2.2
1858
4,203
86
2.0
4,179
60
1.4
Yearly mortality rates for birthgiving women 1784–1849
Semmelweis seeks to demonstrate that the advent of pathological anatomy, and consequently the increase in autopsies, is correlated to the incidence of childbed fever. From 1789–1822 professor Johann Lucas Boër was assigned the teaching post at the maternity ward, however he left the post discouraged of what was then regarded as an enormous mortality rate. He was succeeded by professor Johann Klein who reformed obstetrics to an anatomical orientation emphasizing the value of pathological autopsies. Mortality rates jump markedly.
Yearly puerperal fever mortality rates 1784–1849 in Wien and Dublin. Semmelweis seeks to demonstrate that the advent of pathological anatomy in Wien in 1823 is correlated to the incidence of childbed fever. See section below for data for Dublin.
Yearly patient mortality rates at the Dublin Maternity Hospital 1784–1849
Semmelweis compared mortality rates in Vienna with maternity institutions in the United Kingdom where mortality rates were lower. He wished to show that childbed fever was related to pathological anatomy. His choice, Dublin Maternity Hospital, was like the Viennese hospital, a large teaching institution for physicians.
He argued that, as a rule, German and French maternity hospitals are associated with large general hospitals. Therefore, their students occupy themselves in morgues, and in medical and surgical wards, as well as in maternity wards. In this way they become carriers of the decaying matter responsible for childbed fever.
Contrary hereto, maternity hospitals in the United Kingdom were independent institutions; removed from general hospitals. The students are forced to concern themselves exclusively with obstetrics, they do not carry out pathological autopsies.[13]
Yearly puerperal fever mortality rates for birthgiving women at Dublin Maternity Hospital for the period 1784–1849 reported by Semmelweis.[14]
Year
Births
Deaths
Rate (%)
1784
1261
11
0.9
1785
1292
8
0.6
1786
1351
8
0.6
1787
1347
10
0.7
1788
1469
23
1.6
1789
1435
25
1.7
1790
1546
12
0.8
1791
1602
25
1.6
1792
1631
10
0.6
1793
1747
19
1.1
1794
1543
20
1.3
1795
1503
7
0.5
1796
1621
10
0.6
1797
1712
13
0.8
1798
1604
8
0.5
1799
1537
10
0.7
1800
1837
18
1
1801
1725
30
1.7
1802
1985
26
1.3
1803
2028
44
2.2
1804
1915
16
0.8
1805
2220
12
0.5
1806
2406
23
1
1807
2511
12
0.5
1808
2665
13
0.5
1809
2889
21
0.7
1810
2854
29
1
1811
2561
24
0.9
1812
2676
43
1.6
1813
2484
62
2.5
1814
2508
25
1
1815
3075
17
0.6
1816
3314
18
0.5
1817
3473
32
0.9
1818
3539
56
1.6
1819
3197
94
2.9
1820
2458
70
2.8
1821
2849
22
0.8
1822
2675
12
0.4
1823
2584
59
2.3
1824
2446
20
0.8
1825
2740
26
0.9
1826
2440
81
3.3
1827
2550
33
1.3
1828
2856
43
1.5
1829
2141
34
1.6
1830
2288
12
0.5
1831
2176
12
0.6
1832
2242
12
0.5
1833
2138
12
0.6
1834
2024
34
1.7
1835
1902
34
1.8
1836
1810
36
2
1837
1833
24
1.3
1838
2126
45
2.1
1839
1951
25
1.3
1840
1521
26
1.7
1841
2003
23
1.1
1842
2171
21
1
1843
2210
22
1
1844
2288
14
0.6
1845
1411
35
2.5
1846
2025
17
0.8
1847
1703
47
2.8
1848
1816
35
1.9
1849
2063
38
1.8
Contamination of midwives' hands
The second obstetrical clinic at Vienna General Hospital that instructed midwife students evidently had a lower mortality rate than the first obstetrical clinic, where physicians were instructed.
While the midwife students in Vienna were not partaking in autopsies, there were still opportunities for them to contaminate their hands. In a lecture in 1846 Jakob Kolletschka is reputed to have said, "It is here no uncommon thing for midwives, especially in the commencement of their practice, to pull off legs and arms of infants, and even to pull away the entire body and leave the head in the uterus. Such occurrences are not altogether uncommon; they often happen."[15]
The Maternité in Paris was an exception. It was exclusively for the education of midwives, but it had a mortality rate as great as Paul-Antoine Dubois's Paris Clinic for the education of physicians. In the Maternité, midwives participated in autopsies as frequently physicians would elsewhere.
The hospital midwives and some of their students accompanied the physician on his daily rounds through the infirmary for maternity patients. Each student was assigned a diseased patient for particular observation and was expected to prepare a short case history of the birth and of the physician's treatment. Autopsies were conducted in a building in the garden somewhat removed from the maternity hospital; these were usually attended by student midwives. I was often astonished to see the active part some of the young women took in the dissection of corpses. With bare and bloody arms, holding large knives in their hands, laughing and quarreling, they cut the pelvis apart, having received permission from the physician to prepare the corpse for him.[16]
^Semmelweis (1861). Figures for Jan 1841 to May 1847 from table 3, p. 72; for Jun 1847 to Dec 1847 from table 6, p. 90; for Jan 1848 to Dec 1848 from table 7 p. 91; Jan–Mar 1949 from p89 in text. Rates are computed (not from source). Figures for Dec 1841 are not available, marked as "na"
^Semmelweis (1861). Figures for 1833–1840 from table 11, p. 131; for 1841–1846 from table 1, p. 64; for 1847–1858 from table 12 p. 131. Rates are computed (not from source).
^Semmelweis (1861). Table 14 pp. 142–143. From 1833 and onwards numbers refer to first clinic only. Rates are computed (not from source).
^Semmelweis (1861). Figures for from table 4, p. 78. Rates are computed (not from source).
^Semmelweis (1861). Table 14 pp. 142–143. Rates are computed (not from source).
^Lancet 2 (1855): 503. Quoted in Semmelweis (1861) p. 126 footnote 5
^Johann Friedrich Osiander, Bemerkungen über die französische Geburtshülfe, nebst einer ausführlichen Beschreibung der Maternité in Paris (Hannover: Hahn, 1813). Quoted in Semmelweis (1861) p. 125. The Osiander source is provided by translator Carter, footnote 4 same page (p. 125)
[1] (in German, Gothic print) Ignaz Semmelweis' Open Letter to all professors of obstetrics (1862) presents statistics from other European maternity institutions.
