Historical mortality rates of puerperal fever

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 literally sickened 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 genitials of birthgiving women during the medical examinations at the maternity clinic. He proposed a radical hand washing theory using chlorinated lime, now a known desinfectant. To a contemporary reader this would make perfect sense.

At the time however, the germ theory of infection had not been developed and Semmelweis' ideas ran contrary to key medical beliefs and practices at the time. His ideas were rejected and ridiculed. Quite unusully, his contract was not renewed, effectively expelling him from the medical community in Vienna. He died as an outcast in a mental institution.

Several articles in wiki relates to puerperal fever, or childbed fever. They lack accurate historical data, which are therefore provided here. The main purpose is to supplement the Ignaz Semmelweis page and a page on the history of puerperal fever to come. The data sets are too extensive, and probably also too specialised, to interest the general reader. In order not to clog the main pages with numbers, they are provided on this page.

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An 1841 account of epidemic childbed fever states that insofar as existing historical documents permit one to judge, childbed fever is a modern disease.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. [Semmelweis (1861) p152]

Hospital Hôtel-Dieu de Paris

We encounter the first, as yet unclear indication of childbed fever in the second half of the seventeenth 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. [Semmelweis (1861) p152] 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. [Semmelweis (1861) p153] . (Note the symmetry of the years which could convey meanings of Number mysticism)

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". [Semmelweis (1861) p165-166]

Inconsistencies in data

There are various inconsistencies in the datasets reported by Semmelweis and provided below. 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. [Semmelweis (1861) p64-65] 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 appered 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 1841-1849

The table below shows monthly incidence rates from 1841-1849, in particular the remarkable decline in mortality rates from June 1847 to February 1849, when Semmelweis' handwashing policy was implemented.

Yearly mortality rates for newborn infants 1841-1846 for first and second clinics

The mortality rate for newborn infants was also higher in the first clinic.

Yearly patient mortality rates at the Dublin Maternity Hospital 1784-1849

Semmelweis compared mortalilty 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 [Semmelweis (1861) pp139-140] .

Contamination of midwives' hands

The second obstetrical clinic at Vienna General Hospital that instructed midwife student evidently had a lower mortality rate than the second obstetrical clinic, where physicians were instructed.

While the midwife students at in Vienna were not partaking in autopsies, there were still opportunities for them to contaminate their hands, however. 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." [Lancet 2(1855): 503. Quoted in Semmelweis (1861) p126 footnote 5] .

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 [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 translater Carter, footnote 4 same page (p125) ] .

External links

Ignaz Semmelweis' Open Letter to all professors of obstetrics (1862) presents statistics from other European maternity institutions. The 1862 open letter is available at Austrian literature online, Österreichische Nationalbibliothek [http://www.literature.at/webinterface/library/ALO-BOOK_V01?objid=13184] (in German, Gothic print)

References

Notes

Books