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.
At the time however, the germ theory of infection had not been developed and Semmelweis' ideas ran contrary to key medical assumptions 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Puerperal fever – a modern disease An 1841 account of epidemic childbed fever states that insofar as existing historical documents permit one to judge, childbed fever is a modern disease.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.Semmelweis (1861) p. 152
Hospital Hôtel-Dieu de Paris
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.
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) p. 153
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) pp. 165–166
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) pp. 64–65 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 appeared or worsened. See also a similar underreporting practice at the Charité hospital 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 mortality rates for birthgiving women at the first clinic at the Vienna General Hospital 1841–1849 reported by Semmelweis.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" Year Month Births Deaths Rate (%)Notes 1841
254 37 14.6
239 18 7.5
277 12 4.3
255 4 1.6
255 2 0.8
200 10 5.0
190 16 8.4
222 3 1.4
213 4 1.9
236 26 11.0
235 53 22.6
na na na 1842
307 64 20.8
311 38 12.2
264 27 10.2
242 26 10.7
310 10 3.2
273 18 6.6
231 48 20.8
216 55 25.5
223 41 18.4
242 71 29.3
209 48 23.0
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.Semmelweis (1861) p. 122 (not a verbatim quote)
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).Semmelweis (1861) pp. 102–103 (not a verbatim quote) 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.Semmelweis (1861):98