Historical mortality rates of puerperal fever

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Vienna General Hospital in 1784. Semmelweis worked at the maternity clinic. Copper engraving by Josef & Peter Schafer

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[edit]

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 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[edit]

An 1841 account of epidemic childbed fever states that insofar as existing historical documents permit one to judge, childbed fever is a modern disease.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

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[edit]

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[edit]

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.[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[edit]

Monthly mortality rates for birthgiving women 1841-1849[edit]

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.

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. He devised and instituted a handwashing policy by mid-May 1847. His employment was terminated March 20, 1849 [5]
Year Month Births Deaths Rate (%) Sort restore
1841 Jan 254 37 14.6 1
  Feb 239 18 7.5 2
  Mar 277 12 4.3 3
  Apr 255 4 1.6 4
  Maj 255 2 0.8 5
  Jun 200 10 5.0 6
  Jul 190 16 8.4 7
  Aug 222 3 1.4 8
  Sep 213 4 1.9 9
  Okt 236 26 11.0 10
  Nov 235 53 22.6 11
  Dec na na na 12
1842 Jan 307 64 20.8 13
  Feb 311 38 12.2 14
  Mar 264 27 10.2 15
  Apr 242 26 10.7 16
  Maj 310 10 3.2 17
  Jun 273 18 6.6 18
  Jul 231 48 20.8 19
  Aug 216 55 25.5 20
  Sep 223 41 18.4 21
  Okt 242 71 29.3 22
  Nov 209 48 23.0 23
  Dec 239 75 31.4 24
1843 Jan 272 52 19.1 25
  Feb 263 42 16.0 26
  Mar 266 33 12.4 27
  Apr 285 34 11.9 28
  Maj 246 15 6.1 29
  Jun 196 8 4.1 30
  Jul 191 1 0.5 31
  Aug 193 3 1.6 32
  Sep 221 5 2.3 33
  Okt 250 44 17.6 34
  Nov 252 18 7.1 35
  Dec 236 19 8.1 36
1844 Jan 244 37 15.2 37
  Feb 257 29 11.3 38
  Mar 276 47 17.0 39
  Apr 208 36 17.3 40
  Maj 240 14 5.8 41
  Jun 224 6 2.7 42
  Jul 206 9 4.4 43
  Aug 269 17 6.3 44
  Sep 245 3 1.2 45
  Okt 248 8 3.2 46
  Nov 245 27 11.0 47
  Dec 256 27 10.5 48
1845 Jan 303 23 7.6 49
  Feb 274 13 4.7 50
  Mar 292 13 4.5 51
  Apr 260 11 4.2 52
  Maj 296 13 4.4 53
  Jun 280 20 7.1 54
  Jul 245 15 6.1 55
  Aug 251 9 3.6 56
  Sep 237 25 10.5 57
  Okt 283 42 14.8 58
  Nov 265 29 10.9 59
  Dec 267 28 10.5 60
1846 Jan 336 45 13.4 61
  Feb 293 53 18.1 62
  Mar 311 48 15.4 63
  Apr 253 48 19.0 64
  Maj 305 41 13.4 65
  Jun 266 27 10.2 66
  Jul 252 33 13.1 67
  Aug 216 39 18.1 68
  Sep 271 39 14.4 69
  Okt 254 38 15.0 70
  Nov 297 32 10.8 71
  Dec 298 16 5.4 72
1847 Jan 311 10 3.2 73
  Feb 312 6 1.9 74
  Mar 305 11 3.6 75
  Apr 312 57 18.3 76
  Maj 294 36 12.2 77 Handwashing policy instituted mid-May
  Jun 268 6 2.2 78
  Jul 250 3 1.2 79
  Aug 264 5 1.9 80
  Sep 262 12 4.6 81
  Okt 278 11 4.0 82
  Nov 246 11 4.5 83
  Dec 273 8 2.9 84
1848 Jan 283 10 3.5 85 strict controls enforced on students'
negligent hand-wash
  Feb 291 2 0.7 86
  Mar 276 0 0.0 87
  Apr 305 2 0.7 88
  Maj 313 3 1.0 89
  Jun 264 3 1.1 90
  Jul 269 1 0.4 91
  Aug 261 0 0.0 92
  Sep 312 3 1.0 93
  Okt 299 7 2.3 94
  Nov 310 9 2.9 95
  Dec 373 5 1.3 96
1849 Jan 403 9 2.2 97
  Feb 389 12 3.1 98
  Mar 406 20 4.9 99 Semmelweis' employment terminated

Explanatory power of his theory of cadaverous poisoning[edit]

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 1833-1858 for first and second clinics[edit]

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[edit]

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 puerperal fever mortality rates for birthgiving women at
Vienna General Hospital's maternity clinic for the period 1784-1849
reported by Semmelweis.[11]
Year Births Deaths Rate (%) Note
1784 284 6 2.1 No pathological anatomy
1785 899 13 1.4
1786 1,151 5 0.4
1787 1,407 5 0.4
1788 1,425 5 0.4
1789 1,246 7 0.6
1790 1,326 10 0.8
1791 1,395 8 0.6
1792 1,579 14 0.9
1793 1,684 44 2.6
1794 1,768 7 0.4
1795 1,798 38 2.1
1796 1,904 22 1.2
1797 2,012 5 0.2
1798 2,046 5 0.2
1799 2,067 20 1.0
1800 2,070 41 2.0
1801 2,106 17 0.8
1802 2,346 9 0.4
1803 2,215 16 0.7
1804 2,022 8 0.4
1805 2,112 9 0.4
1806 1,875 13 0.7
1807 925 6 0.6
1808 855 7 0.8
1809 912 13 1.4
1810 744 6 0.8
1811 1,050 20 1.9
1812 1,419 9 0.6
1813 1,945 21 1.1
1814 2,062 66 3.2
1815 2,591 19 0.7
1816 2,410 12 0.5
1817 2,735 25 0.9
1818 2,568 56 2.2
1819 3,089 154 5.0
1820 2,998 75 2.5
1821 3,294 55 1.7
1822 3,066 26 0.8
1823 2,872 214 7.5 Pathological anatomy begins
1824 2,911 144 4.9
1825 2,594 229 8.8
1826 2,359 192 8.1
1827 2,367 51 2.2
1828 2,833 101 3.6
1829 3,012 140 4.6
1830 2,797 111 4.0
1831 3,353 222 6.6
1832 3,331 105 3.2
1833 3,737 197 5.3
1834 2,657 205 7.7
1835 2,573 143 5.6
1836 2,677 200 7.5
1837 2,765 251 9.1
1838 2,987 91 3.0
1839 2,781 151 5.4
1840 2,889 267 9.2
1841 3,036 237 7.8 Separation of clinics
1842 3,287 518 15.8 hereafter numbers refer to first clinic only
1843 3,060 274 9.0
1844 3,157 260 8.2
1845 3,492 241 6.9
1846 4,010 459 11.4
1847 3,490 176 5.0 Chlorine washings begin mid-May
1848 3,556 45 1.3
1849 3,858 103 2.7 Semmelweis dismissed from hospital in March

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

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

Puerperal fever mortality rates for newborn infants at the first and second clinic at the Vienna General Hospital 1841-1846 reported by Semmelweis.[12]
  First clinic   Second clinic
Year Births Deaths Rate (%)   Births Deaths Rate (%)
1841 2,813 177 6.3   2,252 91 4.0
1842 3,037 279 9.2   2,414 113 4.7
1843 2,828 195 6.9   2,570 130 5.1
1844 2,917 251 8.6   2,739 100 3.7
1845 3,201 260 8.1   3,017 97 3.2
1846 3,533 235 6.7   3,398 86 2.5

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

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.[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[edit]

The second obstetrical clinic at Vienna General Hospital that instructed midwife student 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]

External links[edit]

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, Austrian National Library [1] (in German, Gothic print)

References[edit]

Notes[edit]

  1. ^ a b Semmelweis (1861) p152
  2. ^ Semmelweis (1861) p153
  3. ^ Semmelweis (1861) p165-166
  4. ^ Semmelweis (1861) p64-65
  5. ^ Semmelweis (1861). Figures for Jan 1841 to May 1847 from table 3, p72; for Jun 1847 to Dec 1847 from table 6, p90; for Jan 1848 to Dec 1848 from table 7 p91; Jan-Mar 1949 from p89 in text. Rates are computed (not from source). Figures for Dec 1841 are not available, marked as "na"
  6. ^ Semmelweis (1861) p122 (not a verbatim quote)
  7. ^ Semmelweis (1861) pp102-103 (not a verbatim quote)
  8. ^ Semmelweis (1861):98
  9. ^ Semmelweis 1861:116
  10. ^ Semmelweis (1861). Figures for 1833-1840 from table 11, p131; for 1841-1846 from table 1, p64; for 1847-1858 from table 12 p131. Rates are computed (not from source).
  11. ^ Semmelweis (1861). Table 14 pages 142-143. From 1833 and onwards numbers refer to first clinic only. Rates are computed (not from source).
  12. ^ Semmelweis (1861). Figures for from table 4, p78. Rates are computed (not from source).
  13. ^ Semmelweis (1861) pp139-140
  14. ^ Semmelweis (1861). Table 14 pages 142-143. Rates are computed (not from source).
  15. ^ Lancet 2(1855): 503. Quoted in Semmelweis (1861) p126 footnote 5
  16. ^ 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 (p125)

Books[edit]

Semmelweis, Ignaz; K. Codell Carter (translator and extensive foreword) (1861). Etiology, Concept and Prophylaxis of Childbed Fever. University of Wisconsin Press, September 15, 1983. ISBN 0-299-09364-6.