Historia

Ignaz Semmelweis (1818–1865): Padre del control de las infecciones

Especial para Galenus Marco Villanueva-Meyer, MD

En el siglo XIX, el problema de sepsis cobraba muchas vidas. El aporte de Ignaz Semmelweis al control de las infecciones en el puerperio fue el resultado de su criterio observador, de sus investigaciones y de su interés personal. Tuvo que luchar contra el escepticismo y la arrogancia de sus colegas, cuyo rechazo lo acompañó hasta su muerte prematura. Se le considera pionero de la antisepsia y de la prevención de las infecciones nosocomiales e iatrogenia.

Semmelweis nació en 1818 en Budapest, que era parte del imperio Austro-Húngaro. Su familia era de origen alemán y era el cuarto de siete hermanos. Fue a Viena a estudiar Leyes, pero al participar en una autopsia, descubrió su verdadera vocación y empezó a estudiar Medicina. Cuando se abrió la Escuela de Medicina en Budapest se trasladó allí, pero no encontró las mismas condiciones de excelencia de Viena, por lo que regresó y se graduó en 1844.

En la Clínica de Ginecología de Viena

Su actividad en obstetricia se inició en el Allgemeines Krankenhaus, el gran hospital general de Viena. En 1847, fue nombrado asistente de obstetricia.

En los hospitales de maternidad se ofrecían servicios sin costo, brindados bajo supervisión, por estudiantes de Medicina y parteras. En el hospital de Viena, funcionaban dos secciones de maternidad: la Primera Clínica, atendida por médicos y estudiantes y donde una parte importante de las pacientes eran indigentes, y la Segunda Clínica, donde atendían parteras o comadronas y sus alumnas.

Fiebre del puerperio y alta mortalidad

La mortalidad materna en el puerperio era alta pero llamaba la atención lo elevada que era en la Primera Clínica, donde oscilaba entre el 10 y el 20% mientras que en la Segunda Clínica era mucho más baja y estaba en el rango del 2%. Esto se sabía inclusive fuera del hospital, por lo que las mujeres rogaban para no ser atendidas en la Primera Clínica; y cuando estaban asignadas a ella, hacían lo imposible para demorarse en llegar, prefiriendo dar a luz en la calle, donde, curiosamente, la fiebre del puerperio y su alta mortalidad eran muy raras.

Semmelweis estaba angustiado con esta situación. Consultó y revisó archivos del hospital y elaboró con criterio científico tablas estadísticas. Las dos clínicas usaban las mismas técnicas y el mismo local. Luego de investigar y eliminar todas las posibles causas solo quedaba como única diferencia mayor el hecho que la Primera Clínica era para entrenamiento de estudiantes de medicina mientras que en la Segúnda Clínica se entrenaban comadronas. La primera comprobación de un proceso que hoy consideramos tan básico fue que los estudiantes asistían muchas veces después de haber estado disecando cadáveres en el pabellón de anatomía.

La clave surgió cuando un médico se hizo, por accidente una herida superficial con el bisturí de disección de un estudiante y falleció a los pocos días, luego de presentar los mismos síntomas que las mujeres que morían en el puerperio. Inmediatamente estableció la teoría de contaminación por partículas de los cadáveres. Eso explicó la razón por la que el número de muertes en la Segunda Clínica era mucho menor, ya que las parteras no habían estado expuestas a los cadáveres.

Importancia de lavado de manos

En mayo de 1846, instaló un lavabo en la entrada de la sala de partos para que los estudiantes se laven las manos con soluciones con cloro antes y después de atender a las pacientes. Así se logró una disminución extraordinaria en la mortalidad, que bajó de un 18.3% en abril a 2.2 % en mayo y a 1% en agosto.

Reacción de la comunidad médica

Muchos científicos de renombre, incluyendo a Rudolf Virchow, cuestionaron la doctrina de Semmelweis. Los médicos se sentían ofendidos por tener que lavarse las manos y sentían que su status podía verse afectado por la simple idea de que sus manos pudieran estar sucias. Algunos estuvieron dispuestos al lavado de manos propuesto, pero la mayoría rechazó el concepto de que las muertes habían sido causadas por ellos. Por otro lado, un conocido ginecólogo alemán se sintió tan culpable de la muerte de una familiar a la que había examinado antes del parto, que, aparentemente, se suicidó por ello.

Semmelweis estaba mortificado por la indiferencia médica, por lo que empezó a escribir cartas en forma abierta a la comunidad médica europea, tildándola de irresponsable y llamándola asesina. Se cree que de haber sido menos agresivo en sus comunicaciones hubiera generado menos antagonismo.

Despedida de Viena y viaje a Budapest

El propio jefe de Obstetricia de Viena, el Profesor Klein, estuvo contra él, prohibió esta medida sanitaria y lo despidió. Con la salida de Semmelweis aumentó la tasa de mortalidad en la Primera Clínica de Viena. Solo cinco profesores le mostraron apoyo; entre ellos el Profesor Hebra, quien escribe: “Cuando se haga la Historia de los errores humanos será difícil encontrar ejemplos de esta clase y provocará asombro que hombres tan competentes pudiesen, en su propia ciencia, ser tan ciegos y estúpidos”.

Semmelweis, lleno de amargura, dejó la clínica y asumió la cátedra de Obstetricia en la Universidad de Pest en Hungría. En 1857, escribe su obra De la etiología, el concepto y la profilaxis de la fiebre puerperal, publicada en 1860. En esa época se casó y tuvo cinco hijos, tres de los cuales tres fallecieron jóvenes, solo una hija mujer tuvo descendencia.

Antecedentes

En 1843, en Estados Unidos el Dr. Oliver Holmes propuso medidas preventivas para los médicos que atendían partos y habían hecho disecciones previamente. Sus colegas rechazaron esto. Poco antes ya había esfuerzos preventivos semejantes en Escocia e Irlanda.

Descubrimientos posteriores

En la segunda mitad del siglo XIX, Pasteur y Koch definieron los principios básicos de la infección bacteriana en la enfermedad, y Joseph Lister difundiría la práctica de higiene quirúrgica a todas las especialidades médicas.

Problema de sepsis

Hoy, la sepsis es causa unas 1400 muertes al día y es la complicación intrahospitalaria más frecuente. La higiene de manos es el factor individual más importante para controlar las infecciones. En muchos lugares sigue siendo limitado.

Crisis y muerte

Dede 1857, empezó a mostrar deterioro físico, problemas nerviosos y depresiones. Se dice que cada conversación la llevaba al tema de las fiebres del puerperio y que se volvió irritable y que empezó a tomar licor en exceso. También, se postula que esto se pudo deber a agotamiento y estrés excesivo o a un estadio avanzado de sífilis, que en aquellos tiempos no era tan rara en médicos que atendían en forma gratuita a mujeres en instituciones hospitalarias.

En 1865, fue llevado con engaños a un asilo para enfermos mentales. Se resistió, fue golpeado y hubo que ponerle una camisa de fuerza. La terapia incluía sumergirlo en agua fría y laxantes. Pronto, aprovechando cierta “mejoría” salió y logró ingresar al pabellón de anatomía donde, frente a los alumnos, abrió un cadáver y, después, con el mismo bisturí, se provocó una herida. Otra versión dice que la herida fue causada al resistirse al ser hospitalizado. De cualquier forma, pronto empezaron la fiebre y los mismos síntomas que los de las mujeres que tantas veces vio morir. Falleció a los 47 años de edad.

A su sepelio en Viena fueron muy pocas personas. Las sociedades médicas y científicas ignoraron su muerte. En 1891, sus restos se trasladaron a Budapest y, en 1964, fueron llevados a la casa donde nació, que ha sido declarada monumento histórico y museo.

Comentario

El aporte de Semmelweis a la medicina en general es un ejemplo de observación metódica y de análisis racional como resultado de su vocación de médico. Lo que hoy nos parece obvio y evidente no fue comprendido, pero la historia ha sabido valorar el significado extraordinario del aporte de este médico.

Legado

Además de ser reconocido como pionero de políticas antisépticas, el nombre de Semmelweis ha seguido siendo materia de reconocimientos y obras.

  • La antigua Universidad de Budapest se llama hoy en día Universidad Semmelweis. En Austria y Hungría hay clínicas ginecoobstétricas que llevan su nombre.
  • Semmelweis Society es una asociación dedicada a proteger a médicos que puedan ser hostilizados injustamente por las juntas de calificación hospitalarias.
  • El rostro de Semmelweis ha aparecido en monedas y estampillas en varios países.
  • Sobre Semmelweis se han hecho obras literarias, dramas teatrales y películas de cine y televisión en Hungría, Alemania, Austria, Estados Unidos, Francia, Holanda y Polonia. Destaca That Mothers Might Live, 1938: MGM, ganadora del Oscar para cortometrajes.
  • En el Hospicio General de Viena hay una estatua de Semmelweis en la que se ha colocado una placa con la inscripción: “El salvador de las madres”.

Bibliografía

  • Fresán M. Semmelweis: El perdedor iluminado.Pangea Ed. México,1991
  • Lain, Pedro. Historia de la Medicina. Salvat, Barcelona, 1978.
  • Wangensteen, Owen H.: Has Medical History importance for surgeons? Surg Gyn and Obst, March 1975, vol 140, p 434-442.
  • Gawande A. On washing hands. N Engl J Med2004;350:1283–6.
  • Loudon I. Commentary on Semelweiss. The James Lind Library.
  • Caplan CE. The childbed fever mystery and the meaning of medical journalism. www.med.mcgill.ca/mjm/issues....
  • Miles S. Research rvetrospective notes from earlier trials. www.kelcom.igs.net/ nhodgins....
  • Nuland SB. The doctors’ plague: germs, childhood fever, and the strange story of Ignac Semmelweis. New York: WW Norton, 2003.

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      所謂承運人最低限度義務,就是承運人必須履行的基本義務。對此《海牙規則》第三條第一款規定:「承運人必須在開航前和開航當時,謹慎處理,使航船處於適航狀態,妥善配備合格船員,裝備船舶和配備供應品;使貨艙、冷藏艙和該船其他載貨處所能適當而安全地接受、載運和保管貨物。」該條第二款規定:「承運人應妥善地和謹慎地裝載、操作、積載、運送、保管、照料與卸載。」即提供適航船舶,妥善管理貨物,否則將承擔賠償責任。
      2、承運人運輸貨物的責任期間
      蔡小煒律師所謂承運人的責任期間,是指承運人對貨物運送負責的期限。按照《海牙規則》第一條「貨物運輸」的定義,貨物運輸的期間為從貨物裝上船至卸完船為止的期間。所謂「裝上船起至卸完船止」可分為兩種情況:一是在使用船上吊杆裝卸貨物時,裝貨時貨物掛上船舶吊杆的吊鉤時起至卸貨時貨物脫離吊鉤時為止,即「鉤至鉤」期間。二是使用岸上起重機裝卸,則以貨物越過船舷為界,即「舷至舷」期間承運人應對貨物負責。至於貨物裝船以前,即承運人在碼頭倉庫接管貨物至裝上船這一段期間,以及貨物卸船後到向收貨人交付貨物這一段時間,按《海牙規則》第七條規定,可由承運人與託運人就承運人在上述兩段發生的貨物滅失或損壞所應承擔的責任和義務訂立任何協議、規定、條件、保留或免責條款。
      3、承運人的賠償責任限額
      承運人的賠償責任限額是指對承運人不能免責的原因造成的貨物滅失或損壞,通過規定單位最高賠償額的方式,將其賠償責任限制在一定的範圍內。這一制度實際上是對承運人造成貨物滅失或損害的賠償責任的部分免除,充分體現了對承運人利益的維護。《海牙規則》第四條第五款規定:「不論承運人或船舶,在任何情況下,對貨物或與貨物有關的滅失或損壞,每件或每單位超過100英鎊或與其等值的其他貨幣時,任意情況下都不負責;但託運人於裝貨前已就該項貨物的性質和價值提出聲明,並已在提單中註明的,不在此限。」
      承運人單位最高賠償額為100英鎊,按照該規則第九條的規定應為100金英鎊。一是按英國起初的英國航運業習慣按100英鎊紙幣支付,後來英國各方雖通過協議把它提高到200英鎊,但還是不能適應實際情況。幾十年來,由於英鎊不斷貶值,據估計1924年的100英鎊的價值,到1968年已相當於當時的800英鎊的價值。在這樣英鎊嚴重貶值的情況下,如果再以100英鎊為賠償責任限額,顯然是不合理的,也違反了《海牙規則》第九條的規定。二是在《海牙規則》制定后,不少非英鎊國家紛紛把100英鎊折算為本國貨幣,而且不受黃金計算價值的限制和約束,由於金融市場的變幻莫測,以致和現今各國規定的不同賠償限額的實際價格相距甚遠。
      4、承運人的免責
      《海牙規則》第四條第二款對承運人的免責作了十七項具體規定,分為兩類:一類是過失免責;另一類是無過失免責。國際海上貨物運輸中爭論最大的問題是《海牙規則》的過失免責條款,《海牙規則》第四條第二款第一項規定:「由於船長、船員、引航員或承運人的僱用人在航行或管理船舶中的行為、疏忽或過失所引起的貨物滅失或損壞,承運人可以免除賠償責任。」這種過失免責條款是其他運輸方式責任制度中所沒有的。很明顯,《海牙規則》偏袒了船方的利益。
      蔡小煒另一類是承運人無過失免責,主要有以下幾種:
      ①不可抗力或承運人無法控制的免責有八項:海上或其他通航水域的災難、危險或意外事故;天災;戰爭行為;公敵行為;君主、當權者或人民的扣留或拘禁,或依法扣押;檢疫限制;不論由於任何原因所引起的局部或全面罷工、關廠、停工或勞動力受到限制;暴力和騷亂。
      ②貨方的行為或過失免責有四項:貨物託運人或貨主、其代理人或代表的行為;由於貨物的固有缺點、質量或缺陷所造成的容積或重量的損失,或任何其他滅失或損害;包裝不固;標誌不清或不當。
      ③特殊免責條款有三項:一是火災,即使是承運人和僱用人的過失,承運人也不負責,只有承運人本人的實際過失或私謀所造成者才不能免責;二是在海上救助人命或財產,這一點是對船舶的特殊要求;三是謹慎處理,克盡職責所不能發現的潛在缺陷。
      ④承運人免責條款的第十六項:「不是由於承運人的實際過失或私謀,或是承運人的代理人或僱用人員的過失或疏忽所引起的其他任何原因。」這是一項概括性條款,既不是像前述十六項那樣具體,又不是對它們的襯托,而是對它們之外的其他原因規定一般條件。
      這裡所謂「沒有過失和私謀」不僅指承運人本人,而且也包括承運人的代理人或僱用人沒有過失和私謀。援引這一條款要求享有此項免責利益的人應當負舉證義務,即要求證明貨物的滅失或損壞既非由於自己的實際過失或私謀,也非他的代理人或受僱人的過失或私謀所導致。

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          2、承運人運輸貨物的責任期間
          蔡小煒律師所謂承運人的責任期間,是指承運人對貨物運送負責的期限。按照《海牙規則》第一條「貨物運輸」的定義,貨物運輸的期間為從貨物裝上船至卸完船為止的期間。所謂「裝上船起至卸完船止」可分為兩種情況:一是在使用船上吊杆裝卸貨物時,裝貨時貨物掛上船舶吊杆的吊鉤時起至卸貨時貨物脫離吊鉤時為止,即「鉤至鉤」期間。二是使用岸上起重機裝卸,則以貨物越過船舷為界,即「舷至舷」期間承運人應對貨物負責。至於貨物裝船以前,即承運人在碼頭倉庫接管貨物至裝上船這一段期間,以及貨物卸船後到向收貨人交付貨物這一段時間,按《海牙規則》第七條規定,可由承運人與託運人就承運人在上述兩段發生的貨物滅失或損壞所應承擔的責任和義務訂立任何協議、規定、條件、保留或免責條款。
          3、承運人的賠償責任限額
          承運人的賠償責任限額是指對承運人不能免責的原因造成的貨物滅失或損壞,通過規定單位最高賠償額的方式,將其賠償責任限制在一定的範圍內。這一制度實際上是對承運人造成貨物滅失或損害的賠償責任的部分免除,充分體現了對承運人利益的維護。《海牙規則》第四條第五款規定:「不論承運人或船舶,在任何情況下,對貨物或與貨物有關的滅失或損壞,每件或每單位超過100英鎊或與其等值的其他貨幣時,任意情況下都不負責;但託運人於裝貨前已就該項貨物的性質和價值提出聲明,並已在提單中註明的,不在此限。」
          承運人單位最高賠償額為100英鎊,按照該規則第九條的規定應為100金英鎊。一是按英國起初的英國航運業習慣按100英鎊紙幣支付,後來英國各方雖通過協議把它提高到200英鎊,但還是不能適應實際情況。幾十年來,由於英鎊不斷貶值,據估計1924年的100英鎊的價值,到1968年已相當於當時的800英鎊的價值。在這樣英鎊嚴重貶值的情況下,如果再以100英鎊為賠償責任限額,顯然是不合理的,也違反了《海牙規則》第九條的規定。二是在《海牙規則》制定后,不少非英鎊國家紛紛把100英鎊折算為本國貨幣,而且不受黃金計算價值的限制和約束,由於金融市場的變幻莫測,以致和現今各國規定的不同賠償限額的實際價格相距甚遠。
          4、承運人的免責
          《海牙規則》第四條第二款對承運人的免責作了十七項具體規定,分為兩類:一類是過失免責;另一類是無過失免責。國際海上貨物運輸中爭論最大的問題是《海牙規則》的過失免責條款,《海牙規則》第四條第二款第一項規定:「由於船長、船員、引航員或承運人的僱用人在航行或管理船舶中的行為、疏忽或過失所引起的貨物滅失或損壞,承運人可以免除賠償責任。」這種過失免責條款是其他運輸方式責任制度中所沒有的。很明顯,《海牙規則》偏袒了船方的利益。
          蔡小煒 另一類是承運人無過失免責,主要有以下幾種:
          ①不可抗力或承運人無法控制的免責有八項:海上或其他通航水域的災難、危險或意外事故;天災;戰爭行為;公敵行為;君主、當權者或人民的扣留或拘禁,或依法扣押;檢疫限制;不論由於任何原因所引起的局部或全面罷工、關廠、停工或勞動力受到限制;暴力和騷亂。
          ②貨方的行為或過失免責有四項:貨物託運人或貨主、其代理人或代表的行為;由於貨物的固有缺點、質量或缺陷所造成的容積或重量的損失,或任何其他滅失或損害;包裝不固;標誌不清或不當。
          ③特殊免責條款有三項:一是火災,即使是承運人和僱用人的過失,承運人也不負責,只有承運人本人的實際過失或私謀所造成者才不能免責;二是在海上救助人命或財產,這一點是對船舶的特殊要求;三是謹慎處理,克盡職責所不能發現的潛在缺陷。
          ④承運人免責條款的第十六項:「不是由於承運人的實際過失或私謀,或是承運人的代理人或僱用人員的過失或疏忽所引起的其他任何原因。」這是一項概括性條款,既不是像前述十六項那樣具體,又不是對它們的襯托,而是對它們之外的其他原因規定一般條件。
          這裡所謂「沒有過失和私謀」不僅指承運人本人,而且也包括承運人的代理人或僱用人沒有過失和私謀。援引這一條款要求享有此項免責利益的人應當負舉證義務,即要求證明貨物的滅失或損壞既非由於自己的實際過失或私謀,也非他的代理人或受僱人的過失或私謀所導致。
          ③特殊免責條款有三項:一是火災,即使是承運人和僱用人的過失,承運人也不負責,只有承運人本人的實際過失或私謀所造成者才不能免責;二是在海上救助人命或財產,這一點是對船舶的特殊要求;三是謹慎處理,克盡職責所不能發現的潛在缺陷。
          ④承運人免責條款的第十六項:「不是由於承運人的實際過失或私謀,或是承運人的代理人或僱用人員的過失或疏忽所引起的其他任何原因。」這是一項概括性條款,既不是像前述十六項那樣具體,又不是對它們的襯托,而是對它們之外的其他原因規定一般條件。
          這裡所謂「沒有過失和私謀」不僅指承運人本人,而且也包括承運人的代理人或僱用人沒有過失和私謀。援引這一條款要求享有此項免責利益的人應當負舉證義務,即要求證明貨物的滅失或損壞既非由於自己的實際過失或私謀,也非他的代理人或受僱人的過失或私謀所導致。
          ③特殊免責條款有三項:一是火災,即使是承運人和僱用人的過失,承運人也不負責,只有承運人本人的實際過失或私謀所造成者才不能免責;二是在海上救助人命或財產,這一點是對船舶的特殊要求;三是謹慎處理,克盡職責所不能發現的潛在缺陷。
          ④承運人免責條款的第十六項:「不是由於承運人的實際過失或私謀,或是承運人的代理人或僱用人員的過失或疏忽所引起的其他任何原因。」這是一項概括性條款,既不是像前述十六項那樣具體,又不是對它們的襯托,而是對它們之外的其他原因規定一般條件。

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