醫學 1861

產褥熱的病因、概念與預防

伊格納茨·塞麥爾維斯

醫生用自己的手把死亡帶進產房——一盆氯水，止住了它。

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In depth · the introduction

分娩最危險的地方，竟是由醫生坐診的那間病房——因為醫生正用自己的手，渾然不覺地把死亡從解剖室帶了進來。

核心想法

在維也納一家大醫院裡，兩間產科病房並排而設。一間由醫生和他們的學生坐診，另一間由助產士坐診。在醫生那間病房，產婦死於產褥熱——分娩後一場兇猛的感染——的機率要高出好幾倍。沒人知道為什麼，產婦們都哀求別把自己送進去。

塞麥爾維斯找到了答案。與助產士不同，醫生們還要在解剖室裡解剖屍體——然後不洗手便徑直走向產床。他們正用自己的手，把看不見的「腐敗物質」從死者帶給活人。他的對策，簡單得近乎令人難堪：在碰病人之前，用氯水洗手。醫生那間病房的死亡，從大約每八名產婦中一人，驟降到約每八十人中一人。

它是如何誕生的

那是 1847 年，比任何人知道細菌的存在還早了幾十年。塞麥爾維斯，一位在維也納的年輕匈牙利醫生，被自己病房裡的死亡率折磨著。他把流行的種種理論一個個排除——壞空氣、擁擠，甚至床的擺位——因為沒有一種能解釋：為什麼自己這間病房，比隔壁助產士那間糟糕得多。

隨後，他的同事雅各布·科萊奇卡在解剖時劃破了手指，死於一種看上去與產褥熱一模一樣的病。塞麥爾維斯靈光一閃：那個害死好友的致命之物，正是害死產婦的同一樣東西，而醫生的手，就是那座橋。他下令用氯水洗手，於是，死亡停住了。

它為何重要

塞麥爾維斯用確鑿的數字證明：醫生自己的手，可能就是那個兇手——而一次簡單的清洗，就能成千上萬地拯救生命。這是人類頭一回，像現代醫學那樣，靠「施加干預、再清點結果」來證明一個醫學想法。然而他的同行大多拒絕他：承認他對，就等於承認自己曾害死人命。好的證據，被冷落了整整一代人——這是一句告誡：若你無法讓他人傾聽，僅僅是「正確」還遠遠不夠。

一個可以想像的畫面

想想有人在廚房裡處理生雞肉，然後不洗手就去拌沙拉——你看不見他手上有什麼，但你絕不會去吃那盤沙拉。塞麥爾維斯意識到，產房也是同一個道理：危險既不在空氣裡，也不在病人身上，而在照護者帶進來的那個看不見的東西。先把它沖掉，傷害便壓根不會到來。

它的位置

塞麥爾維斯，來得正好趕在能解釋他的人之前。不出二十年，路易·巴斯德便證明：活的微生物會引起發酵與疾病；約瑟夫·李斯特又據此建起消毒外科——這才給了塞麥爾維斯的氯水洗手那個一直欠缺的「為什麼」。在本館裡，你可以順著這條線索往下走到亞歷山大·弗萊明，他的青黴素讓醫學不僅能把微生物擋在外面，更能殺死那些已經進到體內的。今天，每一家醫院對手部衛生那份不鬆懈的執著，正是塞麥爾維斯的想法——終於被人相信了。

The original document

Original source text

兩座診所

Ignaz Semmelweis · Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers · 1861 (trans. K. Codell Carter, 1983)

In the Vienna maternity hospital, expectant mothers were admitted on alternate days to one of two clinics. The first was the teaching service of physicians and medical students; the second was the school for midwives. The two differed in almost nothing — except that, year after year, far more mothers died of childbed fever in the first clinic than in the second.

The disparity was no secret. The patients knew it, and dreaded assignment to the first clinic; some, Semmelweis records, would rather give birth in the street than be admitted there.

屍體的線索

On the death of Jakob Kolletschka, March 1847

The decisive clue came when his colleague Jakob Kolletschka, his finger pricked by a student's knife during an autopsy, died of an illness identical in its course to childbed fever. Semmelweis drew the inference that undid the mystery: what killed Kolletschka and what killed the mothers were one and the same.

Day and night I was haunted by the image of Kolletschka's disease, and was forced to recognize, ever more decisively, that the disease from which Kolletschka died was identical to that from which so many maternity patients died.

產褥熱是什麼

The definition

Semmelweis gave childbed fever a single cause. Every case, without exception, he held to be a resorption fever — the consequence of decaying animal-organic matter absorbed into the mother's bloodstream. In his own German: “die Resorbtion eines zersetzten thierisch-organischen Stoffes.”

Childbed fever is, without exception, a resorption fever caused by the resorption of decaying animal-organic matter.

The carriers of that matter, he wrote, were the examining finger, the operating hand, instruments, bed linen, the air, sponges — anything that touched decomposing matter and then the genitals of women in labour or just delivered.

氯水洗手的規定

The prophylaxis · Vienna, May 1847 onward

The cadaveric material adhering to the examining hand of the accoucheur is the cause of the greater mortality in the first obstetrical clinic; I have eliminated this factor by the introduction of the chlorine washings.

From mid-May 1847 every doctor and student was required to wash the hands in a solution of chlorinated lime until the cadaveric smell was gone, before each examination. The mortality of the first clinic, which had reached 18.3 per cent in April 1847, fell within months to a few per cent; for the full year 1848, under the rule, it was 1.27 per cent.

作者的自省

Semmelweis understood what his discovery implied about the years before it — about the hands, including his own, that had carried the contagion. He did not spare himself.

Only God knows the number of patients who went prematurely to their graves because of me. I have examined corpses to an extent equalled by few other obstetricians.

Ignaz Philipp Semmelweis · Pest · 1861

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