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Reid3Semmelweis - Ignaz Semmelweis From a portrait by...

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Unformatted text preview: Ignaz Semmelweis. From a portrait by Abranyi Lajos in 1858 CHAPTER THREE ntil well into the twentieth century the death of a woman in or after childbirth was accepted as the recurring price of sexual intercourse. Childbed fever — puerperal fever — was a terrible blight on every lying—in hospital in Europe, particularly during the first half of the nineteenth century. The pattern the disease ran was cruel. On the third day after delivery the woman’s pulse would rise, she would become prostrate With fever, develop a discharge from her Womb, be- come delirious, have diarrhoea and shortly, as nothing could usually be done to stem the vicious progress of the disease, die. The extent to which childbirth fever swept up its victims was vastly different in different hospitals. In 1856 a newly graduated young doctor, working his first year in the Paris Maternité, was shocked to discover that the overall deathrate for that year was 6 per cent. The fever struck in sudden, uncontrollable waves. During one of these periods he wrote, ‘From the first of May to the 10th there were 32 cases of labour and we registered 3 I deaths’. Belatedly, the hospital was closed. If there were any useful lessons to be got from history, the Maternité had conspicuously failed to learn them. Seventy years earlier, in Man- chester, Charles White had claimed to have radically reduced his cases of the fever by insisting on cleanliness, isolation of cases whenever they occurred, and by getting women off their beds within twenty-four hours of delivery. And ten years after that Alexander Gordon in Aber- deen had shown just how fatally easy it was for midwives to spread the infection to their patients. But in most major cities of Europe the disease recurred with depress- ing persistence. Vienna of the 1840s had a particularly bad reputation in spite of the fact that it was the city which housed one of the most enlightened Medical Schools of Europe: the Vienna General Hospital. When Ignaz Semmelweis joined the lying-in clinic of this hospital as an obstetrical assistant in 184.4 he knew its reputation for puerperal fever rate very well; that year almost one in ten pregnant women who entered it died. Semmelweis, who came from an affluent Hungarian family to study in Vienna, had chosen medicine as a vocation, originally having travelled to Austria to read law. He was an emotional young man, and the condi- tion of the women suffering from Childbed fever moved him. The state of the wards which he had to walk, however, he probably accepted as commonplace; the primitive hospital management and facilities did not differ vastly from city to city. In the Vienna General, wards were crowded. The stench from the open sores of infection was appalling, and 27 MICROBES AND MEN 28 particularly so, the smell from the discharge from puerperal fever. But there were other sources of odours. It was customary for the closets, with their open sewers or buckets, to lead directly from the ward. In many cases — and the delivery room of the lying-in division in which Semmelweis worked was a case in point — autopsy rooms were joined by doors directly to the wards. Frequently students learned their medicine on the dead bodies of patients in the room next to which the patients had once lain. There was no universal tradition of cleanliness, either with respect to patients, practitioners or surroundings. A surgeon would not necessarily clean or change his apron between operations, and some would wear the bloodstains on it like medals, carrying them round from day to day, and from patient to patient. It was fashionable to tuck whip- cord, used for tying up arteries, in the buttonhole of the lapel of the coat. Wards were washed monthly or yearly according to nursing whim. Semmelweis was a well-built, prematurely bald young man, already running to fat, who looked older than he was and whose behaviour had the authority of age. His authority was mixed with a certain dynamism which would qualify him for the twentieth-century definition of a Hun- garian, as a man who goes into revolving doors behind you and comes out in front. When, quite soon after his arrival at the Vienna General, he began to question some of the techniques he saw in hospital practice, he was listened to with attention. He was also a truculent young man with no evidence of tact. As a new— comer to the hospital, he had no hesitation in letting anybody, including his superiors on the teaching staff, know his conclusions on all matters relating to obstetrics. His methods of communication seriously handi- capped him throughout his life, particularly here in this hospital: the pride of the Austro-Hungarian Empire, and founded by the Emperor himself. Semmelweis was over—conscious of his own Hungarian origins, spoke German with a thick Hungarian accent, and never mastered the art of written German. Semmelweis’s immediate superior at the Vienna General, Klein, was professor of midwifery and director of the teaching clinic of the lying-in division. There were two clinics in the division. These had been formed when the hospital had been reorganised in 1840. The second, staffed by midwives, was run in the same way as the first clinic, except that medical students were not taught there. The existence of the two clinics was to make Semmelweis, first by implication then de facto, a virulent critic of Klein. Semmelweis’ first untoward observation was not merely unoriginal, CHILDBED FEVER it was shared by the vast majority of those who, as patients, had ex- perience of one of the lying-in clinics; it was that the death-rate from childbed fever in the first clinic was far higher than that in the second. it was an opinion not generally shared by the rest of the medical teach- ing. staff. Semmelweis had become convinced that the gossip among patients was true when he saw the depths of their fears of the first clinic. His easily stirred emotions were disturbed by several experiences. He watched cabbies driving their horses round and round the hospital square late at night, waiting until midnight struck, so that the heavily pregnant women inside need not be taken in to the hospital until the early minutes of the morning. The midwives admitted women in labour only on certain days of the week. Some women would prefer to give birth in the streets rather than be taken in to the first clinic. Working in that clinic Semmelweis himself had seen women with dry tongues, with high pulse rates and high temperatures, feigning good health in order to get an early discharge. And he had seen them get down on their knees to beg to be released from what he soon began to agree appeared to be a sentence to a higher chance of death. ‘ There was even a young wives’ tale as to what caused the death-rate in the teaching division; it was due, women said, to the examination by doctors. As he walked the wards, Semmelweis watched how obstetri- Cians and midwives worked. Fundamentally he could see no diflerences either in the way stafl' behaved, or in the organisation of the two clinics: but there was a way in which he could investigate. The chance organisa- tion of the lying-in division itself presented him with an experimental technique which could be applied to medicine as it had never been i applied before. The arrangement of the divisions into two parts pro- vided Semmelweis with a control group of patients in one clinic against which he could measure the effects of any changes of conditions in the other. Even better, the Vienna General, being a Teutonically efl'iciently documented establishment, kept an exact record of admissions, deaths and causes of deaths, to which Semmelweis had access. He collected the statistics of childbed mortality for the two years to 1846 that he had worked in the hospital, and for the four previous years. The results were unambiguous. In the teaching clinic in those six years 1989 Viennese Women had died: ten per cent of the total admissions. In the midwives’ clinic the figure was nearer three per cent. However bad the figures for the midwives’ clinic had been, in no single year had they shown any sign of being as devastating as those in the teaching clinic. This discovery of a control group, and the application of simple statistical methods, was a landmark in the understanding of the nature 29 MICROBES AND MEN 3O \ of disease. So far Semmelweis, the large blunt Hungarian among the Austrians, now so frequently depressed by the deaths around him, had only used the technique with already existing data to emphasise to those with whom, and for whom, he was working, that there was something seriously wrong in their system. But the technique was such that he could easily use it to try to discover how puerperal fever was so effec- tively killing-off so many young women. . There were almost as many theories of the origin of the disease as there were deaths. It was said to occur frequently in cases of still-births, to depend on whether a woman was married or single, to be influenced by the weather or to be caused by a mysterious halo clinging to the obstetrician. For many years obstetricians had taught that it was a fever of the milk, and one French worker even claimed to have found milk in the peritoneal cavity. Some practitioners had decided that diseases such as scarlet fever, measles, smallpox and erysipelas were related to child- bed fever and that one could turn into the other. How the disease spread was another tale of ignorance. Some medical schools had it that the disease was contagious, but there was no useful theory as to how the contagion spread. Much mumbo-jumbo was talked about ‘atmospheric telluric influence’. Looking back over more than a hundred years it is easy to despise this terrible replacement of ignorance by ignorant phrases. Nevertheless, this sort of phrase is not far removed from some in daily use in modern medicine. In 184.0, the year the Obstetric Division of the Vienna General Hos- pital had been divided into its two clinics, a German pathologist, Jakob Henle, had formulated a theory in which he supposed that disease could be caused by ‘miasms’, or polluted air, and that ‘contagia’ were miasms that had developed in the human body. There was nothing new in the idea that bad odours carry disease, as readers of the Bible or Shakespeare well know. Henle’s originality lay in the fact that he sup- posed contagia to be organic, living things which survived on the human body as parasites do. _ Henle’s guess - it was no more — was a significant contribution to the germ theory of disease, and it was available to Semmelweis when he began his work on puerperal fever. But like the rest, it was only a theory. Henle had done nothing to confirm it and had no technique by which he could do so. There is no evidence that Semmelweis knew of it. And even if he had, there were too many other theories available to him to assume that it might have influenced him unduly. Semmelweis was an obses- sive, pragmatic Hungarian. As he strode round the wards to see what he could see, no existing theory of that time could tell him what practical THE TWO CLINICS measures to take to eliminate the disease causing one bed in ten to be emptied of a dead woman. The patients and midwives in the hospital would talk freely to the fat, rather humourless foreigner with the forthright manner. When some whispered that the cause of death in the first division’s delivery ward was due simply to the fear that women had of being there, he took the suggestion with absolute seriousness; he did not reject the possible psychological origin of illness. Besides, he had already had the affecting experience of women crouching at his feet, clinging to his trousers, begging not to be sent to the first division. No matter how na'i've his approach, the control group of patients at his disposal made it a relatively simple matter to test, falsify and discard what was of no use. He went to some trouble to dispose of the ‘fear’ theory. He had noticed during the time he spent in the five wards in his clinic that the daily event which more than any other evoked a reaction of dread and worry among the women lying in their beds was the sight of a robed priest and the sound of his attendant’s bell as they walked through the wards to reach the sick-room to give the last sacrament to a dying patient. Semmelweis also noticed that the priest’s route from the chapel to the sick-room of the midwives’ clinic was not through the wards. A quiet word from Semmelweis soon had the man walking to the sick- room by a roundabout route and without his bell. The result had no effect whatever on the deathrate in the first clinic. The simplicity of the technique, however, encouraged Semmelweis to look for more dif- ferences in procedure between the teaching ward and the midwives’ ward, whose influence he could easily assess. He rejected ideas about some of the differences without bothering to apply them in a comparative study with his control group. For example, there was a suggestion that childbed fever in the first division was linked to the low social class of the patients by the sense of shame felt by poor women when they were being examined by medical students. Semmelweis argued, not unreasonably, that the high-society patients who were lucky enough to be attended by a doctor in their own homes ought to suffer an even greater wound to their modesty at being handled by a strange man; yet the incidence of puerperal fever in these home deliveries was far less than in hospital. Another suggestion was that the examination of patients by the mid- wives was an altogether gentler process than that carried out by the students in their first division teaching rounds. But how small, said Semmelweis, is the likely damage of a student’s finger in the long vagina of a pregnant woman compared with the injury inflicted by a baby on 31 MICROBES AND MEN 32 its birth passage? His supposition was correct, but had he used his control group as a verification it might have led him to some related important conclusions. Semmelweis compared as many of the conditions in the two clinics as appeared relevant. Ventilation was identical, there was no perceptible difference in the standard of cleanliness, the laundry was washed in the same way, food was supplied by the same caterer. There was no obvious solution. However, Semmelweis’s emotional involvement with the problem confirmed its existence at every turn. There was a poor and worsening life-expectancy of women lying in the teaching clinic. But there was one group of women which was the rule’s exception. The General hospital was a charitable institution and the city was vast. Many poor women arrived at the gates having failed to reach the place in time by foot, carrying their babies in their arms. They had given birth in shop doorways, under archways, in horse-drawn cabs, or any- where they could find shelter. Yet the mortality rate from puerperal fever among these women was low and, Semmelweis found, roughly the same in both divisions. It was a consolation for poverty. The other embarrassing statistic which Semmelweis extracted was that under the regime of the previous professor of midwifery, mortality had been extremely low. Under Professor Klein, it was extremely high. A tactful junior doctor would not have bandied about the information carelessly. But Semmelweis’s uncontrollable volatility and emotion were incompatible with tact. Klein, his regime and methods, were firmly implicated with the cause of the high childbed fever death rate. Klein had the reputation of being a dull, unadventurous and insecure man. Semmelweis was humourless too, but also manically depressive and volatile by turns. It seems, in retrospect, that however Semmelweis had presented the results of his findings to Klein, the characters of the two men were such that Klein’s instinct to territorial protection could not fail to surface. When one of Semmelweis’s more senior friends at the hospital, Skoda, a diagnostician with a growing European reputa- tion, proposed that a commission of inquiry should meet to investigate Semmelweis’s statistical results, Klein felt bound to take action. He invoked the protection of the Minister of Education and the commission was never allowed to meet. But when in 1846 the numbers of deaths in the first division from puerperal fever reached more than four times that in the second, a com- mission did meet and made a recommendation. It was that the most likely cause of the disease was injury to the genital organs inflicted by rough examination by students during their course of instruction. More SEMMELWEIS AND KLEIN particularly, it was concluded that the injuries were caused by foreign students whose numbers should be reduced. Xenophobia had been introduced into medical judgement. Semmelweis, the foreigner, watched his students reduced from 42 to 20, with foreigners almost completely excluded. He also watched his statistics. Mortality in his wards at first dropped, and then rose to frightening heights. By April 1847 it had reached I 8 per cent. During this period Semmelweis had one of the deep fits of depression which he experienced at different times throughout his life. His needed little to trigger its peaks and troughs. On this occasion, however, there was a ready excuse if one was needed. Throughout the clinic Semmel— weis could sense a deep feeling of contempt among his patients and even among the domestic staff for the medical staff. The laymen were con- vinced that the medics were themselves in some way responsible for the appalling deathrate. Semmelweis himself stood among the accused. He looked for obvious reasons which might support the patients’ accusations, but there were none. In desperation, when he noticed a difference in the method of delivery used in the two divisions, he ordered that his own delivery ward should adopt a new method. He wrote: Like a drowning man clutching at a straw, I gave up the dorsal position in labour, which was customary in the first clinic, and because the lateral position was that adopted in the second clinic. I do not believe that the dorsal position was so disadvantageous compared with the lateral position as to cause the higher mortality. He was right. It made no difference whether women were delivered on their backs or on their sides. In the first division clinic they died at an unchanging, appalling rate. So far Semmelweis had succeeded only in stirring up antipathy to- wards himself, by emphasising a problem which reflected the short- comings of his superior. He had challenged orthodoxy, but had not re- placed its techniques with anything preferable. It cannot have come as a complete surprise to Semmelweis when, in October 1846, Klein de- clined to renew his assistantship, but offered a provisional appointment instead. Semmelweis, touchy and haughty, was offended. He brooded over his future, left Vienna, and half-heartedly took up a study of English with a view to going to Dublin to investigate puerperal fever there. But by February of i 847 his old post was again vacant and he was reappointed. Back in Vienna in a refreshed frame of mind, he had been walking the wards for only a few hours when the news reached him that one of the 33 MICROBES AND MEN 1W7 34 professors he admired most in the Medical School’s faculty, Kolletschka, was dead. While carrying out a post—mortem a pupil’s knife had slipped and pierced Kolletschka’s finger. He had died his painful death within a few days of an infection setting in. The symptoms were described to Semmelweis, who reacted in his typical hypomanic fashion: In the excited condition in which I then was, it rushed into my mind with irresistible clearness that the disease from which Kolletschka had died was identical with that from which I had seen so many hundreds of lying-in women die . . . Day and night the vision of Kolletschka’s malady haunted me, and with ever increasing conviction I recognised the identity of the disease. In fact he ...
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