Authors: Richard Hollingham
Something needed to be done. A commission was set up to
investigate the disparity. Its conclusions were desperate. Male
student doctors, 'particularly foreigners', were blamed for being too
rough in their examinations. Most foreign students were removed.
When this failed to reduce the death rate the 'atmospheric-cosmicterrestrial
conditions of Vienna' were blamed for spreading disease
– a 'miasma' was pervading the wards. The authorities struggled,
though, to explain why, if there was something in the air, more
women died in the First Clinic than the Second.
The patients themselves were blamed. These women were often
the poorest in society; the wealthy would usually give birth at home
(where the mortality rate was less than 1 per cent). Perhaps it was to
do with the mothers' temperament or their slack morals? Many of
them were fallen women. In an eventual admission of defeat, the
authorities changed the days of admission, so women no longer
knew which clinic they would end up in. It became, in effect, a
lottery as to how likely they were to die.
There was one major difference between the clinics that the
commission had failed to spot or perhaps considered unimportant.
In order to refine their skills, the doctors had access to the bodies
of the recently deceased. The midwives were forbidden by law to
practise on cadavers, and had to make do with wax mannequins and
porcelain models. As a result, the doctors and medical students
spent much of their time in the mortuary. When needed, they
returned to the wards to attend to their patients, the sweet smell of
cadavers still on their hands. Some students even claimed that the
scent was attractive to women.
In 1847 a twenty-nine-year-old Hungarian physician called Ignaz
Semmelweis was appointed as first assistant to the professor of obstetrics
at the hospital. He had responsibility for the First Clinic and saw
for himself the horrible ravages of childbed fever. An intense yet
kind young doctor, Semmelweis became obsessed with solving the
mystery of all these deaths. Driven by the knowledge that for every
ten patients he treated, two would die, he set out to find a solution.
As well as conducting autopsies on his deceased patients,
Semmelweis pursued every theory he could think of. He suggested
the disease was something to do with the position of the women
when they were giving birth. Childbed fever seemed to affect firsttime
mothers more than others – perhaps this was something to do
with their labour being more prolonged. Could it be fear of the
doctors that was causing the deaths? Being examined for the
instruction of male students was surely offending their modesty. If
the women were already predisposed to puerperal fever, maybe
their fear of being examined led to the onset of the disease? Of
course, their modesty could be offended in many ways, so this
theory was quickly dismissed.
Semmelweis observed that a priest was passing among the
women – usually to administer the last rites. Maybe the disease
was something to do with a man of the cloth spreading the fear
of death? Certainly the priest had more cause to visit the First
Clinic than the Second. He was very understanding when asked
not to ring the little bell he carried around with him. But even if
fear was a factor in the women's deaths, this would not explain
the deaths of the infants.
Nothing seemed to work. Every theory Semmelweis came up
with failed to answer the fundamental question: why were more
women dying in the First Clinic than in the Second? Obsession
turned to frustration and anger as he failed to solve the mystery. His
superiors noted that he was behaving oddly, making lots of bizarre
changes to little effect. Semmelweis needed a holiday – for everyone's
sake.
In March 1847 he and two colleagues set off for Venice. The
Italian city was part of the Austrian Empire and had, once again,
become a popular tourist destination. This was in part because it was
much easier to get to than it had been previously, thanks to the new
railway line speeding through the Austrian countryside – a wonder
of the age. It was hoped that seeing the art treasures of Venice would
revive Semmelweis's spirits, and it did seem to have the desired
effect. He headed back to Vienna reinvigorated, ready to resume
the challenge of tackling childbed fever.
He returned to find that, in his absence, one of his best friends
had died. Professor Jakob Kolletschka, a pioneer of forensic medicine,
had become fascinated by finding out how people died, and
conducted regular autopsies. It was during an autopsy that he met
his fate. He had been dissecting a body with some students. The
hand of one of them slipped while making an incision and accidentally
pricked Kolletschka's finger. The professor thought nothing of
it – the cut was small, these sorts of things happened all the time.
For anyone involved in surgery or medicine, cutting yourself with a
scalpel was an occupational hazard.
Within a few hours there was some redness around the wound,
but nothing to worry about. The redness started to spread up
Kolletschka's arm, he became feverish and sores began to develop.
Soon he was covered in multiple abscesses and had a swollen
abdomen. The post-mortem found that his organs were infected and
he experienced pneumonia and meningitis. Kolletschka eventually
became delirious and slipped into a coma. Only a few days after
becoming infected, he was dead. Semmelweis was distraught.
Kolletschka was not only a close friend – the two men had often
worked together, and Kolletschka had supported Semmelweis
throughout his obsession with childbed fever. But Kolletschka was to
help Semmelweis one last time.
Reading through the post-mortem protocol, it did not take long
for Semmelweis to realize that his friend's symptoms were identical to
those of the women who died of childbed fever. His mourning would
have to wait. Now he knew what was killing the women. 'The exciting
cause of Professor Kolletschka's death was known,' he proclaimed. 'It
was the wound by the autopsy knife that had been contaminated by
cadaverous particles. Not the wound, but the contamination of the
wound by the cadaverous particles caused his death.'
Semmelweis had realized that if his friend had been killed by
particles from a dead body, then the same particles were killing the
women. Doctors were conducting autopsies and then administering
to their patients. At best they might wash their hands with soap
before conducting vaginal examinations, but this still left the lingering
smell of the cadavers. The doctors were spreading the disease.
They had been carrying death on their hands. Semmelweis had
been killing the very patients he was trying to help. The conclusion
was shocking. 'I have examined corpses to an extent equalled by few
other obstetricians,' he wrote. 'Only God knows the number of
women who descended prematurely into the grave because of me.
None of us knew that we were causing the numerous deaths.'
Semmelweis decided that something more than a quick wash
with soap and water was needed to stop the spread of material from
cadavers to patients. In the middle of May 1847 he introduced a
strict new regime in the clinic. Before examinations all doctors had
to wash their hands in chloride of lime, a caustic chemical much like
bleach. He posted notices to this effect:
All students and doctors who enter the wards for the purpose
of making an examination must wash and scrub their fingers
and hands thoroughly in the solution of chlorinated lime
placed in basins at the entrance to the wards. One disinfection
is sufficient for one visit, but between the examination of each
patient the hands must be washed with soap and water.
The results were better than Semmelweis could have hoped for.
In April 1847 there had been 57 deaths, the worst monthly
mortality rate yet at 18.27 per cent. In May the figure came down to
36 deaths, or 12.24 per cent. The June figure was remarkable: there
were only six deaths – a rate of 2.38 per cent, better even than the
midwives' clinic. The following months were better still: in March
and August 1848 not one patient died. Statistically, it was now safer
for women to give birth in the hospital than at home. Thanks to
Semmelweis, the hospital was now doing its job – saving lives.
The findings could not be clearer: childbed fever was caused by
cadaverous particles transferred from the bodies of the dead. It was
nothing to do with the atmospheric-cosmic-terrestrial conditions of
Vienna, fear or foreigners. Semmelweis drew up tables to prove his
point. 'Unchallengeable proof,' he said, 'for my opinion that
childbed fever originates with the spread of animal-organic matter.'
He should have been a hero. Perhaps his manner did not help,
or the fact that he himself was a foreigner. Some colleagues mocked
him. They found the new regime of washing in chloride of lime
inconvenient. It irritated their skin. And although everyone
accepted that the number of deaths on the wards had dropped
dramatically, where was the scientific explanation for Semmelweis's
findings? What was this 'animal-organic matter' he talked of? How
could the lingering smell of this material – this decaying flesh –
possibly be enough to kill any healthy young woman?
His 'unchallengeable proof' was challenged by the head of the
clinics – an ineffectual man drifting towards retirement. He did not
want any controversy in his final months at the hospital, and this
assistant was becoming increasingly troublesome. The doctors were
complaining about this confounded new procedure. Semmelweis
was sowing discontent and didn't know his place.
Semmelweis himself might also have been partly to blame for
failing to get proper recognition for his work. He became
entrenched in his views, would quarrel with anyone who disagreed
with him and flew into rages. Except for those within the hospital
and a small number of visiting doctors from elsewhere in Europe,
few people knew of Semmelweis's discovery. Eventually his findings
were published, but not by him. Some other hospitals adopted his
procedures, but many did not.
The upshot was that hardly anyone outside the hospital and
Semmelweis's immediate circle of friends knew anything of what he
had achieved. His superiors eventually had enough of him and it
came as little surprise when his contract was not renewed. In 1850
he returned to Hungary and took up the post of professor of obstetrics
at St Rokus Hospital in Pest (later Budapest).
Here, if anything, conditions were even worse than they had
been in Vienna. The Vienna General Hospital was at least a modern
establishment, but of the eight beds in the obstetric unit at Rokus,
one contained the dead body of a woman who had passed away the
night before of childbed fever; the next bed contained a woman
who was nearing the end of her life. The other six women were in
the final stages of labour, but as they were also suffering from
childbed fever it was extremely unlikely they would leave the hospital
alive. The surgeon in charge carried out post-mortem examinations
every morning before doing his rounds of the wards.
Semmelweis was quick to instigate a programme of cleanliness.
He introduced chloride of lime and rigorous procedures for washing
hands and instruments. By 1856 the mortality from childbed
fever at the hospital was to drop to less than 1 per cent – lower than
he had achieved in Vienna.
After much political wrangling (he was not the first choice for
the job), Semmelweis was appointed head of obstetrics at the
University of Pest medical school. The position sounded better than
it was. The wards were filthy. The facilities consisted of a few
cramped and poorly ventilated rooms in a tenement block. Of those
women who were admitted – and even the poorest women made
every effort to avoid this – a third would die of childbed fever. Again,
Semmelweis introduced his reforms, but this time the mortality rate
remained obstinately high. Then he examined the bedlinen.
In a cost-saving measure, the hospital had taken on a surprisingly
cheap laundry firm. It soon became clear why the price was
so surprising, when Semmelweis realized they were not actually
washing the linen. They seemed merely to collect the stinking
and stained sheets one day and return them in a similar condition
the next. This time disease was being spread not by doctors but
by 'matter' on the sheets. The laundry firm was sacked; the mortality
rate dropped.
In 1857, now in his late thirties, Semmelweis married the
nineteen-year-old daughter of a friend. His young wife gave birth to
five children, the first died shortly after birth, the second from an
infection – neither, at least, from childbed fever. Despite these
tragedies, which were not an unusual occurrence in the nineteenth
century, Semmelweis appeared settled and even declined a job offer
from abroad. He decided it was time to write up his life's work.
When it was published in 1860
The Etiology, Concept and
Prophylaxis of Childbed Fever
was greeted with overwhelming apathy.
Those responses it did receive were generally unfavourable;
Semmelweis' theories were discounted. Prominent surgeons, including
Scotland's James Simpson, lined up to criticize him. Many
surgeons had theories of their own about the causes of childbed
fever, including a suggestion that it was related to swelling of
the Fallopian tubes. The Vienna General Hospital had already
abandoned his 'crackpot' ideas as unworkable. 'We believe that this
chlorine washing theory has long outlived its usefulness,' one doctor
wrote in the
Viennese Medical Journal
. 'It is time we are no longer to
be deceived by this theory.'
Unfortunately, even the most objective person reading the
book would be inclined to treat Semmelweis with a degree of scepticism.
Only a relatively small part of
The Etiology, Concept and
Prophylaxis of Childbed Fever
is taken up with his experiments in
Vienna and his defeat of disease. The rest reads as a bitter polemic
on the way he was treated, underlined throughout by a sense of
frustration that so few people would take him seriously. The
epilogue reads as a morbid and futile cry for help, albeit tinged
with some hope for the future.