Blood and Guts

by Richard Hollingham

  The invention of anaesthesia meant that surgeons had now conquered the third barrier to successful surgery. This, allied with a full understanding of anatomy and the ability to stem blood flow, meant they could now attempt new and more daring operations. People would seek treatment earlier. Women in particular might see a surgeon to have a small lump removed from their breast before the cancer took hold.

  In theory, more lives than ever should have been saved. In practice, more and more people were dying. One out of five patients would probably end up in the dead house. In some hospitals, half of those operated on would be expected to die. Disease would ravage entire hospital wards. The disease even had a name: 'hospitalism'. Admittance to some hospitals amounted to a death sentence, and many people decided they would rather take their chances at home. Despite all the advances in science and medicine, no one could figure out why so many patients were dying.

  NOW WASH YOUR HANDS

  Vienna, 1846

  * * *

  Childbed or puerperal fever was a terrible disease. Within days of giving birth, the mother would start to experience discomfort, soreness and a rising temperature. Abscesses and sores developed and spread across the body, accompanied by a swelling of the abdomen. As the infection spread, it devoured tissues and attacked the vital organs. Meningitis – a swelling in the lining of the brain – might be accompanied by fits and periods of unconsciousness. Few women recovered. And while this was bad enough, in many cases their newborn babies died too.

  In one clinic in the maternity wing at Vienna General Hospital, puerperal fever was killing hundreds of mothers each year. In January 1846, out of 336 births, there were 45 deaths. In February of the same year, 53 out of 293 women died. This was a death rate of 18 per cent – one in five patients.

  There were two clinics at the hospital. In the First Clinic the patients were seen by doctors – mostly medical students. The Second Clinic was run entirely by midwives. When the authorities divided the maternity unit into the two clinics, they expected to see a rise in mortality rates in the ward where the midwives were in charge. It was, they argued, only common sense: midwives received less training, were less scientific in their approach and, of course, less rigorous in their intellect (there were no women doctors).

  But the opposite was happening. In the clinic run by midwives there were far fewer deaths. In 1846 a total of 459 women (11.4 per cent) died in the doctor's clinic compared with 105 (2.7 per cent) in the midwives' care. It was a striking difference – and one that soon became well known throughout the city.

  The two clinics admitted patients on alternate days. The changeover between the clinics was at four o'clock in the afternoon. Women in the advanced stages of labour would delay admission as long as possible so that they would be admitted to the midwives' rather than the doctors' clinic. As a result, women were giving birth in the street or in carriages. Others would run screaming from the hospital or had to be dragged through the corridors when they discovered they'd been put in the First Clinic.

  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 infect
ed, 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.

  When, with my current convictions, I look into the past, I can endure the miseries to which I have been subjected only by looking at the same time into the future?If I am not allowed to see this fortunate time with my own eyes, therefore, my death will nevertheless be brightened by the conviction that sooner or later this time will inevitably arrive.

  The rambling and sometimes vitriolic nature of the book revealed Semmelweis's declining mental health. He had become even more irritable, absent-minded and depressed. He wrote to doctors accusing them of murder for failing to listen to him. He went to the hospital chapel to pray for forgiveness for the deaths he had caused. He took to heavy drinking and visited prostitutes. His wife was being driven to despair. His own doctors suggested he take a holiday.

  The Semmelweis family took a train to Vienna, where they were met by an old friend, Professor Hebra. The professor seemed keen to show Semmelweis his new hospital. Leaving his wife and children behind, he accompanied the professor to see the facilities. The hospital turned out to be the Lower-Austrian Mental Home. Semmelweis was held, tied into a straitjacket and confined to the ward for maniacs.

  When his wife came to visit him the next day she was forbidden from seeing him. It seemed Semmelweis had tried to escape and had been restrained by six attendants. He was being held in a secure cell for his own protection. Accounts are confused about what happened next. Some believe that in being restrained he had in effect been beaten up; others say that he cut his finger (this could also have happened when he was restrained). Within days Semmelweis had become seriously ill: he was feverish, his body swollen, covered in abscesses and sores. Two weeks after entering the asylum, Ignaz Semmelweis was dead. He died from the same disease that had killed his friend Jakob Kolletschka and all those thousands of women.