In engrossing detail, Obenchain recreates for readers the sights, smells, and activities within a hospital of that day. In an era before the acceptance of modern germ science, physicians saw little need for cleanliness or hygiene. As a consequence, antiseptic measures were lax and rudimentary. Especially vulnerable to contamination were new mothers, who frequently contracted and died from childbed fever (puerperal fever). Genius Belabored follows Semmelweis’s awakening to the insight that many of these deaths could be avoided with basic antiseptic measures like hand washing.
The medical establishment, intellectually unprepared for Semmelweis’s prescient hypothesis, rejected it for a number of reasons. It was unorthodox and went against the lingering Christian tradition that the dangers of childbirth were inherent to the lives of women. Complicating matters, colleagues did not consider Semmelweis an easy physician to work with. His peers described him as strange and eccentric. Obenchain offers an empathetic and insightful argument that Semmelweis suffered from bipolar disorder and illuminates how his colleagues, however dedicated to empirical science they might have been, misjudged Semmelweis’s methods based upon ignorance and their emotional discomfort with him.
In Genius Belabored, Obenchain identifies Semmelweis’s rightful place in the pantheon of scientists and physicians whose discoveries have saved the lives of millions. Obenchain’s biography of Semmelweis offers unique insights into the practice of medicine and the mindsets of physicians working in the premodern era. This fascinating study offers much of interest to general readers as well as those interested in germ theory, the history of medicine and obstetrics, or anyone wishing to better understand the trajectory of modern medicine.
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Childbed Fever and the Tragic Life of Ignaz Semmelweis
By Theodore G. Obenchain
The University of Alabama PressCopyright © 2016 University of Alabama Press
All rights reserved.
On a sweltering midnight in July 1846, Erna, obstetrical head nurse at the gigantic Vienna General Hospital (Allegemeine Krankenhaus) approached the entrance to the physician's on-call room. Looking up at the door, she gave a series of crisp, rapid knocks, only to have the urgency of her visit entirely wasted on the room's occupant, Ignaz Semmelweis, newly appointed assistant accoucheur (obstetrician) in the Obstetrics Department's First Division. He lay in his call quarters in the deep sleep of exhaustion, having just endured a hectic twenty-four hour marathon of deliveries, a rude introduction to his first week on duty. Finally aroused from sleep, he staggered to open the door, leaning heavily upon its casing. Upon seeing Semmelweis, Erna began expressing her unease concerning a young mother who appeared to be developing medical problems a mere twenty-four hours after her delivery. Realizing that the seriousness of this problem would require his visiting the ward, Semmelweis turned to a washbowl, throwing some cool water onto his face, giving Erna just enough time for a quick visual assessment of his quarters. Furnished with only a chair, a chest of drawers, and a straw-stuffed mattress lying upon something more like a cot than a bed, it was depressingly Spartan by any definition. For a man only two years out of medical school, being the obstetrical assistant was a position equivalent to a modern chief-resident in a major university teaching hospital. Any physician successfully surviving the rigors of his chosen specialty at this famous Vienna hospital could be virtually assured of a prestigious position somewhere in Europe upon leaving the confines of arguably the finest hospital on the continent.
Semmelweis, by now, had become fully aware of his surroundings. After donning a cover gown, giving his moistened hair an obligatory swipe with the palms of his hands, he exited his room, proceeding with Erna along a corridor poorly illuminated by lantern-light. After traversing two lying-in wards of expectant women, he entered a cavernous gymnasium-like room with beds arranged in rows, one along each wall and a third coursing down the center. So closely arranged were the adjacent beds that each occupant could easily reach out, both right and left, and touch the outstretched arm of her neighbor. Lack of personal space on such wards was a given. If one wished for privacy, the best she could hope for was some empathetic nurse placing curtains around her bed. As Semmelweis approached the proper row of beds, peering through the lantern light, he immediately recognized his patient, a puerile-appearing sixteen year old, lying supine, with eyes closed. He could not escape the irony; she seemed a mere child on Monday, yet was a mother on Tuesday. Just to be certain he had the right patient, he made that confirmatory glance at the chalkboard above her bed displaying the name, "Renate." She had been a resident of the ward for the past six weeks, that is, since the time her pregnancy made it impossible to continue work as a chambermaid for a prominent Viennese family. Renate, like most of her ward-mates, was going through the delivery without the support of the child's father. After she informed him of her gravid state, he pulled a sudden disappearing act, leaving her alone to grapple with her sudden change of fortune. Still, she had actually looked forward to the birth of her child, unlike many of the single women on the ward, despite the expected financial hardship brought on by single parenthood. She enjoyed the good fortune of having a sister and some devoted friends who had volunteered to help with her childcare.
Renate's delivery had presented a problem for Semmelweis and his team. Her labor had progressed slowly and inefficiently, something not uncommon in primiparous women, those experiencing their first deliveries. With his usual retinue of four medical students in tow, Semmelweis had closely monitored her progress through labor with frequent pelvic examinations. Each student, by ministerial edict, was obliged to examine the patient after Semmelweis. What better way for a student to become familiar with the changing dynamics of labor? Ordinarily, a solo accoucheur might carry out three to four exams during the eighteen hours of such a difficult labor. But, taking the four medical students and their examinations into consideration, in reality, four exams meant twenty individual internal probings over the full course of labor. Yet, one could argue that being vigilant was wise. Serial examinations enabled the obstetrician to remain alert to upcoming problems. He could intervene more expeditiously should some emergency arise. One could better assess how the uterus was progressing through labor either by direct palpation of the abdomen, or by feeling with the finger tip. Were the contractions strong? Was the cervix dilating and effacing (thinning out) adequately? Was the proper part of the fetus engaging appropriately in the upper pelvis before beginning its descent into the lower part of the birth canal? The earlier the obstetrician detected some problem with the fetus or labor, the more timely could his intervention be on behalf of both mother and fetus. If a child presented in a mal-rotated state, with perhaps an arm and shoulder engaging the pelvic brim, a simple manual rotation of the fetus by an alert obstetrician could avert disaster, saving the life of both mother and child. Certain other problems might require the rare employment of forceps or even, as a last resort, a Caesarean section.
Although Renate's labor had been difficult and prolonged, she required none of these measures, finally delivering spontaneously after eighteen painfully long hours. Both mother and son appeared to have survived the ordeal with no obvious problem. Per hospital protocol, Renate walked back to her bed, unassisted, three hours after delivery. With liberal doses of laudanum (tincture of opium) she could finally relax. Now, nearly twenty hours later, as Semmelweis examined her in the flickering lantern light, he could feel the dried residue of sweat on her face and in her hair. Noticing her parched lips and dry tongue, he recalled having admonished her, shortly after delivery, to begin drinking the barley water at her bedside as he exited the ward around 4:00AM. Now, with her vomiting, fluid intake posed a problem.
Even though her pulse was only mildly elevated, barely over one hundred beats per minute, it was too high for this stage of her delivery. The nurse reported a temperature of 100° F, now twenty hours after delivery. She appeared moderately distressed, complaining of nausea, malaise, and some ill-defined abdominal pain centered just above her pubic bone, but she was alert and capable of full activity. As he applied a stethoscope to her abdomen, only the rarest of bowel sounds were evident, indicating a worrisome lack of bowel function. Semmelweis had his suspicions about the dreaded puerperal fever, but in her present condition he could detect no definitive signs that would make the diagnosis a certainty. Nor could he be absolutely certain of her future course at such an early point in time. Such uncertainty allowed him to put up a positive front to the patient without feeling dishonest. He informed Renate that he suspected an inflammation in her uterus (metritis) or fallopian tubes (salpingitis). As long as the inflammation remained localized, it might very well resolve of its own accord. He offered a treatment plan to her: more laudanum for her pain and the application of abdominal poultices. In spite of her nausea, the nursing staff would continue encouraging fluids, the barley water, to minimize her dehydration.
Now that Semmelweis was fully awake, his sleep interrupted, he remained up, retreating to another part of the ward to address other miscellaneous items. When he returned to Renate an hour later for an update on her symptoms, even from a distance he noted a worrisome subtle change. While lying on her back, she subconsciously held both hips and knees in a flexed attitude. Something about that position brought her relief — a reduction in a painful tension she sensed emanating from her lower belly. Alerted, Semmelweis pressed his fingers into her lower abdominal wall, causing her some nondescript discomfort. More significantly, when he suddenly released his pressure, her pain increased dramatically, to the point of making her cry out. She had rebound pain, an early sign of peritonitis, a serious inflammation of her abdominal lining.
Despite being a comparative novice, Semmelweis had already witnessed too many heartrending cases of puerperal fever beginning in just this manner. He had an ominous foreboding — a dread for what was likely in store for this innocent young woman — and sensed the incipient stages of a nightmarish scenario. It reduced Semmelweis, this idealistic caregiver, used to being in control, to the uncomfortable position of observer, powerless to slow the fulminating process in any definitive manner.
Semmelweis made brief visits, short spot-checks, to her bedside throughout the night. By 2:00 AM her pulse remained elevated, while her temperature had risen to 102°F. Her abdominal pain was worse. Although she could respond appropriately to most questions, she had become delirious, tremulous, and confused. On this exam, Semmelweis noted red streaks, central lines sprouting off short tributaries at random, like scarlet sprigs of thyme, coursing from her upper-inner thighs along the pale-white skin of her lower abdominal wall. Adding to his disquiet, he discovered small, swollen, bluish-black spots of discoloration in the skin of her private parts. Of equal concern, her lochia, the normal discharge after delivery, had become strongly malodorous. It was the stench of putrefaction. As he stood over her supine figure, Semmelweis noted the sudden onset of uncontrollable shaking throughout her body, accompanied by a chattering of teeth that persisted for several minutes. To the uninitiated, her movements might have been mistaken for a convulsion. But Semmelweis recognized the event for what it was, the onset of blood "crasis," a mysterious, fermentive degeneration taking place within her bloodstream — a grave and irreversible development. Too bad his medical students were home in bed, sleeping through such a teachable moment. The full understanding of blood crasis, or "blood poisoning" as an infection within the bloodstream was not yet appreciated. In fact, it would take decades and full elucidation of the germ theory before physicians recognized the shaking and chattering for what it truly represented — the sudden invasion of massive numbers of bacteria into the bloodstream. But Semmelweis, through prior cases, was experienced enough to know that Renate's future was now all too clear. Her uncontrollable rigors signaled the onset of fulminating disease, her calamitous descent over the medical precipice. In this era before antibiotics, her death was a foregone conclusion.
After a short and fitful night, Semmelweis arose around 6:00 AM. Per his usual routine, he proceeded immediately to the dead house, the hospital morgue, a converted old rifle factory where autopsies were performed on all patients dying within the hospital. Semmelweis had been fortunate to work out an agreement with his pathology professor that allowed him to perform autopsies on all patients dying within the maternity department. Puerperal fever represented, by far, the largest percentage of such deaths. After completing his morning dissections over the course of several hours, he gave a perfunctory wipe of his hands and arms with a dry cloth. Next he washed them thoroughly with soap and water. Still, as he left the morgue, negotiating the stairway to the obstetrics floor, he could not help but notice. Not that it was anything out of the ordinary, but his hands still reeked of putrefaction, the fetid odor of death. But he was used to that. Despite the most vigorous scrubbing with soap and water the aroma was not easily washed away. After performing autopsies daily over a period of time one became inured to the odor. It seemed to penetrate all layers of the skin. By the time he reached the maternity ward, all thoughts of putrefaction had been pushed to the back of his mind. His concerns switched, instead, to the patients awaiting his attention.
As he approached Renate's bed, Semmelweis was hardly surprised to see that she was worse. Obviously, the feeble attempts at treatment had been pitifully inadequate. The nurse reported a fever of 104° with a pulse of 150. Bending closer to her, he noted that her lips and nail beds were a dusky-blue. When he addressed her by name she mumbled something about Hans, the absentee father of her newborn, but her ramblings were largely unintelligible. To better assess her level of consciousness, Semmelweis rubbed a knuckle across her breast bone causing her eyes to open briefly. She raised her arms moving them about in an aimless manner. By now, her abdomen was rigid, like the skin of a drum, and so distended it could be detected from across the ward. As paroxysms of pressure coursed through her abdomen she shrieked out in pain. Those red streaks, incipient when he had first seen her abdomen at midnight, had now coalesced into full bloom. The massively swollen soft tissues of her private area had turned a shade of deep blue-black. Deprived of their blood supply, these tissues were dying. Then, as Semmelweis stood at her bedside, Renate suffered a true convulsion, beginning first with a twitching of her face, then her arm and leg, all confined to her right side. Within seconds the seizure spread to all of her extremities, continuing for nearly a minute. Then a slow decrescendo of spasms ensued until she lay completely immobile, utterly flaccid throughout, not even breathing for nearly a full minute. Just as the nurses began wondering if she were dead, her breathing returned in a slow crescendo, along with improvement in her coloring. But she was moribund, flaccid, and deeply unconscious. It was all but over.
Charged with other patient responsibilities, Semmelweis and his medical students continued on with their working rounds. Still, as he progressed from one bed to another, he could not help but cast nervous glances back to where Renate lay. Finally, when he observed the nurses pulling the duvet over her face he knew it was over. Her body would remain in bed and on the ward for hours until hospital staff could make a place for her in the morgue. She would be on Semmelweis's autopsy schedule for the following day — another in a long line of tragic deaths. One could not help but reflect on the sad ending for this young woman who had entered the hospital in such a cheerful and optimistic state. She was now but another in a long line of new mothers succumbing to puerperal fever, the scourge of maternity wards the world over. One wry observation circulating around the morgue from time to time highlighted an all too frequent grim scenario: "Enter the hospital, have an operation, end up on the dissecting slab," or, expressed more tersely, "Diagnose, Operate, Die, Dissect." High mortality rates from puerperal fever had been a problem for over one hundred years, persisting well into the nineteenth century. As late as 1879, noted French accoucheur, Jacques Hervieux, observed, "Epidemic puerperal fever is to women what war is to men. Like war, it cuts down the healthiest, bravest, and most essential part of the population; like war, its victims are in the prime of their lives."
Even though Semmelweis brought a high level of enthusiasm to his dissections in the early stages, the continual onslaught of puerperal fever victims gave him no opportunity to gain any emotional respite from dealing with the deaths of young women in his charge. Entering the morgue each morning preparing for his string of autopsies did little to assuage his angst. Handling such events had posed little problem for him when he was a medical student, merely passing through the morgue and a course in obstetrics. Objectifying the dead and dying had been easier. While that stark image of some anonymous, hoary human form lying supine on the autopsy table may have made an impression on him, he was not personally connected to it. Any image of the unknown dead that may have occupied his mind immediately slipped out of mind as he left the premises, going on to other pursuits.
But now, as prime caregiver to these young women, the situation was far different. His close identification with them was inescapable. However brief the interaction with his young patients might have been in their days of confinement, he knew them. In Renate's case, they had shared some light moments. She had even related how eagerly she anticipated her child's birth. How could he not vividly recall Renate's personality? Seeing her body lying supine on the autopsy slab, one would have to be heartless to blithely dissociate from her past, and from her tragic recent history. With the usual waxing and waning of puerperal fever on the wards as many as perhaps a score of women per week died under his care. He autopsied them, one and all, in an unremitting scenario. The steady drumbeat of young women dying on the wards, their bodies then arriving in the morgue week after week weighed heavily on the young assistant.
Excerpted from Genius Belabored by Theodore G. Obenchain. Copyright © 2016 University of Alabama Press. Excerpted by permission of The University of Alabama Press.
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Table of ContentsContents List of Figures Introduction Puerperal Fever Prodrome Old School; New School Vienna General Hospital Puerperal Fever Theories Assistantship Enlightenment Revolution Semmelweis Speaks Budapest Aetiology Reaction to Aetiology Open Letters Illness and Descent Lower Austrian Mental Asylum Resurrection Notes Bibliography Index