The Doctor's Plague by Sherwin B. Nuland
The Doctor's Plague: Germs, Childbed Fever, and the Strange Story of Ignace Semmelweiss
Sherwin B Nuland
Atlas Books W.Norton & Company, New York and London.
191 pp. 21.95
ISBN 0-393-0 5299-0
In its early days, modern medicine struggled with recurrent epidemics of a doctor-induced disease, a fatal infection killing mothers as they were giving birth. The disease began its malignant spread with the building of hospitals and became endemic all over Europe.
Autopsies had become a recognized method of training physicians. "When corpses were opened on the autopsy table, they released a stench so foul that medical students vomited and fainted when encountering it for the first time." Ignace Semmelweiss pioneered the discovery that it was doctors who left the dissecting table to deliver pregnant women who were creating this carnage. He himself became a psychological victim of his unpopular discovery, and died insane.
Medical writer Sherwin Nuland, a scholar and surgeon, has brought the discipline of historical research, the curiosity of a detective, and professional fascination with medical details into the story of Semmelweiss's success and failure. These epidemics occurred prior to the discovery of the germ theory of disease. Doctors had a vague concept of infection or contagion, considered to be spread by foul air, a kind of localized miasma. No treatment was effective. Given the panic aroused by its prevalence, the disease was sometimes attributed to fear, or even modesty felt by women exposed to so many male eyes and hands. A whitish fluid found during autopsies, bacterial pus, was thought to be milk ducts.
"One of the remarkable phenomena familiar to the staff was the frequency with which the mothers would become sick in rows all at one time...each woman in labor was formally examined in rounds twice a day, in the morning by the professor and in the afternoon by the assistant. They would proceed from one bed to the other, contaminating each patient in sequence. After chloride of lime hand washing was instituted, the outbreaks ended."
Semmelweiss discovered that the disease was always preventable if doctors delivering pregnant women washed their hands. His finding came about because of his training-- a method of reasoning based both on meticulous clinical observation and painstaking time spent doing autopsies, observing minute changes in organs. Understandably, doctors were shocked. They were reluctant to accept his doctrine, or Lehre, as it was named, even though it was known that women who were delivered by midwives were spared. Still, it was hard to deny the detailed statistics gathered at the Algemeine Krankenhous, at the time the most progressive hospital in Europe.
Semmelweiss had the bad luck to pursue his medical career during the revolution of 1848. All over Europe mobs were rioting in the streets, and the established political order was in danger of being overthrown. Nuland notes that "students and young faculty who supported the revolution created a uniformed group which they named the Academic Legion. Semmelweiss openly wore the uniform of the Legion, making it clear that he was in sympathy with the goals of the rebels." Semmelweiss's superior was a political appointee, who represented the old guard very much at odds with the new scientific thinking in the minds of the younger faculty. In spite of his dramatic discovery Semmelweiss was not reappointed to his position as assistant obstetrician.
Hungarian-born, Semmelweiss retreated to a far more primitive institution at the University of Pest. Lacking the support of the sympathetic colleagues he had had in Vienna, he had less power to convince the staff of the necessity for his sanitation requirements.
"He was obliged to teach in the corridors or in any available room he could find. His impatient and verbally abusive response to laxity alienated many. It soon became obvious that some of the physicians and nurses were doing their best to circumvent the rigid rules regarding cleanliness and chlorine."
Nuland is careful to avoid presenting Semmelweiss as a kind of medical saint, martyred by the profession he served. Rather he points out his mistakes-- his lack of experience in the new field of microscopic studies, or the techniques of controlled experiment, which were just beginning, as part of his failure to convince. Semmelweiss' mental health began to degenerate. He became more and more obsessed and erratic in his behavior. At a faculty meeting when he was expected to deliver a report, he was inarticulate and could do nothing but repeat the Midwife's Oath. He was taken to a mental hospital. Judging from the autopsy report, Nuland thinks he died of violence at the hands of attendants subduing him.
Still the question arises--given the overwhelming consistency of the statistical data even under worse circumstances, was it really Semmelweiss's personality deficiencies that prevented him from achieving wide acceptance of a technique so simple, effective and of such great service to humanity?
Nuland's scrupulous research can offer a different interpretation. Every radical new idea is a challenge to a context of previously accepted ideas. The Semmelweiss affair was a conflict between two camps of medical thinking. He also sets it into the social context of radical political turbulence threatening the overthrow of governments, as well as the self interest of physicians eager to retain their image, as well as their livelihoods. In America one prominent physician denied the theory completely, but was careful to wash his hands anyway-- why not?
Medical history has numerous examples of institutional reluctance to change, and individuals to acknowledge error. In the authoritarian British navy sailors died of scurvy for decades after the more pragmatic merchant marine introduced fresh limes into the sailors' diet, giving them the nickname limeys. In our time, in the fifties, the nutrient folic acid was eliminated from a standard multiple vitamin mineral pill, on the flimsy reason that its presence obscured the result of a rarely used test. Now fifty years later, it is recognized as a vital nutrient necessary for the prevention of a number of diseases. Even more recently menopausal women have been treated with estrogen from pregnant mares and artificial progesterone with the promise that these drugs would diminish their changes of incurring breast cancer and heart disease, promises not supported by research. The drugs are, however, heavily supported by pharmaceutical companies protecting their patents.
The message of Semmelweiss' struggle goes beyond a dramatic human interest tale of an individual's brilliance and personality failure. Some would say that it could call attention to the need for more handwashing and careful sanitation in today's hospitals. But then as now, institutional resistance to change in accepted ideas, and economic interests as expressed through medical culture create ongoing problems which may be as obscure to us now as childbed fever was in Semmelweiss's time.
Phyllis Ehrenfeld has received the Arnold Gingrich Award in prose for the most highly evaluated fellowship from the New Jersey State Council for the Arts. She has been Editor of the American Anorexia Bulima Associaton for many years. Several of her plays have been presented as staged readings in the Bergen County area. She is presently representative to the united Nations for the National Service Conference of the American Ethical Union.
The Doctor's Plague: Germs, Childbed Fever, and the Strange Story of Ignace Semmelweiss
Sherwin B Nuland
Atlas Books W.Norton & Company, New York and London.
191 pp. 21.95
ISBN 0-393-0 5299-0
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