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A READER'S JOURNAL
The Cry and the Covenant
Published by Garden City Books/NY in 1949
Book Review by Bobby Matherne ©2010
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This is a book that begged for a re-reading. I first read it almost twenty years ago while taking a course in Dr. Andrew Galambos' Volitional Science from Evan Soulé — it was part of the reading library that he provided for students of the course. Ignaz Semmelweis, whose story this is, was a pioneer in medical prophylaxis, the innovator of hand-washing and antiseptic solutions for surgeons and obstetricians. Unbelievable as it seems, professors and their students in medical universities went from the dissecting room, where they demonstrated and practiced delivering babies from cadavers, to the Lying In rooms where they examined women about to give birth — all without washing or disinfecting their hands. A gratuitous rubbing of their bloody hands on their lab coats was considered ample readiness, and in fact the presence of bloody matter on their coats was deemed almost a badge of honor. Semmelweis turned that all around in a revolution that was to save millions of new mothers' lives all over the world. Did the majority of the doctors take kindly to removing their "badges of honor" for the sake of saving lives? One would think so, and one would be very wrong. Therein lies a tale, one that Morton Thompson relates in all the gory details. So gory that even with a movie-going public enured to scenes of violence and gore, one cannot imagine a movie made that incorporates details of screaming bloated women filling a maternity ward and closeups in the dissecting rooms where women who had recently died from childbed fever or puerperal fever were used to practice deliveries in the dissecting room. The upper torso was removed and the lower torso was prepared by inserting a dead baby in preparation for delivery. After about a dozen deliveries, new cadavers and babies were brought into replace the old ones.
Semmelweis was a country bumpkin from Hungary in the sophisticated milieu of Vienna and his cup of social graces was as empty as his font of empathy for his patients was full. Exactly the opposite of what the noble profession of medical doctor, surgeon and professor of medicine required. Also he had a dangerous penchant for innovation that was unwelcome in a university whose job was deemed to be that of teaching what was known of medicine as it existed at the time. Childbed fever had always existed and always will, one of his friends told him. Ignaz, or Naci, as his friends called him, rebelled at the thought that there was no hope for stemming this carnage of human life. Unanswered questions filled his thoughts: Why did the women who gave birth in the streets not die of childbed fever? Why was the rate of death in the Second Ward one-third that of the First Ward? Why was the rate in Vienna so high compared to England? To France?(1) And most importantly what was the etiology, the one true cause of childbed fever?
There was no dearth of explanations of what caused childbed fever: mother's milk, errors in diet, chilling, gastric-bilious fever, miasma, congested rooms, bad ventilation, male sperm, fear, constipation, modesty, epidemic peritonitis, and so on. The remedies to be applied to prevent death were as diverse as the suspected causes.(2) When Semmelweis finally gets complete control over a small maternity ward back home in Hungary, his superior prescribes bowel purging as the remedy of choice to a condition he is convinced is due to constipation. Semmelweis was given free rein, as long as he prescribed purging, to insist on hand cleaning and antiseptic washing with a hypochlorite solution and the deaths went to zero the first year. Did his superior proclaim Semmelweis' success as due to prophylaxis? Not at all — his superior attributed his success to Semmelweis' assiduous application of bowel purges.
Let's see what his first boss, Dr. Klein in Vienna, taught him about childbed fever and how he was supposed to react to it:
[page 170] "Henceforth, Dr. Semmelweis, you will regard puerperal fever as an ailment traceable to milk. You will regard it as an aliment for which no human mind has ever found a remedy. No remedy ever will be found. You will accustom yourself to the unhappy incidence and the consequent fatalities of this disease as one of the normal expressions of living and of giving birth, and you will behave toward it as a doctor is expected to react to the inevitable occurrences of life and of death."
And what was this medical director's authority for saying this? None other than the words of the Emperor of Austria himself, which were spoken when he founded the division. Here is how Semmelweis' boss instructed him, quoting the Emperor's words directly.
[page 171] "'Keep yourself to what is old, for that is good. If our ancestors have proven it to be good, why should we not do as they did? Mistrust new ideas. I have no need of learned men. I need faithful subjects. He who would serve me must do what I command. He who cannot do this or who comes full of new ideas may go his way. If he does not, I shall send him.' Do you understand, Dr. Semmelweis?"
How did Semmelweis begin his search for a cure for childbed fever? In the diseased bodies of the dead women themselves, in the autopsy room. Surely the answer would be found there, right in the diseased tissues. Corpse after corpse he dissected and always noted the same milky fluid, the same inflammation of tissues, but never a clue as to the cause. As he searched for the answer to the horrendous deaths of the women, he was taking his hands from the autopsy room to the delivery rooms and causing more deaths. Somehow he had to look somewhere else for a clue. The first clue came in the statistics. He began tallying the deaths by ward and found a huge difference between two otherwise identical wards of the hospital. The First Division had three times as many deaths as the Second Division. The Second trained only midwives and the First students. Perhaps the men were rougher with the women, their bigger hands, etc, came the hypothesis from the head of the Second Division. Not much help, but here was a doctor making a systematic study of the etiology of a disease from statistics, perhaps for the first time in history.(3)
Still the big break was to come with the unfortunate death of Kolletschka, a colleague of his who had his finger stabbed by a student during an accident while teaching dissection. He developed a fever and died. Ignaz was out of town when his friend died, and decided to review the death certificate for the medical findings. To his amazement, the descriptions of the autopsy on his friend matched that of every autopsy he'd done of a case of childbed fever. What if the dreaded fever was not specific to women, but was due to cadaveric poisoning? It would be simple to test: simply wash one's hands and disinfect them and see if any deaths occurred. Ah, if life in the real world of intrenched paradigms and university politics were as simple. Semmelweis began using a liquid chlorine which was too expensive, so he had to innovate a solution of chlorated lime that was strong enough to remove all traces of the smell of the autopsy room from his hands. Then he began insisting that every student wash his hands and dip them in the chlorated lime solution before working on women in the delivery rooms.
The students who balked, he discharged them. Some of the students fought back and his boss, Dr. Klein, insisted that he drop the hand cleaning. Semmelweis persisted with his washings and eventually Dr. Klein had Semmelweis removed from his position at the hospital. As soon as the washings were removed, the death rate of the women returned to where it was before, almost 30% at times. One in three of the thousands of women per year who came into the First Division died within days after a normal child birth experience. To Dr. Klein, this was the natural order of things; to Dr. Semmelweis, this was grotesque murder. Semmelweis made this observation to a colleague:
[page 252] There will always be doctors like Klein. I don't think the Kleins of the world are in the majority. But while other doctors are healing people, the Kleins are making a secure position for themselves. They don't use medicine to do this. They use the protection of medicine and the politics of medicine. And because of the way medical liberals split up among themselves, it's the Kleins who really run the universities and the hospitals.
Not all his students rebelled at Semmelweis's washings. One day a group of six students, all graduates, came to see him.
[page 211] He looked at them expectantly. There were all graduates. Kussmaul of Deidelberg, Stendrichs of Amsterdam, Routh of London, Arneth who was replacing Zipfel; Wieger of Strassbourg, and Schwarz of Kiel. . . . "We want you to know we believe in you, sir," blurted Routh. "We have seen your doctrine work. We have seen what we have seen. Our term is ending. We are going to carry the news when we go home. And in the meantime we have divided Europe among us. We each of us will write to our professors at home. We each will write to the chief obstetrician in our cities. We have taken the liberty, sir — with your permission — the letters are already written . . ."
[page 212] The letters of the graduate students went into the cities of the world in early January. They were received in the British Isles where puerperal fever mortality records were the lowest in the world but where there was puerperal fever and even occasional epidemics of it, and where puerperal fever was for the most part regarded as a miasmatic contagion passed from patient to patient, or interpreted as scarlatina, erysipelas, or zymotic disease.
In the book, Plague Time, published in 2000, Paul W. Ewald wrote about Arneth taking Semmelweis's message to Edinburgh and laying the foundation for the reception received by Joseph Lister's work which followed there soon after Arneth's presentation.
[page 18 of Plague Time] Over a decade later, in 1851, while Joseph Lister was finishing his medical studies in London and Semmelweis was starting work at St. Rochus Hospital, the staunch Semmelweis supporter J. F. von Arneth arrived in Edinburgh to present Semmelweis's findings after having been rebuffed by leading Parisian obstetricians. . . . The 24-year-old Lister moved to Edinburgh a year later. Though Lister missed von Arneth's presentation, the responsive atmosphere in Edinburgh must have fostered the line of thinking that he would soon formulate.
Ewald adds a comment that Lister's work was better received than Semmelweis's because Lister "had friends in high places." Perhaps so, but Lister also stood on the shoulders of Semmelweis, and Semmelweis mostly stood alone.
One of these students, J. F. von Arneth, explained to Semmelweis how he saw the situation of medicine vis-a-vis his innovation, and innovations in general.
[page 301] "Do you know," said Arneth slowly, "it's true of your discovery as it has been of every discovery in the whole history of medicine. When we take our medical oath we undertake to lengthen life and ease suffering. We are all united in seeking new means. And every time a man has come forward with a demonstrable truth, a remedy for good, the profession seems to have done its best to crush the discoverer and hide the discovery. No quackery — no criminality — nothing seems to make us so furious as a discovery."
Finally Semmelweis was stripped of his position at the university by Klein and was blocked at every turn from an appointment as Privat-Dozent, or private practice where he could use and teach students to use his methods of prophylaxis. Running out of money he returned to Hungary and worked in a very small clinic where he was allowed free rein to practice his methods and the death rate from childbed fever went to zero, all the while the wards of the prestigious Lying In Hospital in Vienna remained a scene of grotesque carnage. He published papers around the world and the journal editors added footnotes to the effect that “Everyone knows the cause of childbed fever is x.” where x was whatever their pet theory was. He wrote a book on his work, but those that needed it most never read it, because it was a new theory and they were in a profession that respected the old tried and true methods.
Semmelweis died in obscurity in Hungary at the age of about fifty, but the work that he pioneered has subsequently saved untold millions of lives. As Naci's friend said to him once, "As long as there are trees, there will be crosses." Ignaz Phillipe Semmelweis took up his cross at a young age and single-handedly wiped out the scourge of womanhood known as childbed or puerperal fever. Not only a martyr to the medical profession, but a martyr to every innovator who makes a discovery that can ease the pain of humanity and benefit every one till the end of time.
---------------------------- Footnotes -----------------------------------------
Footnote 1. Semmelweis was later to discover that in England no dissecting was done at the maternity facilities, and in France the doctors-in-training hired prostitutes for their training in gynecological inspections, using live bodies instead of dead ones as they did in Vienna. This helped to explain the two countries' low incidence of childbed fever. [Note: Semmelweis is pronounced as if it were spelled "zam-mel-veis".]Return to text directly before Footnote 1.
Footnote 2. Can you think of modern day diseases for which a plethora of supposed causes exist? The remedies of choice depend upon which cause the doctor is predisposed to. Some diseases that come to mind are: depression, bipolar disorder, and fibromyalgia. The moving from one treatment, one drug, to another is a sure sign that the root cause of the disease is still a wild guess, but most doctors of today, the Dr. Kleins, act as if they were positive of the cause and the remedy.Return to text directly before Footnote 2.
Footnote 3. Semmelweis’ method of studying statistics to root out causes of diseases seems to me to be the most common form of medical research in recent years. Any time the medical condition of a suspected group of people is compared to a control group, the researcher is using this technique. It may be that Ignaz Semmelweis was the first researcher to do this type of statistical study of diseases, and if so, he deserves credit for this innovation as well.Return to text directly before Footnote 3.
Any questions about this review, Contact: Bobby Matherne
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