Shelf Life

Dispatches From the Operating Room

An excerpt from The Invention of Surgery

By Katie Daniels | March 3, 2020
Flickr/VCU Libraries
Flickr/VCU Libraries

“I want to be able to play softball this summer and I don’t want scars,” requests a patient of surgeon David Schneider after falling 20 feet from a zip line, dislocating his elbow so badly that broken bones stick out of his arm. For Schneider, the case is a reminder of the stunning progress the medical community has made over the past century alone—for instance, doctors only began using penicillin to treat infections in 1942. One hundred years ago, his patient’s injury would most likely have been a death sentence. Instead, his patient survives with a functioning arm and unnoticeable scars. In his new book, The Invention of Surgery, Schneider chronicles the “renegades” who pioneered modern medical practices, weaving their stories alongside his own tales from the operating room to craft an engaging overview of the many breakthroughs in surgical history. In the following excerpt, he explores one such life-saving insight, which radically improved the survival of new mothers.

A startling transformation began in the 19th century: hospitals stopped being death houses, and became healing institutions, and even a venue to cultivate life. The French Revolution had transformed physicians’ ideas about the body, and had ushered in an era of uninhibited physical exam of the female body. With an improved scientific understanding of anatomy and pathology, the mechanics of childbirth became interesting to physicians themselves. Childbirth had only ever been commandeered by midwives, but obstetrics arose as a specialty, challenging the supremacy of midwifery. Nobility and the upper classes began choosing to have physicians (rather than mid- wives) deliver their babies in Europe and throughout the Continent. But the ultimate shock was this: women (and their babies) were much more likely to die if delivery was handled by a doctor.

A confounding duality therefore existed throughout the 19th century, wherein women were (directly or indirectly) pressured to deliver with a physician obstetrician in a hospital, in spite of the fact that the known risk of dying was many times higher than delivery with a midwife. What was the cause of death? Puerperal fever, also known as childbed fever. Typically, it would strike a woman in the hours after delivering, and would start as a lower abdominal pain, with a striking tenderness and swelling of the vaginal tissues. A foul discharge of pus would follow, and within hours, a gaseous distention of the belly and a spiking fever would develop. Most patients would rapidly progress toward shock, with shallow breathing, delirium, and profuse sweating in the hours before death. There was simply no effective treatment for a patient suffering from puerperal fever, and there was no explanation. Why—and how—were doctors making matters worse?

Infections were a complete mystery to every generation of physicians, from Hippocrates to court physicians to every emperor and king in Europe in the 19th century. Epidemics had occurred in waves, including the plague, typhoid, yellow fever, malaria, and cholera, but lacking proper science to analyze the means of transmission, and having no way to visualize the culprits, contagions were as scary and insoluble as the demons in a Botticelli or Michelangelo painting. Most theorists pondered the “foul air” associated with an infection, wondering if there was something noxious in the atmosphere (in Italian, bad air is “malaria”). The miasma theory of infection posited that bad air was indeed to blame, and therefore, when puerperal fever was ravaging through a maternity unit, physicians concluded that some phantom agent was responsible. It simply wasn’t in the minds of men to conclude that small germs, bacteria, or viruses, were to blame.

Ignác Semmelweis was always an outsider. Born in Budapest, Hungary, in 1818, to a grocer, he would always speak German with a Buda-Swabian accent, reinforcing his role as a Hungarian interloper in Austria. He transferred to Vienna to complete medical school, and after two years of wrangling for a residency position, Semmelweis landed in the newfound department of obstetrics. Biding time, Semmelweis volunteered in the pathology division of Carl von Rokitansky, focusing on autopsies of women who had perished of gynecological diseases and operations. Alongside Morgagni, Louis, and Virchow, Rokitansky was the one of the major physicians who established Austria and the German nations as the new leaders of medicine by adopting the anatomic pathological basis of disease—the recognition that diseases (and the symptoms they generate) are organ-based. Semmelweis absorbed Rokitansky’s methods of analysis and observation, and armed with the cognitive tools to untangle the mysteries of disease, he solved the enigma of puerperal fever, paving the way for the eventual understanding of germs.

Arriving at the Vienna General Hospital, Semmelweis would have noted the Wiener Gebärhaus, a maternity wing to accommodate single women who were discreetly admitted through a dedicated private entrance. The “Pregnant Gate” was the entrance from the Rotenhausgasse, a narrow alleyway that today faces Austria’s National Bank. In the 1800s, the Pregnant Gate was the covert entrance that was accessed by laboring women, sometimes wearing “a mask or veil, and [were] unrecognizable as they wanted.” Once admitted, the women were directed to one of two divisions: the First Division where deliveries were carried out by doctors and medical students, and the Second Division, where midwives and students of midwifery performed the duties. Assignment was based upon the day of the week, which included weekend admissions to the First Division. With obstetrics gaining a foothold as a separate specialty, a specialized division to handle the deliveries of Vienna’s unwed mothers seemed to be a blessing for all parties involved. The newcomer Semmelweis discovered the horrifying reality that women cared for in the First Division were dramatically more likely to perish from puerperal fever than those attended to by midwives in the Second Division. Puerperal fever would strike in the hours following childbirth, initially causing painful swelling and redness of the birth canal, followed by severe, agonizing inflammation of the skin, and eventual systemic infection and lethal sepsis. Death was an excruciating certainty and an almost welcome respite from the ravages of fever.

Semmelweis began investigating the oddly lethal effect of physician care, and as a young trainee, became responsible for the welfare of the women in the First Division. He “sought knowledge in the library, the autopsy room, and at the bedside, and few of his waking hours were spent elsewhere.” In his reading, he realized his hospital was not unique: there were publications in the preceding decades that detailed similarly poor outcomes among obstetric physician deliveries. In London, between 1831 and 1843, the mortality rate when delivered at home was ten for every ten thousand mothers, versus London’s General Lying-In Hospital where six hundred women per ten thousand died of puerperal fever—a sixtyfold increase. Similar articles from Paris, Dresden, Australia, and America showed the same trend.

Ignác Semmelweis, twenty-nine years old, considered every variable. He contemplated the different techniques of midwives versus physicians, the surroundings, the conditions of the buildings, the exposure of the women to medical students, the way drugs were administered, and the protocol of postpartum care. Semmelweis even altered some of the physicians’ practices to match those of the midwives, including altering the ventilation, but with no change. Doctors were still more dangerous to pregnant women than midwives. Semmelweis was “like a drowning man, who grasps at a straw;” nothing was adding up. If it was not the air, nor the bed linens, and not the delivery technique, what could possibly explain the scandalous difference?

As the awful death hastened by puerperal fever was becoming almost routine for Semmelweis, he continued his daily practice of dissecting cadavers in the deadhouse of the Imperial and Royal General Hospital, thanks to the “kindness of Professor Rokitansky, of whose friendship I could boast . . .” Engulfed in disease, death, fever, and confusion, Semmelweis decided to take a break, and departed for Venice for a vacation, hoping to clear his mind and somehow untangle the clues behind the problem that tortured him.

When Semmelweis returned to Vienna, a catastrophic finding awaited him: his close friend, Jakob Kolletschka, a Rokitansky disciple and forensic pathologist, was dead. Kolletschka had been performing an autopsy days before when his finger was accidentally sliced by a student’s knife. With little delay, Kolletschka became ill, eventually succumbing to a massive infection. His body was dissected by his grieving coworkers, who encountered pus throughout his abdominal cavity and organs in a pattern all too familiar. Semmelweis was understandably traumatized by the grisly nature of his friend’s death, reading and rereading the autopsy transcript, when a shock wave of insight came over him. A decade later he wrote:

Totally shattered, I brooded over the case with intense emotion until suddenly a thought crossed my mind; at once it became clear to me that childbed fever, the fatal sickness of the newborn and the disease of Professor Kolletschka were one and the same, because they all consist pathologically of the same anatomic changes. If, therefore, in the case of Professor Kolletschka general sepsis arose from the inoculation of cadaver particles, then puerperal fever must originate from the same source. Now it was only necessary to decide from where and by what means the putrid cadaver particles were introduced into the delivery cases. The fact of the matter is that the transmitting source of those cadaver particles was to be found in the hands of the students and attending physicians.

Semmelweis realized that his dedicated practice of daily morning cadaver inspection, in an era of no handwashing and prior to the invention of rubber or latex gloves, was leading to the introduction of “cadaver particles” to his own obstetric patients. He concluded, “puerperal fever was nothing more or less than cadaveric blood poisoning.” In a slight twist to the convention of the day, disease was not caused by the smell in the air, but was instead triggered by the particles from the cadavers that generated foul-smelling air. What Athanasius Kircher guessed were “invisible living corpuscula” in 1658 and what Leeuwenhoek referred to as “animalcules” he had visualized with his crude microscopes in 1677, were microscopic creatures that had now become Semmelweis’s enemy.

Already in the 19th century Westerners were using chloride solutions to rid homes and workplaces of the noxious odors of putrid materials; Semmelweis reasoned that chloride’s effectiveness was the destruction of the particles themselves. Within two months of Kolletschka’s death, a bowl of chlorina liquida, a dilute concentration of the disinfectant, was placed at the entrance to the First Division, with the order that every medical attendant wash his hands. Within months, the puerperal death rate plunged, until it was equal to the midwives’ ward, where no handling of the cadavers had ever been performed. The seeds of a revolution were sown and, in Vienna alone, the lives of thousands of women were poised to be saved.

Excerpted from The Invention of Surgery by Dr. David Schneider, published by Pegasus Books. Reprinted with permission. All other rights reserved.

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