The entry says that Skoda tried to make the institution read the result and that the Ministry forbade it. This piece tells how, from Skoda’s own account to the Imperial Academy of Sciences on 18 October 1849 and from the letter Michaelis wrote from Kiel. The three evenings of 1850 on which the Society of Physicians argued it out are in the companion piece on the forty-one post-mortems. All quotations are translated from the German by the writer of the entry.
What Skoda thought he had
Skoda’s lecture, printed in the Academy’s proceedings and reprinted in Győry’s edition of Semmelweis’s works, is the clearest statement of the case that anyone made in the 1840s, and it was made by a physician, not an obstetrician. He opened by calling it “one of the most important discoveries in the field of medicine,” and divided his lecture into “the facts and conclusions from whose combination the discovery arose” and “the measures that seemed necessary to put the discovery beyond doubt.”
The facts were five. First, that for decades the lying-in women of the hospital had sickened and died more often than women outside it, “although the care in the institution was better than is possible among country people and the less prosperous townsfolk,” and that during the worst of it nobody had seen more women fall ill in Vienna or in the country, which “had to remove every thought of an epidemic cause directly active in producing the puerperal diseases.” Second, the table of the two clinics from 1839 to 1846, printed in the companion on the tables, with his judgment of the explanations that had been offered: that medical treatment was to blame, which “overlooked only the circumstance that the medical treatment on the two divisions was not different”; that the women’s modesty was wounded by the presence of young men, “an opinion that only someone wholly inexperienced can hold”; that the institution’s bad name frightened the women, which “left the beginning of the frequent illnesses out of account,” since the bad name had come from the deaths. Third, what the Vienna school of pathological anatomy had found in the bodies: that the puerperal disease began as an exudation on the raw inner surface of the womb or as pus in its veins, and became pyaemia, “pus-formation in the blood.” Fourth, that the usual explanation, a peculiar constitution of the blood in lying-in women excited by a chill or an emotion, “was again contradicted by the highly unequal number of illnesses on the two divisions.” Fifth, that pyaemia without a prior suppuration “arises, according to experience, through the action of putrefying animal substances on the blood,” and that after delivery the womb was a wound.
So “the question had to be raised whether in any way putrefying, or putrefaction-exciting, substances could come into contact with the genitals of the lying-in women.” Semmelweis, “after weighing all the circumstances for some months,” had recognised that he and the students dissected constantly, that “the cadaveric smell disappears from the hands, despite repeated washing, only after a long time,” and that they “not seldom went straight from the examination of the corpse to the examination of the parturient.” It was “the only possible way” for putrefying matter to reach the women, and “at the same time the only one among the possible causes of the puerperal diseases that was either not at all or only in a very limited measure active on the division for midwives.”
Skoda then added what Semmelweis’s own account leaves implicit: that the quiet months of December 1846 to March 1847 and the terrible April and May “agreed perfectly with the supposition that the disease-making potency came from the dissecting room,” because the assistant in those months “for reasons that do not come into consideration here, seldom visited the dissecting room, and the native students, whose number had moreover been reduced from 42 to 20, seem to have followed the assistant’s example. The foreigners were excluded from the institution altogether. At the end of March 1847 Dr Semmelweis became assistant and undertook examinations and exercises on corpses with unusual zeal.” The washings were ordered “towards the end of May 1847,” and “on this order the lying-in women on the division for students suddenly fell ill no more often than on the division for midwives.” “Thus from June 1847 to the present, that is already for more than two years, during which the chlorine washings are in use, there is almost no difference in the mortality on the two divisions of the lying-in institution, whereas before, through a period of seven years, the mortality on the division for students was three times as great as on the division for midwives.”
The four tasks
Semmelweis had told Rokitansky, Skoda “and some other physicians of the hospital” his idea once the washings had worked for a while. “We did not doubt for a moment that the view would prove correct, and I did not delay in drawing the attention of the director of medical studies to the discovery, in the expectation that on so important a matter a commission’s proceedings could not fail to follow. My notice seems, however, merely to have been noted.”
There was a quicker hope. The lying-in institution at Prague “likewise from time to time had very numerous illnesses, and to all appearances from the same cause as in Vienna. I therefore called for the introduction of the chlorine washings in the Prague lying-in institution.” Skoda’s letter went to Nadherny, and in the proceedings it provoked at Prague “the view that the puerperal illnesses are caused by epidemic influences kept the upper hand, and it seems that the chlorine washings have so far either not been applied at all or not applied in earnest.”
Semmelweis wrote to several professors of midwifery abroad “with the request that they subject the view he had expressed on the cause of the puerperal diseases to a test. Only from the small lying-in institution at Kiel did a definite answer come.” Kiwisch of Würzburg “on the contrary maintained that he had not seldom examined pregnant and parturient women immediately after post-mortems and had observed no harm from it.”
Then the professors’ colleges were given charge of the universities, at the end of 1848, and Skoda “held it to be the duty of the Vienna medical professors’ college to subject a discovery made in Vienna, of such great scientific and practical importance, to a decisive test, and, if it should prove itself, to procure it recognition. I therefore moved that the professors’ college appoint a commission for the purpose.” The commission was to do four things.
The first was a table. “A table was to be drawn up on which, as far as the data reach, the number of women delivered and of those who died was given from month to month, together with a list of the assistants and students in the order in which they had served and practised at the lying-in institution. Since Professor Rokitansky has served at the pathological-anatomical institute since 1828, those assistants and students who had occupied themselves with post-mortems could be picked out partly from his memory, partly from the post-mortem protocols and by questioning other physicians, and it would have appeared whether the number of illnesses in the lying-in institution stood in connection with the employment of the assistants and students in the dissecting room.”
The second was the street births: women delivered on the way in were not examined on admission unless the afterbirth had to be removed, so “if Dr Semmelweis’s view is correct, fewer illnesses must occur after street births.” The third was returns: “exact statements of the number of births and deaths” from every lying-in institution in the Austrian monarchy and, so far as possible, abroad, “in order to establish whether at all institutions where an infection by cadaveric poison cannot be assumed the mortality is lower.” The fourth was “experiments on animals.”
“The motion was adopted by the professors’ college with a very large majority, and the commission at once appointed; but the Ministry decided, on a protest from the professor of obstetrics, that the commission’s proceedings might not take place. In consequence of this decision I called on Dr Semmelweis to undertake the experiments on animals himself. If these succeeded, the solution of the remaining tasks was of little importance.”
Nine rabbits
“For the experiments, for several reasons, rabbits were used first.” The experimenters were Semmelweis and Dr Lautner, Rokitansky’s assistant, “who undertook them with great care and great conscientiousness, and made the post-mortems of the animals together.” Skoda reported nine.
In the first, on 22 March 1849, a doe that had littered a quarter of an hour before had “a brush moistened with discoloured exudate from an endometritis” passed into the vagina and the cavity of the womb. She seemed well until 24 April, when she was found dead, with the lining of the horns of the womb coated in a dirty grey-red fluid exudate, fluid in the left chest, part of the left lung consolidated, and the heart wrapped in a pale yellow coat of exudate.
In the second, on 12 April, a doe twelve hours after a litter of five was treated the same way, and, because the first animal had seemed so well, the brush was passed in every day. On the fourteenth she showed pain at the brush and the womb pressed out a thick yellowish-white exudate; on the seventeenth she was plainly ill, and on 23 April she was found dead, with exudate gluing the loops of the bowel together, the lining of the vagina and womb coated and infiltrated with it, and in the left lung a bean-sized patch with a point of pus at its centre. The third, from 15 April, daily until her death on 21 April, showed the same picture, with pus in the liver.
The fourth is the interesting one. On 24 May a strong doe, an hour after a litter of five, had the brush passed in dipped “this time in blood, diluted with water, from the corpse of a man dead thirty-six hours of marasmus”; on the twenty-fifth in pleuritic exudate; on the twenty-sixth and twenty-seventh in the peritoneal exudate of a tuberculous patient; and then no more. “The animal remained to all appearances completely healthy, and littered a second time on 24 June.” The fifth, from 2 June, had the same peritoneal exudate for four days and then pleuritic exudate on 29 and 30 June, stayed well, littered again on the twenty-eighth, and was killed on 17 July for another experiment with no sign of pyaemia. The sixth, from 10 June, had purulent pleuritic exudate from a male corpse and then, from 11 to 30 June, the peritoneal exudate of a man dead of typhus, stayed well and littered on 13 July; then the brush was passed in daily from that day to 24 July, and she wasted and was found dead on 30 July, with the veins of the womb “crammed full of stiff yellow exudate.”
The seventh, from 16 June, had pus “from an abscess between the ribs, found in the corpse of a lunatic dead of cholera,” by brush daily until 3 July, stayed well and littered on 18 July. “The experiment is now modified in such a way that no brush is used, in order to avoid a mechanical injury”: the fluid was put into the genitals with a syringe through a three-inch tube, and “immediately after the injection the animal presses the fluid out again.” Injected daily until 24 July, she wasted and was found dead on the twenty-ninth, with exudate in both chests and the belly but “the womb normal, pale, no exudate on its lining.” The eighth was the doe of the fourth experiment, brushed daily from 24 June to 8 July; she was found dead on 25 July with an ulcer where the vagina met the womb. The ninth, from 8 August, was injected with peritoneal exudate from a man daily until the fifteenth, and was found dead on the twentieth, with yellow foci of inflammation in the liver and the right horn of the womb swollen to twice its volume.
“It is hardly necessary to mention that the changes found in the bodies of the rabbits are the same as those which appear in human bodies in consequence of the puerperal diseases and in general in consequence of pyaemia.” Skoda put the objection himself: that a larger quantity of putrefying matter had acted, “and that in eight cases the putrefying substance was brought into contact with the genitals of the animal many days running and in only one case only once, whereas the quantity of putrefying matter clinging to the hands, when the hands, as always happened, were washed with water after the post-mortem, can only be thought very small.” He did not think it weighed much, since the experience of wounds at post-mortems showed that the effect on the blood “cannot depend on the quantity of the putrefying matter, as the infection not seldom follows through wounded places that are hardly visible because of their smallness.” But “to remove every doubt it seems appropriate that further and variously modified experiments on animals should be made,” and he moved that Semmelweis be granted money for them, and that “since to remove any doubts of the correctness of the experiments it is necessary that these experiments also be undertaken by a member of the Academy,” Professor Brücke should take them on. The class voted Semmelweis a hundred gulden “for the time being,” and Brücke agreed.
They did not go on long. Lautner was accused of a part in the revolution of 1848, held, released, and left Austria to become physician to the Viceroy of Egypt; and with him, Schürer von Waldheim wrote in 1905, “the animal experiments came to an end.”
The letter from Kiel
Michaelis’s answer, which Skoda summarised and Schürer von Waldheim printed in full, was written to Dr Hermann Schwarz of Holstein, who had passed the Vienna news on, and is dated Kiel, 18 March 1848.
“Your letter of 21 December 1847 has aroused my highest interest. I was again in the greatest distress. Our institution was closed from 1 July to 1 November in consequence of the puerperal fever. The three first readmitted fell ill, one died and two were only just saved. So we wanted to close the institution again. Meanwhile the state of health improved again; two newly fallen ill were easily cured, only one died, in February. Since then all are well. Your communications first gave me some courage again; the proof of the effectiveness of the chlorine washings, so far as it has been made in Vienna, is already of significance from the great numbers. I introduced them in the institution at once, and nobody, neither candidates nor midwives, may examine since then without having washed with chlorine.”
Then the sentence that the entry refers to. “Since last summer, when my cousin died of puerperal fever, whom I examined after the birth at a time when I had been examining puerperal patients and dissecting corpses, I have been convinced of the transmission.” He had refused to attend births for four weeks; the doctor who went in his place “dissected a great deal, anatomised daily; the woman delivered fell ill of puerperal fever,” and was saved. Since the washings, “in none delivered by me or by my pupils has even the mildest degree of the fever occurred again,” except the one case in February, which he put down to a badly cleaned catheter. “I thank you for your communication from the whole heart; it has perhaps already saved our institution from ruin. I ask you to commend me to Dr Semmelweis, and to thank him in this sense too; he has perhaps made a great find. You know that puerperal fever has properly been at home with us only since 1834. But that is also about the time since which I have taken the teaching more actively in hand, and in particular the examining by the candidates has been more regularly introduced. This matter too can thus be brought into connection.”
In April 1848 Michaelis published a German translation of the Copenhagen professor Levy’s report on the lying-in hospitals of London and Dublin, with a preface dated Kiel, 17 April 1848, which Semmelweis reprinted. “Last year in Vienna the happy discovery was made that by a cleansing of the hands with chlorine before examining, the disease was restricted in a striking manner in the division of the lying-in house where it had hitherto raged frightfully. Without doubt Dr Semmelweis, to whom we owe this discovery, will shortly publish the particulars; and if everything does not deceive, a happier time opens for our lying-in houses.”
A few months later, “as one of his pupils later told Semmelweis in Vienna,” Michaelis “sank into deep melancholy. He could no longer tear himself free of the thought of having brought about, even if unknowingly, the death of many a parturient woman, above all of his cousin. One day the unhappy man had himself crushed by a railway train near Hamburg.” Litzmann took over his clinic in the autumn of 1848.
What was lost
The table Skoda asked for in 1848, the clinic’s deaths month by month set against the names of the men who had served and dissected, was the one piece of evidence that could have turned a comparison of two clinics into a comparison of hands. Rokitansky had the memory, the dead-house had the protocols, and the professors’ college had voted for it. The animals had been meant to make the table unnecessary; the animals stopped when Lautner left; and the only man who ever made such a table was Zipfl, in 1850, from his own forty-one protocols, as the next companion piece tells.