Charles Clanton Rogers

Reflections based on poetry, music, visual art, book reviews, history of science, first-person history, philosophical essays and International Blogging

chidbed

In the 1800s Ignaz Semmelweis  determined that  maternal mortality from childbed fever was caused by doctors failure to wash their hands. [1]

It is believed that Jane Seymour, the third wife of England’s King Henry VIII, died of puerperal fever two weeks after giving birth to Henry’s only surviving son the future Edward VI of England. 

Maternal mortality in Nineteenth Century rises to forty percent! [3]

In the first half of the nineteenth century, women who gave birth at home had death from childbirth of rates of 5 in 1000  (European women).  Death rates in maternity hospitals were ten times that;  the hospitals stayed open because doctors had an incurable faith in good intentions, and patients a poor grasp of mortality statistics.[2]

This post is the second of a series building to my first-person history of medicine and surgery in The Twentieth Century.  These early, historical,  posts are necessary to set the stage for comparison  to the dramatic revolution occurring in the last three percent of recorded history. The first post was: http://therogerspost.com/2016/01/30/american-medicine/ 

The substance of today’s post is my edit of two reprints  of

[1] Hilary J. Lane, MLS, Nava Blum, PhD, and Elizabeth Fee, PhD , Am J Public Health   and

[2]  a very informative review by Dr. Druin Burch who was a medical resident and a tutor at the University of Oxford. [2007].

Credit goes to these authors; assign errors to me. [ccr]

Today we grow concerned about birth not being natural enough, having become too medical. Historically it was thoroughly natural, wholly unmedical, and gravely dangerous.

childbirth

“In the 18th Century, English feminist Mary Wollstonecraft and William Godwin, the radical philosopher and novelist, were married. And love was what followed. Theirs was a successful marriage of contraries, the fiery and intemperate feminist and the icy philosopher. Suddenly there was fertile happiness for both. At the end of August 1797, Godwin wrote, Mary “was taken in labour.” Attended at home by a midwife from a nearby hospital, she gave birth eighteen hours later to a girl. The baby, also called Mary, would grow up to marry the poet Shelley and write the novel Frankenstein.

Four days after the birth, however, Wollstonecraft became feverish. A part of her placenta needed to be pulled out by a doctor’s hand. She developed puerperal sepsis, an infection of the genital tract, which very painfully, and over the period of about a week, killed her.”

quill

Today we grow concerned about birth not being natural enough, having become too medical. Historically it was thoroughly natural, wholly unmedical, and gravely dangerous. Only from the early eighteenth century did doctors begin getting seriously involved, with obstetrics becoming a medically respectable specialty and a rash of new hospitals being built. Unfortunately, the impact of both was bad. Puerperal, or childbed, fever was a mystery, but both doctors and hospitals made it worse. Wherever the medical men went the disease grew more common, and in their hospitals it was commonest of all.

Childbed fever killed at the cruelest moments. It was described as a “desecration,” an aspect of the natural world that felt almost deliberately evil. What caused it? Some thought “a failure of uterine discharge”; others, a little later, called it “milk metastasis,” noting that the internal organs of the women who died seemed covered in milk. Eventually it was accepted that the fluid was not milk at all. It was pus.

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Compound microscopes had been developed in the seventeenth century, opening up the world of miniature “animalcules.” Inexplicably, an initial flurry of medical interest quickly died away. Even though the technology was now in place to help demonstrate it, germ theory took another two hundred years to arrive. In the meantime doctors were puzzled, blaming puerperal fever on a host of different causes: mists, sewage, poor ventilation, cold, or vague “putrid tendencies.”

quill

In 1791, the year Wollstonecraft and Godwin first met, an epidemic of puerperal fever was ripping through Scotland. Alexander Gordon was Aberdeen’s leading obstetrician, and when puerperal fever came along he studied it and wrote down his conclusions. They amounted to what he felt were three great truths: the disease was spread by doctors and midwives; it was somehow related to skin infections; and the only treatment was bleeding — by the bucketload. A pint and a half was a good initial measure.

quill

Portrait of Antonie van Leeuwenhoek microscope(1632–1723) by Jan Verkolje Born October 24, 1632Delft, Dutch Republic Died August 26, 1723 (aged 90) Nationality Dutch
Fields Microscopist and Biologist credited for first medical microscope.

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Bleeding was quickly and incorrectly accepted as a cure, but it took almost a century for the contagious nature of puerperal fever to be widely recognized. Many cases were isolated and sporadic, undermining those who argued the disease was infectious. At other times its epidemic nature was clear. William Campbell, another Scot, was a close contemporary of Gordon’s. He first denied the contagiousness of puerperal fever, but personal experience changed his mind. He dissected the corpse of a woman killed by the disease, putting her uterus in his coat pocket so that he could show it to his students. He felt neither gloves nor hand washing was needed.

“The same evening,” he wrote, “without changing my clothes, I attended the delivery of a poor woman in the Canongate; she died. Next morning I went with the same clothes to assist some of my pupils who were engaged with a woman in Bridewell, whom I delivered with forceps; she died.”

Campbell’s language, as well his report, is a reminder that no one then spoke of delivering a baby. Obstetricians and midwives talked of delivering women — delivering them from the peril of childbirth.

quill

In the first half of the nineteenth century about five European women in a thousand died from childbirth. Death rates in maternity hospitals were often ten times that; the hospitals stayed open because doctors had an incurable faith in good intentions, and patients a poor grasp of mortality statistics. The physician and poet Oliver Wendell Holmes led the American campaign to stop the spread of the disease by getting doctors to wash their hands.[1]  Oliver_Wendell_Holmes_Sr_c1879 Oliver Wendell Holmes Sr. c. 1879 Born Oliver WendellHolmesAugust29,1809Cambridge, MassachusettsDied October 7, 1894 (aged 85)
Boston, Massachusetts Obstetricians felt slighted. “Doctors are gentlemen,” said Charles Meigs of the Jefferson Medical College in Philadelphia, arguing that no such care was needed, “and gentlemen’s hands are clean.” How could the pure of heart possibly be spreading disease? For Meigs and many others, noble intentions mentally equated to good outcomes. It would be hard to find another example of the sympathetic fallacy with such far-reaching and tragic consequences. Yet hand washing slowly grew commoner. Aided by Louis Pasteur’s advocacy of germ theory, hygiene improved. Giving birth began to get safer.

quill

In the 1800s Ignaz Semmelweis noticed that women giving birth at home had a much lower incidence of childbed fever than those giving birth in the doctor’s maternity ward. His investigation discovered that washing hands with an antiseptic solution before a delivery reduced childbed fever fatalities by 90%. semmelweis Publication of his findings was not well received by the medical profession. The idea conflicted both with the existing medical concepts and with the image doctors had of themselves. The scorn and ridicule of doctors was so extreme that Semmelweis moved from Vienna and was eventually committed to a mental asylum where he died. [1]

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A few different organisms turned out to be capable of causing puerperal fever, but the vast majority of cases were due to just one: Streptococcus pyogenes. strptococcusThe etymology is revealing. Pyogenes means creator of pus. The bacterium lives only on humans, and consists of roughly 1,800 genes, a third of which “have no identifiable function,” according to a 2001 paper reporting one complete genome sequence of the bug. Of the genes we partially understand, around forty seem directly connected with the virulence of the organism. S. pyogenes causes a range of other diseases, including strep throat, scarlet fever, rheumatic fever, and skin infections such as mild impetigo and catastrophic necrotizing fasciitis (now commonly called the “flesh-eating disease”). Epidemics of puerperal fever historically matched those of skin infections, and a person who contracted one was able to pass along the other.

quill

We know that Pasteur and the germ theorists were right, but the mysteries that slowed their intellectual victories still exist. Why should such a generally harmless bug sometimes become troublesome? Today we might phrase the question differently: why should it be in the evolutionary interests of a bacterium to leap from docility into rampaging ferocity? What’s in it for the bug? Sporadic cases might be chance, but trends suggest an evolutionary imperative.

Joseph J. Ferretti, a University of Oklahoma specialist in streptococci, notes that S. pyogenes has some remarkable qualities, containing “more virulence-factor genes than any other bacterial species.” Moreover, he says some strains possess genetic switches for hypermutation, which increase mutation rates over a hundred-fold. We are a long way from fully understanding how all these virulence mechanisms work. And that makes it even more difficult to explore the deeper questions about how evolution is driving them.

quilloperating room

Modern Obstetrical Theater. The bacteria is successfully managed with common antibiotics which includes  a combination of ampicillin and gentamicin but prevention with careful sterile technique is the gold standard in modern obstetrics.

 

 

 

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Charles Clanton Rogers, MD, FACR, emeritus professor, GWU February 1, 2016

References and Addendum

[1] Hilary J. Lane, MLS, Nava Blum, PhD, and Elizabeth Fee, PhDAm J Public Health. 2010 June; 100(6): 1008–1009.doi: 10.2105/AJPH.2009.185363PMCID: PMC2866610

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866610/
Oliver Wendell Holmes (1809–1894) and Ignaz Philipp Semmelweis (1818–1865): Preventing the Transmission of Puerperal Fever
Hilary J. Lane, MLS, Nava Blum, PhD, and Elizabeth Fee, PhD
Author information ► Article notes ► Copyright and License information ►
IN THE EARLY TO MIDnineteenth century in Europe and America, thousands of young women died from childbed fever, also known as puerperal fever, a disease rampant in the charity maternity clinics of the time.1 Women were generally affected within the first three days after childbirth. The disease progressed rapidly and caused acute symptoms of severe abdominal pain, fever, and debility. Therapy usually involved bloodletting, but with or without this treatment the disease was often fatal.

Two heroes in the fight against puerperal fever were Oliver Wendell Holmes and Ignaz Philipp Semmelweis. If Holmes now stands in Semmelweis’s shadow, it is because Holmes’s own medical reputation was largely eclipsed by the brilliant success he achieved in the fields of literature, poetry, and popular lectures.2 In the late nineteenth and early twentieth centuries, Holmes’s literary and poetic works were reprinted in hundreds of editions by American and British publishers. Even his own profession came to value him more as a professor and poet than as a fearless and outspoken defender of the life and health of childbearing women.Born into a family whose ancestors had distinguished themselves in both literature and medicine, Holmes attended Harvard University and also studied at the prestigious medical schools of Paris. After two and a half years, he returned to the United States and received his medical degree from Harvard in 1836. He maintained a small medical practice for 12 years but found that his main interests lay in teaching and research. Hearing of the death of a physician one week after performing a postmortem exam on a woman who had died of puerperal fever, Holmes began a thorough investigation and read a paper on “The Contagiousness of Puerperal Fever” before the Boston Society for Medical Improvement in 1843. Because the paper was published in the New England Quarterly Journal of Medicine and Surgery,3 a journal with a very small circulation which ceased publication after only one year, it went largely unnoticed until it was republished in 1855 as a booklet entitled Puerperal Fever, as a Private Pestilence.4 Holmes argued the controversial view that physicians with unwashed hands were responsible for transmitting puerperal fever from patient to patient.

[2] Druin Burch was a medical resident and a tutor at the University of Oxford. http://www.livescience.com/3210-childbirth-natural-deadly.html

[3] The historical level of maternal deaths is probably around 1 in 100 births.[17] Mortality rates reached very high levels in maternity institutions in the 1800s, sometimes climbing to 40 percent of birthgiving women (see Historical mortality rates of puerperal fever). At the beginning of the 1900s, maternal death rates were around 1 in 100 for live births. Wikipedia.

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866610/

 

 

3 thoughts on “Jayne Seymour, Queen, Dies of Puerperal Fever

  1. This is so so interesting Doctor Charles.
    hand washing is the single most important habit & technique in medical care!

    Liked by 2 people

    1. clanton1934 says:

      What impresses me is that up until 150 years ago, birthing mothers were not protected from this life threatening problem. Until then, having a baby was “Russian roulette! c

      Liked by 1 person

      1. Sadly in some parts of the world it still is!

        Liked by 2 people

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