“You are all familiar with Dr. Chipman’s aphorism, ‘The process of parturition is the same in the countess as in the cow.’ Very true, but, unfortunately, the results are infinitely better in the cow than in the countess.” — Karl M. Wilson, M.D.1
Dr. Wilson published his comment about countesses and cows in 1936. He lamented the fact that Canadian mothers were paying “an appalling price in human lives for bringing their children into the world.”1 In truth, the problem of women dying in childbed remained high in the early 20th century, even though it was known that certain bacterial infections caused childbed fever (also called puerperal fever) — the leading cause of maternal death. In 1936, as in Jane Austen’s day, the medical profession resisted the idea that it contributed to the problem. A few 18th- and early 19th-century doctors believed medical practitioners themselves were guilty of spreading the disease, but it smacked of heresy to suggest such a thing.
Dr. Charles White (1728-1813) was a famous surgeon and man-midwife. In 1773 he published a treatise on managing pregnant and lying-in women. Written some 70 years before the work of Louis Pasteur (a chemist whose studies confirmed the germ theory of disease), Dr. White believed that childbed fever was contagious—not arising from noxious fumes carried on foul air, as was commonly believed at the time, but from some other agent acting in a way not yet understood. He advised isolating affected patients and disinfecting their rooms and bedding. He argued for preventing childbed fever by observing strict cleanliness, providing good ventilation, and promoting the free drainage of lochia by having mothers sit up to nurse. His ideas were well ahead of his time, and his proof is in the pudding: at a time when one in 25 women died from childbed sepsis, he had never lost a patient to this disease in his 21 years of practice.2
Mr. Alexander Gordon (1752-1799), a naval surgeon, also believed “some factor” was passed from woman to woman by the medical practitioners attending them. In the 1790s he observed an epidemic of childbed fever at the Dispensary in Aberdeen. Observing the outcome of 77 cases under his care, he confessed: “… it is a disagreeable fact that I, myself, was the means of carrying the infection to a great number of women.”3
Early 19th-Century Heresy by Two Doctors: An American and an Hungarian
Oliver Wendell Holmes (1809-1895) is mostly remembered as an American poet, but he was also a physician. Trained in Boston and Paris, he published in 1843 a treatise on the contagiousness of childbed fever. He believed the often deadly disease was passed from patient to patient by medical practitioners. Various rules for preventing the spread of the disease were listed at the end of his essay (italics mine):4
- A physician who is actively involved in attending women during childbed should never participate in post mortem examinations of puerperal fever cases.
- If a physician attends such autopsies, he should wash himself thoroughly, change every article of his dress, and allow at least 24 hours or more to lapse before attending a midwifery case.
- If a single case of puerperal fever occurs in his practice, the physician is obligated to consider that the next woman he treats may become infected if at least several weeks have not passed.
- If two cases of puerperal fever occur within a short time period, and there is no disease in the neighborhood, then the physician would be wise to give up his obstetrical practice for at least one month.
- If three or more cases occur in the practice of one physician, he must consider himself the source of the contagion.
These were controversial recommendations. Give up practice for one month or more? Acknowledge that I, the doctor, might be spreading contagion? Preposterous! Several prominent obstetricians were deeply offended. Dr. Charles Meigs, Professor of Obstetrics at Jefferson Medical College in Philadelphia, protested that gentlemen had clean hands and, therefore, were not responsible for the contagion.5Following on the heels of Dr. Holmes, an Hungarian doctor named Ignaz Semmelweis began a crusade to convince his colleagues that puerperal fever was spread by doctors with unclean hands. He could never have imagined the resistance he would face.
Dr. Semmelweis began his career as an assistant to a professor in the First Obstetrical Clinic of the Vienna General Hospital. The hospital, like many other such hospitals in Europe, was designed to address the issue of problems with illegitimate children. It offered free care to poor, destitute mothers and their children; in return, the hospital’s doctors and midwives were trained using these women and their children as subjects.6
Semmelweis had observed that the First Clinic at the Vienna General Hospital had an average maternal mortality rate due to puerperal fever of roughly 10%, whereas the so-called Second Clinic had an average mortality rate of 4%. The fact of these different death rates was widely known outside of the hospital. In fact, the First Clinic had such a bad reputation because of its death rate that pregnant women pretended to give birth on the street as a means of avoiding the dreaded First Clinic and obtaining access to the better, safer Second Clinic.6
Semmelweis noticed that the main difference between the two clinics was that the First Clinic was used to train medical students (all male), while the Second Clinic was used to train midwives (all female).7 When a friend and colleague died from septicemia after injuring his finger while conducting a post mortem examination on a woman who had died of puerperal fever, Semmelweis concluded that physicians were carrying what he called “cadaverous particles” from the autopsy room to their childbirth patients in the First Clinic. Because the midwives were not involved in autopsies and had no contact with corpses, there was no transfer of cadaverous particles from the midwives to their patients in the Second Clinic and, hence, the mortality rate was low. He advised physicians to wash their hands in chloride of lime before examining a pregnant or peurperal woman.8
Some 15 years later, Semmelweis published a book outlining his theory about the cause of childbed fever. He took to calling some prominent European obstetricians murderers, which only inflamed the public ridicule of his ideas. The medical profession did not take his ideas seriously. Although he descended into depression and possibly psychosis, his theory would be proven correct.8 In 1879, Louis Pasteur identified one of the bacteria (e.g., Streptoccocus) that causes childbed fever.
The maternal death rate from childbed fever remained high until the 1930’s, when antiseptic procedures were introduced into the delivery room, the sulfonamides were developed to fight infections, and better obstetrical care was implemented.9 Although the use of antibiotics, antiseptics and surgery have greatly reduced the maternal death rate from childbed fever, many women still die of this disease every year.10
1Wilson, Karl M. The problem of maternal mortality. Canadian Medical Association Journal. 1936; 34(5): 518-525.
2Dunn P.M. Charles White (1728-1813) and natural birth. Archives of Disease in Childhood. 1990; 65: 395-396.
3Chamberlain, Geoffrey. British maternal mortality in the 19th and early 20th centuries. Journal of the Royal Society of Medicine. 2006; 99: 559-563.
4Cullingworth, Charles J. Oliver Wendell Holmes and the Contagiousness of Puerperal Fever: An Address. (London: Henry J. Glassier, 1906), pp. 31-32 (PDF pp. 48-49). Holmes’s complete essay can be downloaded from Google Books.
5Meigs, Charles D. On the Nature, Signs, and Treatment of Childbed Fevers. (Philadelphia: Blanchard and Lea, 1854), p. 104 (PDF p. 95).
6Ataman, Ahmet Dogan, et al. Medicine in stamps-Ignaz Semmelweis and peurperal fever. Journal of the Turkish-German Gynecological Association. 2013; 14: 35-39.
7Dunn, PM. Ignac Semmelweis (1818-1865) of Budapest and the prevention of puerperal fever. Archives of Disease in Childhood and Fetal Neonatal Education. 2005; 90: F345-8.
8Lane, Hilary J, et al. Oliver Wendell Holmes (1809-1894) and Ignaz Philipp Semmelweis (1818-1865): preventing the transmission of puerperal fever. American Journal of Public Health. 2010 (June); 100 (6): 1008-9.
9Loudon I. Deaths in childbed from the eighteenth century to 1935. Medical History. 1986;30:1-41.
10Hamilton, SM, et al. Pregnancy-related group A Streptococcal infections: temporal relationships between bacterial acquisition, infection onset, clinical findings, and outcome. Clinical Practice 2013; 57: 870-6.