Puerperal fever or childbed fever, was a significant cause of fever and sepsis among postpartum women. This scourge can be traced back to the 5th century BC in the writings of Hippocrates. It gained popular notoriety in European hospitals and maternity wards in the 17th and 18th centuries, probably as more people became centralized in hospitals rather than treated at home, allowing epidemics of childbed fever to arise. Ignaz Semmelweis, a Hungarian physician at Vienna General Hospital, is often credited with discovering puerperal fever, refuting the concept that it was caused by evil humors, emotional disturbances, and bad air, and insisting it was caused by unclean hands, often contaminated by cadaveric remains.
At the time, it was not uncommon for physicians and medical students to go directly from the autopsy room to the delivery room, without sterile technique or washing of their hands. Semmelweis had astutely observed that mortality was higher in the maternity wards staffed by physicians and medical students, who performed autopsies, than those of midwives, who did not.
During delivery, abrasions and tears would commonly occur in the vagina and lining of the uterus, allowing various microorganisms (yet to be discovered) to invade the tissue, among them Group A Streptococcus Pyogenes. Infections would fester and sepsis would lead to death after a simple, uncomplicated delivery. Antibiotics, of course, had yet to be discovered.
Semmelweis’s proclamation was the beginnings of germ theory. He instituted hand washing prior to delivery with chlorinated lime solution, dropping the occurrence and mortality of puerperal fever dramatically. His article was presented to the Medical Society of Vienna in 1847, and was entitled The Etiology, Concept, and Prophylaxis of Childbed Fever.
Meanwhile, a 4 years earlier and a continent away, American physician, essayist, and Harvard professor, Oliver Wendell Holmes Sr., came to the same conclusions. He published his findings in the New England Quarterly Journal of Medicine and Surgery, in 1843. It was entitled The Contagiousness of Puerperal Fever. His findings concluded that puerperal fever was contagious, and spread by physicians, medical students, nurses and midwives, and especially those who worked with cadavers. He recommended strict hand hygiene and avoidance of practice by any physician who had a recent case.
Holmes was immediately hit with ridicule from his colleagues, including Charles Meigs, a famous obstetrician. Meigs’s famously stated that “Doctors are gentleman, and gentleman’s hands are clean.” Holmes, however, stood his ground and stressed the ethical responsibility of physicians, a shocking concept at the time. He was eventually proved right.
Puerperal fever is now uncommon in many countries but still remains a threat to women in undeveloped countries and during unhygienic abortion procedures.
Oliver Wendel Holmes in his own words on the Contagiousness and Prevention of Puerperal Fever
“The recurrence of long series of cases like those I have cited, reported by the most interested to disbelieve in contagion, scattered along through an interval of half a century, might have been thought sufficient to satisfy the minds of all inquirers that there was something more than a singular coincidence. But if on a more extended observation, it should be found that the same ominous groups of cases, clustering about individual practitioners, were observed in a remote country, at different times, and in widely separated regions, it would seem incredible that any should be found too prejudiced or indolent to accept the solemn truth knelled into their ears by the funeral bells from both sides of the ocean – the plain conclusion that the physician and the disease entered hand in hand into the chamber of the unsuspecting patient … out of this train of cumulative evidence the multiplied groups of cases clustering about individuals, the deadly results of autopsies, the inoculation by fluids from the living patient, the murderous poison of hospitals, does there not result a conclusion that laughs all sophistry to scorn and renders all argument an insult?”
“The woman about to become a mother, or with her new‐born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden, or stretches her aching limbs … God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly!”
“1. A physician holding himself in readiness to attend cases of midwifery, should never take any active part in the post‐mortem examination of cases of puerperal fever.
2. If a physician is present at such autopsies, he should use thorough ablution, change every article of dress, and allow twenty‐four hours or more to elapse before attending to any case of midwifery. It may be well to extend the same caution to cases of simple peritonitis.
3. Similar precautions should be taken after the autopsy or surgical treatment of cases of erysipelas, if the physician is obliged to unite such offices with his obstetrical duties, which is in the highest degree inexpedient.
4. On the occurrence of a single case of puerperal fever in his practice, the physician is bound to consider the next female he attends in labor, unless some weeks, at least, have elapsed, as in danger of being infected by him, and it is his duty to take every precaution to diminish her risk of disease and death.
5. If within a short period two cases of puerperal fever happen close to each other, in the practice of the same physician, the disease not existing or prevailing in the neighborhood, he would do wisely to relinquish his obstetrical practice for at least one month, and endeavor to free himself by every available means from any noxious influence he may carry about with him.
6. The occurrence of three or more closely connected cases, in the practice of one individual, no others existing in the neighborhood, and no other sufficient cause being alleged for the coincidence, is prima facie evidence that he is the vehicle of contagion.
7. It is the duty of the physician to take every precaution that the disease shall not be introduced by nurses or other assistants, by making proper inquiries concerning them, and giving timely warning of every suspected source of danger.
8. Whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery, the time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as a misfortune but a crime; and in the knowledge of such occurrences, the duties of the practitioner to his profession, should give way to his paramount obligations to society.”
