Although it had been recognized from as early as the time of the
Hippocratic corpus that women in childbed were prone to fevers, the distinct name "puerperal fever" appears in historical records only from the early 18th century. The death rate for women giving birth decreased in the 20th century in
developed countries. The decline may be partly attributed to improved environmental conditions, better
obstetrical care, and the use of
antibiotics. Another reason appears to be a lessening of the virulence or invasiveness of Streptococcus pyogenes. That organism is also the cause of
scarlet fever, which declined over the same period but has seen a rise in the last decade worldwide, especially in Asia, with smaller outbreaks in the US and Canada. The UK reported 12,906 cases between September 2015 and April 2016, which is the largest outbreak since 1969.
"The Doctor's Plague" presented evidence to demonstrate that the advent of
pathological anatomy in Vienna in 1823 (vertical line) was correlated to the incidence of fatal childbed fever there. Onset of
chlorine handwash in 1847 marked by vertical line. Rates for the Dublin maternity hospital, which had no pathological anatomy, are shown for comparison (
view rates). His efforts were futile, however. From the 17th century through to the mid-to-late 19th century, the majority of childbed fever cases were caused by the doctors themselves. With no knowledge of
germs, doctors did not believe hand washing was needed. Hospitals for childbirth became common in the 17th century in many European cities. These "lying-in" hospitals were established at a time when there was no knowledge of
antisepsis or
epidemiology, and women were subjected to crowding, frequent vaginal examinations, and the use of contaminated instruments, dressings, and bedding. It was common for a doctor to deliver one baby after another, without washing his hands or changing clothes between patients. The first recorded epidemic of puerperal fever occurred at the
Hôtel-Dieu de Paris in 1646. Hospitals throughout Europe and America consistently reported death rates between 20% and 25% of all women giving birth, punctuated by intermittent epidemics with up to 100% fatalities of women giving birth in childbirth wards. In the early 19th century,
Ignaz Semmelweis noticed that women giving birth at home had a much lower incidence of childbed fever than those giving birth in a
maternity ward. His investigation discovered that washing hands before a delivery with a
calcium hypochlorite solution reduced childbed fever fatalities by 90%. His findings were not well received by the medical profession, because they conflicted both with 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, following a breakdown, eventually died in a mental asylum. Semmelweis was not the only doctor ignored after sounding a warning about the problem. In his
Treatise on the Epidemic of Puerperal Fever (1795), ex-naval surgeon and
Aberdonian obstetrician
Alexander Gordon (1752–1799) warned that the disease was transmitted from one case to another by midwives and doctors. Gordon wrote, "It is a disagreeable declaration for me to mention, that I myself was the means of carrying the infection to a great number of women." In 1842,
Thomas Watson (1792–1882), a professor of medicine at
King's College Hospital, London, wrote: "Wherever puerperal fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent
ablution." Watson recommended
handwashing with
chlorine solution and changes of clothing for obstetric attendants "to prevent the practitioner becoming a vehicle of contagion and death between one patient and another."
Hygienic measures In 1843,
Oliver Wendell Holmes Sr. published
The Contagiousness of Puerperal Fever and controversially concluded that puerperal fever was frequently carried from patient to patient by physicians and nurses. He suggested that clean clothing and avoidance of autopsies by those aiding birth would prevent the spread of the disease. Holmes quoted Dr. James Blundell as stating, "... in my own family, I had rather that those I esteemed the most should be delivered unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease." Holmes' conclusions were ridiculed by many contemporaries, including
Charles Delucena Meigs, a well-known obstetrician, who stated, "Doctors are gentlemen, and gentlemen's hands are clean." Richard Gordon states that Holmes' exhortations "outraged obstetricians, particularly in Philadelphia". In those days, "surgeons operated in blood-stiffened frock coats—the stiffer the coat, the prouder the busy surgeon", "pus was as inseparable from surgery as blood", and "cleanliness was next to prudishness". He quotes
Sir Frederick Treves on that era: "There was no object in being clean. Indeed, cleanliness was out of place. It was considered to be finicking and affected. An executioner might as well manicure his nails before chopping off a head." In 1844,
Ignaz Semmelweis was appointed assistant lecturer in the First Obstetric Division of the
Vienna General Hospital (Allgemeines Krankenhaus), where medical students received their training. Working without knowledge of Holmes' essay, Semmelweis noticed his ward's 16% mortality rate from fever was substantially higher than the 2% mortality rate in the Second Division, where midwifery students were trained. Semmelweis also noticed that puerperal fever was rare in women who gave birth before arriving at the hospital. Semmelweis noted that doctors in the First Division performed autopsies each morning on women who had died the previous day, but the midwives were not required or allowed to perform such autopsies. He made the connection between autopsies and puerperal fever after a colleague,
Jakob Kolletschka, died of sepsis after a student accidentally cut his hand while performing an autopsy. Semmelweis began experimenting with various cleansing agents and, from May 1847, ordered all doctors and students working in the First Division to wash their hands in chlorinated lime solution before starting ward work and later ordered this before each vaginal examination. The mortality rate from puerperal fever in the division fell from 18% in May 1847 to less than 3% in June–November of the same year. While his results were extraordinary, he was treated with skepticism and ridicule (see
Response to Semmelweis). He did the same work in St. Rochus hospital in
Pest, Hungary, and published his findings in 1860, but his discovery was again ignored. In 1935,
Leonard Colebrook showed
Prontosil was effective against
haemolytic streptococcus and hence a cure for puerperal fever.
Notable cases Elite status was no protection against postpartum infections, as the deaths of several English queens attest.
Elizabeth of York, queen consort of
Henry VII, died of puerperal fever one week after giving birth to a daughter, who also died. Her son
Henry VIII had two wives who died this way,
Jane Seymour and
Catherine Parr. Suzanne Barnard, mother of philosopher
Jean-Jacques Rousseau, contracted childbed fever after giving birth to him and died nine days later. Her infant son was also in perilous health following the birth; the adult Rousseau later wrote that "I came into the world with so few signs of life that little hope was entertained of preserving me". He was nursed back to health by an aunt. French natural philosopher
Émilie du Châtelet died in 1749.
Mary Wollstonecraft, author of
Vindication of the Rights of Woman, died ten days after giving birth to
her second daughter, who grew up to write
Frankenstein. Other notables include African-American poet
Phillis Wheatley (1784), British housekeeping authority
Isabella Beeton (1865), and American author
Jean Webster in 1916 died of puerperal fever. In
Charles Dickens' novella
A Christmas Carol, it is implied that both
Scrooge's mother and younger sister perished from this condition, explaining the character's animosity towards his nephew Fred and also his poor relationship with his own father. ==See also==