Puerperal priority
Authors: Gerald Weissmann
Journal: The Lancet (1997)

“I do know that others had cried out with all their might against the terrible evil [of puerperal sepsis] before I did and I gave them full credit for it. But I think I shrieked my warning louder and longer than any of them and I am pleased to remember that I took my ground on the existing evidence before the little army of microbes was marched up to support my position”.Oliver Wendell Holmes1Holmes OW Cited in Osler W. Oliver Wendell Holmes.Bull Johns Hopkins Hosp. 1894; 42: 86-89Google Scholar Who conquered childbed fever? The French credit Pasteur for finding the causal microbe;2Pasteur L Septicémie puerpérale.Bull Acad Méd (Paris). 1879; 8 (2me sér.): 505-508Google Scholar England honours Lister for antisepsis;3Lister J On the antiseptic principle in the practice of surgery.Lancet. 1867; ii: 353-356Abstract Scopus (108) Google Scholar, 4Lister J Illustrations of the antiseptic system of treatment in surgery.Lancet. 1867; ii: 668-669Abstract Scopus (24) Google Scholar Europeans acclaim Semmelweis for the aetiology and prophylaxis of puerperal fever;5Semmelweis IF Höchst wichtige Erfahrungen über die Ætiologie der in Gebäranstalten epidemischen Puerperalfieber.Zk&k Gesell Ærtzte Wien. 1847/8; 4: 242-244Google Scholar, 6Semmelweis IF Höchst wichtige Erfahrungen über die Ætiologie der in Gebäranstalten epidemischen Puerperalfieber.Zkg&k Gesell Ærtzte Wien. 1849; 5: 64-65Google Scholar and the USA gives priority to Oliver Wendell Holmes (figure).7Holmes OW The contagiousness of puerperal fever.N Engl Q J Med Surg. 1842; 1: 503-530Google Scholar In Scotland, they proclaim that the “infectious nature of puerperal fever was first demonstrated by Dr Alexander Gordon, Aberdeen, 1795”.8Cullingworth CJ Oliver Wendell Homes and puerperal fever.BMJ. 1905; 2: 1161-1167Crossref PubMed Scopus (5) Google Scholar There is, of course, glory enough for all—sanitarian and microbe-hunter alike; before their efforts, epidemics of puerperal fever killed up to one-third of young mothers.9Lea A Cited in: Loudon I. Puerperal fever, the streptococcus, and the sulfonamides, 1911–1945.BMJ. 1987; 295: 485-490Crossref PubMed Scopus (38) Google Scholar Nevertheless, at the dawn of the 20th century, 2000 women were lost each year in England and Wales “from a cause which is almost, if not entirely, preventable, and puerperal fever continues to prevail, as though Pasteur and Lister had never lived”.8Cullingworth CJ Oliver Wendell Homes and puerperal fever.BMJ. 1905; 2: 1161-1167Crossref PubMed Scopus (5) Google Scholar Why did the epidemics of childbed fever persist for most of the 19th century, and why did so many women die despite Pasteur and Lister? UNICEF estimates that last year 100 000 women worldwide died from puerperal sepsis.10Crosette B Tally of world tragedy: women who die giving life.New York Times. June 11, 1996; : A1-A12Google Scholar The history of childbed fever may shed light on why those “almost, if not entirely, preventable” diseases caused by streptococci, spirochetes, or retroviruses persist today. 200 years ago, Alexander Gordon knew that puerperal fever was a contagious disease of which physicians or midwives were vectors:11Gordon A A treatise on the epidemic of puerperal fever of Aberdeen. GG&J Robinson, London1795Google Scholar “I had evident proofs that every person who had been with a patient in the puerperal fever became charged with an atmosphere of infection which was communicated to every pregnant woman who happened to come within its sphere”. Confessing “that I myself was the means of carrying the infection to a great number of women”, he concluded11Gordon A A treatise on the epidemic of puerperal fever of Aberdeen. GG&J Robinson, London1795Google Scholar “These facts fully prove that the cause of the puerperal fever… was a specific contagion, or infection, altogether unconnected with a noxious condition of the atmosphere”. But Gordon's argument was ignored by his colleagues who believed that infections were caused by “a noxious condition of the atmosphere”, the miasmatic theory. By 1843, a more powerful voice was raised. Oliver Wendell Holmes had returned to Boston from studies in Paris. The Ecole de Médecine was transforming medicine into a science based on number, measure, and observation, and the chief proponent of the new method was Holmes' mentor, Pierre C-A Louis, professor of medicine. Louis' work on what we now call patient outcomes discredited bloodletting as a treatment for infection;12Louis PCA Recherches sur les effets de la saignée dans quelques maladies inflammatoires, etc. JB Baillière, Paris1835Google Scholar he also founded the Society of Clinical Observation to which Holmes was admitted and the principles of which the young American brought home. The 32-year-old Holmes was well known in Boston. Son of a Harvard divine, his undergraduate poem “Old Ironsides” had helped to save the US frigate The Constitution from the scrapheap. His career as a medical scholar was launched at the Boston Society for Medical Improvement when he read The Contagiousness of Puerperal Fever.7Holmes OW The contagiousness of puerperal fever.N Engl Q J Med Surg. 1842; 1: 503-530Google Scholar He argued persuasively that “the disease known as puerperal fever is so far contagious as to be frequently carried from patient to patient by physicians and nurses”. He reviewed the medical literature, giving full marks to Gordon: “[Gordon's] most terrible evidence is given in these words: ‘I ARRIVED,’ HE SAYS, ‘AT THAT CERTAINTY IN THE MATTER, THAT I COULD VENTURE TO FORETELL WHAT WOMEN WOULD BE AFFECTED WITH THE DISEASE UPON HEARING BY WHAT MIDWIFE THEY WERE TO BE DELIVERED, OR BY WHAT NURSE THEY WERE TO BE ATTENDED, DURING THEIR LYING-IN: AND ALMOST IN EVERY INSTANCE MY PREDICTION WAS VERIFIED’.” (Holmes' caps) Holmes then reviewed the Registrar's statistics, estimating that the mortality in England from puerperal sepsis varied at the time from three per 1000 to five per 1000, a figure, Holmes calculated, in keeping with its incidence in Boston. He contrasted this low sporadic level with certain epidemics arising from one focus: in 1842, a Dr Rutter had reported to the College of Physicians of Philadelphia his personal experience of nearly 70 of these “horrible cases": all within the past 12 months. Holmes commented, “in view of the general incidence of the disease being less than five in a thousand, it does appear a singular coincidence, that one man should have ten, twenty, thirty or seventy cases of this rare disease following his… footsteps with the keenness of a beagle”. Another Philadelphia physician, Dr Warrington, reported that a few days after assisting at necropsy in a case of puerperal peritonitis in which he scooped out the contents of the abdominal cavity with his hands, he delivered three women in rapid succession: all had puerperal fever. Soon afterwards, “[Warrington] saw two other patients, both on the same day, with the same disease: of these five patients, two died”. Holmes anticipated the methods of the fictional detective who was to be named after him.13Weissmann G Doctor Doyle and the case of the guilty gene. In: Democracy and DNA. Hill & Wang, New York1996: 179-192Google Scholar By contacting doctors in whose practices puerperal sepsis had appeared in clusters, he deduced how the contagion spread. One man wrote to Holmes about a “disastrous period in my practice”, when between July 1 and Aug 13, 1835, he attended the delivery of 14 women; eight developed puerperal fever and two died. He admitted that he had not changed his outer coat until Aug 6, the date of confinement of the last woman. Holmes studied two other such focal outbreaks and concluded that “the occurrence of three or more 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… The practical point to be illustrated is the following: The disease known as Puerperal Fever is so far contagious as to be frequently carried from patient to patient by physicians and nurses” (Holmes' italics). The countermeasures he urged were those of the sanitarian revolution: plenty of soap and water, and destruction of contaminated clothing, linens, or blankets; doctors or nurses, he advised, should not deliver babies for several months after an outbreak. Holmes' warning caused few ripples outside New England; The New England Quarterly Journal of Medicine and Surgery, the small medical journal in which he published, went under within the year (1842), and Holmes himself moved on to other pursuits. Obstetric practice at the time was dominated by Philadelphians who denied that physicians might carry the disease. In 1852, Hodge's textbook dismissed Holmes, urging doctors to “divest your minds of the overpowering dread that you can ever become… the minister of evil; that you can ever convey, in any possible manner, a horrible virus, so destructive in its effects, and so mysterious in its operations as that attributed to puerperal fever”.14Holmes OW Puerperal fever as a private pestilence. Ticknor And Fields, Boston1855: 103Google Scholar Nor did the influential Charles Meigs regard a clustering of cases in one practice as evidence for contagion:14Holmes OW Puerperal fever as a private pestilence. Ticknor And Fields, Boston1855: 103Google Scholar “I prefer to attribute them to accident, or Providence, of which I can form a conception, rather than to a contagion of which I cannot form any clear idea, at least as to this particular malady”. The general inattention to his earlier warnings led Holmes in 1855 to republish and elaborate his work on puerperal fever.15Holmes OW Puerperal fever as a private pestilence. Ticknor And Fields, Boston1855: 75Google Scholar By then, he had become a stronger force in the profession: he was not only the Parkman Professor of Anatomy at the Harvard Medical School, but also dean of its medical faculty. It was Holmes who gave the name anaesthesia to Morton's discovery (1846). He had also become a respected poet and lyceum lecturer; his monthly essays in The Atlantic—to be collected in The Autocrat of the Breakfast Table—had already made him a household name. In his new pamphlet,15Holmes OW Puerperal fever as a private pestilence. Ticknor And Fields, Boston1855: 75Google Scholar he directed harsher words to his opponents and marshalled statistics: “three deaths in one thousand births [may be] assumed as the average from puerperal fever; no epidemic to be at the time prevailing. I have had the chances calculated by a competent person, that a given practitioner, A, shall have sixteen fatal cases in a month, [data from Philadelphia records] it follows… there would not be one chance in a million million million millions that one such series should be noted. Chance, therefore is out of the question…”. Holmes' conclusion was memorable: “The teachings of the two Professors in the great schools of Philadelphia are sure to be listened to [nevertheless] I am too much in earnest for either humility or vanity, but I do entreat those who hold the keys of life and death to listen to me also for this once. I ask no personal favor; but I beg to be heard in behalf of the women whose lives are at stake, until some stronger voice shall plead for them”. This time the case was overwhelming, as was its acceptance by the US medical community. Elisha Harris in New York took Holmes' side in his review of Meigs' treatise on childbed fever in which the Philadelphian denied its contagious aetiology and advised bloodletting. Harris wrote: “The poetic Harvard professor has furnished an absolute demonstration by facts, of the affirmative, while Meigs has defended the negative with the poetic arguments of fanciful hypothesis”. Puerperal fever had long plagued New York's oldest and largest public hospital, Bellevue, but the situation changed after Holmes' work became known. In April, 1857, Alonzo Clarke described how puerperal fever had broken out at Bellevue. In accord with Holmes' precepts, the infected women were removed, the place cleaned, new furniture installed, and a different set of doctors and nurses placed in charge. The following month Clarke delivered 23 women, not one of whom contracted the fever.17Clarke A Childbed fever; case records and discussion.New-York J Med Collateral Sci (3rd ser). 1857; 3: 105-107Google Scholar Fordyce Barker seconded Clarke's experience and added that Holmes had shown this “many years earlier with an array of facts which must… be convincing to every unprejudiced mind”, and that the work of Ignaz Fülöp Semmelweis in Vienna fully bore out Holmes' observations.16“EH” (Elisha Harris) Review of Meigs C. Childbed fevers.New-York J Med Collateral Sci New Ser. 1855; 15: 258-260Google Scholar The sanitarian revolution had planted its flag in New York. Philadelphia alone remained unconvinced, at least until 1889, when “whether out of concern for modesty, infection, or other reasons, a committee reportedly was organized in Philadelphia to set fire to the newly established university maternity hospital soon after its completion”.19AnonHistory of University of Pennsylvania Department of Obstetrics and Gynecology.http://www.hupen.obgyn.eduGoogle Scholar But in most of the USA the verdict of William Osler was sustained:20Osler W Oliver Wendell Holmes.Bull Johns Hopkins Hosp. 1894; 42: 86-88Google Scholar “so far as this country is concerned, the credit of insisting upon the great practical truth of the contagiousness of puerperal fever belongs to Dr Holmes”. Holmes, like other Americans, knew the work of Semmelweis; indeed while Holmes quoted Semmelweis in 1855, the opposite was not the case, neither in the Hungarian's preliminary abstracts of 18485Semmelweis IF Höchst wichtige Erfahrungen über die Ætiologie der in Gebäranstalten epidemischen Puerperalfieber.Zk&k Gesell Ærtzte Wien. 1847/8; 4: 242-244Google Scholar, 6Semmelweis IF Höchst wichtige Erfahrungen über die Ætiologie der in Gebäranstalten epidemischen Puerperalfieber.Zkg&k Gesell Ærtzte Wien. 1849; 5: 64-65Google Scholar nor in the full publication of 1861,21Semmelweis IF Die Ætiologie, der Begriff und die Prophylaxis der Kindbettfiebers. CA Hartleben, Pest, Wien & Leipzig1861: 350Google Scholar probably because Central Europeans regarded the New World as terra incognito in medical science. Yet, although Semmelweis and Holmes were an ocean apart, their findings were complementary. Holmes had deduced contagion by his retrospective study of private practice and he advised relative asepsis as the remedy; Semmelweis studied contagion prospectively in a charity ward by testing antisepsis as the remedy. Holmes, unlike Semmelweis, lived to see his work accepted by his colleagues the world over. Not so Semmelweis; his biographers agree that if the Hungarian “had written like Oliver Wendell Holmes, his ‘Aetiologie’ would have conquered Europe in twelve months”.22Morton LT A medical bibliography. 4th ed. Gower, Aldershot, Hants1983: 844Google Scholar Unique conditions prevailed at the Algemeiner Krankenhaus in Vienna where the young Semmelweis served as house physician in obstetrics. Before 1840, mortality rates from puerperal fever in the two obstetric divisions of the hospital were roughly equal; but beginning in 1840 the male medical students were all assigned to the first division, while the female midwifery students were assigned to the second. Deaths in the first division exceeded those in the second by four or five-fold (panel).The second division winsIn the first division, mortality sometimes approached 20%, whereas that in the second rarely exceeded 1%. Semmelweis correctly deduced that more women died in the first division because only the medical students attended necropsies. Drawing a connection between the lesions of puerperal sepsis and those found in a case of pyaemia (septicaemia) contracted by a colleague at the necropsy table, he concluded that “fetid material” in the necropsy room was contagious. Thorough cleaning of the hands might prevent the toxin from spreading:23Carter KC Carter BR Childbed fever: a scientific biography of Ignaz Semmelweis. Greenwood Press, Westport, Connecticut1994: 51Google Scholar “In the examination of pregnant or delivering maternity patients, the hands, contaminated with cadaverous particles, are brought into contact with the genitals of these individuals, creating the possibility of resorption. With resorption, the cadeverous particles are introduced into the vascular system of the patient”. In the first division, mortality sometimes approached 20%, whereas that in the second rarely exceeded 1%. Semmelweis correctly deduced that more women died in the first division because only the medical students attended necropsies. Drawing a connection between the lesions of puerperal sepsis and those found in a case of pyaemia (septicaemia) contracted by a colleague at the necropsy table, he concluded that “fetid material” in the necropsy room was contagious. Thorough cleaning of the hands might prevent the toxin from spreading:23Carter KC Carter BR Childbed fever: a scientific biography of Ignaz Semmelweis. Greenwood Press, Westport, Connecticut1994: 51Google Scholar “In the examination of pregnant or delivering maternity patients, the hands, contaminated with cadaverous particles, are brought into contact with the genitals of these individuals, creating the possibility of resorption. With resorption, the cadeverous particles are introduced into the vascular system of the patient”. Beginning in May, 1847, Semmelweis made the medical students wash their hands with chlorinated lime water and, predictably, the mortality rates in the first division dropped from 18·3% to 1·3%. So effective were his methods that between March and August of 1848 no woman died in childbirth in that division. In the spring of 1848, however, the liberal revolution that swept Europe evoked a xenophobic backlash and, because he was a Hungarian, Semmelweis' ideas were dismissed. After two brief presentations to the Viennese Medical Society on puerperal sepsis he again applied for a teaching post but he and the University failed to come to terms.23Carter KC Carter BR Childbed fever: a scientific biography of Ignaz Semmelweis. Greenwood Press, Westport, Connecticut1994: 51Google Scholar Returning to Hungary, Semmelweis repeated his successful attack on childbed fever at the St Rochus hospital in Pest where he worked for the next 6 years, reducing the mortality rate to less than 1%. Alas, Vienna remained as resistant to Semmelweis as had Philadelphia to Holmes. In accord with the notion of Justus von Liebig that infection was chemical and not biological, the Vienna Medical Weekly Wiener Medizinische Wochenschrift urged an end to chlorine hand washes and the mortality rates from puerperal sepsis rose again into the teens. In 1860, Semmelweis published his principal work, Die Ätiologie, Der Begriff Und Die Prophylaxis Des Kindbettfiebers,21Semmelweis IF Die Ætiologie, der Begriff und die Prophylaxis der Kindbettfiebers. CA Hartleben, Pest, Wien & Leipzig1861: 350Google Scholar but the general European response to his summa was dismissive; historians trace the subsequent clouding of his mind to that rejection. Nonetheless, a reading of Die Ätiologie leaves little doubt that Semmelweis had become troubled a few years earlier: his treatise is a mess, presenting unprocessed data and broad surmise in clotted prose. After its publication, Semmelweis became even more distraught, drifting into a “mental condition” that has remained as ill-defined as the circumstances of his death in 1865 in an Austrian mental institution.24Carter KC Carter BR Childbed fever: a scientific biography of Ignaz Semmelweis. Greenwood Press, Westport, Connecticut1994: 67Google Scholar, 25Lister J On the effects of the antiseptic system of treatment upon the salubrity of a surgical hospital.Lancet. 1870; i (40–42.): 4-6Abstract Scopus (34) Google Scholar By the end of 1865, he and his work were in eclipse: public belief had prevailed over public health. Semmelweis returned to posthumous favour along with the microbe hunters, not because he had found how the organism was spread, and by whom, but because he was a pioneer of antisepsis. When the Regius Professorship of Surgery at Glasgow University became vacant in 1865, Joseph Lister—son of J J Lister, a pioneer microscopist—was elected from seven applicants. The Glaswegians, who had recruited Lister to a renovated Royal Infirmary, hoped that operative sepsis, which sometimes claimed over half the surgical patients between 1861 and 1865, would decrease in the new structure and with a new surgeon. Convinced that living agents of fermentation, and not vapours, caused sepsis, Lister turned to carbolic acid as a disinfectant, and thereby reduced surgical mortality from 45% to 15% in his male accident ward between 1865 and 1869.25Lister J On the effects of the antiseptic system of treatment upon the salubrity of a surgical hospital.Lancet. 1870; i (40–42.): 4-6Abstract Scopus (34) Google Scholar By 1873 Lister had validated his “germ theory of fermentation” by isolating the first pure culture of a microbe, the lactobacillus. Lister, who bridged the sanitarian and bacteriological revolutions, paid belated homage to Semmelweis as his colleague in antisepsis: “I think with the greatest admiration of him and his achievement and it fills me with joy that at last he is given the respect due to him”.26IZ (Zoltàn I) Semmelweis In: Encyclopaedia Britannica, 1995. CD-ROM 2.0.Google Scholar And yet, in the largest maternity hospitals of Europe, puerperal sepsis remained unchecked. The Maternité in Paris probably had the highest sustained mortality due to childbed fever of any large institution: between 1861 and 1864, almost one-fifth of all deliveries resulted in the death of the mother. As doctors tried to exorcise the “epidemic genii” there were 310 deaths out of 1350 confinements in 1864, and by 1865 the hospital had closed. When it reopened at the beginning of 1866, Treélat, the surgeon-in-chief, complained that “the sanitary condition seemed perturbed"; by February, there were again 28 deaths out of 103 births.27Vallery-Radot RT The life of Pasteur.in: Devonshire RL Doubleday, Page & Company, Garden City NY1926: 289-290Google Scholar Women continued to die in Paris until Louis Pasteur intervened. Having saved the wine, silk, and dairy industries of France, he turned his attention to the Maternité. At the Academy of Medicine in 1879, Pasteur interrupted a discussion of puerperal fever epidemics, rising from his seat to insist: “None of those things cause the epidemic; it is the nursing and medical staff who carry the microbe from an infected woman to a healthy one”. As a clinician at the podium was replying that he doubted the germ would ever be found, Pasteur rushed to the blackboard to draw several grapelike chains of microbes, and pointed: “There, that is what it is like”.27Vallery-Radot RT The life of Pasteur.in: Devonshire RL Doubleday, Page & Company, Garden City NY1926: 289-290Google Scholar That discussion, and the experimental work on which it was based, was soon published to great acclaim;2Pasteur L Septicémie puerpérale.Bull Acad Méd (Paris). 1879; 8 (2me sér.): 505-508Google Scholar Pasteur's discovery that puerperal fever is caused by the streptococcus was a turning point in the bacteriological revolution. For much of the 19th century many thousands of women died of an “almost, if not entirely preventable” disease, because public beliefs—in the miasmatic theory, or the benign agency of doctors and midwives—prevailed over the facts of public health. In 1996, only three of every 100 000 women in the industralised world died of puerperal sepsis, a rate that would have astounded the sanitarians and microbe hunters. But in countries that lack sanitation, antibiotics (or even an organised social structure, as in for example, Chad, Nepal, and Somalia) the rates are 100 times higher.10Crosette B Tally of world tragedy: women who die giving life.New York Times. June 11, 1996; : A1-A12Google Scholar Changes in the public health of those lands, anthropologists are quick to point out, would require major revisions of public belief. However, those in the western nations who place public health first among the values of civilisation have little reason to feel smug. In the USA many thousands suffer or die from infectious diseases such as Lyme disease, rabies, tuberculosis, or AIDS—afflictions that are “almost, if not entirely preventable”. A sanitarian of the future might argue that our public beliefs in animal rights, civil liberties, and the bottom line have prevailed over public health at the end of the 20th century; he might do worse than to raise the voice of Holmes:28Holmes OW For a meeting of the National Sanitary Association, 1860: In: Collected poems. Vol 2. Houghton Mifflin, Boston1855: 270Google Scholar And lo! the starry folds reveal The blazoned truth we hold so dear: To guard is better than to heal The shield is nobler than the spear.