The Mother's Black Death - A Brief Overview of the Historical Significance of Puerperal Fever

The Mother’s Black Death

A Brief Overview of the Historical Significance of Puerperal Fever

Julia Lemmens

Northwestern Health Sciences University

Bachelor of Science in Human Biology

Word Count: 1920

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It began in lying-in hospitals in the 19th century 1. Hundreds of mothers every month - dying. One out of every four, in fact. Women began coming to hospitals to give birth following the transfer of child delivery service from midwives to much more educated medical men. After further advances in medicine, it was decided that midwives could not be left alone to do a job as crucial as helping women bring children into the world. Instead, medical students and their physician-instructors flocked to the bedside to inspect the mothers and aid them in the delivery process and recovery thereafter. That is when the fevers began. Terrible fevers. A few days after childbirth, most would manifest symptoms of shock and many of them would pass soon thereafter. But the cries of orphaned children rang in the ears of a few devoted physicians. But to other 19th century physicians it was preposterous that a vessel of mercy such as a medical doctor presenting his holy hands to bring life into the world could actually be an minister of death. But however well-meaning or evil-intentioned the doctors may have been, the mothers continued to die.

As the death rate climbed, in London, Boston, and Vienna, three key physicians began investigating the matter with increasing concern. It was the discoveries of these men that encouraged investigation and attention to the rate of puerperal deaths. To this day, their legacy has lived. Every year, more mothers survive the days after childbirth than ever because the investigation has deepened with ongoing studies and record keeping. Why is this so crucial? The death of mothers is significant in society. If mothers cannot survive, their children’s chance of surviving drops significantly. Mothers are the soil that allows societies to flourish. To save and cherish the lives of birthing mothers is, in every generation, to save and cherish the society itself.

This childbed or, “puerperal fever” is an infection of the female genital tract or sex organs that occurs after delivery 2. The “puerperium” period is defined as that of maternal recovery that occurs after the childbirth process 3. Thus “Puerperal Fever” is the fever that is caused by infection that occurs during this time period 2.

“WHO technical working group defined puerperal sepsis as infection of the genital tract occurring at any time between the onset of rupture of membranes or labour and the 42nd day postpartum in which two or more of the following are present: pelvic pain, fever, abnormal vaginal discharge, abnormal smell/foul odour discharge or delay in uterine involution.” 4

The numbers of maternal deaths caused by this puerperal fever increased after the 1800’s new understanding of childbirth.5 What was previously a social event for women became a medical-surgical event where doctors began to use forceps and other tools during the delivery process. As microbiology was yet to be understood (in the late 1800’s and early 1900’s), the standard of cleanliness and understanding of the transfer of disease was still limited to the contagion theory or even more primitive, the miasma theory. It was not yet understood that infection could be introduced into a new subject from a previous one, specifically, an autopsy specimen.5 Three main historical characters played a decisive role in this crucial discovery, the first of which was from England.

In London in 1842 one account tells of a physician and professor who published his observations and ideas about “childbed fever.”1 Thomas Watson’s suspicion was that childbed fever was being transferred from one patient to another by dirty hands and garments. He attempted to address this problem and when he did, he was successful at lowering the maternal death rate. He said “[w]herever puerperal fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent absolution.” His concern was that childbirth attendants were transferring the disease to the new mothers. His recommendations were basically limited to handwashing with a chlorine solution and care to change garments before attending a mother. 1

Meanwhile, in Boston 1843, Dr. Oliver Wendell Holmes’ interest in puerperal infection peaked. 1 One account marked the height of his interest when a colleague and a student became ill and passed away from a post-autopsy infection. Their symptoms? The same as the women who were passing from childbed fever. The diagnosis? Septicemia. He published his “eureka” moment in “The Contageousness of Puerperal Fever” including in his publication recommendations about cleanliness around birthing women. His recommendations stretched beyond Watson’s. He would forbid autopsies and childbirth assistance to occur in close proximity or succession. 1

Holmes’ goal was strictly medical improvement, and his attempts were valiant. However, soon enough the backlash began.1 His fellow physicians believed their holy hands could not possibly be agents of death while doing such a kind service to these helpless women. However well-intentioned, unfortunately for the more ignorant physicians, Holmes was correct. Where his recommendations were followed, the number of early motherhood deaths dropped dramatically. 1

Soon thereafter, in Vienna, Dr. Ignaz Semmelweis worked to find the cure to puerperal fever. In 1844, he was privileged to receive a position at The Vienna Lying-In Hospital’s First Obstetric Division assisting medical students in their obstetric training.1 The hospital had an 18% mortality rate for women who gave birth in the hospital. Semmelweis observed that the medical students who were participating in autopsies as part of their training had a much higher percentage (16%) of patients who passed from puerperal fever. In contrast, the patients cared for by hospital midwives had especially low rates (2%) of maternal deaths. Following these observations, Semmelweis began to require the medical students to perform a regimen of hand washing with a chlorine lime solution. After this was implemented the maternal death rate fell dramatically. From 18% down to a record 3%. Unfortunately, Semmelweis was, like Holmes, largely rejected (and even eventually fired) for his outspoken condemnation of a hospital staff cleanliness regimen.1

Furthermore, in the 19th and early 20th century, advances continued and continue still today in pursuit of eradication of puerperal infection worldwide. A strain of streptococci was identified as one of the main bacteria causing infection in 1874 1. This discovery also further bolstered the use of antisepsis during the birthing period. Antibiotics were later introduced to the scene for post-infection cures and are still widely used today to eradicate puerperal infection in individuals. 1, 6

Though many advances have been made towards the elimination of puerperal infection, it has not yet been extinguished. 75,000 women are still passing every year from puerperal sepsis.7 Most of these women are from poorer regions like sub-Saharan Africa and East Asia where the puerperal mortality can climb to a staggering 50% 4. The bacteria present in the most severe cases of infection include the aforementioned BETA-streptococcus. 7 Since this particular strain of bacteria was identified as the primary cause of maternal infection, the use of antibiotics has become crucial to the survival of these patients. However, proper use of antibiotics is almost more crucial than simple administration. In some nations with sub-par health care systems, women who show signs of puerperal sepsis are simply administered a broad-spectrum antibiotic in response. The concern is that if antibiotics continue to be administered in such a way, women may begin to develop resistant strains of bacteria which would eliminate further effectiveness of antibiotics if needed to fight further infection. 4

Another issue facing doctors seeking to annihilate the presence of early motherhood sepsis is the Caesarian section factor. If a C section has been performed, any mother’s chances of contracting puerperal fever increase 5 to 20-fold. Infection management and continuing the historical legacy of proper antiseptic practices is key to keeping mothers safe and healthy. 4 It is also important that doctors worldwide attempt to lower the frequency of Caesarian sections and encourage and promote vaginal childbirth whenever possible. Simple, informed precautions may help the mortality rate to decrease significantly if paired with increased training in successful vaginal childbirth practices.

Maternal deaths are not isolated incidences. The deaths of mothers much too often also mean the deaths of children ages 5 and under 8. Many women who live in poorer nations have a higher rate of birthing children in successive years which means that maternal deaths are causing the rate of infant and young child death to rise. If death is escaped but infection still keeps the child and mother separated, valuable mother-infant bonding may be seriously delayed which can have a significant impact on young children 4.

In order to supplement our understanding of puerperal sepsis and move toward abolition of it for the sake of mothers and their children, it is important that the record keeping of, not only deaths, but also other symptoms and infections becomes a higher priority for health care facilities. Unfortunately, much of the information we currently have is based on informed guess work which is far from ideal.  It is only well-rounded research that will allow complete understanding of the infection, its causes, and what can be done to eliminate its occurrence worldwide. 4

It is clear. Puerperal infection has been a concerning medical condition throughout the centuries, but especially since the introduction of childbirth to hospitals where bacteria and microbes convene. Since this is the case, it is crucial that we continue the search for every cause of every kind of puerperal illness by maintaining good record-keeping practices. Also, continued training for medical practitioners worldwide in the proper administration of antibiotics, antiseptic use, and successful vaginal childbirth technique will be entirely helpful in eradicating puerperal infection. The lives of our mothers, children and the health of our societies at large depend on the care of physicians to adopt these practices.

References

1. De Costa CM. The contagiousness of childbed fever: a short history of puerperal sepsis and its treatment . citeseerx. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.151.7978&rep=rep1&type=pdf. Published December 2016. Accessed December 11, 2016.
2. AboutZahar C. Global burden of maternal death and disability. Global burden of maternal death and disability. http://bmb.oxfordjournals.org/content/67/1/1.short. Published 2003. Accessed December 11, 2016.
3. Google. https://www.google.com/search?q=puerperium&rlz=1C5CHFA_enUS719US719&oq=puerperium&aqs=chrome..69i57j0l5.491j0j7&sourceid=chrome&ie=UTF-8
4. Bonet M, Oladapo OT, Khan DN, Mathai M, Gülmezoglu AM. New WHO guidance on prevention and treatment of maternal peripartum infections. The Lancet Global Health. 2015;3(11). doi:10.1016/s2214-109x(15)00213-2.
5. Magner LN. A History of Medicine. 2nd ed. New York: M. Dekker; 1992.
6. Teare EL, Smithson RD, Efstratiou A, Devenish WR, Noah ND. An outbreak of puerperal fever caused by group C streptococci. An outbreak of puerperal fever caused by group C streptococci. http://www.sciencedirect.com/science/article/pii/0195670189900534. Published 1989. Accessed December 11, 2016.
7. van Dillen J, Zwart J, Schuette J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Current opinion in infectious diseases. https://www.ncbi.nlm.nih.gov/pubmed/20375891. Published June 23, 2010. Accessed December 11, 2016.
8. Black RE, Cousens S, Johnson HL, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet (London, England). https://www.ncbi.nlm.nih.gov/pubmed/20466419. Published May 11, 2010. Accessed December 11, 2016.