The Tragedy of Childbed Fever by Irvine Loudon, Oxford University Press,
ÂŁ40, ISBN 019820499X
CHILDBIRTH can be a source of great fear as well as great joy. Nowadays few
women risk death in hospital from “puerperal” or childbed fever. But it was once
a grim reality striking the healthy and wealthy as well as the sick in what
should have been safe surroundings. It was a risk of delivery.
Mention puerperal fever and the name of Ignaz Semmelweis leaps to mind. This
young Hungarian physician who worked in Vienna’s main hospital in the mid-19th
century was appalled by the carnage in the hospital’s maternity wards. He
noticed that, of the women who succumbed to post-partum fever, far more had been
attended by medical students than by unschooled midwives.
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This, he inferred, was because the medics had often come straight from
dissecting cadavers in the morgue, carrying infectious material to their
patients on their soiled hands, instruments and clothes. By introducing chlorine
disinfectants Semmelweis slashed the death rate. But his theories were
distrusted and his practices condemned by jealous or bigoted rivals. Forced out
of Vienna, he was driven insane by implacable opposition, and died of
septicaemia in a lunatic asylum, one of medicine’s true heroes and martyrs.
The Semmelweis story as just told owes more to myth than reality, as Irvine
Loudon shows in a characteristically expertly researched, humane and beautifully
written book. In fact, the Hungarian won considerable support for his views, at
least to begin with, only to isolate himself by a mulish talent for making
enemies out of friends. On top of this he was completely unable to brook
criticism—much of it justified, in the light of his dogmatic adherence to
untenable views.
In any case, the Semmelweis episode amounts to just one chapter in the wider
childbed fever saga, which Loudon traces from the 18th century up to the time in
the 1930s when the introduction of sulphonamide antibiotics finally made the
disease treatable. During that period, as Loudon shows in The Tragedy of
Childbed Fever, increasing medical intervention in childbirth had amplified
rather than reduced its dangers.
Childbed fever, a Group A streptococcal infection, childbed fever had
probably always been around, but it did not get much attention until the 18th
century, because it was then that male doctors (accoucheurs or obstetricians)
began to take childbirth out of the hands of lay midwives. The simultaneous
foundation of lying-in hospitals, ghastly hotbeds of infection, created highly
visible mass outbreaks.
Early maternity hospitals, Loudon shows, had maternal death rates which were
regarded as scandalous even at the time: in the worst outbreaks, whole wards of
patients would die. The year 1797 produced an early celebrity victim: the
feminist Mary Wollstonecraft. Loudon opens his book with a graphic account of
her pitiable death.
But a few pioneering physicians— notably Alexander Gordon in Aberdeen
and Oliver Wendell Holmes (snr) in Boston, Massachusetts—looked long and
hard at the problem. Eventually they concluded that the disease was contagious
and largely iatrogenic—spread by doctors. Louis Pasteur had not yet
proposed his form of the germ theory of disease, let alone got it accepted.
Hostility met all suggestions that puerperal fever was somehow spread by doctors
going straight from an infectious case—perhaps erysipelas or some other
fever—to a woman in labour.
Gordon and Wendell Holmes advocated strict hygiene measures. Indeed, those
enlightened and conscientious practitioners who noted that they had suffered a
succession of childbed fatalities would voluntarily quarantine themselves from
maternity cases. But views like those of Wendell Holmes long met scepticism and
hostility from fellow practitioners who held that the disease stemmed from
environmental “miasmas” or from endogenous factors within the pregnant woman
herself. Both of these were rationalisations, Loudon suggests, which
conveniently allowed doctors, resentful at slurs on their profession, to avoid
having to think the unthinkable, that they themselves were the harbingers of
death.
The puerperal fever death rate did begin to fall during the Victorian era,
not directly through Semmelweis’s crusade but through the gradual introduction
of antiseptic and aseptic procedures in hospitals at large. This was thanks to
the routines developed by Joseph Lister and to Pasteur’s bacteriological
theories, which gave them a theoretical and experimental backing. First to
become standard were carbolic disinfectants. Then, slowly, rubber gloves,
sterile drapes and masks made their appearance. By 1900 the disease was under
control in hospitals: puerperal fever was at last preventable.
But it did not go away. Ironically now, for the first time, home deliveries
became a significant danger. Indeed, maternal deaths from puerperal fever were
actually still rising in England in the early decades of the 20th century. Yet
at the same time the death rate was falling in other advanced nations throughout
Europe. Just seventy years ago—that’s during your grandmother’s
childhood—an English woman going into labour still had maybe a 1 in 250
chance of not surviving the birth of her child.
Loudon points the finger of blame at this country’s legacy of barely trained
midwives (mere registration was not required till 1902) and the Cinderella
status of obstetrics in medical education. This, combined with the cavalier
attitudes of many GPs to the perils of childbirth, was to prove fatal. In the
Netherlands and elsewhere, domiciliary midwives were well trained.
A general practitioner turned medical historian, Loudon never resorts to
doctor-bashing; but his is a sobering—indeed, as he says,
tragic—story of how those who have put their trust in the medical
profession all too often needlessly ended up not happy mothers, but corpses.