Obstetrics
was well developed on the mechanical side by the eighteenth century; however,
the benefits were offset by the prevalence of childbed fever, or puerperal
infection. This disease had been known from antiquity as an occasional
occurrence but during the seventeenth, eighteenth and nineteenth centuries it
became a fatal epidemic disease.
Between
the years 1652 and 1862 there were two hundred epidemics of the disease, which
were then attributed largely to the state of the weather. In 1773 a great
epidemic of puerperal fever more than decimated the lying-in hospitals of
Europe, and after three years culminated in Lombardy, where it is said that for
a year not one woman lived after bearing a child.
Most of
the lying-in hospitals, built from the seventeenth century to nearly the
twentieth century and dedicated to the care of destitute child-bearing women,
were humane in intention only. In reality most of them were deadly for the
women who entered them as these hospitals were the breeding grounds for
puerperal infection.
Puerperal
fever starts within a few hours to a few days after the birth of the child. The
following extract is from the record of a case described by a doctor practicing
during an epidemic at Aberdeen, 1789 to 1792, and gives some insight into the
course of the disease and the medical practice of the time:
"In
the afternoon of the 19th August, 1790, John Low. miller of Justice-mills, came
to my house, requesting me to go in immediately to his wife, who, he said,
'.....was in great danger'. I accordingly went, and found her in a dangerous
situation; she complained of an acute pain in the lower part of the abdomen,
attended with a very great degree of fever, the velocity of the pulse being at
the rate of 140 strokes a minute. The disorder commenced with a violent rigor
at six o'clock in the morning, being about thirty-six hours after delivery....I
accordingly ordered bleeding to the quantity of sixteen ounces."
The
physician also ordered a physic and raised a blister on the patients abdomen,
gave her opiates to relieve the pain in that location, and concludes."...the
scene was soon closed." With his patient dead he philosophises on the
ingratitude of the patient's friends and the hardships of medical practice.
"...On
this, as well as many other occasions, I found that scientific practice and
popular opinion very seldom correspond. According to a vulgar custom in this
country, the women came from all quarters to see the patient, and to offer
their advice. Several ladies likewise joined the crowd; and though they neither
knew the nature, nor even the name of the disease, yet they gave their advice
with great freedom! Some said it was wrong to bleed, others that it was
improper to purge a patient in such a situation; some prescribed heating, and
others astringent medicines; and seemingly actuated by other motives than the
good of the patient, they proposed different practitioners.."
In the
United States, in Colonian days, obstetrics did not receive the attention that
it did in Europe. Childbirth in those early days of American civilisation was
considered a simple physiological function, to be carried out in secrecy with a
friend or midwife. The wife of Dr Samuel Fuller, who landed from the Mayflower,
was the first midwife of the Colony. The next was Mrs Hutchinson of Boston, who
was banished for her political heresy. She was succeeded by Ruth Barnaby, who
lived to be one hundred and one. The first person to be executed in the Colony
of Massachusetts Bay was Margaret Jones, female physician; she was accused of
witchcraft.
Incidentally,
she is the only physician whose name was in any way associated ( her
association was involuntary ) with the scandalous persecutions which were
guided by those zealots, Cotton Mather and Samuel Parris.
The
efforts of the Chamberlens to control midwifery in England and Mauriceau's innovation
of conducting childbirth in bed did not influence the activities of the
Colonies, but other things from Europe did. Syphilis entered Boston in 1646,
ten years after Harvard College was founded. The appearance of diphtheria in
Roxbury, Massachusetts, was timed closely with Louis XIV's ascension to the
throne. While Hugh Chamberlen was trying to sell his obstetrical forceps in
Paris, New York was busy with an epidemic of yellow fever, and Boston, soon
after, with one of its numerous epidemics of smallpox..
Forty six
years after Clement delivered the Dauphin of France and made male midwifery
popular among the ladies of the court, New York City passed the first ordinance
in America to control the activities of the midwives. In 1716 it was considered
that midwifery needed some regulation; the ordinance reads:
" It
is ordained that no woman within this corporation shall exercise the employment
of midwifery until she has taken oath before the mayor, recorder or an
alderman...to the following effect: That she will be diligent and ready to help
any woman in labour, whether poor or rich; that in time of necessity she will
not forsake the poor woman and go to the rich; that she will not cause or
suffer any woman to name or put any other father to the child, but only him
which is the very true father thereof; indeed, according to the utmost of her
powers; that she will not suffer any woman to pretend to be delivered of a
child who is not indeed, neither to claim any other woman's child for her own;
that she will not suffer any woman's child to be murdered or hurt; and as often
as she shall see any peril or jeopardy, either in the mother or child, she will
call in other midwives for council; that she will not administer any medicine
to produce miscarriage; that she will not enforce a woman to give more for her
service than is right; that she will not collude to keep secret the birth of a
child; will be of good behaviour; will not conceal the birth of
bastards..."
In 1739 a
special department for instruction in obstetrics was created in the University
of Glasgow, while in America it was six years after that date that there was
the first record of a 'man midwife'. The New York Weekly Post Boy of July 22,
1745, states: "Last night died in the Prime of Life, to the almost
universal Regret and Sorrow of this City, Mr John Dupuy, M.D., Man Midwife; in
which last Character, it may be truly said here, as David did of Goliath's
Sword, there is none like him."
Later
there is mentioned Dr. Attwood of the same city, who " is remembered as
the first doctor who had the hardihood to proclaim himself a man midwife; it
was deemed scandal to some delicate ears, and Mrs. Granny Brown, with her fees
of two dollars or three dollars, was still deemed the choice of all who thought
that women should be modest."
In 1762,
the same year that New York was maintaining its modesty, Dr. William Shippen,
Jr., was opening a school for midwifery in Philadelphia. Dr. Shippen had
returned from abroad, where, after studying with John Hunter and his brother
William Hunter ( he of the rusty forceps ), he had completed his medical
studies at the University of Glasgow. Shippen brought back with him the
advanced ideas of European obstetrics and at once opened a school. As Dr.
Shippen provided 'convenient lodgings' for the accommodation of poor women
during their confinement, it may be said that he established the first lying-in
hospital in America. The following advertisement, inserted by Shippen, appears
in the Pennsylvania Gazette of January 1st, 1765:
"Dr.
Shippen, Jr., having lately been called to the assistance of a number of women
in the country in difficult labours, most of which was made so by the unskilled
old women about them ; the poor women having suffered extremely, and their
innocent little ones being entirely destroyed, whose lives might have been
easily saved by proper management; and being informed of several desperate
cases in the different neighbourhoods which have proved fatal to the mothers as
well as to their infants, and were attended with the most painful
circumstances, too dismal to be related. He thought it his duty immediately to
begin his intended Course in Midwifery, and has prepared a proper apparatus for
that purpose, in order to instruct those women who have virtue enough to own
their ignorance and apply for instruction, as well as those young gentlemen now
engaged in the study of that useful and necessary branch of surgery, who are
taking pains to qualify themselves to practice in different parts of the
country with safety and advantage to their fellow citizens."
There is
no evidence that any women had 'virtue enough to own their ignorance and apply
for instruction', however three years after establishing his private school he
joined with Dr. John Morgan of Philadelphia in organising the medical
department of the Collage of Philadelphia, later the University of
Pennsylvania. There he taught anatomy, surgery, and obstetrics.
The
Collage of Philadelphia gave the first regular medical degree in America,
granting the Bachelor of Medicine on ten men in 1768. The following year King's
College of New York, later Columbia University, graduated two men in medicine,
overcoming its regard for Granny Brown to the extent of teaching obstetrics.
Prior to
the 'regular medical degrees' given by the two American Medical schools there
had been two 'irregular degrees' granted. In 1663, by order of the court of
Rhode Island, one was given to Captain John Cranston to " administer
physicke and practice chirurgerie...and by this court styled Doctor of Physicke
and chirurgerie by the authority of this the general assembly of the
colony."
The other
degree was given by Yale Collage. Although the Yale Medical School was not
established until 1810, the Academic College in 1720 conferred the honorary
degree of M.D. on Daniel Turner in acknowledgment of books that he had
presented to the institution. 'Doctor' Turner's writings dealt largely with
venereal disease, and he also succeeded in improving methods for contraception.
In 1845,
one hundred years after Mr. John Dupuy, M.D., man midwife of New York died,
Oliver Wendell Holmes read a paper entitled, 'The contagiousness of Puerperal
Fever', before the Boston Society for Medical Improvement. In this paper he
showed clearly that the disease which ravaged the women in the lying-in
hospitals of Europe, and which in America also took its toll of lives, was an
infectious disease, and that the infection was carried by the physician or
midwife from one patient to another through lack of cleanliness. This paper,
setting forth the essentials of the greatest discovery ever made in the care of
the child-bearing woman, was received with indifference in Boston, and with
heated condemnation in Philadelphia by Dr. Meigs, who had succeeded Shippen in
the chair of obstetrics at the University.
Dr.
Holmes replied to the attack with a paper, 'Puerperal Fever as a Private
Pestilence', and in it stated that one 'Senderein' had lessened the mortality
from the disease by scrubbing his hands with chloride of lime. The 'Senderein'
was Semmelweis who eventually got the credit for one of the most important
advances in medical history. Holmes's papers were not even heard of in Europe
until noticed as an historical curiosity over fifty years later. Holmes became
professor of anatomy at the Harvard School of Medicine two years after the
publication of his paper on puerperal infection.
Ludwig
Ignaz Philipp Semmelweis,born in Budapest, Hungary, the fourth son of a
prosperous shopkeeper but always inhibited by his lack of a good elementary education,
therefore not considered worthy of note by the eminent medical elite, worked
through a lifetime of oppression and persecution in the vile wards of the
charity lying-in hospitals of Europe pursuing the cause of puerperal fever.
A brief
description of the conditions existing in the lying-in hospitals throughout
Europe provides an insight into the enormity of the task to which Semmelweis
set himself in trying to eradicate childbed fever. England and the Scandinavian
countries had at the time - middle nineteenth century - some ideas of
cleanliness in hospitals, and in England childbed fever came as an occasional
epidemic; in the hospitals in most of Europe it was a perennial epidemic.
Speaking
of these epidemics and still bound to the idea of 'miasma' ( noxious air as a
cause of contagion ), Oliver Wendell Homes said, "Now add to all
this" (transmission of the disease by contact ) "the undisputed fact
that within the walls of lying-in hospitals there is often generated a miasma,
palpable as the chlorine used to destroy it, tenacious so as in some cases
almost to defy extirpation, deadly in some institutions as the plague; which
has killed women in an Old World hospital so fast that they were buried two in
a coffin to conceal its horrors.".... The miasma in these cases was
filth.
Bearing
in mind that childbed fever is wound infection caused by the contamination of
the raw surface left in the uterus after the birth of the child, consider the
state of cleanliness in the Maternité of Paris as described by La Forte after
his visit there in 1864.
"The
principal ward contained a large number of beds placed in alcoves like English
horse-stalls along each side. Ventilation was almost impossible. Floors and
partitions were washed once a month...the ceilings showed that they had not
been whitewashed for many years. Lying-in women who became ill were transferred
to an isolation room regardless of the nature of their illness - puerperal
fever cases and patients affected with diarrhoea, bronchitis, measles, or any
other eruptive fever. Midwife pupils attended normal lying-in patients and
fever cases alike, and performed all the necessary manipulations for every
class of case."
La Forte
speaks of the apparent aversion to water at the hospital, of the clouds of dust
raised by dry sweeping the unwashed floors, and concludes: "It is not
astonishing that the Maternity of Paris has furnished a mortality without
example in any European country. From 1861 to 1864 the patients outnumbered
9,866 of whom 1,226 died; equal to a mortality of 124 in 1,000 births."
In 1858
Semmelweis, while advocating chemical treatment of the hands as a prevention of
the spread of puerperal fever, received a letter from one of his students
describing the conditions at Gratz: " Infection of all sorts occurs at
the Gatz lying-in hospital...The dissection- room is the only place where the
students can meet and pass the time when waiting for their midwifery cases, and
they often devote their attention to dissecting or studying and manipulating
preparations."
(The
cadavers of the dissecting room at that time were not embalmed in antiseptics.)
"When
they ( the students ) are summoned to the lying-in hospital, which is just
across the street, they do not make any pretense at disinfection; some of them
do not even wash their hands...The patients might as well be delivered in the
dissecting- room. As it is, the students cross the street with their hands wet
and bloody from dissecting; they dry their hands in the air, and stick them a few
times in their pockets, and at once proceed to make examinations...It is no
longer a riddle to me why, after a clinical meeting, the medical officer of
Gratz exclaimed: 'The lying-in hospitals are really nothing but murder
institutions !' "
Of the lying-in
hospital of Budapest in 1850, it is said that the patients' view from the
window was the burying- ground, varied on the other side by glimpses of the
dissecting- room, with underneath the privies and an open sewer. In 1860 the
hospital was moved to a new building, and of this the following is written in a
publication of that time:
"While
it is not to be denied that the institutions have obtained the advantages of
more room, it must be admitted also that the internal fittings (furniture,
beds, etc. ) are in the old wretched condition; the broken tables and the
ragged and worn-out bed clothes, all brought from the old hospitals. Especially
the lying-in clinic is in an indescribably pitiable condition; there poor
lying-in women are to be found, some of them partly on straw spread on the
floor, some of them on wooden benches, others crouching in any corner of the
room, weary and worn out; only to a few is it vouchsafed to find a regular bed
on which to stretch their weary limbs. Everywhere you find dirty bed linen,
with bedclothes old and worn and almost in rags."
Regarding
the private practices of physicians among the more well off patients, childbed
fever occurred in occasional cases, and sometimes in epidemics, but, as Holmes
particularly noticed, it was apt to run in a few consecutive cases of some one
physician and then die out for a time.
The
maternity hospital of Vienna, where Semmelweis started his work, was in two
divisions; in one the medical students were instructed and in the other the
women who were to become midwives were trained. In the First Division, that of
the medical students, there was an average of 99 deaths per 1,000 births over a
period of six years. In the Second Division, that of the midwives, the average
for the same period was 33 deaths in 1,000 births.
Fear was
declared by some physicians to be the cause of the fever, for the dread of
going to the First Division was very great; so great that it was thought that
the women sickened and died for that reason. Semmelweis said: " That
they were afraid of the First Division there was abundant evidence. Many
heartrending scenes occurred when patients found out that they had entered the
First Division by mistake. They knelt down, wrung their hands, and begged they
might be discharged. Lying-in patients with uncountable pulse, meteoric
abdomen, and dry tongue, only a few hours before their death would protest that
they were quite well in order to avoid medical treatment, for they believed
that the doctor's interference was always a precursor of death."
Religious
observances were also accused of increasing the mortality; it was usual for the
priests, arrayed in their robes, with an attendant marching before them ringing
a bell according to Catholic ritual, to proceed to the sick woman to administer
the sacrament. According to ordinary arrangement this should be done only once
in twenty four hours, but in childbed fever it was required sometimes every few
hours, adding to the distress of the women.
Semmelweis
said, " it had a strange effect upon my nerves when I heard the bell
hurried past my door; a sigh would escape my heart for the victim that once
more was claimed by an unknown power. This bell was a painful exhortation to me
to search for this unknown cause with all my might. During my first term of
office I appealed to the sense of humanity of the servant of God, and without
difficulty it was arranged that for the future the priests would take a
roundabout route, without ringing the bell, so as to reach the sick-chamber in
silence unobserved. The two divisions were made similar in this respect, but
the difference in their mortality remained."
Death
and the Physician', a woodcut by Hans Holbein. The priest is carrying the
sacrament to some dying man or woman; attendants follow with tapers and holy
water, and death leads the way with a lantern and a bell to announce the coming
of the priest. It was the sound of this bell which distressed Semmelweis
Other and
even more absurd reasons were given for the difference in mortality. "It
was alleged that the reason for the great mortality was because patients were
unmarried women of the most hopeless class of the community, accustomed to earn
their bread in want and misery and amid conditions which produced great and
constant depression of spirits. If this had been the cause of the mortality it
would have been as great in the Second Division, for to it exactly the same
class of patients were admitted. The higher mortality of the First Division was
ascribed to the wounded modesty of the poor women going through the process of
parturition in the presence of men. Most of the patients in the First Division
certainly suffered from fear, but not many were troubled with a sense of shame.
Truly it shows with what want of thought the whole question of the aetiology of
puerperal fever has been discussed when the persons who at times are depicted
as the most abandoned of the population, have attributed to them in the next
sentence a tenderness of modesty such as the upper and highest classes of the
community do not claim. Among the upper and even the highest ranks of society
labour is conducted by physicians, and their patients do not die of puerperal
fever in consequence of wounded modesty in the same proportion as is alleged of
the inmates of the lying-in hospitals who, for the sake of argument, are often
depicted as the most loose and abandoned of the community."
Semelweis
goes on step by step to eliminate ventilation, dirty laundry, and improper diet
on the grounds that these things were the same in the two divisions. yet as he
eliminated these possible causes he knew that the real cause lay undiscovered
before him in the hospital. This fact was proven by the observation that women
who were overtaken with labour on the street while making their way to the
hospital were not affected with childbed fever in the hospital, even though
they might be taken into the First Division.
Constant
criticism of the old orthodox opinions on the causes of childbed fever by
Semelweis fell on deaf ears and caused him to be demoted from assistant in
charge of the First Division, to that of provisional assistant; another
physician was in charge. However, after six months he resumed his former
position. At the same time the death of Dr. Kolletschka occurred at the
hospital under circumstances which greatly impressed Semmelweis. Kolletschka,
while performing a post- mortem examination, received a puncture wound on the
finger from the knife of one of his pupils. In consequence of this slight wound
he sickened and died. The general symptoms of this malady were those of
childbed fever.
Of this
occurrence Semmelweis says: "In the excited condition in which I then
was, it rushed into my mind with irresistible clearness that the disease from
which Kolletschka had died was identical with that from which I had seen so
many hundreds of lying-in women die. Day and night the vision of Kolletschka's
malady haunted me, and with ever-increasing conviction I recognised the
identity of the disease from which Kolletschka died with the malady which I had
observed to carry off so many lying-in women."
Semmelweis
was on the verge of his great discovery that childbed fever was wound
infection, blood poisoning, which was transmitted to women by the unclean hands
of the physicians and medical students who examined them during their
childbirth.
" In
the case of Kolletschka the cause of the disease was cadaveric material carried
into the vascular system; I must, therefore, put this question to myself: Did,
then, the individuals whom I had seen die from an identical disease also have
cadaveric matter carried into the vascular system ? To this question I must answer,
Yes ! "
All of
the physicians and students attending the First Division of the hospital had
frequent occasion to come in contact with and work upon the bodies of those who
had died at the hospital. According to the usual method of washing the hands
merely with soap and water, particles adhering to the hands were never
completely removed, a fact demonstrated by the odour which the hands retained.
In the examination of the women in the wards, any of the students were entitled
to make internal examination for their instruction; the raw surfaces left at
delivery were infected; childbed fever followed. Moreover, when one woman was
infected the hands of the examiner, unwashed between examinations, carried the
infection to the next woman examined.
With this
discovery made, Semmelweis at once required each student to wash his hands in a
solution of chloride of lime before making examinations. At that time in his
division there were 120 deaths in 1,000 births; in the next seven months the
deaths fell to 12 in 1,000, and for the first time in the history of the
hospital were below that of the Second Division. In that year also there were
two months in which not one single death occurred among the First Division.
In 1865
Semmelweis suffered an injury to a finger, which probably occurred during one
of his last operations. He was infected with blood poisoning, identical with
puerperal fever. He died August 13th, 1865, a victim of the infection which he
had devoted a lifetime to eradicate from the wards of the maternity hospitals.
Three Kids Gripped By Evil By Polly Mullaney
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