September 18, 1997
Harvard
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  Defeating Infection

How Oliver Wendell Holmes helped conquer the 'black death of childbed'

By Alvin Powell

Special to the Gazette

It was the scourge of European hospitals in the 1800s, a dreaded infection that killed as many as one in five new mothers. Outbreaks at some smaller hospitals were even more deadly, sometimes killing every new mother over a period of months, leaving orphans and widowers grieving in its wake.

The disease was just as feared in America, where hospitals were used less frequently for childbirth. Here, doctors attending women in their homes would have strings of fatal cases, while others practicing nearby had none.

No one knew what caused the illness, called puerperal fever, and many doctors did not believe it was contagious. But in 1843, Boston doctor Oliver Wendell Holmes concluded not only was the disease contagious, but this "black death of childbed" was borne to its victims by the very doctors who sought to cure it.

Holmes' denunciation of the medical profession as a carrier of a plague rather than a deliverer from disease marked a milestone in both Holmes' medical career and in the prevention of the illness.

His paper, "The Contagiousness of Puerperal Fever," is considered his greatest contribution to medicine because it joined the literary skills of a man better known as an author and poet to an array of dismal facts that could not, ultimately, be dismissed as coincidence.

"No one before Holmes had clothed the damning facts in persuasive eloquence, informed by passionate indignation and unshakable conviction," said biographer Eleanor Tilton in her 1947 book on Holmes, who served as Dean of Harvard Medical School from 1847 to 1853.

Puerperal fever is relatively rare today. Medical science eventually identified the streptococci bacteria that cause it. By the 1930s, researchers had developed drugs that could cure the condition.

A different era in medicine

In 1843, both childbirth and medical practices were markedly different from what we know today, according to Amalie Kass, a Medical School lecturer on the history of medicine.

There were no anesthetics to ease the pain of childbirth and no surgical options like Cesarean sections to handle complications. Hemorrhages were handled by packing with ice -- and prayer.

Without advanced drugs and sophisticated treatments, hospitals had little value except as quiet places to deliver babies. Consequently, they were mostly used by poor women. Wealthier women had doctors and midwives visit them at home.

Infection was always a fear. And Holmes concluded that what worked to spread the disease was doctors rushing to patients from the bedside of women with puerperal fever or from autopsies of the diseaseÕs victims.

His conclusions were not welcomed by his fellow physicians.

"No gentleman would infect his patients, and doctors were gentlemen. They were outraged by this," Kass said.

Chief among his critics were two teachers at prestigious medical schools in Pennsylvania, Hugh L. Hodge and Charles D. Meigs, each of whom disputed Holmes' conclusions in their own writings. Even Walter Channing, a former instructor of HolmesÕ at Harvard Medical School, initially took a position against the disease's contagiousness, a position he later abandoned.

The problem was that the illness did not strike every patient who was exposed to it, Kass said. Until Pasteur's work on bacteria, doctors didn't know what the infectious agent was, leaving open the question of transmission.

"Doctors were not being obtuse," Kass said. "They were wrestling with this all the time."

Meanwhile, doctors routinely went from patient to patient wearing the same clothes, sometimes stained with blood and other bodily fluids. The sterilization techniques in effect today were unknown then and simple washings weren't always effective in killing the bacteria that caused the disease.

"There were physicians until the end of the century who washed their hands after delivering a baby, but not before," Kass said.

Medical society sparks interest

Holmes didn't have a particular interest in puerperal fever until it was brought up at a meeting of the Boston Society for Medical Improvement, a small group of Boston-area doctors who met twice a month to discuss cases and medical issues of the day.

One requirement was that members write and present papers to the group. The requirement was a strict one, with members fined and even dismissed if they failed in that duty.

Holmes' former instructor, Channing, first brought up the subject of puerperal fever in mid-1842, when he reported to the Society on 13 fatal cases. Four months later, a second presentation was made concerning a doctor and a medical student who cut themselves during an autopsy of a puerperal fever victim. Both became seriously ill and the medical student died.

The Society's interest in the subject continued, with more presentations on the topic in the following months. In February 1843, Holmes presented his paper "The Contagiousness of Puerperal Fever," which the Society urged him to publish.

The paper itself did not dwell on technical descriptions of this stalker of new mothers or speculate on its causes. Instead, it focused on how it spread. The paper exhaustively listed case after case of physicians around the country and in Europe who encountered strings of the disease in women they attended.

Most striking was that the outbreaks occurred in the practices of single physicians rather than in a broader fashion. They happened while other doctors' patients, even those who lived nearby, showed no signs of it.

In citing evidence for the disease's infectiousness, Holmes quoted a Dr. Blundell, who wrote, ". . . 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."

In researching the disease, Holmes relied not only on the medical literature of the day, but contacted fellow physicians to solicit their personal stories of the disease. The result showed in his paper, where he cited strings of fatalities 40 cases long, 16 cases long, 5 cases long, 16 cases long, and on and on, hammering the point home with dismal repetition.

Initially, the paper did not make much of a splash. The Boston Society for Medical Improvement was a small, private group. The paper was published in The New England Quarterly Journal of Medicine and Surgery, but its circulation was small. An abstract of the paper was published in the American Journal of the Medical Sciences, but the two-page condensation, published without comment by the magazine, lost the power of both Holmes' prose and the sheer weight of the repeated evidence.

Holmes' paper did not reflect the thinking of the day. Medical textbooks as well as prominent physicians either didn't address the issue or said the disease was not contagious. The issue would not be settled finally until late in the century, when Louis Pasteur's experiments with bacteria showed how the disease could be transmitted.

Others Share Concern

Holmes was not the first doctor to conclude puerperal fever was contagious. In his research, he discovered doctors as far back as 1795 advising precautions against transmitting the disease.

Research on the disease was continuing on other fronts as well. One influential doctor was Ignaz Semmelweis, who worked in the maternity clinic of the Vienna General Hospital in the late 1840s. Though the hospital's mortality rate from the disease compared favorably with other European hospitals, the death rate in the division of the hospital attended by doctors was three to five times greater than that in the second division, where women were attended by midwives.

Semmelweis concluded that the doctors were infecting their patients after performing autopsies and began requiring doctors to wash with a chlorine solution, resulting in a large drop in the mortality rate.

The tide of medical opinion was turning. In 1852, Copland's Medical Dictionary supported the idea of puerperal fever's contagiousness, praising Holmes in the process. In 1855, Holmes republished his paper and this time the American Journal of the Medical Sciences gave it an enthusiastic review.

In his preface to the reprinted version of his paper, Holmes focused his famed eloquence on Hodge and Meigs, who were teaching future doctors that the disease was not contagious.

"If I am right, let the doctrines which lead to professional homicide be no longer taught from the chairs of those two great institutions,'' Holmes wrote. "If there is voluntary blindness, any interested oversight, any culpable negligence, even, in such a matter, and the facts shall reach the public ear; the pestilence-carrier of the lying-in chamber must look to God for pardon, for man will never forgive him."

 


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