History and Geography

Women have suffered from puerperal fever, presumably due to streptococci, since ancient times. Many case studies in the books of Epidemics within the Hip-pocratic corpus indicate that women suffered from postpartum fever, debility, and death. Nevertheless, childbed fever was probably never common. Oliver Wendell Holmes, in his masterfully argued "Contagiousness of Puerperal Fever" (1842-3), claimed that childbed fever was rare. When it occurred, it clustered around the practice of an individual physician. Holmes pointed to the need for cleanliness to prevent further victims.

Similarly, in the other classical study of puerperal sepsis first published in 1861, Ignaz Semmelweis (1983) demonstrated that physicians who followed their dead patients to the autopsy room and then returned to the lying-in room to deliver more babies had more of their patients die of puerperal fever than did midwives who did not perform autopsies. These observations of Holmes and Semmelweis (each un aware of the work of the other) point to the tremendous gulf in personal cleanliness that existed between the pre- and post-germ-theory practitioners.

Holmes, for example, tells of distinguished obstetricians who carried pelvic organs removed at autopsy in their street coat pockets. Both accounts also underscore the irony in the fact that the most scientifically oriented physicians, the ones who performed autopsies, were responsible for spreading the illness! Those accounts, however, treat with silence the plight of infants born of infected mothers. We know from twentieth-century experience that many infants emerged unscathed. But in the past, some may have developed a fatal infection, and even the lucky surviving infants would have faced an uncertain future if their mothers were unable to nurse them.

Erysipelas's role in history was an inevitable accompaniment of wounds, whether accidental or surgical (Simpson 1872). Any deep cut through uncleansed skin risked injecting streptococci into susceptible tissue. Erysipelas also accompanied other strepto-coccal-related illnesses, such as childbed fever. Scarlet fever (streptococcal pharyngitis produced by peculiar strains of streptococci that release a toxin yielding a rash) crosses medical history in a number of places. In the early years of bacteriology, Friedrich Loffler (1884) had to sort out scarlet fever cocci from diphtheria bacilli (both produced sore throats). Scarlet fever often occurred in epidemics passed both in the usual droplet fashion and in contaminated food - especially milk — supplies.

Streptococcal pharyngitis, with or without rash, provoked a prominent postinfectious state: acute rheumatic fever. For a period of about a century, rheumatic fever injured more hearts than any other disease. It struck children and young adults, usually less than 25 years of age, in temperate climates. Although mentioned by prominent seventeenth-century writers, such as Thomas Sydenham, rheumatic fever appears not to have become a major problem until the late eighteenth and early nineteenth centuries, when carditis emerged as the major component of rheumatic fever. This seems to have been the result of a biological change in the way the streptococcus provoked the body to respond (rheumatic fever is not an infection in the usual sense, but rather an immunologic response to the streptococcus), coupled with the introduction of the stethoscope that made diagnosis easier (Cheadle 1889).

All streptococcal diseases, except newborn sepsis and meningitis, have become less virulent since the end of the nineteenth century, a phenomenon that has yet to be explained. Their incidence was clearly on the decline before the arrival of specific measures to treat these illnesses. The puzzle to be sorted out is the possibility that the streptococcus, with its biological variability, could have become less inherently invasive in natural fashion. But it did so at the precise time in history (at least in Europe and the United States) when nutrition, housing, and standards of living substantially improved.

Today, however, the streptococcus is usually sensitive to sulfonamides and to penicillins; thus most infections are curable with appropriate antibiotics.

Peter C. English

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