History and Geograpy

The Hippocratic corpus contains case histories of puerperal fever. Various epidemics were recorded in the sixteenth and seventeenth centuries. The disease was first characterized and named in the eighteenth century when serious epidemics began to appear with regularity in the large public maternity clinics of Europe. In the late eighteenth and early nineteenth centuries, various English and American obstetricians concluded that puerperal fever was sometimes contagious. Alexander Gordon and Oliver Wendell Holmes argued that physicians could transmit the disease from one patient to another, and they recommended various measures to reduce the frequency of such accidents. By the early nineteenth century, the disease was responsible for a mortality rate of between 5 and 20 percent of maternity patients in most major European hospitals. Smaller hospitals had outbreaks in which, through a period of several months, 70 to 100 percent of maternity patients died from puerperal fever. The etiology of the disease was unclear, although seasonal patterns and its high incidence in the maternity clinics seemed to suggest that it was usually due to a local poison conveyed through the atmosphere. By the middle of the nineteenth century, the disease was receiving a great deal of attention in the medical literature, and cases were being reported from around the world.

In 1847, Ignaz Semmelweis became assistant in the Vienna maternity clinic. The incidence of puer peral fever in the Vienna hospital was about 7 percent, which compared favorably with other hospitals around Europe. However, the Vienna clinic consisted of two divisions, one for obstetricians and the other for midwives; the first division consistently had a mortality rate three to five times greater than the second division. After several months of intensive investigation, Semmelweis concluded that the difference was due to decaying organic matter, usually from autopsied corpses, which was conveyed to patients on the hands of the medical personnel in the first clinic. He introduced washing in a chlorine solution for decontamination, with the result that the mortality rate in the first clinic dropped below that of the second. However, incidence of the disease had always been seasonal, and most obstetricians were unpersuaded.

By 1850 Semmelweis had become convinced that decaying organic matter was responsible for all cases of puerperal fever - even for the relatively few cases that occurred in the second clinic. Indeed, he provided an etiologic characterization of puerperal fever in which it became true by definition that all cases of the disease were due to contamination. Given Semmelweis's definition it also followed trivially that puerperal fever was not a unique disease but only a form of sepsis. Semmelweis had virtually no evidence for this strong position. His critics immediately cited cases in which women died from puerperal fever without ever having been exposed to decaying organic matter. Semmelweis responded that in such cases the decaying matter must have been produced internally, perhaps by the decomposition of blood or of placental fragments. Even the physicians who accepted his initial results rejected this bold and apparently unwarranted claim.

By the 1860s, Louis Pasteur's work on fermentation and putrefaction drew attention to the possible significance of microorganisms in some disease processes. Building on Pasteur's work, and certainly aware of Semmelweis's theories, Carl Mayrhofer examined the vaginal discharges of more than 100 healthy and diseased patients in the Vienna maternity clinic. In 1865 he identified and described various microorganisms that seemed to be present only in discharges from women suffering from puerperal fever.

Using the best techniques that he had available, Mayrhofer isolated these organisms, cultured them in solutions of sugar, ammonia, and water, and then reproduced the disease by introducing the organisms into healthy test animals.

Mayrhofer's work was unimpressive to his col leagues in Vienna, but it received considerable attention in Berlin. Within a few years a number of writers, many of whom explicitly based their work on the discoveries of Semmelweis and of Mayrhofer, were studying the microorganisms that were identified in puerperal fever and in other forms of sepsis. Through the middle decades of the nineteenth century, most of those who wrote on wound infections gave prominent attention to puerperal fever. These included Edwin Klebs, Robert Koch, and Pasteur. In 1879 Pasteur identified the streptococci that were the principal cause of the disease. By this time, it was apparent to most observers that puerperal fever was actually a form of sepsis. In this sense, therefore, puerperal fever ceased to exist as a unique diagnostic or theoretical entity.

Classical studies in the early decades of the twentieth century led to the serologic classification of streptococci and to the recognition that group A strains were the most prevalent agent in puerperal fever. Group B streptococci were first reported in puerperal sepsis in 1935 and recently have displaced the group A strains as the most prominent agents in puerperal sepsis in the United States and Great Britain. Infections of group A streptococci are generally exogenous and affect puerperae, whereas infections of group B pathogens are usually endogenous and, although the mother may be affected, generally strike the fetus or neonate. The change in relative frequency of causal agents, therefore, has had important ramifications in clinical manifestations, prophylaxis, and therapy. The development and use of various antibacterial agents have obviously revolutionized the management of puerperal sepsis. Improved care for delivering mothers has also had an important impact, and in recent years liberalization of abortion laws has reduced the incidence of puerperal sepsis associated with illegal abortions. However, control of sepsis is now recognized to be more difficult and complex than might once have been believed, and it remains a particularly difficult problem in Third World countries where medical care is not readily available. Therefore, although the incidence of puerperal sepsis has been drastically reduced, taken collectively the various forms of this disorder continue to be a leading cause of maternal and neonatal death throughout the world.

K. Codell Carter

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