The History of the Boston Lying In Hospital and Puerperal Fever in the US

The Boston Lying-in Hospital was foundedc by Dr. Walter Channing of Harvard Medical School in 1832. The hospital was situated at a total of three locations including 24 McClean Street and finally at 221 Longwood Ave. During that time, in 1840, puerperal fever, also referred to as childbed fever, became more common in America, possibly due to increasing physician intervention during childbirth.a Puerperal fever also began to appear in some home deliveries. b

One way that puerperal fever was spread was by doctors transmitting staphylococcus aureus from another patient’s wound or abscess or from autopsy matter, which carried the most deadly bacterium, streptococcus group A. b Strep group A could also be transmitted by clothes, unsanitized instruments, or even nasal passages. b Women received various wounds from birth interventions, which increased the likelihood that an infection would develop. b Some women did survive the fever, becoming very sick, but thousands died from it.

The actual cause of puerperal fever was discovered 1790 by Alexander Gordon of Aberdeen, Scotland, who wrote that childbed fever was spread by medical personnel instead of from noxious elements in the air, as was previously thought. However, America was slow to accept and act upon his finding.

In 1843, Dr. Oliver Wendell Holmes was the first American physician to call childbed fever a contagion spread by doctors in private practice. b He published empirical conclusions and encouraged doctors to cease practice when their patients became ill. b Holmes also encouraged certain practices to stem the fever, such as doctors not taking part in a post-mortem exam of a patient who died of the fever. Abdomens of deceased patients would often be filled with pus and abscesses from infection. Holmes was not alone in drawing attention to the issue of transmission. In 1846, Hungarian doctor Ignaz Philip Semmelwise demonstrated the contagiousness of the fever statistically and proved certain antiseptic means were effective in preventing it.

Holmes went on to issue a monograph in 1855: Puerperal Fever as a Private Pestilence, which responded to American critics who disbelieved the contagiousness of the fever and ridiculed Holmes for his outrageous suggestions that doctors were instruments of death. b Dr. Hodge and Dr. Meigs, two well-known Philadelphia physicians at the time, sternly rejected Holme’s findings. Doctors were viewed positively and to suggest that they could play such a role in causing death was a scandalous assertion. b Hodge believed Holmes’s argument lacked proof. b Meigs retorted that doctors were gentlemen and that gentleman’s hands were clean.

In 1860, Louis Pasteur demonstrated that the microbial chains called streptococci were the major cause of childbed fever and showed that women who had labor injuries were most susceptible to being infected. Shortly after, by the 1870s, bacteriology was developed as a study. Despite these advances in knowledge, puerperal fever was still a serious problem in the United States. In 1873, Dr. Fordyce Barker of New York declared that puerperal fever had reached epidemic scales.

In 1883, 75% of patients in the Boston Lying-in hospital had puerperal fever and 20% died from it. b At that same time, in March of 1883, Dr. Alfred Worcester began his internship at the Boston Lying-In Hospital. At the time, he had only 11 months of medical school education at Harvard, having completed only two-thirds of the lectures in obstetrics, and having only three experiences with outside deliveries including watching a forceps delivery performed by another medical student and a few normal deliveries by his predecessor. He was not the only one with insufficient training.

Worcester describes the nurses at the hospital, none of whom were graduate nurses. Some had even been dismissed from training schools and other hospitals. Others he described as honest and hard working, who earned certificates as “monthly nurses” after a six months’ training course.

Perhaps the most beloved presence by patients and staff alike at the Boston Lying-In Hospital was Eliza Higgins, the hospital matron, who lived in the hospital basement with her family and kept a diary for years of the happenings of the hospital. Worcester writes:

“The matron, E.J. A. Higgins was a wonderful woman, an efficient housekeeper, an excellent midwife, and a great-hearted loyal friend. Her sympathy often made her teary, but never blinded her judgment. She had such perfect self-command that her supremacy was unquestioned […] Her memory of past patients was marvelous, and her kindness to them, boundless.”

In the New England Journal of Medicine, a full 50 years after the start of his internship, Worcester wrote an essay describing his experiences at the Boston Lying-In Hospital in the November 1933 issue. Throughout the essay, he tells the somber tale of the BLIH at the height of the childbed fever epidemic, saying “If, as I suppose, I am the sole survivor of that period [the septic era] I am now the only one who can tell the story.”

At the time, in 1883, a full 20 years after Louis Pasteur’s findings in 1860 about the microbial origin of childbed fever and a full 40 years after Holmes sounded his alarm, there was only slight recognition of what Pasteur had proved. Worcester writes:

“The only reference to the germ origin of disease, which I had heard in medical school, was ‘Let those who will believe in it; I do not.’”

In his essay, Worcester describes a typical case of what it was like to have puerperal fever:

“Generally, the first sign of it would be a terrific chill with high fever immediately following. In some cases, the fever would be continuous […] In others, there would be repeated rigors, with rectal temperatures varying many degrees within even an hour. In one patient this variation was once from 93 degrees to 105 degrees, and nearly as much several times afterwards. To our surprise, she recovered.”

Symptoms also included profuse diarrhea, which doctors and nurses also caught.

Worcester describes the scene at the hospital as sobering.

“That so many of the patients became septic and that so many of them died is not so much of a wonder as it is that any escaped. Against those poor women the dice were loaded, for besides the ordinary perils of childbirth, deadly dangers awaited them in that charnel house. Such conditions as existed then are not in these aseptic days hardly imaginable.”

Worcester speaks at length about the experience of one patient he calls K. F.

“When K.F. applied for admission, as she was not in labor, she was referred to one of the miserable boarding houses nearby, there to wait until her pains began. Prenatal care had not been heard of then. She had no preliminary examination, not even urinalysis. When brought to the hospital she had to pass, in the narrow hallway, the coffin of one of her predecessors waiting there for a pauper burial. The hospital had no other morgue or other entrance. Ominous that, of the invisible and yet terrible dangers that she must encounter! As there was no delivery room, she must be put to bed alongside women already deathly septic.

Still worse for her, she must at once undergo vaginal examination by hands which no washing could remove the stench of intra-uterine douches lately given. As her labor progressed, such digital examinations would again and again be made.[…] Who then could say how this poor girl received the massive infection from which she died on the fifth day? Was it from the sickening odors of the ward, as was then supposed? Alas, we now know that not one of the hospital utensils, not an instrument, and above all neither her nurses or her doctor ought to have been allowed near her defenseless bed.”

It became evident that measures needed to be taken. Unfortunately, the measures taken were misguided and unsuccessful. The first floor wards were ordered to be vacated, repainted and re-furnished, but the newly re-done wards were again soon filed with septic patients.

In the height of despair, Dr. Rufus Kingman called Worcester. He had just returned from Prague where he learned that disinfection of obstetricians could eliminate puerperal fever. A mixture of diluted bichloride of mercury was immediately ordered to be made and regularly used. However, its use was not well-received by Dr. W.L. Richardson, who took turns with Dr. W.E. Boardman on three-months rounds.

“What’s in that basin? And what’s that nail brush for?” Richardson asked.

“That, sir, is a solution of corrosive sublimate to scrub hands with before making a vaginal examination.” Worcester answered.

He goes on to summarize what happened next:

“Although I well remember his words, it will be enough if I quote the gist of his remarks. I was told to throw away the solution, lest as my next folly I should be scrubbing perineums with it. He certainly had a gift for prophecy.”

Worcester persisted in his aseptic pursuits, and aseptic methods were eventually widely adopted in all hospitals, but the death toll had already included thousands of women in the United States before the origins of puerperal fever were accepted and preventive measures were widely implemented. Worcester reflects on this sobering fact:

“The maternal morbidity I have already stated; that of the babies I have never wanted to compute.”

“But this much can be said, that, although it was not until after I left the Lying-In that I ever saw a mother rejoice over the birth of her child, we nevertheless tried to save the babies and to persuade their mothers to take care of them […] The Boston Lying-In was a haven or mercy. She could find there unstinted kindness and at least all the professional help that we knew how to give. For our ignorance, only were we to blame.”

Puerperal fever persisted into the 20th century. In 1913, 15,000 women died in childbirth, half from childbed fever. And in 1917, Maternal Mortality From All Conditions Connected with Childbirth in the United States and Certain Other Countries, a report by Grace Meigs noted that childbirth in 1913 caused more deaths among women aged 15 to 44 years old than any disease except tuberculosis.a

Relief from puerperal fever finally took widespread hold in 1937. Introduction of sulfa drugs in the spring meant that puerperal septicemia was no longer the leading killer of women of childbearing age.a Other things that helped stem the fever included blood transfusions, which helped women maintain their strength; shortening of excessively long labors, which had previously given bacteria easier access to the breaking of the amniotic sac; and overall improvement in women’s health. b

REFERENCES

a. Thomasson MA, Treber J. From Home to Hospital: The Evolution of Childbirth in the United States, 1927-1940 [Internet]. National Bureau of Economic Research; 2004 Nov [cited 2016 Mar 15]. Report No.: 10873. Available from: http://www.nber.org/papers/w10873

b. Wertz RW, Wertz DC. Lying-In: A History of Childbirth in America, Expanded Edition. New Haven: Yale University Press; 1989. 302 p.

c. 09 JMGSN, 2014. Tragedies to transplants, the history of Longwood – The Boston Globe [Internet]. BostonGlobe.com. [cited 2016 Mar 15]. Available from: https://www.bostonglobe.com/lifestyle/health-wellness/2014/11/09/tragedies-transplants-history-longwood/5I7WEMXXIcxUx2BbvaoVAN/story.html

d. Brigham and Women’s Hospital: Integrated Residency Program in Obstetrics and Gynecology [Internet]. [cited 2016 Mar 15]. Available from: http://www.partnersobgynres.org/aff-bwh.asp

e. Long T. Jan. 14, 1794: First Successful Cesarean in U.S. [Internet]. WIRED. 2011 [cited 2016 Mar 16]. Available from: http://www.wired.com/2011/01/0114caesarean-first-us/