Ep 73 Puerperal Fever: Seriously, wash your hands

forty strokes in a minute. I had no difficulty in ascertaining the patient's disorder, having had previous opportunities of seeing it, both in London and in the course of my practice in Aberdeen. For this was the fifteenth case I had attended since the epidemic began, And in every respect this answered the description of that known to practitioners by the appellation of the pupil fever, a distemper which so frequently proves fatal to women in childbed, baffling the skill of

the most eminent physicians. On the twenty first, when I visited her in the morning, I was happy to find that she had been pretty easy throughout the night and had enjoyed some hours sleep. She was in a profuse sweat, which I hoped would prove critical, but I was sorry to find that I was disappointed in my expectation, for when I returned in the afternoon, I found that the sweat had disappeared, being succeeded by a diarrhea. The patient now complained of very great pain, and the swelling of

the abdomen seemed to increase. On the twenty second, I was sorry to find that the disease was making rapid progress in spite of all the remedies employed, and that the patient's health was sinking. All hopes of recovery were now totally abandoned. The patient's agony was now extremely great, and she called loudly for relief. I therefore thought proper to administer opium to mitigate pain and, if possible, to

procure rest. I went early in the morning of the twenty third to visit my distressed patient and found that the storm was lulled into a calm. The friends received me with transports of joy, vainly, thinking that her danger was over. The patient supposed herself perfectly well, asked my permission to rise, for she seemed to feel no pain, and suffered me to touch and press the abdomen without showing any signs of uneasiness, a proof that the parts

were in a state of gangrene. The friends, ignorant of this circumstance, were quite overjoyed to see the patient so composed after such excruciating pain. However, it was evident from the ghastly appearance of the countenance, from the tumbufaction of the abdomen, with the absence of pain, from the sunk state of her pulse, and from the coldness of the extremities, that death was not far off. Accordingly, in a few hours the scene was closed.

status too, But we're gonna do our best. Some of the names that you can find that we haven't already mentioned, puperial sepsis, maternal sepsis, it's also called child bed fever.

There's so many names. But the World Health Organization defined maternal peripartum infections, which means they defined it as a bacterial infection of the genital tract during childbirth, like during labor, even before birth, but after like rupture of the amniotic membrane, but before delivery, or in the post birth the postpartum period up to forty two days postpartum. Oh, okay, that is associated with childbirth. So bacterial infection of the genital

tract associated with childbirth. And what's important about this definition specifically is that it does it include some other infections that used to sometimes get lumped in to postpartum sepsis or maternal sepsis, like mastitis which is an infection of the ducts in the breast or UTIs, even pneumonia. It also does not include infections in surgical sites, so like a C section incision, just an infection of the skin would not be included in this definition.

talking about, how do we define this? And then we'll talk about the risk factors for transmission, what pathogens we're actually dealing with, and finally, who gets it or what the risk factors are for transmission.

in the context of childbirth. This is not a disease that you can only get after childbirth, but in the context of childbirth, the inside of your uterus is exposed to the outside world in a way that it isn't normally right right either, because the cervix is dilated, and then there's a vaginal delivery and bacteria can migrate upwards, or if a c section happens, then the uterus is literally exposed on the abdomen and then put back in place.

But on top of that, after delivery, you have kind of a raw surface exposed inside the uterus because the placenta that had been attached has been removed. So there's not only like roots of infection, but there's also a surface that's more susceptible potentially gotcha. Okay. So that's one possible infection that can happen post birth. Another is an infection that can actually start a little bit earlier in pregnancy. It could happen any time in theory during pregnancy, but

that's called choreo amminitis or intra amniotic infection IAI. And this is an infection of any part of like the lining of the amniotic sac, which is what holds all the fluid that cushions the fetus. It could be an infection of the placenta just basically any part within there, okay. And so that can happen during pregnancy but then result like in a continued infection that can continue after delivery as well. But a maternal peripartum infection can have a

number of other possibilities as well. A peritonitis is infection of the abdominal wall itself, which can happen as a complication, like if the endometritis spreads outside of the uterus, but it can also just happen in the setting, for example of a c section, if the peritoneal cavity, the abdominal cavity becomes contaminated in some way.

uterus that cause like hypercoagulability, and it spreads. Overall. In general, not good infections, But the biggest concern with any of these organ systems or any of these tissues that become infected is when that infection spreads beyond that single organ or that single tissue and enters the blood stream, right, that results in bacteremia, so bacteria in your blood or septicemia, bacteria replicating and growing in your bloodstream and potentially septic shock,

which can lead of course to death. Okay, So in the context of childbirth, the vagina, the uterus, the abdomen, these are just sites of entry for what can easily become an invasive, widespread infection.

all of these other ones. But also some of these conditions, for example, choreoaminitis can happen much earlier in pregnancy and result in pregnancy loss, like spontaneous pregnancy loss, but if it happens around the time of delivery, then it's kind of it might cause different problems down the line. And

same thing with endometritis. That's something that can happen outside the context of childbirth, but if it happens within the context, then you'd want to know that that happened within that context. So I think by grouping them together, you're looking at a broad picture of all these different types of bacterial infections that can happen specific to the context of childbirth.

The other thing, though, and it's a good question that you asked that, Aaron, because the other thing about all these infections is that even though we can differentiate them all in terms of symptoms, they're all very similar okay, okay.

And so that's the other thing is that for a long time we probably weren't differentiating them all because does it matter exactly what tissue type is infected When you're looking at someone who just gave birth and all of a sudden, they spike a fever right up to one hundred and two fahrenheit or thirty nine celsius, and they're sweaty and they're pale, their heart rate is elevated, they're

breathing hard. They're sick, right, and they're sick probably in the context of this traumatic delivery that just happened, or even this non traumatic delivery that just happened. And so I think that's another reason too why you lump it all together. That makes sense in terms of some of

the other symptoms. Aside from fever, which of course is kind of the biggest sign, which is why it got the name puparel fever, other symptoms that tell you that you're dealing with an infection of the genital tract are things like abdomin pain or like paint tenderness in the uterus, and not just the tenderness that's normal after delivery, but like a deep, a deeper tenderness and like a more I don't know how to describe it, a more painful tenderness.

And then also some vaginal discharge is fairly common, especially with endometritis. You can have a very like purulent, like pus filled drainage that can happen from the uterus. And then of course you have all these other general signs of infection, things like I already mentioned, like you have

an elevated heart rate, elevated breathing rate. If you were to take a white blood cell count that would be elevated, and like I said already, to the big concern here is if that infection spreads to the bloodstream, because that can result in shock and potentially death. Yeah, so I've said already this is bacterial infection. What bacteria are we

talk talking about. It's a lot, It's a lot, and so Aerin I think even though I tried really hard not to read about semelweis and not step on your toes at all, I think that largely in that time frame, it's thought that it was group A strep aka Streptococcus piogenies that was the big contributor. Is that correct?

Caveat that that you can find like separate articles that are all about group A strep in the peripartum period, right, But when you read about endometritis, when you read about chorea aminitis, and when you read about just like general maternal sepsis and you use all these sort of buzzword terms, group AA strap is like, yeah, it's on the list along with a whole bunch of other things. Why, I don't really know. Let's kind of let's talk about.

stret piogenies. It also, like I said, causes deeper infections like necrotizing fasciitis if it's untreated. Strep Piogenies is what leads to rheumatic fever, rheumatic heart disease, a number of different post infectious type syndromes. But it's also, of course a potential cause of MPIs, and one of the reasons likely is that during pregnancy and the postpartum period, people are twenty times more likely to become infected with strept

piogenies compared to non pregnant people. Huh, why something about pregnancy makes you far more susceptible to stret parogenes. To answer your question of why, we don't know, except that it might have to do with pregnancy in general is a state of aminosuppression, so it might just be that

that specific type of aminosuppression makes you more susceptible. There are some people that say because being around children is a risk factor for stret piogenies colonization in general, since children are more likely to have it than adults, just like without being sick, just hanging around. So if someone is pregnant, they might also be around kids or have

other young kids. So I don't know, that's kind of whatever, but in any case, times more likely to become infected during pregnancy and postpartum like that short, short postpartum period, because the thing about people who get strap a postpartum is they often are already colonized and then it just becomes an infection postpartum when that bacteria swims into the

bloodstream right right. And while it's not the most common cause of peripartum infections today as far as I can tell, because it's really hard to get numbers on what is causing all these different MPIs. If you look at all invasive group A strep infections, about two to four percent of them are somehow associated with pregnancy. So that's of everyone in the world who gets an invasive group A strep infection, two to four percent of those are associated

with pregnancy. I don't know the proportion of all MPIs that are due to group A strap However, when group A strepp is the causative agent, it is extremely virulent, okay, Yeah, And when and if it progresses to something like toxic shock, mortality can be as high as thirty to fifty percent even today.

causes of infection. Okay, so that's group A strap. There's a whole nother group of strip that we get to talk about, and that is group B strep aka streped caucus A galactae. I think I probably pronounced it wrong. And what I think is so interesting is that today you hear a lot more about group B strep in the context of pregnancy then you hear about group A strap.

And that's because this is something that we actually test for in the US, at least during pregnancy, because we know that group B strep is a very important cause of meningitis in newborns. Yeah, and so we know that by testing for group B strap, because this is another bacteria that just can often colonize the vagina and the rectum.

So if you test pregnant people for group B strep and then treat them with antibiotics during labor, it drastically reduces the probability of that bacteria being transmitted to the baby during delivery and then reduces that baby's risk of meningitis significantly.

a parapartum infection as well in the pregnant person. Other bacterial species E. Coli super common cause in some studies, but also things like anaerobic species like bacteroids, And what's really common overwhelmingly is that you can have polymicrobial infections. So we're not even looking at a single bacterial species. If if you think just about the process of childbirth and that there's so much exposure happening from so many

different potential sources. A lot of these are bacteria that can be found on a lot of different kind of surfaces and skin and things like that, and so it kind of makes sense that you might be able to have polymicrobial, multiple bacterial species.

take into consideration. Yeah, so that's kind of the overall picture of infections and what causes it, and arin you're going to talk a lot I think in the history about kind of the transmission. Yeah, how we figured this out, right, But like I said, a lot of these bacteria are just bacteria that exist around us, whether on providers unclean hands, or on unclean instruments that are used, or even just on our skin just already here or in our vaginal canal.

Or even in our throat or other mucous membranes. So when you add on top that pregnancy is a state of immunal compromise and all of the potential roots of entry that could be opened up during childbirth, and then all of these bacterials be floating around, that's kind of

how you get to transmission, if that makes sense. There are some things that would increase the risk of a maternal peripartum infection, and the biggest one worldwide today, of course, is a C section, which is not really surprising considering

that that's a much more invasive way to deliver a baby. However, in general, antibiotics are used prophylactically during c sections, just like with any other surgery, because we know that surgery is such a big risk for infection overall, right, right, so with antibiotics prophylactically, that drastically reduces the risk of infection associated with ce section.

and I will definitely get to it. But it turns out there's actually so much more to the story of peperil fever, not surprising considering that it's like a ton of different bacterial species and you can get it a ton of different ways and so on.

It never has been, it never will be, and since at least some of the bacteria that cause infections after childbirth are carried naturally with us. As you said, these infections have been around since, you know, as long as humans have been giving birth, so forever. It's you know, humans before humans were humans, and so it's probably not surprising that people had long recognized that fever, severe pains, and a swollen abdomen in the days after giving birth

often led to death. Hippocrates, for example, wrote about it, and there are also descriptions in Hindu texts dating back to fifteen hundred BCE. Several English queens died of infection after childbirth, including Elizabeth of York, queen consort of Henry the seventh and Henry the eighth had two wives that died in the same way, including Jane Seymour, whose death inspired an old ballad that's included in a song inside. Lewin Davis just, I really like the song.

But in so many other ways, they were a perfect setting for the spread of infectious disease. Wards were over crowded, instruments were filthy. Germ theory was still over two hundred years away, as was the importance of cleanliness and limiting infection, so no one was watched their hands, or the bed sheets,

or their clothes or their instruments. It was believed that the stiffer the doctor's coat with blood and fluids and pus, the more respected they were, because it showed that they had experienced.

like pinpoint the very original text. That would be amazing.

and nor was the threat restricted just to hospitals. Physicians or midwives may have moved in between hospitals or in between house to house, leaving a string of deaths behind them. My god, let's put some numbers to the absolute nightmare that hospitals were though, jumping ahead to the eighteen hundreds in London between eighteen thirty one and eighteen forty three, ten mothers per ten thousand died of pupil fever at home, while six hundred per ten thousand died when they gave

birth in the hospital. What uh huh. These numbers were also not unique to Britain, and in some places or during some times, were even higher elsewhere, such as in Paris, where the peak reached eight hundred and eighty per ten thousand, which was seventeen times higher than at home births.

so you can imagine the array of possible causes. One of the most predominant one was that it was caused by the lokia, so the fluid that flows from the uterus after a vaginal delivery. It was caused by the lokia being prevented from freely flowing and then stagnating in

the body. Another was that it was pregnancy itself, like over the course of nine months, impurities accumulated in the blood and as the fetus grew, it pressed down on the intestines and so fecal material was slowly released into the area and then cause pupil fever.

could blame re routed breast milk. For way too long, it was believed that breast milk was actually menstrual fluid, or it originated from the blood going from the uterus to the nipple via adduct huh, despite countless autopsies failing to find any such duct. And so when doctors examined the abdomens of people who had died from childbed fever and found white pockets of pus that kind of resembled breast milk, they thought that it was caused by the

failure of milk to route to the nipple. Oh yes, and then yes, there was always my asthma to blame or poorly ventilated rooms. But before we feel too smug about how dumb people in the sixteen hundred and seventeen hundreds were that you know, we would have seen the connection right away, let's like remind ourselves how little we know about autoimmune diseases or even just how our own immune system works, or what dreaming is, or like all

these things are I mean. But yeah, so back in the sixteen hundred, seventeen hundreds, even eighteen hundreds, you know, doctors lacked training in statistics, and they were working under the assumption that the cause of childbed fever was already known. You know, just pick whatever cause you want to believe in, and so it's kind of understandable that many doctors would focus their efforts on developing treatments for childbed fever rather

than trying to control what seemed inevitable. I mean, we do the same thing today in science and medicine, Like we are all trained on a foundation of knowledge that we're almost taught not to question that these facts have been established, and we could and we should focus our efforts elsewhere to expand this body of knowledge, which we often do for very good reason, because that's how most progress is made, and that's also the path that is

the most rewarded. And so it makes it all the more remarkable when someone doesn't just question the established knowledge, because that's easy enough to do, but they collect and present solid evidence in defense of their questions, despite the resistance that they are often met with.

at least some areas like long before germ theory. But this concept of contagion, where a disease could be transmitted from person to person through skin or contaminated clothing, was disease specific. You touch someone with smallpox, you get smallpox, same with measles. Pupil fever didn't follow this pattern, so miasma or lokia suppression seemed more likely. That Alexander Gordon

rejected those. He noticed that what linked the affected individuals in a pupil fever outbreak was not some characteristic of the mothers or the weather, but rather that they had all been treated by the same person nurse, midwife, physician, and the cases appeared in succession, and he became convinced that it was a contagious disease, one that the medical caretaker played a direct role in which really shook him

to his core. Quote, it is a disagreeable declaration for me to mention that I myself was the means of carrying the infection to a great number of women. He traced an outbreak of the disease to several midwives employed in his practice, and he published his findings in seventeen ninety five. And in this treatise he recommended airing out the room, burning contaminated clothing, and scrubbing hands and the arms of people who delivered the bait as a way

of preventing the spread. And he didn't stop there. He went on to say that he could predict who might be at risk of developing the disease based on who their practitioner or a midwife was. And then he kind of published this like list of the names of seventeen midwives who had exposure to the disease. And so basically he became an unwonted person in the town. And he left obstetrics and joined the navy. Oh goodness, yeah and yeah, then he died at forty seven of tuberculosis.

Oliver Wendell Holmes Senior, an American physician but probably better known as a poet, set out to compile all of the evidence for the contagiousness of pupil fever in such

a way that it could not be denied. He didn't speculate on the exact mode of transmission, whether it was through the air carried by a physician or through the instruments that they used, but he did firmly state that quote, the disease known as pupil fever is so far contagious as to be frequently carried from patient to patient by

physicians and nurses. He also recommended that physicians should not perform autopsies prior to delivery, and that if they had to do so, they should change their clothes and wait twenty four hours before treating a patient. If a case of pupil fever develops, that doctors should consider their next patients at risk and shut down their clinic if necessary.

He didn't necessarily suggest any form of like washing or sanitation specifically, but his conviction of the contagiousness was so strong that he said, in one talk quote, whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery, the time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as

a misfortune but a crime. And in the knowledge of such occurrences, the duties of the practitioner to his profession should give way to his paramount obligations to society.

On March twentieth, eighteen forty seven, Semolviss began a two year appointment as assistant in obstetrics, basically like a residency in the Vienna General Hospital first Division. He came into the medical profession at a very unique time and at a unique place in These circumstances in a way set him up almost perfectly to make the observations that he did.

So let's do a little bit of context. Yes, in the early nineteenth century, the field of pathological anatomy had really taken off, and autopsies were seen as essential instruction for medicine. With each cadaver holding an incredible wealth of knowledge, and there was no better place to do autopsies than at the hospital in Vienna, where one of the field's leaders, Carl von Rokotanski, had been appointed director of Pathological Anatomy

in eighteen forty four. And if you were an obstetric student under Johann Klein at the Vienna General Hospital, you were expected to practus on cadavers every chance that you could, especially in the mornings before rounds began. Just make sure to wipe your cadaver juicy hands on your coat before walking upstairs.

pupil fever. Okay, okay, So under Boer, who was the earlier guy who was like not a fan of autopsies. The mortality rate of child bed fever in the first division lying in ward hovered around one percent, mostly lower. Wow, that's pretty good in autopsy superfan. Klein's first year as director, first year, that number shot up to eight percent, which was probably the lowest it ever was during the entire time he was director.

was appointed an assistant in the first division. There was a second division and a third division, but I won't talk about that. But the first division and the second division were very different. They were both lying in wards where pregnant people would go to give birth. The first division was composed of male medical students and that's where they received training, and then the second division is where the midwives received training, training which importantly did not autopsies.

The death rate in the first division was always at least three times higher than that of the second division, and this super high death rate earned it urban legend status. So if a woman came to the hospital was about to give birth, she would beg and beg not to be admitted to the first division.

died of the disease. Semmelweiss became convinced that the high incidents had to do with the way that the hospital managed its patients, so he began to make small changes, things like the way that medicine was administered, increasing ventilation, having the women deliver on their sides as he had seen the midwives do. But nothing seemed to help, so he began to look for patterns in the hospital records,

and he made six key observations. Number one, even though the first division so med students and the second division midwives had the same number of deliveries per year, so three thousand to thirty five hundred in the first division, six hundred to eight hundred women died of childbed fever on average, whereas only sixty died in the second division.

was that the person would develop childbed fever. Number five. Closing down the ward always stopped the epidemic hu and number six. Infants delivered by mothers who developed childbod fever also often died of a similar disease. And these observations seemed to simulvis very strong evidence that practices at the hospital and specifically the first Division, were contributing to or even causing the pupil fever epidemic, and that the disease

was transmitted through direct contact. But where did did it come from? And as he prepared to deliver this information to his director at the hospital, he was given tragic news that would lead to a Eureka moment. He learned that his friend, Professor jakub Koalechka, had died after being stuck in the finger by a med student wielding a scalpel during an autopsy. Death by cataveric poisoning, as it

was called. Semmelweiss, who was horribly sad about the death of his friend, went to consult his autopsy report, which described fever, pain, swelling, and organs and tissues inflamed and filled with pus. And this sounded awfully familiar to him. Quote Totally shattered, I brooded over the case with intense emotion,

until suddenly a thought crossed my mind. At once it became clear to me that childhood fever, the fatal sickness of the newborn, and the disease of Professor Kalechka were one and the same, because they all consist pathologically of the same anatomic changes. If, therefore, in the case of Professor Kalecchka, general sepsis arose from the inoculation of cadaver particles,

then pupil fever must originate from the same source. Now it was only necessary to decide from where and by what means the putrid cadaver particles were introduced into the delivery cases. The fact of the matter is that the transmitting source of these cadaver particles was to be found

in the hands of the students and attending physicians. This was an incredible light bulb moment linking not just the fact that like kataveric poisoning and pupil fever were the same thing, but that kadaveric material introduced into the body of someone who had just given birth, that is what led to pupil fever.

like and I can't. I can't emphasize enough how it was really in the mornings, whenever you had a spare chance, you cut away, you do autopsies.

do you what's like the concept of contamination? And I think it's it's really fascinating because like, of course, it should come as no surprise that cadavers don't smell that great, and so measures had been taken before to control the smell so that physicians and students could work without the

whrror roble. Odor and chloride solutions were commonly used for this, and so some of ice figured that hey, if this stuff, this chloride stuff gets rid of the bad smell, maybe it gets rid of the bad stuff itself, and so he placed a bowl of diluted chloride solution outside of the first division and made every person who would be treating someone wash their hands in it and also do

regular hand washing. And then later he was forced to switch to chloride of line because the Kline, the head of Obstetrics, was really annoyed at how much money he was spending some of Ice was spending, and within a few weeks of some of Ice implementing this hand washing solution, the effect was like immediate. The mortality rate dropped from

where it was around seven to eight percent. But also there seems to be like Klein might have doctored his records quite a bit to three percent, and that was close to that of the second division, where just the midwives were and after a month of the practice, it dropped down to one point two percent, with the second division clocking in at one point three percent, where hand washing had also been instituted.

for the xenophobic and superior cline. And then came the Revolutions of eighteen forty eight, which made Semmelweiss an even you know, further scary freethinking liberal because he participated in these revolutions of eighteen forty eight. But this, all of this like resistance that he faced within his own department, some of us just kept at it. He was like

evangelical about his hand washing doctrine. Yeah, and the incidents and mortality rates of pupil fever continued to fall, and he became like on fire with this knowledge that this practice had the potential to change the world for the better. And he as a result of this, maybe his personality seems to have changed a bit from being lighthearted and friendly and popular as a young student to sarcastic suspicious contempt,

just how later accounts describe him. If a case of childhood fever popped up, for instance, he played detective to pinpoint who had lapsed, and then he would chew them out publicly. His identity began to be wrapped up in this so called Someemolvis doctrine, and a rejection of the doctrine meant a rejection of him. At the end of his two year assistantship, he applied for renewal, which was really a formality because they were always granted decline denied.

He denied him re renewal. Wow, And so suddenly Somemolweiss found himself not only without a job, but also without any ability to institute his life saving doctrine, and he was devastated. His professor friends, who were part of the new school at the hospital, urged him to present his findings. But then some Ofvis met with a little more difficulty because Klein had barred access to the division's records and

he wouldn't let some Alvis have them. But fortunately some Alvis had kept some of his own, and he finally agreed to speak publicly about his work in eighteen fifty, which is three years after first developing this hand washing doctrine. His lectures were largely met with success, although there was some debate, especially from doctors who refuse to believe that they could be the cause of such widespread disease and death. But Someolvis knew that feeling. He felt horribly guilty for

the role that he had once played. I'll read another quote from him. Because of my convictions, I must here confess that God only knows the number of patients who have gone to their graves prematurely by my fault. I handled cadavers extensively, as painful and depressing. Indeed, as such an acknowledgment is still the remedy does not lie in concealment, and this misfortune should not persist forever, for the truth

must be known to all concerned. And it just seemed like so many of the doctors couldn't look that, they couldn't even consider that possibility because it is horrifying to think about.

how did we not see it? Or just things that like you can't even like how do you even predict what the next paradigm shift might be in medicine or ecology, Like we just don't know because that's not the way that we're trained to investigate problems. That's just interesting. But anyway, besides the you know, forced denial of these doctors and their the guilt that they may have felt, another thing that kept the Semilvis doctrine from gaining tracktion. More broadly,

was the fact that he wouldn't publish. He hated writing.

he could put it into practice. And when the job that he had finally been given, which he was actually first denied and it was a teaching position in Midwiffery, it was changed at the last minute, and he took it to be a personal affront, and you know it was basically he was like, you know, my colleagues refused to see my great accomplishments. I'm surrounded by enemies. I'm being told to publish despite the evidence being so clear, like you shouldn't need a thorough paper, it should be obvious.

How do you not see it? And then now this, like the disrespect he felt from this job thing was the final straw. So he left Vienna he packed up and left to return to Budapest without so much as a goodbye to any of the friends who had supported him and championed his cause for so long.

came through. He was given that position, and he immediately implemented the same hand washing practices and saw a similar immediate drop in pupil fever cases and deaths. But his constant watchfulness and tendency to play detective when someone died of pupil fever didn't exactly make him popular among his employees and students, many of which went to great length to avoid washing their hands just to spite him. I know,

I hate It's so difficult. The story is so wrenching because you're just like w and then he made enemies with the hospital administration, Like the sheets weren't being washed frequently enough in his eyes, so he gathered up a bunch of dirty sheets and dropped them into the office of the hospital administrator, and so the hospital administrator then it started immediately looking for ways to fire him. His personality didn't really endear him to people around him, and he seemed to leave enemies.

book The Eediology, the Concept and the Prophylaxis of childbed Fever. Unfortunately, it turned out to be densely written, difficult to follow, and he included many personal attacks on doctors who had rejected his findings in the past.

his mental health had begun to decline. His moods were becoming increasingly erratic, and he had trouble taking care of himself or performing his job. There are retrospective diagnoses ranging from tertiary syphilis to Alzheimer's pre senile dementia, but in any case, by the summer of eighteen sixty five, his wife realized that she could not take care of him by herself, so she took him to a state run insane asylum, as they were called. Then two weeks after

he walked through the doors, he was dead. The cause of death was determined to be a septic infection. Oh I know, much like the ones that caused pupil fever.

new technique, which he called antisepsis. With this recognition of the germ theory of contaminated wounds came the realization among the medical community that Semmelweiss was right, and starting in the late eighteen hundreds, his story as a martyr to medicine was being rewritten. Wow, what prevented the semolvis doctrine? Which seems so clear in retrospect? What prevented it? From being readily adopted. I mean, could be personalities, stuff, could be that he didn't write about it. But I think

it's kind of the same thing that it always is. Like, this isn't the first. This might be one of the most, like heart wrenching stories, but it's not the first time we've seen similar things. No, it always takes what twenty years to get a new idea into textbooks, and then

when it's outdated, twenty years for it to be removed. Yeah, and so in the eighteen sixties and the eighteen seventies, about twenty years after someblws first proposed his doctrine, the causative agents of pupil fever began to be characterized, and the next big milestone came in nineteen thirty five with the development of the sulfonamide Prontazzle, which greatly reduced mortality

due to pupil fever. The link between scarlet fever arisepalus and pupil fever was recognized, and steady increases in hygiene continued to drive down the rates.

associated with maternal infections what every year. That's what it said in twenty fifteen. I was I am still shocked by that number. Oh my gosh. Yeah, while today, overall rates of maternal infections are still like, even though these numbers are shocking, they're drastically drastically lower than in the past.

it comes to maternal outcomes. We can look not only at deaths, but severe morbidity, so like serious complications as well as mortality. Rates are very high in the US compared to a lot of other high income countries, but the racial and ethnic disparities in the US are also atrocious. So in this country, black women are three to four times more likely to die from pregnancy related causes than white women three to four times.

In the US forty one deaths per one hundred thousand live births, which is the standard metric of measure, forty one per one hundred thousand for non Hispanic Black women, twenty eight point three deaths per one hundred thousand live births for non Hispanic Native American and Alaskan Native women, thirteen point eight deaths per one hundred thousand births for Asian or Pacific Islander women, thirteen point four deaths for non Hispanic white women, and eleven point six deaths per

one hundred thousand live births for Hispanic or Latino women.

takes place. So that means that over sixty thousand people every year in the US are having these severe, likely very traumatizing complications that in so many cases, are preventable. And it's not just the US. In the UK, if you look specifically, even just specifically at maternal sepsist deaths, for every one maternal sepsist death, there are fifty other pregnant people that have life threatening infections. Wow. If we want to look at disparities across the globe, we do,

of course we do. The World Health Organization estimates that eight hundred and ten people, So this is looking more broadly than just maternal infections, but eight hundred and ten people die every day from preventable causes related to childbirth and pregnancy.

childbirth related deaths. So we have a lot of work that needs to be done still, and I think, like someovice, we need to start by figuring out what the root cause of a lot of these problems are so that we can actually fix them. Yeah, but you know, racism is a big part of it here, and for sure there's a lot of yep.

is a fiction book which was really fun. I get to read fiction for not that often for the podcast, and it's called The Cry and the Covenant by Morton Thompson and it's out of print.

that they're having. One of their big campaigns is called Hear Her. So I yeah, because I mean that's a big that's a big part of it, right, is not not paying attention to the person who's experiencing what they say they're experiencing. Yeah, and we've seen that time and again.