The Demon Under the Microscope, page 13
Belief was central to Colebrook’s nature. He was profoundly Christian. He did not proselytize or criticize those who believed differently, but he did his best in daily life to demonstrate the power of Christ’s teachings. He was hardworking yet softhearted, ambitious yet supportive of others, authoritative yet approachable. He sometimes even let slip a bone-dry sense of humor. His was the science of service. Medicine was a way to help the afflicted. As a student he had even planned to become a medical missionary, perhaps in Africa or Asia, bringing the light of modern science and the teachings of the Church of England to the darker parts of the world. Although he had ended up instead in St. Mary’s working for Sir Almroth, Colebrook’s idealism and missionary zeal still showed. He worked long hours, did not care much about salary, and did not treat his patients like experimental subjects. Many of those admitted to St. Mary’s were women who had fallen ill in childbirth, all too common in hospitals at the time; often the new mothers’ concerns about their families added to their physical ills. Colebrook sat up with them, held their hands, listened, counseled, and consoled. Sometimes he spent all night in the wards. He was never considered brilliant, but he was the sort of doctor everyone wanted.
And he was good in the laboratory. Sir Almroth, an unashamed atheist, put up with Colebrook’s faith in part because Colebrook was a strong, reliable researcher and in part because Colebrook was as close as he would ever come to having a son. They were very different but complemented each other. Wright was combative and outspoken; Colebrook was quiet and restrained. Wright was certain his theories were correct; Colebrook doubted any theory until it was proved and then re-proved. Wright was perfectly capable of exaggerating to make a point; Colebrook was described by a coworker as “profoundly honest.” They made a good team. Sir Almroth’s energy helped Colebrook come alive; the older man grounded the younger in the meticulous techniques required by modern medical research and raised his ambition to take on the Big Questions, the ones that counted in medical history. Wright gave Colebrook some backbone and drive. Colebrook, in turn, was Sir Almroth’s faithful second-in-command, loyal supporter, and reliable advocate.
Colebrook’s honesty and diligence were much needed in the lab. The House of Lords was a tight, productive group, but they were mostly young men and they sometimes acted it. They all had nicknames (Colebrook’s was “Coli”). They all lived close to St. Mary’s so they could be available twenty-four hours a day to monitor experiments. Getting married was looked upon with suspicion, although Colebrook did marry at the beginning of the war. They worked hard, put in long hours, and occasionally played: Alexander Fleming, for instance, developed a talent for spreading patterns of different bacteria on agar plates, which after a few days would blossom into a colorful picture of, say, a ballerina. Most of them followed the Old Man to Boulogne and learned the same basic lesson: Once a wound infection started, little could be done to stop it. Certainly no drug could do anything.
After they returned to St. Mary’s at the war’s end, the reconstituted House of Lords went back to studying inoculations, vaccines, and immunity. Quietly through the 1920s, however, so as not to disturb the Old Man, Leonard Colebrook pursued what would have seemed in that environment an almost illicit interest in chemical therapies. He read widely, especially the German journals, and then began his own experiments, following up on techniques Sir Almroth’s group had developed to fight wound infections in the casino. The first substances he tested were arsenicals, chemicals related to Salvarsan.
He immediately faced a problem. At Boulogne they had unlimited numbers of wounded on whom to test their ideas. With the war over, Colebrook faced a limiting factor at St. Mary’s: There were not enough wound infections to support large-scale drug tests. So Colebrook turned to a different kind of infected wound, a wound found in peacetime, a wound that killed young women: the wound of childbirth.
In the 1920s the paradigm for obstetrics—a field that primarily male physicians had finally taken over, during the previous three centuries, from primarily female midwives—was that of illness. “Pregnancy is a disease of nine months’ duration,” one physician had quipped; another advised, “It is best to consider every labor case as a severe operation.” Their remarks underscored the pessimism of caregivers who lost many new mothers after childbirth. The process of birth included a natural wound, deep in the mother’s body, where the placenta detached from the uterus. Most of the time, it healed without a problem. Like every wound, however, it could offer a route for infection. Every new mother, a popular magazine of the day explained, was in an “exquisitely susceptible, wounded condition.” That was a basic reason physicians of the day wanted deliveries done not at home but in hospitals, where new mothers could get adequate care and time for recovery.
Hospitals themselves, unfortunately, were often centers for infection. New mothers—especially those in maternity wards—risked a disease called childbed fever, endemic in many hospitals, that killed tens of thousands of women every year. Colebrook saw the results at St. Mary’s, the dying mothers, the shattered families. He determined to do everything he could to stop it.
His first studies showed that childbed fever was caused by the same strains of Streptococcus that had been found in soldiers in Boulogne, the strep that Sir Almroth’s research had pinpointed as the primary cause of wound infections. Following Sir Almroth’s lead, Colebrook first tried anti-strep vaccines to prevent childbed fever (which failed, just as they had failed the soldiers in France), and then turned to chemicals. Using newly delivered mothers at St. Mary’s and other maternity hospitals as his test group, he mounted an extensive series of experiments gauging the effects of arsenic-containing medicines.
Childbed fever was not a new disease (Hippocrates had described a case in ancient Greece), but it had been no more than an occasional problem back when most women were delivered at home. In the seventeenth century, however, what had been a scatter of isolated cases turned into a horrifying epidemic. It showed up first in Paris, in the Hôtel Dieu (God’s Hostel), the city’s largest and poorest hospital. Founded originally as a wing of Notre Dame, the hospital by the early 1600s was a demonstration of the dangers of mixing pure Christian charity with unbridled municipal growth. The problem was a combination of the hospital’s underlying mission of offering succor to the poor—no one, no matter how poor, was turned away from the Hôtel Dieu—and the ballooning number of poor needing to be saved. By the seventeenth century, the Hôtel Dieu was drastically overcrowded. It sprawled over both sides of the Seine, the wards connected by a bridge devoted to the hospital’s use. It was here, in a two-story building built on the bridge itself, that the world’s first maternity ward was created in 1626. It was followed twenty years later by the world’s first epidemic of childbed fever. It all started as a very good idea: Separating new mothers from the sick and wounded in the rest of the wards represented an advance in medical practice that became a model for other hospitals. “Lying-in hospitals,” as they were often called, sprang up in leading cities of Europe and the Americas during the next two centuries. Unfortunately, given the poverty of the institution and the unfortunates it served, the lying-in ward at the Hôtel Dieu was primitive even by the medical standards of the seventeenth century. Patients were packed into oversize beds called grands lits—two, four, even six to a bed, head to foot. Pregnant women, many of them prostitutes, all of them penniless (those with money tended to avoid hospitals), would arrive at the door of the Hôtel Dieu late in their pregnancies, often at the point of giving birth. They would undergo a cursory examination before being sent to the new ward over the river to await delivery. Those awaiting birth were mixed with those who had already delivered. The women slept with their babies. It was not uncommon for infants to smother when women rolled over in their sleep. Every day the senior doctors would arrive on their rounds followed closely by a gaggle of students. They would pull the women’s covers down, pass hands over their abdomens, point, prod, and discuss. Although the physicians’ wigs were carefully powdered, their hands were generally unwashed. Christian care, which emphasized purity of the soul over that of the body, had replaced Roman hygiene with frequent prayers and infrequent baths. In Paris the privies and slaughterhouses (as well as the hospital wards of the Hôtel Dieu) dumped their waste into the Seine, then drew drinking and washing water from the same source. Bedding was washed infrequently. Lice and fleas abounded. There were no operating rooms, anesthesia did not exist, and physicians often performed surgery in the middle of the wards while the other patients in their beds looked on.
The new mothers who came down with childbed fever felt it first a day or two after delivery, with a looseness in the bowels and stomach pain. The disease progressed very quickly. Within hours the physicians might note a drying and hardening of the uterus, excruciating pain, headache, sometimes a cough, then a high fever. Occasionally the tongue turned black. In other cases the abdomen became distended, almost like a second pregnancy, the skin tight as a drum, so sensitive that women could not stand to have anything touch their bodies, not even blankets. At the Hôtel Dieu, little attempt was made to separate the sick women from those still healthy; the groups were simply placed on opposite sides of the same large room. The victims moaned and screamed. Healthy women awaiting delivery on the other side of the room sometimes became wildly alarmed (an understandable reaction that French physicians of the day classified as hystérique, an emotional outburst linked to a derangement of the uterus, a condition they believed might add to the risk of developing childbed fever). All the usual remedies were tried on the sick women: doses of strong laxatives to empty the stomach and bowels; copious bleeding, cupping, and leeching; even doses of the miraculous Countess’s Powder (a pulverized tree bark from the New World that sometimes cured fevers, a medicine later called quinine). Nothing worked. The victims could do little but pray to St. Margaret, the patron saint of childbirth. The physicians eased their pain with opium preparations, provided what comfort they could, watched, and waited. Some of the women recovered. Most of them did not. The last hours were never pleasant. Death was seen as a mercy.
The first epidemic that raged through God’s Hostel in 1646 killed scores of new mothers within a few weeks. It even afflicted some of those attending the women, nuns included, who came down with a fatal fever that seemed in some ways similar. There was great alarm, but the poorest pregnant women of Paris kept coming, deciding that the once-in-a-lifetime chance for weeks of bed rest and hot food outweighed the risk of disease. The hospital’s premier president believed that the problem was related to location: Below the second-floor women’s ward on the bridge was a room where open wounds were being treated, wounds that sometimes putrefied, releasing noxious vapors. Foul air rising from below, he believed, carried this disease to the women, miasma arising from rotting flesh. Confirming evidence of this theory was found when the dead mothers were autopsied. When physicians cut open the bodies of the newly dead women, there arose such a terrible smell of putrefaction that attending students sometimes fainted. Other physicians thought that rather than miasma the disease might be caused by rotting bits of leftover placenta or other tissues remaining in the uterus, the detritus of delivery. Others viewing the postmortems on the diseased women found on the surface of the intestines what appeared to be curdled milk, leading to a theory that the new disease somehow had been caused by “milk metastasis” related to lactation in the new mothers, a sort of cancer of the milk.
No theory explained it fully, and certainly no treatment worked against it. Then, as suddenly as it had arrived, the epidemic of childbed fever at the Hôtel Dieu disappeared. It was not gone for good, however. It returned a few years later, flared and disappeared, then flared again, more often as time went on. Soon it became an annual visitor to Paris, the number of cases rising in the winter months and subsiding in the summer.
And then the disease began to travel. An epidemic hit the lying-in hospital in Lyons in 1750, then London in 1760, and Dublin in 1763. Childbed fever quickly became a worldwide epidemic, spreading east to Vienna and west to the United States; at its peak in 1772, it was killing up to one in every five new mothers. During an outbreak in 1773 at the Royal Infirmary of Edinburgh in Scotland, almost every woman who delivered a baby was seized by childbed fever, and all of them who caught the disease died. But in Edinburgh the physician in charge of the maternity wards, a Dr. Young, fought back. He decided to treat childbed fever as if it were the plague. After seeing six mothers die in quick succession, he cleared and shut the maternity wards; ordered the mattresses, pillows, and blankets torn off the beds and burned; filled the wards with smoke to rid them of corrupted air; threw open the windows during the day to air the rooms; and shot off gunpowder wherever there had been disease. His actions were based on the old idea of miasma; he was dispelling the bad air. When he felt that the wards had been purified, he ordered every surface in the rooms washed and the walls in the rooms and halls repainted. New bedding was ordered. Then he brought back his patients. And the epidemic was gone. His work was ignored for a while, but by the mid-nineteenth century Young’s approach was becoming widely employed. Infected wards would often be closed and cleansed, driving away the fever for a time. But it always returned. If it got too bad, hospital governing boards were known to recommend simply tearing down or burning the wards and rebuilding.
There were still no answers, only questions: Why newly delivered mothers? Why were some hospitals decimated while others in the same city, in the same winter, rarely saw a case? Within a single hospital, the disease might be rampant in one ward, a minor problem in another. Within a single ward, some women fell prey, and others never caught it. Of those who caught it, some recovered, while others died. It was especially galling that epidemics struck hospitals, the centers of the most advanced care, while the disease was rarely a problem for midwives delivering babies at even the filthiest private homes.
Two centuries after the first outbreak at the Hôtel Dieu, physicians seemed no closer to finding either the cause or cure of childbed fever, although theories continued to sprout: Some believed it was due to “autogenesis,” a disease the women brought upon themselves through inadequate hygiene; others subscribed to the theory of “crasis,” the spontaneous appearance of contagion in the blood; still others linked it to errors in diet, inadequate sewer systems, the shame of being an unmarried mother, or that convenient catchall for many female problems: hysteria. At least there was a solution for that: If a newly delivered woman seemed unusually nervous or irritable, one veteran doctor advised that she be dosed with laudanum to “restore rest to the body and tranquility to the mind.”
Childbed fever caused the “utmost alarm in the physician,” noted one nineteenth-century observer, sensitive to the psychological damage physicians themselves could undergo after repeatedly experiencing “the anxiety and anguish of those so lately rejoicing, the blighting of the sweetest hopes in life, and finally the rupture of its dearest ties, and the melancholy desolation of a home but lately the abode of happiness.” Around 1840, after attending forty-five cases of childbed fever in a single year, Dr. Rutter of Philadelphia finally broke under the strain, leaving the city, burning his clothes, shaving his head, beard, and mustache, paring his nails to the quick, and scrubbing himself relentlessly in hopes of somehow protecting his patients. Unfortunately, when he returned to practice, the next new mother he attended died from the fever.
Cases like Dr. Rutter’s led to new ideas about the source of the disease, put forward by a brilliant young American named Oliver Wendell Holmes. Known today primarily as the father of a future U.S. Supreme Court justice, Holmes in the 1840s was known as a wunderkind: a skilled physician who in his early thirties was already teaching anatomy and physiology at Harvard, simultaneously excelling not only in medicine but in literature, author of the popular poem “Old Ironsides” at age twenty-one, a regular contributor to literary magazines ever since. He was an essayist, a theorist, a practitioner, and a wide-ranging thinker. What Holmes had in abundance was outrage: outrage at the depredations of a disease that he believed could be stopped and outrage at the way in which his medical colleagues were ignoring the facts. In 1843, he published a blistering critique called the “Contagiousness of Puerperal Fever” (the medical name for childbed fever), presenting case after case in which it was apparent that the disease demonstrated its own sort of logic, occuring in clusters linked by geography and personal contact. His most noteworthy idea was that the disease could be carried from victim to victim by physicians and nurses. He wrote passionately and persuasively, making his case not only with numbers but with well-told stories: for instance, the tale of the doctor who, after assisting in the postmortem of a new mother who had died of childbed fever, carried her pelvic viscera in his pocket while attending another birth later that evening, followed by the death of the second woman a few days later, followed by the death of the woman he delivered the next morning, followed by the deaths of many of his other patients during the next few weeks. Holmes’s essay consisted, in fact, more of anecdotes than statistically significant data, but its cumulative impact—case after case where groups of dying mothers were attended by the same physician, while another physician in the same town might deliver many babies without seeing the disease—was overwhelming. “In the view of these facts it does appear a singular coincidence that one man or woman should have ten, twenty, thirty, or seventy cases of this rare disease following his or her footsteps with the keenness of a beagle, through the streets and lanes of a crowded city, while the scores that cross the same paths on the same errands know it only by name,” he wrote.
