Speaker 1: In the afternoon of the nineteenth of August seventeen ninety,
Speaker 1: John Lowe came to my house, requesting me to go
Speaker 1: immediately to his wife, who he said had fevered after
Speaker 1: delivery and was in great danger. I accordingly went and
Speaker 1: found her in a dangerous situation. She complained of an
Speaker 1: acute pain in the lower part of the abdomen, attended
Speaker 1: with a very great degree of fever, the velocity of
Speaker 1: the pulse being at the rate of one hundred and
Speaker 1: forty strokes in a minute. I had no difficulty in
Speaker 1: ascertaining the patient's disorder, having had previous opportunities of seeing it,
Speaker 1: both in London and in the course of my practice
Speaker 1: in Aberdeen. For this was the fifteenth case I had
Speaker 1: attended since the epidemic began, And in every respect this
Speaker 1: answered the description of that known to practitioners by the
Speaker 1: appellation of the pupil fever, a distemper which so frequently
Speaker 1: proves fatal to women in childbed, baffling the skill of
Speaker 1: the most eminent physicians. On the twenty first, when I
Speaker 1: visited her in the morning, I was happy to find
Speaker 1: that she had been pretty easy throughout the night and
Speaker 1: had enjoyed some hours sleep. She was in a profuse sweat,
Speaker 1: which I hoped would prove critical, but I was sorry
Speaker 1: to find that I was disappointed in my expectation, for
Speaker 1: when I returned in the afternoon, I found that the
Speaker 1: sweat had disappeared, being succeeded by a diarrhea. The patient
Speaker 1: now complained of very great pain, and the swelling of
Speaker 1: the abdomen seemed to increase. On the twenty second, I
Speaker 1: was sorry to find that the disease was making rapid
Speaker 1: progress in spite of all the remedies employed, and that
Speaker 1: the patient's health was sinking. All hopes of recovery were
Speaker 1: now totally abandoned. The patient's agony was now extremely great,
Speaker 1: and she called loudly for relief. I therefore thought proper
Speaker 1: to administer opium to mitigate pain and, if possible, to
Speaker 1: procure rest. I went early in the morning of the
Speaker 1: twenty third to visit my distressed patient and found that
Speaker 1: the storm was lulled into a calm. The friends received
Speaker 1: me with transports of joy, vainly, thinking that her danger
Speaker 1: was over. The patient supposed herself perfectly well, asked my
Speaker 1: permission to rise, for she seemed to feel no pain,
Speaker 1: and suffered me to touch and press the abdomen without
Speaker 1: showing any signs of uneasiness, a proof that the parts
Speaker 1: were in a state of gangrene. The friends, ignorant of
Speaker 1: this circumstance, were quite overjoyed to see the patient so
Speaker 1: composed after such excruciating pain. However, it was evident from
Speaker 1: the ghastly appearance of the countenance, from the tumbufaction of
Speaker 1: the abdomen, with the absence of pain, from the sunk
Speaker 1: state of her pulse, and from the coldness of the extremities,
Speaker 1: that death was not far off. Accordingly, in a few
Speaker 1: hours the scene was closed.
Speaker 2: Good God erin.
Speaker 1: Yeah, that was from an account by Alexander Gordon, whom
Speaker 1: I will talk about later in this episode. It's horrifying. Yeah, Hi,
Speaker 1: I'm Aaron Welsh and I'm Aaron Ollman. Updyke and this
Speaker 1: is this podcast will kill you.
Speaker 2: It's really going to be an upper of an episode.
Speaker 1: Yeah, sorry, guys. This week we are talking about child
Speaker 1: bed fever, pupil fever.
Speaker 2: Puper ol, sepsis, maternal fear, who calls it maternal perrypartum infection.
Speaker 1: There we go lots of different pathogens under this umbrella.
Speaker 2: Aaron. It's so it's funny because one of the things
Speaker 2: that you said to me before we started doing this
Speaker 2: episode is that you felt like it was more in
Speaker 2: some ways more typical than the ones that we've done recently,
Speaker 2: in that like the biology and the history are very separate.
Speaker 2: There's not a lot of like overlap. But for me,
Speaker 2: this was not a typical episode. I was like, could
Speaker 2: we structure this like a medical mystery, except that it's
Speaker 2: not a mystery, but it kind of is.
Speaker 1: Oh that that could have been fun.
Speaker 2: It could have been fun. I know.
Speaker 1: No, I mean I as I was. As I was
Speaker 1: researching it too, I was like, Okay, well, my story
Speaker 1: is very clear. And part of the reason that we
Speaker 1: wanted to do this episode is because, you know, we
Speaker 1: had learned about pupil fever in various classes, and it's
Speaker 1: like such a good, interesting story and so crucial to
Speaker 1: the history of medicine, right, But I don't think that
Speaker 1: I realized just how difficult a topic it would be
Speaker 1: to cover.
Speaker 2: So yeah, but it's fine, it's gonna be fun. We'll
Speaker 2: learn a lot. I'm really excited to hear the whole story.
Speaker 2: In terms of the history altogether because I've only heard
Speaker 2: bits and pieces, so.
Speaker 1: Oh I it's been one of my absolute, I think
Speaker 1: favorite ones to research for sure.
Speaker 2: Excellent. Well, before we can get into the episode, of course,
Speaker 2: it's quarantin any time.
Speaker 1: It's quarantine anytime. What are we drinking this week?
Speaker 2: This week we're drinking the Filthy Animal.
Speaker 1: And as you will learn later in the episode, this
Speaker 1: is because at the end of all of our episodes,
Speaker 1: if you've never stayed tuned to the final very end,
Speaker 1: which we can't blame you, we always off by saying,
Speaker 1: wash your hands, you filthy animals. And that's basically what Semmelweiss,
Speaker 1: who's a key player in this story, was saying to
Speaker 1: all of the doctors around him to try to stop
Speaker 1: pupil fever from spreading.
Speaker 2: Yeah, he was just walking around being like, wash your hands,
Speaker 2: you're filthy animals, and everyone was like, ah, you didn't
Speaker 2: listen exactly.
Speaker 1: So what's in the Filthy Animal?
Speaker 2: Well, it's jim Time simple syrup and watermelon blended up.
Speaker 2: It's like a really beautiful drink.
Speaker 1: It's beautiful and really refreshing.
Speaker 2: Summary.
Speaker 1: Yeah, I like it.
Speaker 2: We'll post the full recipe for that Quarantini as well
Speaker 2: as our non alcoholic plusy Brita on our website, this
Speaker 2: podcast will kill You dot com and on all of
Speaker 2: our social media channels other business.
Speaker 1: Basically, go to our website. You'll find lots of stuff there, transcripts,
Speaker 1: alcohol free episodes, book lists of various sorts. Just go there.
Speaker 2: It's great, it's great, it's really great. Yeah, Okay, should
Speaker 2: we get into this episode.
Speaker 1: Let's do it.
Speaker 2: Okay, we'll take a quick break and then dive in. So,
Speaker 2: like I said already, this isn't a very typical episode
Speaker 2: because puperile fever isn't really one single disease, and in fact,
Speaker 2: it's not even really a term that we use anymore.
Speaker 2: We kind of already mentioned there are so many names
Speaker 2: for this illness, which really does make it difficult to
Speaker 2: get a handle on in terms of like the current
Speaker 2: status too, But we're gonna do our best. Some of
Speaker 2: the names that you can find that we haven't already mentioned,
Speaker 2: puperial sepsis, maternal sepsis, it's also called child bed fever.
Speaker 2: There's so many names. But the World Health Organization defined
Speaker 2: maternal peripartum infections, which means they defined it as a
Speaker 2: bacterial infection of the genital tract during childbirth, like during labor,
Speaker 2: even before birth, but after like rupture of the amniotic membrane,
Speaker 2: but before delivery, or in the post birth the postpartum
Speaker 2: period up to forty two days postpartum. Oh, okay, that
Speaker 2: is associated with childbirth. So bacterial infection of the genital
Speaker 2: tract associated with childbirth. And what's important about this definition
Speaker 2: specifically is that it does it include some other infections
Speaker 2: that used to sometimes get lumped in to postpartum sepsis
Speaker 2: or maternal sepsis, like mastitis which is an infection of
Speaker 2: the ducts in the breast or UTIs, even pneumonia. It
Speaker 2: also does not include infections in surgical sites, so like
Speaker 2: a C section incision, just an infection of the skin
Speaker 2: would not be included in this definition.
Speaker 1: Okay, so it's really both locational and time specific.
Speaker 2: Exactly, right. Okay, Yeah, So now that we have that
Speaker 2: out of the way, I'm kind of just going to
Speaker 2: run through this. It's not going to be super detailed
Speaker 2: on like all of the bacterial virulence factors and things
Speaker 2: because it's just too much. But what we will do
Speaker 2: is go through where in the body these infections happen
Speaker 2: because the genital attract is actually kind of a large area.
Speaker 2: We'll talk about why they're problematic, how we know that
Speaker 2: an infection is happening, like what symptoms are we actually
Speaker 2: talking about, how do we define this? And then we'll
Speaker 2: talk about the risk factors for transmission, what pathogens we're
Speaker 2: actually dealing with, and finally, who gets it or what
Speaker 2: the risk factors are for transmission.
Speaker 1: Sounds good, Well, sounds horrible.
Speaker 2: But yeah it does. It sounds horrible. It's pretty horrible.
Speaker 2: So pure peril sepsis maternal. I'm just gonna call it MPI.
Speaker 2: Can I do that?
Speaker 1: Sure?
Speaker 2: Okay? MPI can mean infection in a number of different organs,
Speaker 2: but most often probably it could mean endometritis. Endometritis is
Speaker 2: an infection or inflammation of the endometrium, the lining of
Speaker 2: the uterus, and so this makes a lot of sense
Speaker 2: in the context of childbirth. This is not a disease
Speaker 2: that you can only get after childbirth, but in the
Speaker 2: context of childbirth, the inside of your uterus is exposed
Speaker 2: to the outside world in a way that it isn't
Speaker 2: normally right right either, because the cervix is dilated, and
Speaker 2: then there's a vaginal delivery and bacteria can migrate upwards,
Speaker 2: or if a c section happens, then the uterus is
Speaker 2: literally exposed on the abdomen and then put back in place.
Speaker 2: But on top of that, after delivery, you have kind
Speaker 2: of a raw surface exposed inside the uterus because the
Speaker 2: placenta that had been attached has been removed. So there's
Speaker 2: not only like roots of infection, but there's also a
Speaker 2: surface that's more susceptible potentially gotcha. Okay. So that's one
Speaker 2: possible infection that can happen post birth. Another is an
Speaker 2: infection that can actually start a little bit earlier in pregnancy.
Speaker 2: It could happen any time in theory during pregnancy, but
Speaker 2: that's called choreo amminitis or intra amniotic infection IAI. And
Speaker 2: this is an infection of any part of like the
Speaker 2: lining of the amniotic sac, which is what holds all
Speaker 2: the fluid that cushions the fetus. It could be an
Speaker 2: infection of the placenta just basically any part within there, okay.
Speaker 2: And so that can happen during pregnancy but then result
Speaker 2: like in a continued infection that can continue after delivery
Speaker 2: as well. But a maternal peripartum infection can have a
Speaker 2: number of other possibilities as well. A peritonitis is infection
Speaker 2: of the abdominal wall itself, which can happen as a complication,
Speaker 2: like if the endometritis spreads outside of the uterus, but
Speaker 2: it can also just happen in the setting, for example
Speaker 2: of a c section, if the peritoneal cavity, the abdominal
Speaker 2: cavity becomes contaminated in some way.
Speaker 1: Gotcha.
Speaker 2: It can also mean a vaginal infection or a soft
Speaker 2: tissue infection, especially if you have like a third or
Speaker 2: fourth degree tear that happens during delivery. It can also
Speaker 2: mean something that's a lot more rare, but called septic
Speaker 2: pelvic thrombophlebitis.
Speaker 1: Which sounds very bad.
Speaker 2: It's as bad as it sounds. This is an infection
Speaker 2: that involves bacterial infection of the veins that surround the
Speaker 2: uterus that cause like hypercoagulability, and it spreads. Overall. In general,
Speaker 2: not good infections, But the biggest concern with any of
Speaker 2: these organ systems or any of these tissues that become
Speaker 2: infected is when that infection spreads beyond that single organ
Speaker 2: or that single tissue and enters the blood stream, right,
Speaker 2: that results in bacteremia, so bacteria in your blood or septicemia,
Speaker 2: bacteria replicating and growing in your bloodstream and potentially septic shock,
Speaker 2: which can lead of course to death. Okay, So in
Speaker 2: the context of childbirth, the vagina, the uterus, the abdomen,
Speaker 2: these are just sites of entry for what can easily
Speaker 2: become an invasive, widespread infection.
Speaker 1: Right. Also, I did not know the difference between bacteremia
Speaker 1: and septicemia until this moment.
Speaker 2: Why thank you. I also had to look it up
Speaker 2: because I kept seeing them both and I was like,
Speaker 2: why is that different? So you can just have bacteria
Speaker 2: in your blood and technically that's bacteremia, but if they're
Speaker 2: not like replicating, growing, that would be when you have septoicemia.
Speaker 2: So septocemia is like extreme scary.
Speaker 1: Right, It's yeah, yeah, very bad.
Speaker 2: So that's like all the different types of infections that
Speaker 2: you can have, and you'll notice those are all like
Speaker 2: much more specific. And that makes sense because now we can,
Speaker 2: like with medical technology that exists today, we can actually
Speaker 2: differentiate all of these.
Speaker 1: So how does having this umbrella term sort of help?
Speaker 2: Great question? I think it helps in a number of ways.
Speaker 2: Some of these conditions are quite rare. For example, like
Speaker 2: septic pelvic thrombuffal bitis. That's very rare, so if you
Speaker 2: were looking at stats of only that, your numbers would
Speaker 2: be really low, whereas if you lump it in with
Speaker 2: all of these other ones. But also some of these conditions,
Speaker 2: for example, choreoaminitis can happen much earlier in pregnancy and
Speaker 2: result in pregnancy loss, like spontaneous pregnancy loss, but if
Speaker 2: it happens around the time of delivery, then it's kind
Speaker 2: of it might cause different problems down the line. And
Speaker 2: same thing with endometritis. That's something that can happen outside
Speaker 2: the context of childbirth, but if it happens within the context,
Speaker 2: then you'd want to know that that happened within that context.
Speaker 2: So I think by grouping them together, you're looking at
Speaker 2: a broad picture of all these different types of bacterial
Speaker 2: infections that can happen specific to the context of childbirth.
Speaker 2: The other thing, though, and it's a good question that
Speaker 2: you asked that, Aaron, because the other thing about all
Speaker 2: these infections is that even though we can differentiate them
Speaker 2: all in terms of symptoms, they're all very similar okay, okay.
Speaker 2: And so that's the other thing is that for a
Speaker 2: long time we probably weren't differentiating them all because does
Speaker 2: it matter exactly what tissue type is infected When you're
Speaker 2: looking at someone who just gave birth and all of
Speaker 2: a sudden, they spike a fever right up to one
Speaker 2: hundred and two fahrenheit or thirty nine celsius, and they're
Speaker 2: sweaty and they're pale, their heart rate is elevated, they're
Speaker 2: breathing hard. They're sick, right, and they're sick probably in
Speaker 2: the context of this traumatic delivery that just happened, or
Speaker 2: even this non traumatic delivery that just happened. And so
Speaker 2: I think that's another reason too why you lump it
Speaker 2: all together. That makes sense in terms of some of
Speaker 2: the other symptoms. Aside from fever, which of course is
Speaker 2: kind of the biggest sign, which is why it got
Speaker 2: the name puparel fever, other symptoms that tell you that
Speaker 2: you're dealing with an infection of the genital tract are
Speaker 2: things like abdomin pain or like paint tenderness in the uterus,
Speaker 2: and not just the tenderness that's normal after delivery, but
Speaker 2: like a deep, a deeper tenderness and like a more
Speaker 2: I don't know how to describe it, a more painful tenderness.
Speaker 2: And then also some vaginal discharge is fairly common, especially
Speaker 2: with endometritis. You can have a very like purulent, like
Speaker 2: pus filled drainage that can happen from the uterus. And
Speaker 2: then of course you have all these other general signs
Speaker 2: of infection, things like I already mentioned, like you have
Speaker 2: an elevated heart rate, elevated breathing rate. If you were
Speaker 2: to take a white blood cell count that would be elevated,
Speaker 2: and like I said already, to the big concern here
Speaker 2: is if that infection spreads to the bloodstream, because that
Speaker 2: can result in shock and potentially death. Yeah, so I've
Speaker 2: said already this is bacterial infection. What bacteria are we
Speaker 2: talk talking about. It's a lot, It's a lot, and
Speaker 2: so Aerin I think even though I tried really hard
Speaker 2: not to read about semelweis and not step on your
Speaker 2: toes at all, I think that largely in that time frame,
Speaker 2: it's thought that it was group A strep aka Streptococcus
Speaker 2: piogenies that was the big contributor. Is that correct?
Speaker 1: That's also what I read, But I think they didn't know,
Speaker 1: but it seemed like, yeah, strap biogenies was the first
Speaker 1: causative agent to be isolated and characterized. From what I.
Speaker 2: Recab, that makes a lot of sense because it was
Speaker 2: so interesting because I kind of knew that context. But today,
Speaker 2: when you read about like MPIs in general, it strep A,
Speaker 2: so group A strip or strap piogenies really doesn't even
Speaker 2: come up as a very big topic of conversation in
Speaker 2: most of the articles about it, which is very interesting.
Speaker 2: Caveat that that you can find like separate articles that
Speaker 2: are all about group A strep in the peripartum period, right,
Speaker 2: But when you read about endometritis, when you read about
Speaker 2: chorea aminitis, and when you read about just like general
Speaker 2: maternal sepsis and you use all these sort of buzzword terms,
Speaker 2: group AA strap is like, yeah, it's on the list
Speaker 2: along with a whole bunch of other things. Why, I
Speaker 2: don't really know. Let's kind of let's talk about.
Speaker 1: It, Okay, Okay, I have some guesses, maybe, but I.
Speaker 2: Have several guesses, so we'll see if our guesses are
Speaker 2: the same guesses. So we'll start by talking about strep
Speaker 2: biogenies and what might make it a particularly interesting bug
Speaker 2: to talk about, and then I'll go through what the
Speaker 2: other bacteria are too. But I'm not going to get
Speaker 2: into a lot of detail on strep biogenies because it's
Speaker 2: also the causative agent of necrotizing fasciitis, which spoiler listeners
Speaker 2: were going to be covering shortly in this season.
Speaker 1: Yes, yeah, so you'll.
Speaker 2: Learn all you want to know about the details of
Speaker 2: stret piogenies later. But in short, it's a gram positive
Speaker 2: little ball forms little chains like beads on a string
Speaker 2: when you look at it under a microscope, and it's
Speaker 2: a pretty common group of bacteria. Strett Piogenies can exist
Speaker 2: on our skin, it can exist in our throat. I
Speaker 2: think twenty five percent of kids are colonized in their
Speaker 2: throat and like five percent of adults. It's what causes
Speaker 2: strep throat right, Like, so you've all probably heard of
Speaker 2: stret piogenies. It also, like I said, causes deeper infections
Speaker 2: like necrotizing fasciitis if it's untreated. Strep Piogenies is what
Speaker 2: leads to rheumatic fever, rheumatic heart disease, a number of
Speaker 2: different post infectious type syndromes. But it's also, of course
Speaker 2: a potential cause of MPIs, and one of the reasons
Speaker 2: likely is that during pregnancy and the postpartum period, people
Speaker 2: are twenty times more likely to become infected with strept
Speaker 2: piogenies compared to non pregnant people. Huh, why something about
Speaker 2: pregnancy makes you far more susceptible to stret parogenes. To
Speaker 2: answer your question of why, we don't know, except that
Speaker 2: it might have to do with pregnancy in general is
Speaker 2: a state of aminosuppression, so it might just be that
Speaker 2: that specific type of aminosuppression makes you more susceptible. There
Speaker 2: are some people that say because being around children is
Speaker 2: a risk factor for stret piogenies colonization in general, since
Speaker 2: children are more likely to have it than adults, just
Speaker 2: like without being sick, just hanging around. So if someone
Speaker 2: is pregnant, they might also be around kids or have
Speaker 2: other young kids. So I don't know, that's kind of whatever,
Speaker 2: but in any case, times more likely to become infected
Speaker 2: during pregnancy and postpartum like that short, short postpartum period,
Speaker 2: because the thing about people who get strap a postpartum
Speaker 2: is they often are already colonized and then it just
Speaker 2: becomes an infection postpartum when that bacteria swims into the
Speaker 2: bloodstream right right. And while it's not the most common
Speaker 2: cause of peripartum infections today as far as I can tell,
Speaker 2: because it's really hard to get numbers on what is
Speaker 2: causing all these different MPIs. If you look at all
Speaker 2: invasive group A strep infections, about two to four percent
Speaker 2: of them are somehow associated with pregnancy. So that's of
Speaker 2: everyone in the world who gets an invasive group A
Speaker 2: strep infection, two to four percent of those are associated
Speaker 2: with pregnancy. I don't know the proportion of all MPIs
Speaker 2: that are due to group A strap However, when group
Speaker 2: A strepp is the causative agent, it is extremely virulent, okay, Yeah,
Speaker 2: And when and if it progresses to something like toxic shock,
Speaker 2: mortality can be as high as thirty to fifty percent
Speaker 2: even today.
Speaker 1: That's like with the use of antibiotics.
Speaker 2: That's yeah, if it progresses to shock, so that would
Speaker 2: probably mean that you didn't correctly identify it and treat
Speaker 2: it before it progressed that far. Okay, Yeah, So it's
Speaker 2: I think because of that. Because it's so virulent, it
Speaker 2: often has a very quick onset like within twenty four
Speaker 2: to forty eight hours after delivery, and then people can
Speaker 2: just get really sick from it. So I think because
Speaker 2: of that, it's like one of the really scary ones,
Speaker 2: even though it maybe isn't one of the most common
Speaker 2: causes of infection. Okay, so that's group A strap. There's
Speaker 2: a whole nother group of strip that we get to
Speaker 2: talk about, and that is group B strep aka streped
Speaker 2: caucus A galactae. I think I probably pronounced it wrong.
Speaker 2: And what I think is so interesting is that today
Speaker 2: you hear a lot more about group B strep in
Speaker 2: the context of pregnancy then you hear about group A strap.
Speaker 2: And that's because this is something that we actually test
Speaker 2: for in the US, at least during pregnancy, because we
Speaker 2: know that group B strep is a very important cause
Speaker 2: of meningitis in newborns. Yeah, and so we know that
Speaker 2: by testing for group B strap, because this is another
Speaker 2: bacteria that just can often colonize the vagina and the rectum.
Speaker 2: So if you test pregnant people for group B strep
Speaker 2: and then treat them with antibiotics during labor, it drastically
Speaker 2: reduces the probability of that bacteria being transmitted to the
Speaker 2: baby during delivery and then reduces that baby's risk of
Speaker 2: meningitis significantly.
Speaker 1: And so is the same treatment used for group B
Speaker 1: that's also used for.
Speaker 2: Group A the same bacteria. Yeah, you'd use like a
Speaker 2: penicillin right type.
Speaker 1: Okay, so that would treat both yeah, okay, okay, And
Speaker 1: so is that part of the reason why we see
Speaker 1: so few nowadays.
Speaker 2: It's a good question. We I mean, we don't test
Speaker 2: for group A strep, so okay, Yeah, but it's it's
Speaker 2: a good question. But group B strep, even though we
Speaker 2: know that it definitely can cause, you know, illness in newborns,
Speaker 2: it's also has the potential to cause a perinatal infection,
Speaker 2: a parapartum infection as well in the pregnant person. Other
Speaker 2: bacterial species E. Coli super common cause in some studies,
Speaker 2: but also things like anaerobic species like bacteroids, And what's
Speaker 2: really common overwhelmingly is that you can have polymicrobial infections.
Speaker 2: So we're not even looking at a single bacterial species.
Speaker 2: If if you think just about the process of childbirth
Speaker 2: and that there's so much exposure happening from so many
Speaker 2: different potential sources. A lot of these are bacteria that
Speaker 2: can be found on a lot of different kind of
Speaker 2: surfaces and skin and things like that, and so it
Speaker 2: kind of makes sense that you might be able to
Speaker 2: have polymicrobial, multiple bacterial species.
Speaker 1: Infections just a bunch of opportunists exactly.
Speaker 2: Yeah. But really, in general, we don't often know what
Speaker 2: the causative agent is. So most studies, even the ones
Speaker 2: that kind of looked at it where they tried to
Speaker 2: figure out, like what was the cause of these particular infections,
Speaker 2: even when we're looking we often only identify like thirty
Speaker 2: to forty percent of cases with like a laboratory confirmed organism.
Speaker 1: Is that just because like you know, toss some antibiotics
Speaker 1: and the person gets better, exactly right.
Speaker 2: We use like a kind of for any kind of
Speaker 2: postpartum fever or fever during delivery and after delivery anything
Speaker 2: like that. There's kind of like a standard regimen of
Speaker 2: antibiotics and if those don't work within twenty four hours,
Speaker 2: then you add a penicillin in case it's a strap,
Speaker 2: and then that's it. So it's kind of it's a
Speaker 2: pretty yeah, because do you give antibiotics that are going
Speaker 2: to cover that whole range? Because you don't know, it
Speaker 2: could be any of those.
Speaker 1: Right time is of the essence like exactly exactly, And
Speaker 1: so is there a risk this might be jumping the gun,
Speaker 1: but you're a risk of antibiotic resistance?
Speaker 2: Good question. Of course, It's always always a potential risk, right,
Speaker 2: The answer is always yes, But I don't have stats
Speaker 2: on what the rates of resistance of like npisr to
Speaker 2: the kind of mainstay antibiotics at this point are One
Speaker 2: of the big problems is that kind of at least
Speaker 2: one of the big antibiotics that we often use can
Speaker 2: be quite expensive. So in other parts of the world,
Speaker 2: I don't think they use that use different antibiotics that
Speaker 2: are less expensive. So there's also always the cost to
Speaker 2: take into consideration. Yeah, so that's kind of the overall
Speaker 2: picture of infections and what causes it, and arin you're
Speaker 2: going to talk a lot I think in the history
Speaker 2: about kind of the transmission. Yeah, how we figured this out, right,
Speaker 2: But like I said, a lot of these bacteria are
Speaker 2: just bacteria that exist around us, whether on providers unclean hands,
Speaker 2: or on unclean instruments that are used, or even just
Speaker 2: on our skin just already here or in our vaginal canal.
Speaker 2: Or even in our throat or other mucous membranes. So
Speaker 2: when you add on top that pregnancy is a state
Speaker 2: of immunal compromise and all of the potential roots of
Speaker 2: entry that could be opened up during childbirth, and then
Speaker 2: all of these bacterials be floating around, that's kind of
Speaker 2: how you get to transmission, if that makes sense. There
Speaker 2: are some things that would increase the risk of a
Speaker 2: maternal peripartum infection, and the biggest one worldwide today, of course,
Speaker 2: is a C section, which is not really surprising considering
Speaker 2: that that's a much more invasive way to deliver a baby. However,
Speaker 2: in general, antibiotics are used prophylactically during c sections, just
Speaker 2: like with any other surgery, because we know that surgery
Speaker 2: is such a big risk for infection overall, right, right,
Speaker 2: so with antibiotics prophylactically, that drastically reduces the risk of
Speaker 2: infection associated with ce section.
Speaker 1: And so I guess, since this umbrella term, well, is
Speaker 1: an umbrella term and covers a lot of different things,
Speaker 1: asking what is the case fatality rate is not very
Speaker 1: easy to answer.
Speaker 2: It's very very difficult. We'll talk in the current events
Speaker 2: section about like what the stats are today, and I
Speaker 2: think that'll give us a little bit more. But yeah,
Speaker 2: just like looking at overall, it's almost impossible to get that.
Speaker 1: I mean, yeah, yeah, yeah, Sorry, Aaron, I making you
Speaker 1: do this one, this is very difficult.
Speaker 2: I do feel like we put this one off for
Speaker 2: a while, and it was because I was like, oh no,
Speaker 2: how am I gonna even do this?
Speaker 1: Well, I think it's been great so far.
Speaker 2: Oh good, because I'm pretty much done. I do just
Speaker 2: want to say, because I think it's a very interesting fact.
Speaker 2: If we go back to group A step for a second,
Speaker 2: it's far more common following a vaginal delivery than a
Speaker 2: C section delivery, unlike some other infections from other bacterial species.
Speaker 2: Is that interesting? Interesting? So yeah, that is maternal perry
Speaker 2: partum infections. Aaron, you want to walk us through this?
Speaker 1: Oh, I can't wait, but let's take a quick break.
Speaker 1: You may think that this story begins more or less
Speaker 1: with Igna's Semmelweiss. Yeah, and that's reasonable to think because
Speaker 1: if you had heard of pupil fever before this episode,
Speaker 1: there was a good chance it was in connection with
Speaker 1: his name and his story. And I love that story
Speaker 1: and I will definitely get to it. But it turns
Speaker 1: out there's actually so much more to the story of
Speaker 1: peperil fever, not surprising considering that it's like a ton
Speaker 1: of different bacterial species and you can get it a
Speaker 1: ton of different ways and so on.
Speaker 2: And also it's this podcast, so I would expect nothing less.
Speaker 1: So let's begin at the beginning, which also is easier
Speaker 1: said than done for all the things you have already
Speaker 1: talked about. I also wanted to say we will also
Speaker 1: be at some point, whether it's the season or not,
Speaker 1: probably not, we will be doing scarlet fever, so another
Speaker 1: group a strip situation. But in the interest of time,
Speaker 1: I'm just going to start with the beginnings of the
Speaker 1: concept of pupil fever, okay, which, as you might guess,
Speaker 1: goes way back. Giving birth is not a risk free activity.
Speaker 1: It never has been, it never will be, and since
Speaker 1: at least some of the bacteria that cause infections after
Speaker 1: childbirth are carried naturally with us. As you said, these
Speaker 1: infections have been around since, you know, as long as
Speaker 1: humans have been giving birth, so forever. It's you know,
Speaker 1: humans before humans were humans, and so it's probably not
Speaker 1: surprising that people had long recognized that fever, severe pains,
Speaker 1: and a swollen abdomen in the days after giving birth
Speaker 1: often led to death. Hippocrates, for example, wrote about it,
Speaker 1: and there are also descriptions in Hindu texts dating back
Speaker 1: to fifteen hundred BCE. Several English queens died of infection
Speaker 1: after childbirth, including Elizabeth of York, queen consort of Henry
Speaker 1: the seventh and Henry the eighth had two wives that
Speaker 1: died in the same way, including Jane Seymour, whose death
Speaker 1: inspired an old ballad that's included in a song inside.
Speaker 1: Lewin Davis just, I really like the song.
Speaker 2: It's beautiful.
Speaker 1: But it was only in seventeen sixteen that the term
Speaker 1: pupil fever was introduced from pure pu er the Latin
Speaker 1: for child and perere, meaning to bring forth.
Speaker 2: Why did it take so.
Speaker 1: Long for there to be a term for what was
Speaker 1: obviously known about and probably not that uncommon In short hospitals,
Speaker 1: the sixteen hundred saw the establishment of many so called
Speaker 1: lying in hospitals where women would go to give birth,
Speaker 1: and the growth of these hospitals was in advance in
Speaker 1: some ways, like through the use of forceps and difficult deliveries,
Speaker 1: and through the beginnings of formalization of medical education and
Speaker 1: the growth of obstetrics and gynecology as a separate field.
Speaker 1: But in so many other ways, they were a perfect
Speaker 1: setting for the spread of infectious disease. Wards were over crowded,
Speaker 1: instruments were filthy. Germ theory was still over two hundred
Speaker 1: years away, as was the importance of cleanliness and limiting infection,
Speaker 1: so no one was watched their hands, or the bed sheets,
Speaker 1: or their clothes or their instruments. It was believed that
Speaker 1: the stiffer the doctor's coat with blood and fluids and pus,
Speaker 1: the more respected they were, because it showed that they
Speaker 1: had experienced.
Speaker 2: Stop. That really makes me nauseous.
Speaker 1: I know.
Speaker 2: Oh, I can picture that far too well.
Speaker 1: I know, I know.
Speaker 2: Yeah.
Speaker 1: And these hospitals were often used as training grounds for
Speaker 1: future physicians, which meant that a pregnant person would often
Speaker 1: be subjected to repeated vaginal exams as student after student
Speaker 1: came to practice on them.
Speaker 2: By the way, speaking of that, because that's a thing
Speaker 2: that still sometimes happens, I should have probably mentioned that that's.
Speaker 2: One of the biggest risk factors for transmission of bacterial
Speaker 2: infections is the number of cervical exams that take place,
Speaker 2: as well as the how long you're in labor, like
Speaker 2: the longer the duration of labor, especially after the membranes
Speaker 2: are ruptured. But oh that.
Speaker 1: Yep, yep, that makes complete sense. Yeah, it does, yep.
Speaker 1: And so, knowing what we know now about the transmission
Speaker 1: of pupil fever, it's not surprising that it was at
Speaker 1: one of these lying in hospitals that the first described
Speaker 1: epidemic of pupil fever happened in Paris in either sixteen
Speaker 1: forty six or seventeen forty six. Different papers say different things,
Speaker 1: and I couldn't get to the bottom of it. My
Speaker 1: guess is seventeen forty six. But honestly, it's someone can
Speaker 1: like pinpoint the very original text. That would be amazing.
Speaker 2: That's so fascinating.
Speaker 1: Yeah. Up until the development of these hospitals, outbreaks of
Speaker 1: pupil fever tended to be more isolated, with like single
Speaker 1: cases or maybe a few here or there. But this
Speaker 1: marked the beginning of an era in which pupil fever
Speaker 1: seems like inescapable. Essentially, from that first epidemic, pupil fever
Speaker 1: never really left and outbreaks of the disease were not
Speaker 1: unique to France, where the first epidemic happened, or even Europe,
Speaker 1: and nor was the threat restricted just to hospitals. Physicians
Speaker 1: or midwives may have moved in between hospitals or in
Speaker 1: between house to house, leaving a string of deaths behind them.
Speaker 1: My god, let's put some numbers to the absolute nightmare
Speaker 1: that hospitals were though, jumping ahead to the eighteen hundreds
Speaker 1: in London between eighteen thirty one and eighteen forty three,
Speaker 1: ten mothers per ten thousand died of pupil fever at home,
Speaker 1: while six hundred per ten thousand died when they gave
Speaker 1: birth in the hospital. What uh huh. These numbers were
Speaker 1: also not unique to Britain, and in some places or
Speaker 1: during some times, were even higher elsewhere, such as in Paris,
Speaker 1: where the peak reached eight hundred and eighty per ten thousand,
Speaker 1: which was seventeen times higher than at home births.
Speaker 2: Oh my gracious.
Speaker 1: So many infants lost their mothers to childhood fever that
Speaker 1: many of these hospitals had like a home attached or
Speaker 1: a home nearby specifically for the care of these and
Speaker 1: other infants. Oh my, yeah, And so it's hard to
Speaker 1: believe that physicians or the general public would fail to
Speaker 1: notice this massive uptick in childbood fever. But what did
Speaker 1: they think caused it? This was still pre germ theory,
Speaker 1: so you can imagine the array of possible causes. One
Speaker 1: of the most predominant one was that it was caused
Speaker 1: by the lokia, so the fluid that flows from the
Speaker 1: uterus after a vaginal delivery. It was caused by the
Speaker 1: lokia being prevented from freely flowing and then stagnating in
Speaker 1: the body. Another was that it was pregnancy itself, like
Speaker 1: over the course of nine months, impurities accumulated in the
Speaker 1: blood and as the fetus grew, it pressed down on
Speaker 1: the intestines and so fecal material was slowly released into
Speaker 1: the area and then cause pupil fever.
Speaker 2: Terrible, be terrible.
Speaker 1: And why was this? You know, either fecally contaminated fluid
Speaker 1: or lochia suppressed what could be due to the blood
Speaker 1: being too thick or cold air inadvertently received into the
Speaker 1: uterus was one example, or drinking cold water or fear terror, grief,
Speaker 1: any shock to the system. And if you weren't a
Speaker 1: fan of the lochia of the suppressed lochia, cause you
Speaker 1: could blame re routed breast milk. For way too long,
Speaker 1: it was believed that breast milk was actually menstrual fluid,
Speaker 1: or it originated from the blood going from the uterus
Speaker 1: to the nipple via adduct huh, despite countless autopsies failing
Speaker 1: to find any such duct. And so when doctors examined
Speaker 1: the abdomens of people who had died from childbed fever
Speaker 1: and found white pockets of pus that kind of resembled
Speaker 1: breast milk, they thought that it was caused by the
Speaker 1: failure of milk to route to the nipple. Oh yes,
Speaker 1: and then yes, there was always my asthma to blame
Speaker 1: or poorly ventilated rooms. But before we feel too smug
Speaker 1: about how dumb people in the sixteen hundred and seventeen
Speaker 1: hundreds were that you know, we would have seen the
Speaker 1: connection right away, let's like remind ourselves how little we
Speaker 1: know about autoimmune diseases or even just how our own
Speaker 1: immune system works, or what dreaming is, or like all
Speaker 1: these things are I mean. But yeah, so back in
Speaker 1: the sixteen hundred, seventeen hundreds, even eighteen hundreds, you know,
Speaker 1: doctors lacked training in statistics, and they were working under
Speaker 1: the assumption that the cause of childbed fever was already known.
Speaker 1: You know, just pick whatever cause you want to believe in,
Speaker 1: and so it's kind of understandable that many doctors would
Speaker 1: focus their efforts on developing treatments for childbed fever rather
Speaker 1: than trying to control what seemed inevitable. I mean, we
Speaker 1: do the same thing today in science and medicine, Like
Speaker 1: we are all trained on a foundation of knowledge that
Speaker 1: we're almost taught not to question that these facts have
Speaker 1: been established, and we could and we should focus our
Speaker 1: efforts elsewhere to expand this body of knowledge, which we
Speaker 1: often do for very good reason, because that's how most
Speaker 1: progress is made, and that's also the path that is
Speaker 1: the most rewarded. And so it makes it all the
Speaker 1: more remarkable when someone doesn't just question the established knowledge,
Speaker 1: because that's easy enough to do, but they collect and
Speaker 1: present solid evidence in defense of their questions, despite the
Speaker 1: resistance that they are often met with.
Speaker 2: It's going to get good.
Speaker 1: Some Avice was one of these questioners in the story
Speaker 1: of pupil fever, but he wasn't the first. The person
Speaker 1: who wrote the account that I read at the beginning
Speaker 1: of this a Scottish obstetrician named Alexander Gordon. He recognized
Speaker 1: the contagious nature of pupil fever in the seventeen nineties,
Speaker 1: about fifty years before Selvis Oh wow, and before germ theory.
Speaker 1: So contagion as a concept, as we've talked about, is
Speaker 1: pretty old, and it had some pretty strong consensus and
Speaker 1: at least some areas like long before germ theory. But
Speaker 1: this concept of contagion, where a disease could be transmitted
Speaker 1: from person to person through skin or contaminated clothing, was
Speaker 1: disease specific. You touch someone with smallpox, you get smallpox,
Speaker 1: same with measles. Pupil fever didn't follow this pattern, so
Speaker 1: miasma or lokia suppression seemed more likely. That Alexander Gordon
Speaker 1: rejected those. He noticed that what linked the affected individuals
Speaker 1: in a pupil fever outbreak was not some characteristic of
Speaker 1: the mothers or the weather, but rather that they had
Speaker 1: all been treated by the same person nurse, midwife, physician,
Speaker 1: and the cases appeared in succession, and he became convinced
Speaker 1: that it was a contagious disease, one that the medical
Speaker 1: caretaker played a direct role in which really shook him
Speaker 1: to his core. Quote, it is a disagreeable declaration for
Speaker 1: me to mention that I myself was the means of
Speaker 1: carrying the infection to a great number of women. He
Speaker 1: traced an outbreak of the disease to several midwives employed
Speaker 1: in his practice, and he published his findings in seventeen
Speaker 1: ninety five. And in this treatise he recommended airing out
Speaker 1: the room, burning contaminated clothing, and scrubbing hands and the
Speaker 1: arms of people who delivered the bait as a way
Speaker 1: of preventing the spread. And he didn't stop there. He
Speaker 1: went on to say that he could predict who might
Speaker 1: be at risk of developing the disease based on who
Speaker 1: their practitioner or a midwife was. And then he kind
Speaker 1: of published this like list of the names of seventeen
Speaker 1: midwives who had exposure to the disease. And so basically
Speaker 1: he became an unwonted person in the town. And he
Speaker 1: left obstetrics and joined the navy. Oh goodness, yeah and yeah,
Speaker 1: then he died at forty seven of tuberculosis.
Speaker 2: Oh gosh, burned a few bridges on his way out.
Speaker 1: Yeah, and for the most part. His contributions would not
Speaker 1: be recognized until way later. So into the early nineteenth century,
Speaker 1: many physicians, especially British and American, had started to maybe
Speaker 1: consider that pupil fever might be a contagious disease, but
Speaker 1: the exact nature of this was isn't clear, like how
Speaker 1: was it contagious? What was being transported here and there?
Speaker 1: Oliver Wendell Holmes Senior, an American physician but probably better
Speaker 1: known as a poet, set out to compile all of
Speaker 1: the evidence for the contagiousness of pupil fever in such
Speaker 1: a way that it could not be denied. He didn't
Speaker 1: speculate on the exact mode of transmission, whether it was
Speaker 1: through the air carried by a physician or through the
Speaker 1: instruments that they used, but he did firmly state that quote,
Speaker 1: the disease known as pupil fever is so far contagious
Speaker 1: as to be frequently carried from patient to patient by
Speaker 1: physicians and nurses. He also recommended that physicians should not
Speaker 1: perform autopsies prior to delivery, and that if they had
Speaker 1: to do so, they should change their clothes and wait
Speaker 1: twenty four hours before treating a patient. If a case
Speaker 1: of pupil fever develops, that doctors should consider their next
Speaker 1: patients at risk and shut down their clinic if necessary.
Speaker 1: He didn't necessarily suggest any form of like washing or
Speaker 1: sanitation specifically, but his conviction of the contagiousness was so
Speaker 1: strong that he said, in one talk quote, whatever indulgence
Speaker 1: may be granted to those who have heretofore been the
Speaker 1: ignorant causes of so much misery, the time has come
Speaker 1: when the existence of a private pestilence in the sphere
Speaker 1: of a single physician should be looked upon not as
Speaker 1: a misfortune but a crime. And in the knowledge of
Speaker 1: such occurrences, the duties of the practitioner to his profession
Speaker 1: should give way to his paramount obligations to society.
Speaker 2: I mean, that's pretty.
Speaker 1: Bold, very bold, bold words and bold strong evidence. But
Speaker 1: guess what not really listened to at that net point. Yeah,
Speaker 1: completely dismissed completely. A lot of physicians were like, they
Speaker 1: took great offense to his claim that they were responsible
Speaker 1: for the sickness, since, as was commonly believed, and as
Speaker 1: one of his main opponents said, a doctor is a gentleman,
Speaker 1: and a gentleman's hands are never dirty. Oh no, yeah,
Speaker 1: so uh we're seeing a pattern yet.
Speaker 2: Yeah.
Speaker 1: If two is not quite a pattern, here comes the third,
Speaker 1: Here comes the third. Semolvis Ignaz Semmelweis was born in Budapest,
Speaker 1: Hungary then controlled by Austria, on July one, eighteen eighteen.
Speaker 1: After finishing school in Budapest, he enrolled as a law
Speaker 1: student in Vienna, but changed to medicine after attending an
Speaker 1: anatomy lecture. After graduation, Semolvis found himself an obstetrics after
Speaker 1: his first two choices had fallen through gosh and so.
Speaker 1: On March twentieth, eighteen forty seven, Semolviss began a two
Speaker 1: year appointment as assistant in obstetrics, basically like a residency
Speaker 1: in the Vienna General Hospital first Division. He came into
Speaker 1: the medical profession at a very unique time and at
Speaker 1: a unique place in These circumstances in a way set
Speaker 1: him up almost perfectly to make the observations that he did.
Speaker 1: So let's do a little bit of context. Yes, in
Speaker 1: the early nineteenth century, the field of pathological anatomy had
Speaker 1: really taken off, and autopsies were seen as essential instruction
Speaker 1: for medicine. With each cadaver holding an incredible wealth of knowledge,
Speaker 1: and there was no better place to do autopsies than
Speaker 1: at the hospital in Vienna, where one of the field's leaders,
Speaker 1: Carl von Rokotanski, had been appointed director of Pathological Anatomy
Speaker 1: in eighteen forty four. And if you were an obstetric
Speaker 1: student under Johann Klein at the Vienna General Hospital, you
Speaker 1: were expected to practus on cadavers every chance that you could,
Speaker 1: especially in the mornings before rounds began. Just make sure
Speaker 1: to wipe your cadaver juicy hands on your coat before
Speaker 1: walking upstairs.
Speaker 2: Please don't ever say cadaver juicy hands.
Speaker 1: Sorry. And this was a big change from the previous
Speaker 1: director in the abstetrics ward and this Vienna General Hospital,
Speaker 1: who felt that autopsies should only be performed if absolutely necessary,
Speaker 1: and he never allowed an autopsy on a woman who
Speaker 1: had died after or while giving birth. And so I
Speaker 1: think it's interesting, knowing what we know about the transmission
Speaker 1: of pupil fever, to look at some numbers about how
Speaker 1: these two different approaches might have affected the rates of
Speaker 1: pupil fever. Okay, okay, So under Boer, who was the
Speaker 1: earlier guy who was like not a fan of autopsies.
Speaker 1: The mortality rate of child bed fever in the first
Speaker 1: division lying in ward hovered around one percent, mostly lower. Wow,
Speaker 1: that's pretty good in autopsy superfan. Klein's first year as director,
Speaker 1: first year, that number shot up to eight percent, which
Speaker 1: was probably the lowest it ever was during the entire
Speaker 1: time he was director.
Speaker 2: Oh my god.
Speaker 1: And so this is the guy Klein is the guy
Speaker 1: that Semmelweis started his assistant ship under in eighteen forty seven, okay,
Speaker 1: and he entered this hospital. Then he started his assistantship
Speaker 1: during a time when one out of every six women
Speaker 1: that gave birth in that first division died of child
Speaker 1: bed fever.
Speaker 2: One in six.
Speaker 1: That's what was a very common rate, and it was
Speaker 1: nearly standard all over the world.
Speaker 2: Oh my yeah.
Speaker 3: Yeah.
Speaker 1: Every day, almost every hour, it seemed that you could
Speaker 1: hear the ringing of the priest spell as he walked
Speaker 1: down the rows of beds in the first division giving
Speaker 1: absolution to those who were dying of pupil fever. Became
Speaker 1: like a haunted noise for everyone who was there and
Speaker 1: also for Someelvis and I also want to throw in
Speaker 1: one more piece of information, about this hospital and about
Speaker 1: the substetrics ward. So, as I mentioned, Semlvieis was an assistant,
Speaker 1: was appointed an assistant in the first division. There was
Speaker 1: a second division and a third division, but I won't
Speaker 1: talk about that. But the first division and the second
Speaker 1: division were very different. They were both lying in wards
Speaker 1: where pregnant people would go to give birth. The first
Speaker 1: division was composed of male medical students and that's where
Speaker 1: they received training, and then the second division is where
Speaker 1: the midwives received training, training which importantly did not autopsies.
Speaker 1: The death rate in the first division was always at
Speaker 1: least three times higher than that of the second division,
Speaker 1: and this super high death rate earned it urban legend status.
Speaker 1: So if a woman came to the hospital was about
Speaker 1: to give birth, she would beg and beg not to
Speaker 1: be admitted to the first division.
Speaker 2: Oh my god.
Speaker 1: Yeah, and some advice was not blind to this horror.
Speaker 1: He couldn't bear it. He vowed to do something about it.
Speaker 1: First he was like, all right, I have to get
Speaker 1: a handle on what exactly pupil fever was, because despite
Speaker 1: having many texts and articles written about it, a precise
Speaker 1: definition was just not there. And so to do this,
Speaker 1: some avice would start off each day by dissecting cadavers.
Speaker 1: Oh gosh, just I know, and there was never any shortage.
Speaker 1: Some months, as many as thirty percent of postpartum mothers
Speaker 1: died of the disease. Semmelweiss became convinced that the high
Speaker 1: incidents had to do with the way that the hospital
Speaker 1: managed its patients, so he began to make small changes,
Speaker 1: things like the way that medicine was administered, increasing ventilation,
Speaker 1: having the women deliver on their sides as he had
Speaker 1: seen the midwives do. But nothing seemed to help, so
Speaker 1: he began to look for patterns in the hospital records,
Speaker 1: and he made six key observations. Number one, even though
Speaker 1: the first division so med students and the second division
Speaker 1: midwives had the same number of deliveries per year, so
Speaker 1: three thousand to thirty five hundred in the first division,
Speaker 1: six hundred to eight hundred women died of childbed fever
Speaker 1: on average, whereas only sixty died in the second division.
Speaker 2: Oh my yeah.
Speaker 1: Number two, the epidemic of childbed fever was localized to
Speaker 1: the hospital. There was no similar rate of childbed fever
Speaker 1: cases seen outside the hospital walls, and he actually found
Speaker 1: that you had a better chance of surviving if you
Speaker 1: gave birth in the street on your way to the hospital.
Speaker 1: Number three, the incidence of pupil fever was definitely not
Speaker 1: related to the weather. Pretty easy to conclude. Number four,
Speaker 1: the more trauma experienced during delivery, the more likely it
Speaker 1: was that the person would develop childbed fever. Number five.
Speaker 1: Closing down the ward always stopped the epidemic hu and
Speaker 1: number six. Infants delivered by mothers who developed childbod fever
Speaker 1: also often died of a similar disease. And these observations
Speaker 1: seemed to simulvis very strong evidence that practices at the
Speaker 1: hospital and specifically the first Division, were contributing to or
Speaker 1: even causing the pupil fever epidemic, and that the disease
Speaker 1: was transmitted through direct contact. But where did did it
Speaker 1: come from? And as he prepared to deliver this information
Speaker 1: to his director at the hospital, he was given tragic
Speaker 1: news that would lead to a Eureka moment. He learned
Speaker 1: that his friend, Professor jakub Koalechka, had died after being
Speaker 1: stuck in the finger by a med student wielding a
Speaker 1: scalpel during an autopsy. Death by cataveric poisoning, as it
Speaker 1: was called. Semmelweiss, who was horribly sad about the death
Speaker 1: of his friend, went to consult his autopsy report, which
Speaker 1: described fever, pain, swelling, and organs and tissues inflamed and
Speaker 1: filled with pus. And this sounded awfully familiar to him.
Speaker 1: Quote Totally shattered, I brooded over the case with intense emotion,
Speaker 1: until suddenly a thought crossed my mind. At once it
Speaker 1: became clear to me that childhood fever, the fatal sickness
Speaker 1: of the newborn, and the disease of Professor Kalechka were
Speaker 1: one and the same, because they all consist pathologically of
Speaker 1: the same anatomic changes. If, therefore, in the case of
Speaker 1: Professor Kalecchka, general sepsis arose from the inoculation of cadaver particles,
Speaker 1: then pupil fever must originate from the same source. Now
Speaker 1: it was only necessary to decide from where and by
Speaker 1: what means the putrid cadaver particles were introduced into the
Speaker 1: delivery cases. The fact of the matter is that the
Speaker 1: transmitting source of these cadaver particles was to be found
Speaker 1: in the hands of the students and attending physicians. This
Speaker 1: was an incredible light bulb moment linking not just the
Speaker 1: fact that like kataveric poisoning and pupil fever were the
Speaker 1: same thing, but that kadaveric material introduced into the body
Speaker 1: of someone who had just given birth, that is what
Speaker 1: led to pupil fever.
Speaker 2: Yeah, and that was on the hands of the students
Speaker 2: and the residents and the physis. Yeah. Yeah.
Speaker 1: And as he later you know, learned and talked about,
Speaker 1: it wasn't just particles from cadavers. It was also like
Speaker 1: he noticed if someone came in with an infection on
Speaker 1: their knee or on their hand or something like that,
Speaker 1: like that could also be a way to introduce an
Speaker 1: outbreak of pupil fever.
Speaker 2: Okay, yeah, that makes sense.
Speaker 1: But this so, this this moment where he was able
Speaker 1: to link this material to pupil fever, like you know,
Speaker 1: the bits of cadavers to pupil fever. It also led
Speaker 1: him to come up with a very simple solution for
Speaker 1: preventing the disease, because if you read the hands, the
Speaker 1: contaminated hands or instruments of the cadaveric material, you would
Speaker 1: prevent blood poisoning. Yeah, wash your hands, Wash your hands,
Speaker 1: like and I can't. I can't emphasize enough how it
Speaker 1: was really in the mornings, whenever you had a spare chance,
Speaker 1: you cut away, you do autopsies.
Speaker 2: You're down in the lab, and then.
Speaker 1: Just wipe your hands on your coat, and you bring
Speaker 1: the instruments that you were using upstairs, not cleaned nothing,
Speaker 1: and you could see, like some of us observed that
Speaker 1: during holidays, for instance, or during the summer, the rates
Speaker 1: of pupil fever would decline because students weren't there because
Speaker 1: because really nice outside and they were spending more time
Speaker 1: not in the autopsy lab but hanging out. I yeah,
Speaker 1: but like this is still pre germ theory. So how
Speaker 1: do you what's like the concept of contamination? And I
Speaker 1: think it's it's really fascinating because like, of course, it
Speaker 1: should come as no surprise that cadavers don't smell that great,
Speaker 1: and so measures had been taken before to control the
Speaker 1: smell so that physicians and students could work without the
Speaker 1: whrror roble. Odor and chloride solutions were commonly used for this,
Speaker 1: and so some of ice figured that hey, if this stuff,
Speaker 1: this chloride stuff gets rid of the bad smell, maybe
Speaker 1: it gets rid of the bad stuff itself, and so
Speaker 1: he placed a bowl of diluted chloride solution outside of
Speaker 1: the first division and made every person who would be
Speaker 1: treating someone wash their hands in it and also do
Speaker 1: regular hand washing. And then later he was forced to
Speaker 1: switch to chloride of line because the Kline, the head
Speaker 1: of Obstetrics, was really annoyed at how much money he
Speaker 1: was spending some of Ice was spending, and within a
Speaker 1: few weeks of some of Ice implementing this hand washing solution,
Speaker 1: the effect was like immediate. The mortality rate dropped from
Speaker 1: where it was around seven to eight percent. But also
Speaker 1: there seems to be like Klein might have doctored his
Speaker 1: records quite a bit to three percent, and that was
Speaker 1: close to that of the second division, where just the
Speaker 1: midwives were and after a month of the practice, it
Speaker 1: dropped down to one point two percent, with the second
Speaker 1: division clocking in at one point three percent, where hand
Speaker 1: washing had also been instituted.
Speaker 2: Wow.
Speaker 1: The only other change that had been made besides the
Speaker 1: hand washing during this time was a new ventilation system.
Speaker 1: So guess what Kleine, the head of the unit, felt
Speaker 1: was responsible for the drop in deaths.
Speaker 2: Obviously the new ventilation.
Speaker 1: Yeah, Klein was a member of the old guard at
Speaker 1: the hospital who believed that new ideas were dangerous, like
Speaker 1: he tried to get a professor kicked out for using
Speaker 1: a stethoscope, which were new at the time, and that
Speaker 1: you shouldn't ask why things were the way they were,
Speaker 1: they just were. You just had to accept that. And
Speaker 1: on top of this, Semmelweiss was foreign. He was from Hungary,
Speaker 1: and so his Hungarian tinged accent made him a target
Speaker 1: for the xenophobic and superior cline. And then came the
Speaker 1: Revolutions of eighteen forty eight, which made Semmelweiss an even
Speaker 1: you know, further scary freethinking liberal because he participated in
Speaker 1: these revolutions of eighteen forty eight. But this, all of
Speaker 1: this like resistance that he faced within his own department,
Speaker 1: some of us just kept at it. He was like
Speaker 1: evangelical about his hand washing doctrine. Yeah, and the incidents
Speaker 1: and mortality rates of pupil fever continued to fall, and
Speaker 1: he became like on fire with this knowledge that this
Speaker 1: practice had the potential to change the world for the better.
Speaker 1: And he as a result of this, maybe his personality
Speaker 1: seems to have changed a bit from being lighthearted and
Speaker 1: friendly and popular as a young student to sarcastic suspicious contempt,
Speaker 1: just how later accounts describe him. If a case of
Speaker 1: childhood fever popped up, for instance, he played detective to
Speaker 1: pinpoint who had lapsed, and then he would chew them
Speaker 1: out publicly. His identity began to be wrapped up in
Speaker 1: this so called Someemolvis doctrine, and a rejection of the
Speaker 1: doctrine meant a rejection of him. At the end of
Speaker 1: his two year assistantship, he applied for renewal, which was
Speaker 1: really a formality because they were always granted decline denied.
Speaker 1: He denied him re renewal. Wow, And so suddenly Somemolweiss
Speaker 1: found himself not only without a job, but also without
Speaker 1: any ability to institute his life saving doctrine, and he
Speaker 1: was devastated. His professor friends, who were part of the
Speaker 1: new school at the hospital, urged him to present his findings.
Speaker 1: But then some Ofvis met with a little more difficulty
Speaker 1: because Klein had barred access to the division's records and
Speaker 1: he wouldn't let some Alvis have them. But fortunately some
Speaker 1: Alvis had kept some of his own, and he finally
Speaker 1: agreed to speak publicly about his work in eighteen fifty,
Speaker 1: which is three years after first developing this hand washing doctrine.
Speaker 1: His lectures were largely met with success, although there was
Speaker 1: some debate, especially from doctors who refuse to believe that
Speaker 1: they could be the cause of such widespread disease and death.
Speaker 1: But Someolvis knew that feeling. He felt horribly guilty for
Speaker 1: the role that he had once played. I'll read another
Speaker 1: quote from him. Because of my convictions, I must here
Speaker 1: confess that God only knows the number of patients who
Speaker 1: have gone to their graves prematurely by my fault. I
Speaker 1: handled cadavers extensively, as painful and depressing. Indeed, as such
Speaker 1: an acknowledgment is still the remedy does not lie in concealment,
Speaker 1: and this misfortune should not persist forever, for the truth
Speaker 1: must be known to all concerned. And it just seemed
Speaker 1: like so many of the doctors couldn't look that, they
Speaker 1: couldn't even consider that possibility because it is horrifying to
Speaker 1: think about.
Speaker 2: Right, because then it's it's you, you, You have done this, right,
Speaker 2: like yeah, to countless humans, Yeah, and their families and
Speaker 2: their babies, and.
Speaker 1: Right, yeah, but it seems even more difficult to imagine
Speaker 1: not considering that, like not trying this out, Like what's
Speaker 1: the harm?
Speaker 2: It's a lot. It's also it's just so interesting because
Speaker 2: like you know, hindsight twenty twenty whatever, like it's so
Speaker 2: painfully obvious it is when you look back on it.
Speaker 2: But and so it's almost difficult to put yourself in
Speaker 2: that mindset of you know, right, how could you?
Speaker 1: Which is well, which is why, like I had thought
Speaker 1: a lot during this research about how it's so easy
Speaker 1: to fall into the trap of we know everything, and yeah,
Speaker 1: there are a few things left to be uncovered, but like,
Speaker 1: huh uh, there are going to be incredibly huge paradigm
Speaker 1: shifts right or whatever in the future. We're like, how
Speaker 1: how did we not see it? Or just things that
Speaker 1: like you can't even like how do you even predict
Speaker 1: what the next paradigm shift might be in medicine or ecology,
Speaker 1: Like we just don't know because that's not the way
Speaker 1: that we're trained to investigate problems. That's just interesting. But anyway,
Speaker 1: besides the you know, forced denial of these doctors and
Speaker 1: their the guilt that they may have felt, another thing
Speaker 1: that kept the Semilvis doctrine from gaining tracktion. More broadly,
Speaker 1: was the fact that he wouldn't publish. He hated writing.
Speaker 2: I hated it, oh goodness.
Speaker 1: And so a few of his professor friends and some
Speaker 1: former students tried to write it up, but they lacked
Speaker 1: all the data and they couldn't capture some of Wes's
Speaker 1: thought process that led him to his conclusions. So it
Speaker 1: was more just like, hey, here are results that we found.
Speaker 1: That's it. And so he continued applying for jobs where
Speaker 1: he could put it into practice. And when the job
Speaker 1: that he had finally been given, which he was actually
Speaker 1: first denied and it was a teaching position in Midwiffery,
Speaker 1: it was changed at the last minute, and he took
Speaker 1: it to be a personal affront, and you know it
Speaker 1: was basically he was like, you know, my colleagues refused
Speaker 1: to see my great accomplishments. I'm surrounded by enemies. I'm
Speaker 1: being told to publish despite the evidence being so clear,
Speaker 1: like you shouldn't need a thorough paper, it should be obvious.
Speaker 1: How do you not see it? And then now this,
Speaker 1: like the disrespect he felt from this job thing was
Speaker 1: the final straw. So he left Vienna he packed up
Speaker 1: and left to return to Budapest without so much as
Speaker 1: a goodbye to any of the friends who had supported
Speaker 1: him and championed his cause for so long.
Speaker 2: Wow.
Speaker 1: Back in Budapest, some Ofvice seemed to be at least
Speaker 1: a little bit reinvigorated when he learned of an outbreak
Speaker 1: of pupil fever at the hospital nearby. And so he
Speaker 1: visited the hospital and found that the obstetric ward was
Speaker 1: under the management of the chief of surgery, who was
Speaker 1: also responsible for doing all forensic autopsies, and so Someolvis
Speaker 1: was like, Okay, I will be the unsalaried director of
Speaker 1: this lying in ward at the hospital. Wow, And that
Speaker 1: came through. He was given that position, and he immediately
Speaker 1: implemented the same hand washing practices and saw a similar
Speaker 1: immediate drop in pupil fever cases and deaths. But his
Speaker 1: constant watchfulness and tendency to play detective when someone died
Speaker 1: of pupil fever didn't exactly make him popular among his
Speaker 1: employees and students, many of which went to great length
Speaker 1: to avoid washing their hands just to spite him. I know,
Speaker 1: I hate It's so difficult. The story is so wrenching
Speaker 1: because you're just like w and then he made enemies
Speaker 1: with the hospital administration, Like the sheets weren't being washed
Speaker 1: frequently enough in his eyes, so he gathered up a
Speaker 1: bunch of dirty sheets and dropped them into the office
Speaker 1: of the hospital administrator, and so the hospital administrator then
Speaker 1: it started immediately looking for ways to fire him. His
Speaker 1: personality didn't really endear him to people around him, and
Speaker 1: he seemed to leave enemies.
Speaker 2: Yeah, a lot of places. That's a real bummer.
Speaker 1: He made enemies more easily than he made friends, for sure.
Speaker 1: But I eventually he did reach a sort of like
Speaker 1: point where he was like, you know what, this is
Speaker 1: too many years of being met with ridicule and scorn,
Speaker 1: and he finally decided to sit down and write. Finally, finally,
Speaker 1: and so in eighteen sixty one, just fourteen years after
Speaker 1: he first developed the hand washing technique, he published his
Speaker 1: book The Eediology, the Concept and the Prophylaxis of childbed Fever. Unfortunately,
Speaker 1: it turned out to be densely written, difficult to follow,
Speaker 1: and he included many personal attacks on doctors who had
Speaker 1: rejected his findings in the past.
Speaker 2: He's killing me, I know, I know's killing me.
Speaker 1: He's his own worst enemy. So his book did little
Speaker 1: to increase acceptance of his doctrine, although I will say
Speaker 1: it had picked up a couple of supporters in some
Speaker 1: places who wrote grateful, joyous letters to someviss But maybe
Speaker 1: the saddest part of this story is that Somelvis himself
Speaker 1: wouldn't live to see his doctrine vindicated. In the early
Speaker 1: eighteen sixties, it became clear to those around him that
Speaker 1: his mental health had begun to decline. His moods were
Speaker 1: becoming increasingly erratic, and he had trouble taking care of
Speaker 1: himself or performing his job. There are retrospective diagnoses ranging
Speaker 1: from tertiary syphilis to Alzheimer's pre senile dementia, but in
Speaker 1: any case, by the summer of eighteen sixty five, his
Speaker 1: wife realized that she could not take care of him
Speaker 1: by herself, so she took him to a state run
Speaker 1: insane asylum, as they were called. Then two weeks after
Speaker 1: he walked through the doors, he was dead. The cause
Speaker 1: of death was determined to be a septic infection. Oh
Speaker 1: I know, much like the ones that caused pupil fever.
Speaker 2: Oh my gracious.
Speaker 1: However, it was not from a wound during a gynecological surgery,
Speaker 1: as the facility's officials told his wife, but rather from
Speaker 1: an infection following violent beatings by the asylum staff while
Speaker 1: trying to restrain him.
Speaker 2: Oh my god, I know it is horrific. It is Yeah.
Speaker 1: What the year that Semmelweiss died, a guy by the
Speaker 1: name of Joseph Lister came across a series of papers
Speaker 1: by Louis Pasture and began to study under the microscope
Speaker 1: the puffs from amputation wounds. He realized that the microbes
Speaker 1: he was observing may be causing the systemic disease that
Speaker 1: he was seeing, and that spraying them with carbolic acid
Speaker 1: could prevent it. After he did this, mortality dropped by
Speaker 1: almost two thirds, and he published a description of his
Speaker 1: new technique, which he called antisepsis. With this recognition of
Speaker 1: the germ theory of contaminated wounds came the realization among
Speaker 1: the medical community that Semmelweiss was right, and starting in
Speaker 1: the late eighteen hundreds, his story as a martyr to
Speaker 1: medicine was being rewritten. Wow, what prevented the semolvis doctrine?
Speaker 1: Which seems so clear in retrospect? What prevented it? From
Speaker 1: being readily adopted. I mean, could be personalities, stuff, could
Speaker 1: be that he didn't write about it. But I think
Speaker 1: it's kind of the same thing that it always is. Like,
Speaker 1: this isn't the first. This might be one of the most,
Speaker 1: like heart wrenching stories, but it's not the first time
Speaker 1: we've seen similar things. No, it always takes what twenty
Speaker 1: years to get a new idea into textbooks, and then
Speaker 1: when it's outdated, twenty years for it to be removed. Yeah,
Speaker 1: and so in the eighteen sixties and the eighteen seventies,
Speaker 1: about twenty years after someblws first proposed his doctrine, the
Speaker 1: causative agents of pupil fever began to be characterized, and
Speaker 1: the next big milestone came in nineteen thirty five with
Speaker 1: the development of the sulfonamide Prontazzle, which greatly reduced mortality
Speaker 1: due to pupil fever. The link between scarlet fever arisepalus
Speaker 1: and pupil fever was recognized, and steady increases in hygiene
Speaker 1: continued to drive down the rates.
Speaker 2: Of the disease.
Speaker 1: But Aaron, this is not a disease of the past
Speaker 1: by any means. Can you bring us up to speed?
Speaker 1: On what's going on with pupil fever today.
Speaker 3: I'd love to let's take a quick break first, worldwide.
Speaker 2: This, by the way, it's kind of just a depressing story,
Speaker 2: so I'm just going to leave it out there. Great,
Speaker 2: maybe we'll find a way to find some light in
Speaker 2: this tunnel. But worldwide, bacterial infections during labor and the
Speaker 2: immediate postpartum period, so MPIs account for an estimated ten
Speaker 2: percent of the global burden of maternal deaths.
Speaker 1: Oh my god.
Speaker 2: So of all maternal deaths, about ten percent are associated
Speaker 2: with bacterial infections. The World Health Organization, the most recent
Speaker 2: data that they have on their site is from twenty fifteen.
Speaker 2: They estimate that there are about seventy five thousand deaths
Speaker 2: every year due to these infections.
Speaker 1: Besides, wow, yeah, that's a lot.
Speaker 2: It is, And the thing is that that's not the
Speaker 2: whole story. It's not just death. These infections also carry
Speaker 2: with them the potential for long term disability, including chronic
Speaker 2: pelvic pain, secondary infertility due to infection. And on top
Speaker 2: of that, like you kind of mentioned, Aaron, maternal infections
Speaker 2: can have a big impact on newborn mortality as well.
Speaker 2: So that same World Health Organization report from twenty fifteen
Speaker 2: estimates that over one million, one million newborn deaths are
Speaker 2: associated with maternal infections what every year. That's what it
Speaker 2: said in twenty fifteen. I was I am still shocked
Speaker 2: by that number. Oh my gosh. Yeah, while today, overall
Speaker 2: rates of maternal infections are still like, even though these
Speaker 2: numbers are shocking, they're drastically drastically lower than in the past.
Speaker 1: I mean, eight hundred and eighty one per ten thousand.
Speaker 2: Yeah, and that's just deaths, right, that's not even that
Speaker 2: that's just death that's not incidents. Yeah. But however, even
Speaker 2: though we've come a really long way, there's still some
Speaker 2: huge disproportionate impacts, not only between countries, so high income
Speaker 2: countries have drastically lower infection and maternal death rates compared
Speaker 2: to lower income countries. But even within higher income countries
Speaker 2: like the US, there's a huge disparity in terms of race.
Speaker 2: So in the US in general, we're not great when
Speaker 2: it comes to maternal outcomes. We can look not only
Speaker 2: at deaths, but severe morbidity, so like serious complications as
Speaker 2: well as mortality. Rates are very high in the US
Speaker 2: compared to a lot of other high income countries, but
Speaker 2: the racial and ethnic disparities in the US are also atrocious.
Speaker 2: So in this country, black women are three to four
Speaker 2: times more likely to die from pregnancy related causes than
Speaker 2: white women three to four times.
Speaker 1: Wow.
Speaker 2: So I kind of just want to read you, like
Speaker 2: the overall numbers of pregnancy related mortality in the US,
Speaker 2: and this is averaged from twenty fourteen to twenty seventeen.
Speaker 2: In the US forty one deaths per one hundred thousand
Speaker 2: live births, which is the standard metric of measure, forty
Speaker 2: one per one hundred thousand for non Hispanic Black women,
Speaker 2: twenty eight point three deaths per one hundred thousand live
Speaker 2: births for non Hispanic Native American and Alaskan Native women,
Speaker 2: thirteen point eight deaths per one hundred thousand births for
Speaker 2: Asian or Pacific Islander women, thirteen point four deaths for
Speaker 2: non Hispanic white women, and eleven point six deaths per
Speaker 2: one hundred thousand live births for Hispanic or Latino women.
Speaker 1: Those are very different numbers.
Speaker 2: They're very different. I mean, I would say all of
Speaker 2: them are too high, yes, but they're very very different.
Speaker 2: So just sit with that for a minute. Yeah, because,
Speaker 2: like I said, it's not just death that's the worst
Speaker 2: possible outcome. It's estimated that in the US, for every
Speaker 2: maternal death, there are one hundred other severe events, whether
Speaker 2: that means infection or severe hemorrhage or emergency surgery that
Speaker 2: takes place. So that means that over sixty thousand people
Speaker 2: every year in the US are having these severe, likely
Speaker 2: very traumatizing complications that in so many cases, are preventable.
Speaker 2: And it's not just the US. In the UK, if
Speaker 2: you look specifically, even just specifically at maternal sepsist deaths,
Speaker 2: for every one maternal sepsist death, there are fifty other
Speaker 2: pregnant people that have life threatening infections. Wow. If we
Speaker 2: want to look at disparities across the globe, we do,
Speaker 2: of course we do. The World Health Organization estimates that
Speaker 2: eight hundred and ten people, So this is looking more
Speaker 2: broadly than just maternal infections, but eight hundred and ten
Speaker 2: people die every day from preventable causes related to childbirth
Speaker 2: and pregnancy.
Speaker 1: Eight hundred and ten every day.
Speaker 2: Eight hundred and ten every day. That's two hundred and
Speaker 2: ninety five thousand lives lost every year in low income
Speaker 2: countries that maternal mortality ratio the number of maternal deaths
Speaker 2: per one hundred thousand live births. You said, Arin, sometimes
Speaker 2: it was like eight hundred in like the seventeen hundreds. Today,
Speaker 2: in low income countries it's four hundred and sixty two.
Speaker 1: Four hundred and sixty two deaths per ten thousand, per
Speaker 1: one hundred thousand, oh per one hundred thousand. Yeah, wow, Yeah,
Speaker 1: some avice would be appalled.
Speaker 2: Yep. In high income countries it's eleven on average. Though
Speaker 2: in the US as of twenty seventeen, on average, seventeen three.
Speaker 2: And we know that those averages don't tell the whole.
Speaker 1: Story, right, So what's going on?
Speaker 2: I mean, it's such a good question, Aaron, because the
Speaker 2: other thing is it's not getting better. It's getting worse,
Speaker 2: at least here in the US. Worldwide, from two thousand
Speaker 2: to twenty seventeen, the maternal mortality ratio has actually decreased
Speaker 2: by like thirty eight percent. So worldwide, the trend is
Speaker 2: going down, okay, But in the US specifically, our maternal
Speaker 2: mortality ratio has been increasing year after year.
Speaker 1: What's happening?
Speaker 2: Yeah, I don't it's a great question. I don't have
Speaker 2: an answer for you.
Speaker 1: I mean, I guess it's really difficult because, like, because
Speaker 1: there are so many different causes. Prevention is not a
Speaker 1: one size fits all type of thing. It's a lot
Speaker 1: of different things you have to do.
Speaker 2: And it's definitely not I want to just be clear,
Speaker 2: this is not all infection related. In fact, infection is
Speaker 2: a ten percent or less contributor at least when we
Speaker 2: look at deaths overall. But that doesn't change the fact
Speaker 2: that things like hemorrhage, pre acclamsia, eclampsia, cardiac issues worldwide,
Speaker 2: unsafe abortion practice is another major contributor to pregnancy and
Speaker 2: childbirth related deaths. So we have a lot of work
Speaker 2: that needs to be done still, and I think, like someovice,
Speaker 2: we need to start by figuring out what the root
Speaker 2: cause of a lot of these problems are so that
Speaker 2: we can actually fix them. Yeah, but you know, racism
Speaker 2: is a big part of it here, and for sure
Speaker 2: there's a lot of yep.
Speaker 1: Yeah, it's a multi factorial problem.
Speaker 2: Sure is Gosh, I wish I had something more uplifting
Speaker 2: to end it on. Sources.
Speaker 1: Yeah, I was like, I can't really think of anything sources. Yeah,
Speaker 1: so I relied on primarily I have some articles, but
Speaker 1: primarily I relied on two books, both of which I
Speaker 1: highly enjoyed. One is called The Doctor's Plague by Sherwin Newland,
Speaker 1: and that is a nonfiction book mostly about some device,
Speaker 1: but also more broadly about pupil fever. And then another
Speaker 1: is a fiction book which was really fun. I get
Speaker 1: to read fiction for not that often for the podcast,
Speaker 1: and it's called The Cry and the Covenant by Morton
Speaker 1: Thompson and it's out of print.
Speaker 2: Actually, oh wow.
Speaker 1: I had to give it at library.
Speaker 2: Okay, libraries, I of course, because this was kind of
Speaker 2: a mess of a biology. There's a lot of different
Speaker 2: papers that you can read, some specific to group a steps,
Speaker 2: some just looking at, you know, maternal peripartum infection. Overall,
Speaker 2: I will say that, you know, to add a slightly
Speaker 2: happy ending. The CDC has a number of new campaigns
Speaker 2: specifically to try and address a lot of this, and
Speaker 2: a lot of it is just paying attention to the
Speaker 2: person who was pregnant and actually listening to the symptoms
Speaker 2: that they're having. One of their big campaigns is called
Speaker 2: Hear Her. So I yeah, because I mean that's a
Speaker 2: big that's a big part of it, right, is not
Speaker 2: not paying attention to the person who's experiencing what they
Speaker 2: say they're experiencing. Yeah, and we've seen that time and again.
Speaker 1: It's a little bit frustrating that it needs to be
Speaker 1: a public health campaign that like this is not something
Speaker 1: that is inherently taught or learned. But yeah, yeah, so
Speaker 1: we will post the all of our sources on our website,
Speaker 1: This podcast will kill you dot com yep.
Speaker 2: Thank you to Bloodmobile for providing the music for this
Speaker 2: episode and every one of our episodes.
Speaker 1: And thank you to the Exactly Right Network, of whom
Speaker 1: we are a proud member, and thank.
Speaker 2: You to you listeners. This was I mean, it was
Speaker 2: a very interesting journey, very depressing ending, but thanks for
Speaker 2: sticking with us.
Speaker 1: Yeah, thank you. And I guess we've been just stealing
Speaker 1: this line from some ofvis all along, but I feel
Speaker 1: I feel very excited to sign off this episode with
Speaker 1: a wash your hands.
Speaker 2: You filthy animals. Bum bu
Speaker 1: Bumbo ou