12 May

During the second half of the eighteenth century, the population of Europe began a steep increase, unprecedented in extent, duration, and per- manence. The eighteenth century, a period of particular interest to philosophers, political scientists, demographers, and historians of medi- cine, has been called the age of enlightenment and revolution. Within this context of social and intellectual change, medical men first made significant inroads into the traditionally female domain of childbirth. Epidemics of the previously rare and sporadic disease known as puer- peral or childbed fever apparently became more common during this period, especially in the lying-in hospitals that accommodated poor women in cities and towns throughout Europe. The death of new mothers was of special interest to social reformers and physicians like Johann Peter Frank (1745–1821), who believed that the greatest wealth of the state should be measured in terms of the number, health, and pro- ductivity of its subjects. The state could not afford to lose its peasants, workers, sailors, and soldiers to disease. It could not, therefore, afford to lose fertile women through diseases associated with childbirth. In an ideal state, the health of mothers would be properly valued so that they could continue to produce healthy new workers. Frank believed that each nation should establish a Supreme Medical Board to collect and analyze lists of births and deaths from each village, town, district, and province in order to discover the local causes of excessive mortality, especially the factors responsible for the deaths of pregnant women, women in childbirth, postpartum women, infants, and children. It has been a tenet of historical demography and of many feminist scholars that there must have been a causal relationship between the apparent rise of epidemic puerperal fever and the development of a new medically oriented obstetrics, characterized by the ‘‘man midwife’’ and the lying-in ward of the urban hospital. Puerperal fever, or childbed fever, is generally and nonspecifically defined as a severe, generalized

infection  that  occurs  within  11 days  of childbirth.  In  addition  to  the raging fever and pus emanating from the birth canal, victims often developed painful abscesses in the abdominal  cavity and chest, and fatal septicemia. The reason for the vulnerability  of puerperal  women to life- threatening infections  had  been  recognized  by the  great  seventeenth- century  physician  and  physiologist  William Harvey  (1578–1657): after childbirth  the site of placental  detachment constituted a large internal wound.  Except  for  burns,  which  often  become  infected,  wounds  are rarely  very large.  Although  the  term  puerperal  fever implies a causal link to childbirth,  the definition provides no specific information about the  etiology  of the  disease.  Not  all postpartum fevers and  infections should  be called puerperal  fever, a condition  now typically attributed to  Group   A  hemolytic  streptococcus.   Streptococcal   disease  can  also appear as scarlet fever, septic sore throat, erysipelas, and rheumatic fever. This makes the task of tracing the history of childbed fever and its pos- sible causal connection  to changes in patterns  of fertility, use of lying-in hospitals,  and the evolution  of gynecology and obstetrics  very difficult.

In  addition  to  its place within  the  larger  history  of women  and medicine  and  the  professionalization  of  the  healing  arts,  the  battle against  puerperal  fever can be seen as part  of the story of the develop- ment of antiseptic  surgery,  because  puerperal  fever is essentially equi- valent  to wound  infection.  Unfortunately, although  an understanding of the etiology, contagiousness,  and prevention  of puerperal  fever pre- ceded the development of antiseptic surgery, acceptance of the principles of asepsis and antisepsis in the nineteenth century did not lead to the uni- versal adoption of practices that could have prevented most cases of puer- peral fever. Even in the 1930s, before the introduction of sulfanilamide, puerperal  fever remained the most important illness threatening parturi- ent women. In the maternity  wards of even the best American  teaching hospitals,  it was not  unusual  for at  least 20 percent  of the women  to develop  fevers after  giving birth  and  for  patients  to  die of puerperal infections. Once puerperal fever set in, there was little that medical inter- vention could accomplish, although doctors confidently administered mercurochrome via vaginal instillation during labor and intravenously in infected  patients,  along  with  other  useless and  dangerous  treatments, such as intramuscular injections  of cow’s milk, intravenous injections of alcohol, blood transfusions, and hysterectomy.

Case histories in the Hippocratic texts indicate that puerperal infection  was rare,  but  not  unknown  in ancient  Greece.  The transfor- mation of a rare, private tragedy into a well known, frequent,  and much feared  epidemic disease of lying-in hospitals  apparently took  place in the eighteenth  century.  Epidemics occurred  at the Hoˆ tel Dieu in Paris and  the newly established  lying-in hospitals  of Great  Britain.  Several doctors suggested that puerperal fever might be contagious, but Alexander Gordon (1752–1799) of Aberdeen  and  Charles  White  (1728–1813) of

Manchester were probably  the first to realize that  doctors  could carry the fever from patient  to patient.  White boasted  that  he had never lost a patient  to puerperal  fever, while colleagues who performed  autopsies often  lost several patients  in succession.

It was the relationship  between autopsies  and childbed fever that led the American  poet  and  physician  Oliver Wendell Holmes  and  the Hungarian obstetrician Ignaz Philipp Semmelweis to their understand- ing of the contagiousness of the disease. Not all historians  award major honors  to  Oliver  Wendell  Holmes  for  his essays on  puerperal  fever. Physician  and  educator  Sir  William  Osler  (1849–1919), for  example, praised  Holmes  for his logical and  convincing  arguments,  but  did not believe that  Holmes  had  actually  discovered the cause and  prevention of  puerperal   fever.  Osler  agreed  with  British  clergyman  and  satirist Sydney Smith  (1771–1845) that  credit  for  a discovery  did  not  belong to the first man to say something,  but to the one who says it ‘‘so long, so loudly, and so clearly that  he compels men to hear him.’’

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