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.’’