The Mystery of Childbed Fever: a 19th Century Understanding of Puerperal Fever, William Potts Dewees
By Madeline Brown
An accelerated pulse, extreme abdominal pain, bloating, teeth-chattering chills, weakness, and decreased milk production were all signs of a mother stricken with childbed fever [1]. In the nineteenth century, it was often fatal. The first American epidemics of childbed fever occurred in Pennsylvania around 1817 and 1818 [2]. The mid-nineteenth century saw outbreaks in Vermont, New Hampshire, Ohio, New York, Connecticut, and Missouri, where up to thirty lives were lost at a time [3]. William Potts Dewees (1768-1841), was a well-known obstetrician and physician, and he wrote many textbooks on female anatomy and illnesses in both women and children, including an edition in 1831 that attempted to explain the disease that took many mothers’ lives, particularly in Europe. The Parisian Hotel Dieu saw numerous outbreaks such as the 1664 [4] and 1746 [5] epidemics that caught the attention of many practitioners. Dewees wrote that childbed fever came about in the “most whimsical manner” [6], cropping up no matter the weather conditions or the place.
The deadly infection inspired numerous theories concerning its nature and origin. Dewees described it as the “inflammation… of the peritoneum” that came within days after delivery [7]. The peritoneum is the membrane surrounding the abdominal organs to hold them in place and protect them against pathogens [8]. Dewees, while he did not settle on a cause for puerperal fever, thoroughly compiled the studies of other physicians and midwives who had encountered it. Each practitioner had their own theories about the ultimate culprit; one believed it was due to cold weather or moisture in the air, while others speculated that difficult labor caused the quick death. Dewees rejected these possibilities since the fever occurred year-round, and there were cases even after easy deliveries [9]. He also believed some practitioners mistook childbed fever for other diseases or gave misleading names for the same disease, such as general inflammatory disease; putrid fever; or even typhoid, due to “feeble or inefficient practice, or to one decidedly wrong” [10]. Other early nineteenth-century theories of the cause of puerperal fever included poor nutrition, breeched modesty from having examinations by male doctors, and guilt from having children out of wedlock [11]. Emotional distress could be lethal for middle-class white women who had a reputation for being fragile and the leaders of morality. Other physicians subscribed to the idea that women were suffering from blocked intestines caused by an enlarged uterus, and prescribed purgatives and enemas [12]. Another theory was that the breast milk went to the abdominal cavity, since milk production was significantly less than usual in those suffering from the disease [13]. Dewees detailed many different treatments for puerperal fever that were in common use at the time: bleeding, purging, blisters, fomentations or hydrotherapy, spirit of turpentine, and mercury frictions. He also mentioned the work of Dr. Gordon and Mr. Hey, who gave a mixture of calomel and jalap to women the day after the delivery, although it was not very effective [14].
Miasma theory was a widely accepted explanation for disease before the advent of germ theory. Strong odors, filth, pollution, and other environmental factors were believed to be the main causes of illnesses. Invisible particles from “swamps, sloughs, or open sewers” could infect the air and lead to “zymotic diseases” in all who were unfortunate enough to live in unclean environments [15]. Clean spaces and linens, ventilation, and even a change of clothes for physicians were recommended [16]. In 1848, Dr. Ignaz Semmelweis introduced the practice of hand washing in his clinic, using water and chloride of lime, in his fight against puerperal fever. It limited cross contamination between patients, and protected the physicians, too. However, handwashing did not spread very far in the medical field until later. The very idea of the physician himself spreading deadly infection from patient to patient was offensive, taken as an attack on their practice and skills.
Semmelweis was not the only physician to link puerperal fever and erysipelas to the attending physicians as the cause for the mysterious deaths. Erysipelas is a Group A strep disease that results from the introduction of bacteria to open wounds [17]. As early as 1795, Gordon of Aberdeen published research stating that doctors who attended both erysipelas patients and those in labor were leaving “puerperal fever victims in their wake” [18]. Oliver Wendell Holmes claimed the same thing in his 1843 article “The Contagiousness of Puerperal Fever” [19]. And James Simpson released research in 1850 comparing the symptoms of erysipelas to puerperal fever: red marks on the skin, chills, and a “stupor, and confusion as… the “toxin” entered [blood] circulation” [20]. Physicians inadvertently helped spread the disease as they moved from call to call, treating diseases and delivering babies with the same tools. After Semmelweis, Joseph Lister picked up the mantle, and introduced hand washing and disinfectants which have helped protect patients and physicians.
Thanks to the germ theory of disease in the end of the nineteenth-century, physicians could better understand bacterial infections like puerperal fever. Leaders like Louis Pasteur and Robert Koch led the field with their research on microorganisms and the development of clinical solutions to give humans protection against life-threatening diseases. Antibiotics, discovered in the 20th century, are invaluable in the treatment of infections such as puerperal fever to ensure that postpartum infection is no longer a death sentence.
(This post was written for the course HIST H364/H546 The History of Medicine and Public Health. Instructor: Elizabeth Nelson, School of Liberal Arts, Indiana University, Indianapolis).
References:
[1] William P. Dewees, A Treatise on the Diseases of Females, 3rd ed (Philadelphia: Carey and Lea, 1831), 370, 401.
[2] Ibid., 375.
[3] Gail Pat Parsons, “Puerperal Fever, Anticontagionists, and Miasmatic Infection, 1840–1860: Toward a New History of Puerperal Fever in Antebellum America,” Journal of the History of Medicine and Allied Sciences 52, no. 4 (October 1997): 424, https://www.jstor.org/stable/24624220.
[4] Theodore G. Obenchain, “Puerperal Fever Theories,” Genius Belabored: Childbed Fever and the Tragic Life of Ignaz Semmelweis (Tuscaloosa: The University of Alabama Press, 2016), 75, https://iucat.iu.edu/catalog/15650686.
[5] Dewees, A Treatise on the Diseases of Females, 3rd ed, 373.
[6] Ibid., 376.
[7] Dewees, A Treatise on the Diseases of Females, 3rd ed, 370.
[8] Cleveland Clinic, “Peritoneum,” accessed September 15, 2023, https://my.clevelandclinic.org/health/body/22894-peritoneum.
[9] Dewees, A Treatise on the Diseases of Females, 3rd ed, 375-376.
[10] Ibid, 394-395.
[11] Obenchain, Genius Belabored, 71.
[12] Ibid., 77.
[13] Ibid., 76.
[14] William P. Dewees, A Treatise on the Diseases of Females, 3rd ed, 379.
[15] Obenchain, Genius Belabored ,74-75.
[16] Ibid., 81.
[17] Advanced Dermatology & Skin Cancer Center, “Erysipelas,” accessed December 12, 2023, https://www.advancedderm.net/erysipelas/#:~:text=Like other forms of cellulitis, insect bite, or scratch.
[18] Ibid., 77.
[19] Ibid., 81.
[20] Ibid.