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The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory

Published online by Cambridge University Press:  07 December 2011

Christine Hallett
Christine Hallett
Affiliation:
School of Nursing, Midwifery and Health Visiting, Coupland 3 Building, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK e-mail: Christine.Hallett@man.ac.uk
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Puerperal fever was a devastating disease. It affected women within the first three days after childbirth and progressed rapidly, causing acute symptoms of severe abdominal pain, fever and debility. Although it had been recognized from as early as the time of the Hippocratic corpus that women in childbed were prone to fevers, the distinct name, “puerperal fever” appears in the historical record only in the early eighteenth century.

Type
Articles
Information
Medical History , Volume 49 , Issue 1 , 01 January 2005 , pp. 1 - 28
Copyright
Copyright © The Author(s) 2005. Published by Cambridge University Press

References

1 The debate about when this term first emerged is presented by Irvine Loudon, The tragedy of childbed fever, Oxford University Press, 2000, p. 8.

2 Margaret DeLacy, ‘Puerperal fever in eighteenth-century Britain’, Bull. Hist. Med., 1989, 63 (4): 521–56; George W Lowis, ‘Epidemiology of puerperal fever: the contribution of Alexander Gordon’, Med. Hist., 1993, 37: 399–410; Loudon, op. cit., note 1 above, passim. See also Stanley A Seligman, ‘The lesser pestilence: non-epidemic puerperal fever’, Med. Hist., 1991, 35: 89–102.

3 Loudon, op. cit., note 1 above, pp. 1–13, 189–212; Group B streptococcus has also been implicated, see D I Lansing, W R Penman, and D J Davis, ‘Puerperal fever and the Group B beta haemolytic streptococcus’, Bull. Hist. Med., 1983, 57: 70–80; Seligman, op. cit., note 2 above, DeLacy, op. cit., note 2 above, pp. 526–9.

4 Loudon, op. cit., note 1 above; idem, Death in childbirth: an international study of maternal care and maternal mortality, 1800–1950, London, Clarendon Press, 1992; idem, ‘On maternal and infant mortality, 1900–1960’, Soc. Hist. Med., 1991, 4 (1): 29–73. See also, J S Lewis, In the family way: childbearing in the British aristocracy, 1760–1860, New Jersey, Rutgers University Press, 1986. For interesting comment, see also Angus McLaren, ‘The pleasures of procreation: traditional and biomedical theories of conception’, in W F Bynum and Roy Porter (eds), William Hunter and the eighteenth-century medical world, Cambridge University Press, 1985, pp. 323–41.

5 William Campbell, A treatise on the epidemic puerperal fever, Edinburgh, Bell and Bradfute, 1822, pp. 26–52. Eighteenth- and early-nineteenth-century descriptions of the symptoms and course of puerperal fever were usually minute and detailed. William Campbell was born in Scotland. He practised man-midwifery in Edinburgh, and was physician to the Edinburgh Infirmary during the 1820s. For other descriptions of the symptoms and progress of puerperal fever, see Thomas Denman, Essays on the puerperal fever and puerperal convulsions, London, printed for J Walter, 1768, pp. 8–10. There is a much more detailed description in Denman's later edition: idem, Essays on the puerperal fever, 2nd ed., London, printed by J Cooper for J Walter, 1773, pp. 9–12; Henry Manning, A treatise on female diseases, London, printed for R Baldwin, 1771, pp. 390–3; Nathaniel Hulme, A treatise on the puerperal fever, London, printed for T Cadell, 1772, pp. 1–19; William Butter, An account of puerperal fevers, London, T Payne, 1775, pp. 1–6; Charles White, A treatise on the management of pregnant and lying-in women, London, E and C Dilly, 1773, pp. 13–17; Philip Pitt Walsh, Practical observations on the puerperal fever London, for C Dilly (and others), 1787, pp. 1–10; John Clarke, An essay on the epidemic disease of lying-in women, London, J Johnson, 1788, pp. 12–22, 30–4; idem, Practical essays on the management of pregnancy and labour, London, J Johnson, 1793, pp. 123–35; Alexander Gordon, A treatise on the epidemic puerperal fever of Aberdeen, London, printed for G G and J Robinson, 1795, pp. 5–13; G E Mitchell, Inaugural essay, on the puerperal state of fever, Philadelphia, printed by John H Oswald, 1805, pp. 11–13; John Armstrong, Facts and observations relative to the fever commonly called puerperal, London, Longman, Hurst, Rees, Orme and Brown, 1814, pp. 1–12; Robert Gooch, Account of some of the most important diseases peculiar to women, London, Murray, 1829, pp. 1–2; John Alexander, Medical commentaries on puerperal fever, London, Longman, 1836, pp. 9–10; A C Baudelocque, Treatise on puerperal peritonitis, transl. G S Bedford, New York, Elliot and Palmer for Collins and Hannay, 1831, pp. 154–79.

6 See, for example, Campbell's discussion of the attempts of William Hunter to treat by various different methods: Campbell, op. cit., note 5 above, p. 14; on the symptoms and “character” of fevers more generally, see William Fordyce, A new inquiry into the causes, symptoms and cure of putrid and inflammatory fevers, London, printed for T Cadell, J Murray and W Davenhill, 1777, pp. 12–14; For an example of a particularly intractable case, see Samuel Cusack, A brief notice of the disease popularly termed puerperal fever, Edinburgh (extracted from the Edinb. med. surg. J., no. 98), 1829, pp. 26–7.

7 Loudon, op. cit., note 1 above, p. 190; Denman refers to puerperal fever as “very often fatal”, Denman, 1st ed., 1768, op. cit., note 5 above, p. 5. See also Manning, op. cit. note 5 above.

8 Clarke, Practical essays, op. cit., note 5 above, pp. 102–5. John Clarke was born in Wellingborough; he became a member of the Corporation of Surgeons and established a surgical practice in Chancery Lane. He lectured on midwifery at St Bartholomew's Hospital. He became MD in 1791 and Licentiate in Midwifery of the Royal College of Physicians in London in 1787. He was physician to the Lying-in Hospital in Store Street, and the Asylum for Female Orphans in the 1780s and 1790s.

9 Seligman, op. cit., note 2 above, p. 89; DeLacy, op. cit., note 2 above, p. 521. For a list of puerperal fever epidemics, see August Hirsch, Handbook of geographical and historical pathology, transl. Charles Creighton, London, New Sydenham Society, 1885, vol. 2, pp. 422–4. See also, Fleetwood Churchill (ed.), Essays on puerperal fever and other diseases peculiar to women, London, printed for the Sydenham Society, 1849, p. 6.

10 Campbell, op. cit., note 5 above, pp. 8, 12–13. Campbell refers to works by M Malouin and Jean Astruc. Moore appears also to have consulted this text, but in its second edition of 1718: G Moore, An enquiry into the pathology, causes, and treatment of puerperal fever, London, S Highley, 1836, p. 5. Mention is also make of this text in Alexander, op. cit., note 5 above, p. 3. See also Michael Ryan, A manual on midwifery, London, printed for Longman etc., 1828, p. 319. Loudon quotes the first edition of 1716, op. cit., note 1 above, p. 15.

11 John Mackintosh, A treatise on the disease termed puerperal fever, Edinburgh, W Blackwood, 1822, p. 5. John Mackintosh was born in Scotland and obtained his MD from Edinburgh University. He practised man-midwifery in Edinburgh, and was physician to the Edinburgh Infirmary during the 1820s.

12 Gordon, op. cit., note 5 above. Gordon was practising as a man-midwife in Aberdeen at the time he wrote this treatise. He was also physician to the Aberdeen Dispensary.

13 William Hey was practising as a man-midwife in Leeds during the second decade of the nineteenth century; John Armstrong was practising in Sunderland at around the same time. Both wrote treatises based on observations from their own practice: William Hey, A treatise on the puerperal fever, illustrated by cases, which occurred in Leeds and its vicinity in the years 1809–1812, London, Longman, Hurst, Rees, Orme and Brown 1815; Armstrong, op. cit., note 5 above.

14 Mackintosh, op. cit., note 11 above, pp. 1–5. Alexander refers to epidemics in Dublin in 1767, Edinburgh in 1773 and 1821–2, London in 1787–8, Leeds in 1809, Paris in 1829, Glasgow in 1819 and Manchester, where he himself was based, in 1828–9; Alexander, op. cit., note 5 above.

15 Although see the attempts at epidemiological analysis by DeLacy and Seligman, both op. cit., note 2 above.

16 See, for example, Charles White, An appendix to the second edition of Mr. White's treatise on the management of pregnant and lying-in women, London, printed for E and C Dilly, 1777, pp. 15–16.

17 Jean Donnison, Midwives and medical men, 2nd ed., London, Historical Publications, 1988; Adrian Wilson, The making of man-midwifery, London, UCL Press, 1995; Loudon, op. cit., note 1 above; idem, Medical care and the general practitioner, 1750–1850, Oxford, Clarendon Press, 1986; idem, ‘Medical practitioners 1750–1850 and the period of medical reform in Britain’, in A Wear (ed.), Medicine in society, Cambridge University Press, 1992.

18 Donnison, op. cit., note 17 above, p. 53.

19 Adrian Wilson, ‘William Hunter and the varieties of man-midwifery’, in Bynum and Porter (eds), op. cit., note 4 above, pp. 343–69.

20 W F Bynum, ‘Physicians, Hospitals and career structures in eighteenth-century London’, in Bynum and Porter (eds), op. cit., note 4 above, pp. 105–28; Donnison, op. cit., note 17 above, pp. 53–71.

21 For example, Charles Meigs, Females and their diseases, Philadelphia, Lea and Blanchard, 1848; Peter de Sales La Terrière, A dissertation on the puerperal fever, Boston, printed by Samuel Hall, 1789; and Mitchell, op. cit., note 5 above.

22 For example, Jean Astruc, A treatise on the diseases of women, transl. J Nourse, London, printed for J Nourse, 1762, vol. 3; and Baudelocque, op. cit., note 5 above.

23 R Ferguson, Essays on the most important diseases of women, London, J Murray, 1839; Churchill (ed.), op. cit., note 9 above.

24 Christopher Lawrence, ‘Ornate physicians and learned artisans: Edinburgh medical men, 1729–1776’, in Bynum and Porter (eds), op. cit., note 4 above, pp. 153–76; Andrew Cunningham, ‘Medicine to calm the mind: Boerhaave's medical system, and why it was adopted in Edinburgh’, in A Cunningham and R French (eds), The medical enlightenment of the eighteenth century, Cambridge University Press, 1990, pp. 40–66.

25 Michel Foucault, The birth of the clinic, transl. A Sheridan, London, Routledge, 1973; N D Jewson, ‘The disappearance of the sick-man from medical cosmology, 1770–1870’, Sociology, 1976, 10: 225–44; E Ackerknecht, Medicine at the Paris hospital, 1794–1848, Baltimore, Johns Hopkins Press, 1967; Bynum and Porter (eds), op. cit., note 4 above; Cunningham and French (eds), op. cit., note 24 above; W F Bynum, Science and the practice of medicine in the nineteenth century, Cambridge University Press, 1994.

26 See, for example, the numerous references to earlier—including ancient—writers in Hulme, op. cit., note 5 above; see also Mitchell, op. cit., note 5 above, pp. 9–10.

27 See, for example, Sir Richard Manningham, The symptoms, nature, causes and cure of the febricula, London, for J Robinson, 1746. On the cause of puerperal fever in the “sudden removal of pressure from the blood vessels at the time of delivery”, see Clarke, Practical essays, op. cit., note 5 above; p. 55. On fever as a stagnation of the blood brought about by the cold fit, see J Leake, Practical observations on the child-bed fever, London, for J Walter, 1772, p. 85. See also J Leake, Medical instructions towards the prevention and cure of chronic diseases peculiar to women, 6th ed., London, printed for R Baldwin, Murray and Egerton, 1787, and idem, A lecture introductory to the theory and practice of midwifery, 3rd ed., London, printed for R Baldwin, 1776.

28 William Fordyce, A new inquiry into the causes, symptoms, and cure of putrid and inflammatory fevers, 4th ed., London, for T Cadell, J Murray and W Davenhill, 1777, pp. 48–53.

29 Thomas Kirkland, An essay towards an improvement in the cure of those diseases which are the cause of fevers, London, J Dodesley, 1767, p. 31.

30 See, for example, Leake, Practical observations, op. cit., note 27 above, pp. 81–97.

31 See, for example, Denman, 2nd ed., 1773, op. cit., note 5 above, pp. 11–12. Thomas Denman was born in Bakewell in 1733. He worked as a navy surgeon until 1763, then went to Aberdeen University where he obtained his MD degree in 1764. He was “physician-accoucheur” to the Middlesex Hospital from 1769 to 1783. He died in 1815.

32 See, for example, John Aitken, Principles of midwifery: or puerperal medicine, 3rd ed., London, J Murray, 1786, pp. 171–82; Denman, 2nd ed., 1773, op. cit., note 5 above, pp. 17–23.

33 Herman Boerhaave, Aphorisms: concerning the knowledge and cure of diseases, transl. by J Delacoste, London, William and John Innys, 1724; idem, Academical lectures on the theory of physic, 6 vols, London, W Innys, 1742–46; G A Lindeboom, Herman Boerhaave: the man and his work, London, Methuen, 1968.

34 Baron G F van Swieten, Commentaries upon Boerhaave's Aphorisms, 18 vols, Edinburgh, printed for C Elliot, 1776.

35 Ibid., vol. 3, pp. 245, 248.

36 Ibid. The material on inflammations is contained mainly in vol. 3. See Aphorism 370, p. 245; Aphorism 371, p. 248; Aphorism 372, p. 252; Aphorism 375, p. 261; Aphorism 376, p. 268; Aphorism 377, p. 270; and van Swieten's commentaries on these.

37 Ibid., vols 4, 5, and 6, see especially, vol. 5, Aphorisms 572 and 573, p. 28.

38 See, for example, reference being made to the basis in Harvey's findings of inflammatory theory, as late as the 1820s: William Stoker, A dissertation on the institutes of medicine, Dublin, R Milligen, J Cumming, and Hodges and M'Arthur, 1826, p. lxvii.

39 Boerhaave, Academical lectures, op. cit., note 33 above; see also John Hunt, Observations on the circulation of the blood, London, printed for J Johnson, and C Elliot, Edinburgh, 1787.

40 Dorinda Outram, The Enlightenment, Cambridge University Press, 1995, p. 34.

41 Roselyne Rey, ‘Vitalism, disease and society’, in Roy Porter (ed.), Medicine in the Enlightenment, Amsterdam, Rodopi, 1995; E Haigh, Xavier Bichat and the medical theory of the eighteenth century, Med. Hist. Supplement, No. 4, London, Wellcome Institute for the History of Medicine, 1984. On the medical perspective, see Thomas Morgan, The mechanical practice of physick, London, T Woodward, 1735.

42 Marina Benjamin, ‘Medicine, mortality and the politics of Berkeley's tar-water’, in Cunningham and French, op. cit., note 24 above, pp. 165–93, on p. 171. Julian Martin refers to the British Newtonian physicians Pitcairne, Cheyne, Keill, Arbuthnot, Hales, Jurn and Wainewright, in ‘Sauvages's nosology: medical enlightenment in Montpellier’, in Cunningham and French (eds), op. cit., note 24 above, pp. 111–37, on p. 131.

43 William Cullen, First lines of the practice of physic, 4 vols, London, printed for J Murray; Edinburgh, printed for William Creech, 1777–1784, vol. 1, pp. 54–5. See also, C Clayson, ‘William Cullen in eighteenth century medicine’, in A Doig, J P S Ferguson, I A Milne, and R Passmore (eds), William Cullen and the 18th century medical world, Edinburgh University Press, 1993, pp. 87–97; G B Risse, ‘Cullen as clinician: organisation and strategies of an eighteenth century medical practice’, in the same volume, pp. 133–51.

44 Cullen, op. cit., see note 43 above, pp. 55–60.

45 Ibid., Book 1 of vol.1 is on fevers, Book 2 is on inflammations or phlegmasiae.

46 On the nature of the blood, see William Cullen, Institutions of medicine. Part I: Physiology, 3rd ed., Edinburgh, Charles Elliot; London, T Cadell, 1785. pp. 192–4. On the changes which take place in inflammation, see also Cullen, First lines, op. cit., note 43 above, pp. 181–5; Fordyce, op. cit., note 6 above, pp. 23–4.

47 Cullen, op. cit., note 43 above, pp. 189–93.

48 Ibid., pp. 190–204.

49 Ibid., pp. 191–6, 204–5.

50 Ibid., pp. 192–200.

51 Ibid., pp. 197–202. Cullen also mentions other rarer terminations: “schirus [sic], or indolent hardness”, and, in the case of inflammation of internal organs, the production of a “viscid concretion” and a “thin serous fluid”, pp. 201–2.

52 Fordyce, op. cit., note 6 above, pp. 43–6. On the “cold” and “hot fits” see also p. 48.

53 Sir Richard Manningham, The symptoms, nature, causes and cure of the febricula, 2nd ed., London, for J Robinson, 1750, p. 29. Sir Richard Manningham was physician to the lying-in Infirmary of London during the mid-eighteenth-century. A number of other eighteenth-century writers were expressing similar ideas. Jean Astruc's influential A treatise on the diseases of women, of 1762 (op. cit., note 22 above), presented puerperal fever as an essentially inflammatory condition caused by suppression of the lochia following delivery. He added that the disease can become putrid through a simple process of suppuration. In his treatise of 1793, John Clarke explained how the inflammatory characteristics of puerperal fever could produce the typical symptoms of the disease: pain in the lower abdomen, diminution of the lochia, suppression of the milk, and more generalized systemic symptoms such as heat; rapidity, strength and fullness of the pulse; white, dry tongue; thirst; headache; vomiting and diarrhoea. Clarke, Practical essays, op. cit., note 5 above, pp. 62–80. See also John Aitken, Principles of midwifery, 3rd ed., London, J Murray, 1786, pp. 171–8; Denman, 2nd ed., 1773, op. cit., note 5 above, p. 3. For examples of discussions of inflammation in inaugural dissertations, see Henricus Slaughter, Dissertatio medica inauguralis, de febre puerperali, Edinburgh, Balfour and Smellie, 1780; Thomas Evory, Dissertatio medica inauguralis, de febre puerperarum, Edinburgh, Balfour and Smellie, 1782.

54 Leake, Practical observations, note 27 above, pp. 81–97. John Leake was born in Ainstable in Cumberland. He obtained his MD from Rheims in 1763. He was made a licentiate of the Royal College of Physicians of London in 1766, and became First Physician of the Westminster Lying-in Hospital. He died in 1792. See also: Evory, op. cit., note 53 above, pp. 19–34.

55 Hulme, op. cit., note 5 above, pp. 147–75. Nathaniel Hulme was born in Yorkshire in 1732. He obtained his MD from Edinburgh University in 1765. During the 1770s he was physician to the Charterhouse and to the London Lying-in Hospital.

56 Leake, Observations on the child-bed fever (1772), in Churchill (ed.), op. cit., note 9 above, p. 145. John Clarke discusses how “from the sudden removal of pressure from the blood vessels at the time of delivery, a greater proportion of fluids than circulate there in a natural state may rush upon some particular part”: Clarke, Practical essays, op. cit., note 5 above. p. 55; see also Campbell, op. cit., note 5 above pp. 196–201.

57 Leake, op. cit., note 56 above, p. 145. For Cullen's discussion of inflammation of the intestines, which may have influenced Leake, see Cullen, op. cit., note 43 above, pp. 315–18.

58 Leake, op. cit., note 56 above, p. 146. Moore, in his treatise of 1836, summarized earlier perspectives on inflammation, observing that some had attributed it to an “increased action” of the blood vessels, whilst others had seen it as the consequence of the “act of dilatation” of vessels, which are acting “with less force than the trunks from which they are derived”. He pointed out that these hypotheses are complementary rather than contradictory. Moore, op. cit., note 10 above, pp. 94–5.

59 Leake, op. cit., note 56 above, p. 146. On the stagnation of the blood brought on by the cold fit, see also original version op. cit. note 27 above, pp. 83–5. See also Leake, A lecture, op. cit. note 27 above, p. 16, and Leake, Medical instructions, op. cit., note 27 above, p. 159.

60 On these issues and on the dangers of “tight binding” the abdomen, see Denman, op. cit., note 5 above, 1st ed., 1768, p. 19; 2nd ed. 1773, p. 7. On binding of the abdomen, see also Manning, op. cit., note 5 above, p. 397; and Campbell, op. cit., note 5 above, pp. 20, 202–3.

61 Leake, op. cit., note 56 above, pp. 147–9.

62 Ibid., p. 150; La Terrière, op. cit. note 21 above, p. 8; pp. 15–17; Mitchell, op. cit. note 5 above, p. 5; p. 19. Mitchell's work—like La Terrière's—is noted here in acknowledgement of the fact that British and North American treatise writers had a profound influence on each other during this period. On North American medicine, see Helen Brock, ‘North America, a western outpost of European medicine’, in Cunningham, and French (eds), op. cit., note 24 above, pp. 194–216.

63 Alexander Gordon was Physician to the Aberdeen Infirmary in the mid-1790s and had an important private practice as a man-midwife in Aberdeen.

64 Gordon, op. cit. note 5 above, p. 119. For a clear exposition of Gordon's ideas on the inflammatory nature of puerperal fever, see pp. 52–5.

65 Ibid., pp. 115–16.

66 Denman, 2nd ed., 1773, op. cit., note 5 above, p. 3.

67 Gordon, op. cit. note 5 above, p. 9. See also, Clarke, Practical essays, op. cit., note 5 above, p. 12: “the blood drawn from women in pregnancy is generally covered with a buff, the red globules having fallen to the bottom of the cake”.

68 Campbell, op. cit. note 5 above, p. 46.

69 Ibid., pp. 195–6. On the inflammatory nature of puerperal fever, see also pp. 197–201. Campbell cites in support of his view of puerperal fever as an inflammatory complaint, William Hunter, John Hunter, Denman, Leake and Gordon.

70 See, for example, Ferguson, op. cit. note 23 above, pp. 98–100. Moore, op. cit., note 10 above, p. 106.

71 In his treatise of 1768, Thomas Denman stated that these predisposing factors could include difficult labours, and constipation, see note 5 above, pp. 17–19. Henry Manning suggested that they might include “accidents after delivery”, “sudden frights” and “too hasty a separation of the placenta”, op. cit., note 5 above, p. 397. In 1751, Burton observed that inflammation of the uterus could be caused either by damage inflicted by the midwife, or by the suppression of lochia, thus demonstrating the links between the mechanistic way of thinking and the notion of suppressed fluids; John Burton, An essay towards a complete new system of midwifry [sic], London, J Hodges, 1751: on suppression of the lochia, see pp. 334–40; on inflammation of the uterus, pp. 335–7. Burton's ideas are also cited by Hulme, op. cit., note 5 above, pp. 88–146. The French physician, Astruc, observed in 1762 that the excitability which caused inflammation was occasioned by allowing cold air into the uterus (which would cause it to contract spasmodically), by a pre-existing diarrhoea, by damage to the uterus during childbirth, or by “passions of the mind”, thus raising echoes of the “non-naturals” discussed by earlier authors. Astruc, op. cit., note 22 above, pp. 227–30.

72 Robert Ferguson was born in India in 1799. He obtained his MD from Edinburgh in 1823. He became a licentiate of the Royal College of Physicians in 1824; physician to the Westminster Lying-in Hospital; Professor of Midwifery at Kings College in 1831; Fellow of the Royal College of Physicians in 1837, “Physician-Accoucheur” to the Queen in 1840 and “Physician-Extraordinary” to the Queen in 1857.

73 Ferguson, op. cit., note 23 above, p. 106. On the dangers of retained placenta, see Robert Lee, ‘Clinical reports of difficult cases in midwifery’, Lond. med. Gaz., 1838–39, 2: 554–62; 665–70; 713–17; 872–7; 908–10; idem, Pathological and practical researches on the uterine inflammation in puerperal women, London, printed by G Woodfall, 1831, pp. 58–9. See also Campbell, op. cit., note 5 above, on the dangers of forcible removal of the placenta, pp. 203–5; on “severe labours”, pp. 205–10; on the effects of cold, pp. 211–12. On the link between puerperal fever and damage caused during labour, see Clarke, Practical essays, op. cit., note 5 above, p. 17.

74 Clarke, Practical essays, op. cit., note 5 above, pp. 19–20. For a later discussion of the same issue, reaching very similar conclusions, see Armstrong, op. cit., note 5 above, pp. 42–44.

75 Ibid., p. 20. On the dangers of “the too early use of cordials and stimuli” see also, Campbell, op. cit., note 5 above, p. 212.

76 Clarke, Practical essays, op. cit., note 5 above, pp. 20–1. On the likelihood that midwives will cause damage to the “os uteri”, see Astruc, op. cit., note 22 above, pp. 227–30. On damage caused during delivery, see Baudelocque, op. cit., see note 5 above, pp. 54–64; on retention of placenta, pp. 98–110.

77 Hulme, A treatise on the puerperal fever (1772), in Churchill (ed.), op. cit., note 9 above, esp. pp. 69, 103; Leake, op. cit., note 56 above, p. 145. This view was also held by Joseph Clarke, physician at the Dublin lying-in hospital in the late eighteenth century, see his ‘Observations on the puerperal fever’, Edinburgh Medical Commentaries, 1790, 15: 299, reprinted in Churchill (ed.), pp. 351–62, esp. pp. 355–6.

78 Hulme, op. cit., note 77 above, p. 69.

79 Ibid., p. 106. For a much later, nineteenth-century perspective on the affection of the intestines in puerperal fever, see John Burns, The principles of midwifery, 3rd ed., London, Longman, Hurst, Rees, Orme and Brown, 1814, p. 427.

80 Thomas Kirkland, An essay on childbed fevers, etc., in Churchill (ed.), op. cit., note 9 above, pp. 291–2.

81 Clarke, An essay on the epidemic disease, op. cit., note 5 above, p. 33.

82 Ibid., pp. 28, 34–5.

83 Clarke, Practical essays, op. cit., see note 5 above, pp. 51–170.

84 Leake, Practical observations on the child-bed fever, op. cit., note 27 above, pp. 49–50, 80, 84–5, 145. See also Aitken, op. cit., note 32 above, pp. 171–8.

85 Gordon, op. cit., see note 5 above, p. 53. Gordon gave a number of cases of the latter type of crisis: in the case of Janet Cormack, a release of purulent matter took place through the umbilicus; in the case of Thomas McRoberts' wife, there was an erysipelas of one of the arms accompanied by a severe diarrhoea, and in the case of Isaac Allen's wife there was a “discharge of purulent matter from the urethra”. Ibid: on Cormack, pp. 41–2; on McRoberts, pp. 44–7; on Allen, pp. 47–9.

86 Ibid., p. 54.

87 See, for example, DeLacy, op. cit., see note 2 above, pp. 521–56. Loudon, op. cit., see note 1 above, passim, esp. pp. 11–12.

88 K Kiple, ‘Ergotism and erysipelas: Saint Anthony's Fire’, in K Kiple, (ed.), Plague, pox and pestilence, London, Weidenfeld and Nicolson, 1997, p. 37.

89 It is uncertain who was actually the first to make this link, but it was certainly made by Thomas Denman, 2nd ed., 1773, op. cit., see note 5 above, p. 13. Gordon himself refers to puerperal fever as being “of the nature of … erysipelas [rather than] phlegmon”, adding, however, that the usual cures for erysipelas were not effective in this disorder. Gordon, op. cit., note 5 above, p. 55.

90 Clarke, An essay on the epidemic disease, op. cit., note 5 above, p. 11.

91 Walsh, op. cit., note 5 above, pp. 17–18.

92 L G Wilson, ‘Fevers and science in early nineteenth century medicine’, J. Hist. Med., 1978, 33: 386–407, pp. 394–8; D C Smith, ‘Gerhard’s distinction between typhoid and typhus and its reception in America, 1833–1860', Bull. Hist. Med., 1980, 54: 368–85, p. 369.

93 Gooch, op. cit., note 5 above, Preface, p. xi.

94 Moore, op. cit., note 10 above, p. 104.

95 Charles White, A treatise on the management of pregnant and lying-in women (1773), in Churchill (ed.), op. cit., note 9 above, p. 260; White, op. cit., note 16 above, p. 30.

96 Leake, op. cit., note 56 above, pp. 118, 136; Hulme, op. cit., note 77 above, pp. 66, 79–88, 105–7.

97 Gordon, op. cit., note 5 above; Armstrong, op. cit., note 5 above, Preface; Hey, op. cit., note 13 above, Preface.

98 Gooch, op. cit., note 5 above, p. 62.

99 Cusack, op. cit., note 6 above, p. 2.

100 Samuel Ashwell, A practical treatise on parturition, London, T Tegg, 1828, pp. 493–4. The influential French treatise by Baudelocque also presented this disease as “puerperal peritonitis”. Baudelocque, op. cit., note 5 above; on “the lesions observed in the peritoneum after death”, see pp. 273–90.

101 White, A treatise, op. cit., note 95 above, p. 213. White did, however, write a new edition of this work in 1777, to which he added an Appendix dealing entirely with the nature of puerperal fever: White, op. cit., note 16 above.

102 Butter, op. cit., note 5 above, pp. viii, 18.

103 Walsh, op. cit., note 5 above, p. 16. Philip Pitt Walsh was physician to the General Lying-in Hospital, Consulting Physician to the General Lying-in Dispensary and Physician to the British Lying-in Hospital.

104 Kirkland, op. cit., see note 80 above, pp. 286, 292.

105 Ibid., p. 286.

106 Walsh also suggests that inflammatory symptoms may accompany “diseases of debility”, which are usually viewed as putrid types—or fevers of the classification “typhus”: Walsh, op. cit., note 5 above, p. 16. He further refers to a “want of firmness and strength in the coats of the vessels, and of course in the solids at large” as a circumstance which will predispose to inflammation (p. 19). The explanation offered by John Leake for the origin of puerperal fever clearly linked inflammatory and solidist explanations of disease. He argued that “neither inanition nor plethora is natural to the body in a healthy state; … the one extreme is as hurtful as the other, and will produce irritation in as high a degree; for in plethoric habits, where the vessels are overcharged, and violently upon the stretch, all the symptoms of irritability are evidently increased”: Leake, op. cit., note 56 above, pp. 154–5. Another important insight into the link between inflammatory and vitalist explanations of puerperal fever is offered by Whitehead, who, in presenting a translation of a report by the French physician Doulcet, argued in one of his own footnotes that laxity of fibres—a typically solidist explanation—predisposed to inflammation, by allowing the pooling of blood in flaccid arteries: John Whitehead, A report made by order of government, of a memoir, containing a new … method of treating the child-bed or puerperal fever, made use of by the late M. Doulcet, London, Frys and Couchman, 1783, ftn on pp. 23–4.

107 John Alexander was Licentiate of the Royal College of Physicians and Medical Officer to the General Dispensary for Children during the 1830s.

108 Alexander, op. cit., note 5 above, p. 16.

109 Kirkland, op. cit., note 29 above; see also White and Butter, both cited in note 5 above.

110 Kirkland, op. cit., note 29 above, esp. pp. 1, 13–27, 31–2.

111 Matthew Dobson, A medical commentary on fixed air, London, printed for T Cadell, 1779, p. 74.

112 Ibid., pp. 75–6; see also Fordyce, op. cit., note 6 above, pp. 15–18.

113 Fordyce, op. cit., note 6 above, pp. 25–9.

114 Whitehead, op. cit., note 106 above.

115 Albrecht von Haller, A dissertation on the sensible and irritable parts of animals, Preface by S A D Tissot, London, J Nourse, 1755, p. xxi.

116 Manning, op. cit., note 5 above, p. 404.

117 White, op. cit., note 5 above; Butter, op. cit., note 5 above, esp. pp. 4, 15–18. A member of the Corporation of Surgeons of London, Charles White was vice-president of the Literary and Philosophical Society of Manchester. He practised midwifery in Manchester for part of his career. William Butter was born in the Orkneys in 1726. He obtained his MD from Edinburgh University in 1761, and became a licentiate of the Royal College of Physicians of London and a Fellow of the Royal College of Physicians of Edinburgh.

118 White, op. cit., note 5 above, p. 7. The inaugural dissertation of Patrick Keary discusses the putrid nature of the disease and cites the work of White: Patrick Keary, Dissertatio medica inauguralis, de febre puerperarum, Edinburgh, Balfour and Smellie, 1774.

119 See, for example, J George Adami, Charles White of Manchester (1728–1813), and the arrest of puerperal fever, Liverpool University Press, 1922.

120 Denman, 1st ed., 1768, op. cit., note 5 above, pp. 11–12.

121 Denman, 2nd ed., 1773, op. cit., note 5 above, pp. 12–13.

122 Denman, 1st ed., 1768, op. cit., note 5 above, p. 11.

123 White, A treatise, op. cit., note 95 above pp. 205–6; See also Appendix op. cit., note 16 above, pp. 27–8.

124 White, A treatise, op. cit., note 95 above, p. 206.

125 Ibid., p. 207.

126 Ibid., p. 207.

127 Ibid., p. 207.

128 Ibid., pp. 207–9.

129 White, op. cit., note 16 above, pp. 18–27.

130 Ibid., p. 28; White, A treatise op. cit., note 95 above, pp. 262–3.

131 White, A treatise, op. cit., note 95 above, p. 213.

132 Butter, op. cit., note 5 above, Preface, pp. viii, 11–15.

133 Ibid., p. 4.

134 Kirkland, op. cit., note 29 above, p. 31.

135 Kirkland, op. cit., note 80 above, p. 293; see also pp. 293–97. For an example of a case explained by putrid effluvium, see Churchill (ed.), ibid., p. 298.

136 John Whitehead was born in Lancashire. He obtained his MD from Leyden in 1780. He became a licentiate of the Royal College of Physicians of London in 1782.

137 Whitehead, op. cit., note 106 above, p. 32.

138 Ibid., p. 24.

139 Burns, op. cit., note 79 above, p. 428.

140 Ibid., p. 428. The French physician, Baudelocque, argued for the influence of a number of factors that had come to be seen as causative elements in the process of putrefaction: poor quality food, alcohol, constipation, “impure matter” in the alimentary canal, retention of the urine, and “impurity” of the atmosphere: Baudelocque, op. cit., note 5 above, pp. 64–8, 96–8, 112–153.

141 Armstrong, op. cit., note 5 above, p. viii; on the inflammatory nature of the disease, see Preface, esp. pp. vii–viii, and pp. 14–22; on the contagious nature of puerperal fever, see pp. 12, 33–4.

142 Hey, op. cit., note 13 above, Preface. William Hey was surgeon to both the General Infirmary and the House of Recovery in Leeds.

143 It is likely that Hey and Armstrong were particularly heavily influenced by those of their predecessors who had emphasized what they saw as an inflammatory nature to puerperal fever: among others, Leake, Hulme, and most particularly, Gordon. Leake, Practical observations, op. cit., note 27 above; Hulme and Gordon both cited in note 5 above.

144 Campbell, op. cit., note 5 above, p. 172.

145 Ibid., pp. 172–3.

146 Ibid., p. 175.

147 Mackintosh, op. cit., note 11 above, pp. 1–2.

148 Ibid. p. 5.

149 Gooch, op. cit., note 5 above, pp. 2, 62. Robert Gooch was born in Yarmouth in 1784. He obtained his MD from Edinburgh University in 1807, and was a licentiate of the Royal College of Physicians. He was physician to the Lying-in Hospitals of London and Westminster during the 1820s, and later became physician to the City of London Lying-in Hospital. He lectured on midwifery at St Bartholomew's Hospital. He died in 1830. Irvine Loudon has suggested that Fleetwood Churchill in his treatise of 1849 was the first to propose the name “puerperal peritonitis”. Loudon, op. cit., note 1 above, p. 8.

150 Gooch, ibid., pp. 62–3. The same view is expressed by Campbell, op. cit., note 5 above, p. 11.

151 Moore, op. cit., note 10 above, pp. 74, 93–4.

152 William Campbell was physician to the Edinburgh Infirmary. Samuel Cusack was a member of the Royal College of Surgeons in Ireland. He was “Superintending Accoucheur” to the Wellesley Dispensary for Lying-in Females on Mercer Street, in Dublin. Robert Lee was born in Melrose, Roxburghshire in 1793. He obtained his MD from Edinburgh in 1814 and became a licentiate of the Royal College of Physicians in 1823. He became physician to the British Lying-in Hospital in 1826, Regius Professor of Midwifery to the University of Glasgow in 1834, Professor of Midwifery at St George's Hospital later the same year, and Fellow of the Royal College of Physicians in 1841.

153 Campbell, op. cit., note 5 above, pp. 191–4; Cusack, op. cit., note 6 above, pp. 2–5. For further discussion of Cusack's view, see Samuel Cusack, ‘On puerperal fever—letter from Dr. Samuel Cusack to the editors’, Dublin Journal of Medical Science, 1836, 9: 162–5. On the inflammatory nature of puerperal fever, see also Ryan, op. cit. note 10 above, esp. p. 330.

154 Lee, Pathological and practical researches, op. cit., note 73 above, p. 2.

155 Ibid., p. 4.

156 Ibid., pp. 4–6.

157 Ferguson, op. cit., note 23 above. For an introduction to the schema, see pp. 1–2. The direct quotations are taken from p. 21. In discussing his other “forms” of puerperal fever, Ferguson, in common with other late-eighteenth- and early-nineteenth-century writers, identified the inflammation as being of an “erysipelatous” form: ibid., p. 28. Ferguson included one case study—number XXXIII—with the clear purpose of illustrating this link between puerperal fever and erysipelas. Lucy Roberts had symptoms of puerperal fever, accompanied by an “erysipelatous blush … on the right hip”. The erysipelas spread to the limbs and an abscess broke out on the arm. The patient recovered, but only after several weeks. Ibid., pp. 168–75. On the erysipelatous nature of puerperal fever, see also Gordon, op. cit, see note 5 above, p. 55. Also George Weatherhead, An essay on the diagnosis between erysipelas, phlegmon and erythema, London, Longman, Hurst, Rees, Orme and Brown, 1819, pp. 14–18; Moore, op. cit., note 10 above, pp. 142–8; and Lee, Pathological and practical researches, op. cit., note 73 above, p. 66. Lee cites other authors who argue that puerperal fever represents erysipelas, among them Pouteau, Home, and Young of Edinburgh, Gordon, Pinel, Bayle, Garsc and Laënnec, see pp. 66–70.

158 Cullen, op. cit., note 43 above, pp. 63–4.

159 Thomas S Kuhn, The structure of scientific revolutions, 3rd ed., University of Chicago Press, 1996, pp. 178–9.

160 Oliver W Holmes, ‘The contagiousness of puerperal fever’, Medical Classics, 1937–37, 1: 211–43, reprinted from the N. England Q. J Med. Surg., 1843, 1 (4): 503–30; idem, ‘Puerperal fever as a private pestilence’, Medical Classics, 1936–37, 1: 211–68.

161 I Semmelweis, The etiology, concept and prophylaxis of childbed fever, transl. K Codell Carter, Madison, University of Wisconsin Press, 1983.

162 James Young Simpson, ‘On the analogy between puerperal fever and surgical fever’, Edinb. mon. J. med. Sci., Nov. 1850: 414. See also James Young Simpson, ‘On the communicability and propagation of puerperal fever’, Proceedings of the Medico-Chirurgical Society, April 1851, reprinted in the Edinb. mon. J. med. Sci., July 1851: 72. Both reprinted in the Obstetric memoirs and contributions of James Y Simpson, Edinburgh, A & C Black, 1855–56.

163 Ferguson, op. cit., note 23 above, Part I. Puerperal fever.