Book Review

The Tragedy of Childbed Fever

N Engl J Med 2000; 343:587August 24, 2000

Article

The Tragedy of Childbed Fever
By Irvine Loudon. 249 pp. New York, Oxford University Press, 2000. $65. ISBN: 0-19-820499-X

Even though this book opens with the chilling tale of Mary Wollstonecraft's death from childbed fever in 1797, the author, a British medical historian and physician, does not focus on women's experiences with the dreaded postpartum infection. His concern, in this interesting and thorough account of the history of puerperal fever, lies rather in uncovering medical thinking about and treatment of the disease, from its early identification in the 18th century to its effective demise (following the introduction of sulfonamides and antibiotics) in the 20th. Loudon's previous books have already demonstrated his acute insight and tenacious research; this book should gain him an even greater following among scholars and general readers. Its narrow focus on a single disease makes it more accessible than his encyclopedic, international study Death in Childbirth (New York, Oxford University Press, 1992).

What we now recognize as a bacterial infection (usually streptococcal) of the uterus or genital tract of women after childbirth, puerperal fever or childbed fever in the 18th and 19th centuries affected, on average, 6 to 9 women in every 1000 deliveries, killing 2 to 3 of them with peritonitis or septicemia. During times of epidemics, many more suffered and died. It was the single most common cause of maternal mortality, accounting for about half of all deaths related to childbirth, and was second only to tuberculosis in killing women of childbearing age.

A woman struck by the infection suffered severe pain and agony. Physician Charles Meigs of Philadelphia told his students in 1848 that he had seen women “who not only suffered intolerable pain, but in whose minds that pain seemed to excite the most unspeakable terror.” Because its course was so dramatic and frightening, witnessed often by neighboring women, childbed fever brought anticipatory fear to pregnant women greater even than its statistics might warrant and accounted for women's repeatedly seeking ever more extensive medical attention beyond their traditional midwife attendants.

It is about this medical attention that Loudon writes. In two ways he narrates the historical course of the disease: by providing valuable tables and graphs depicting cases and deaths in a variety of settings over time and by taking readers chronologically through medical thought and activity beginning with the first English-language appearance of the term “puerperal fever” in 1716. He covers most effectively Scottish physician Alexander Gordon, whose 1795 treatise on the Aberdeen epidemic posited a single cause of the disease and its (now confirmed) link with erysipelas, covers various town and hospital outbreaks, and reviews with fresh eyes and insight the more familiar stories of James Young Simpson, Oliver Wendell Holmes, Ignaz Semmelweis, Joseph Lister, and the development and early use of antibiotics. He also covers some less familiar ones — the story, for example, of Leonard Colebrook, a physician who turned his attention to puerperal fever after a friend's wife died from it and whose studies and clinical trials in the 1920s and 1930s demonstrated the effectiveness of sulfonamides.

The book covers many important themes in the history of childbirth. It not only follows the early identification and understanding of what we know today — such as the link between puerperal fever and erysipelas — but also analyzes topics that historians have found important. One, for example, concerns hospital safety. Loudon demonstrates that because of childbed fever, hospitals were often dangerous places for childbirth, more dangerous than women's homes. He asks why, when “the sensible, the humane thing to have done, would have been to abolish the lying-in hospitals,” this was not done and, not shy of blaming physicians when he thinks they deserve it, concludes that one powerful reason for keeping the “murderous” (using the word of American physician Barton Cooke Hirst) institutions open “was the status they conferred on their staff.” Loudon also asks why women agreed to be admitted to such dangerous institutions, answering that women probably were not familiar with the mortality and morbidity statistics and that even dangerous hospitals provided more care and comfort than a woman who lived in a “slum, exposed to draughts and dirt, cold and hunger” could expect at home.

Loudon writes in an engaging style, often adding his personal commentary, identifying a policy as “foolish” or ideas as “muddled” and even noting the “idiocy” of some of the changes in disease terminology and reporting policies. He focuses on England and Wales, but he uses continental and U.S. examples comparatively. Amsterdam, for example, provides an effective contrast to London in terms of the death rates from childbed fever between 1880 and 1910: the two cities started at the same level, but the Dutch city's mortality rate fell significantly in those years, as it did in other northern European cities, demonstrating more effective antisepsis practice on the continent. Although the comparative examples well illuminate Britain's experiences, readers trying to find out about American experiences with childbed fever will find Loudon's sporadic use of U.S. examples more frustrating than helpful. He does not systematically review the literature or provide a narrative history of the disease outside England and Wales.

No one interested in the history of childbirth will want to miss this book. It is full of examples and insights that will form the basis of any future study (in whatever national setting); but even more it is full of wisdom that extends well beyond the specific disease to the history of medicine in general. Loudon, by example and by commentary, demonstrates his keen connections to the historical material and a good dollop of honest common sense. For example, when examining early-19th-century practices, he concludes: “We assume that practitioners in, say, the 1840s possessed a clear and agreed system of beliefs that it is our job as historians to interpret and understand. One has only to spell out such an assumption to see that it leaves no room for plain, ordinary, muddle and confusion, which, I strongly suspect, was, in many instances, the prevailing state of mind.” This kind of plain talk should find its way into more history books.

Judith Walzer Leavitt, Ph.D.
University of Wisconsin, Madison, Madison, WI 53706