The Tragedy of Childbed Fever (review)

Irvine Loudon. The Tragedy of Childbed Fever. Oxford, Oxford University Press, 2000. xiii, 236 pp., figures, tables. $65.

Irvine Loudon’s latest book examines the history of disease within the realm of childbirth. An outgrowth of his previous research on maternal mortality, this study provides a fine overview of the history of puerperal fever, also known as childbed fever. Epidemics of puerperal fever affected towns and villages, as well as lying-in or maternity hospitals throughout Europe and North America. It was one of the major causes of maternal mortality from the mid-eighteenth century until its decline in the mid-twentieth century.

Loudon examines the scandal of preventable maternal deaths by documenting changing medical ideas about puerperal fever, a bacterial infection of women’s reproductive organs in the postnatal period. He charts the disease from its identification as a common, fatal illness in the eighteenth century, a time when medical men started to take part in normal childbirth and lying-in hospitals emerged, to the twentieth century, when sulfonamides and penicillin provided the first effective treatments.

Loudon’s approach is to examine medical men’s views of the disease. He tries "to get under the skin (or into the minds) of past practitioners as they struggled to make sense of the vagaries of fevers and epidemics" (p. 83). He wades through what he calls "the muddled ideas that surrounded this disease" (p. 23) to locate the significant advances by medical men to an understanding of puerperal fever. He concludes that Ignaz Philipp Semmelweis, "probably the most famous figure in the history of obstetrics" (p. 88), was not the hero we had thought. Physicians and historians have credited Semmelweis, a Hungarian physician working in a Vienna hospital in the nineteenth century, with saving lives when he identified the role of the physician in transmitting disease to birthing women. Semmelweis concluded that medical students and physicians who performed postmortem examinations contributed to puerperal fever among these patients. Therefore, he instituted a policy that birth attendants must wash their hands in disinfectant. However, Loudon suggests that his impact on obstetrics was not widespread, but limited to Vienna. It was only some twenty years after the death of Semmelweis that he emerged as a medical hero.

Instead, Loudon is far more impressed with the contributions to reduced maternal mortality of British physicians and surgeons like Alexander Gordon, James Young Simpson, and Joseph Lister. Gordon, who practiced medicine in Scotland, helped establish the notion that puerperal fever was contagious. In 1795, Gordon studied a town epidemic and warned that doctors and midwives transmitted the disease from patient to patient. Loudon explains "Gordon had more influence than appears at first sight. His work was not cited because it smelt of unorthodoxy, because it lay outside the accepted canon of knowledge. Yet the traces of his influence were there beneath the surface" (p. 34). In the 1850s, Simpson was the first to identify birth attendants’ fingers as the mechanism of contagion in cases of puerperal fever.

Finally, according to Loudon, it was not Semmelweis but Lister who improved obstetric practice and reduced maternal mortality especially in lying-in hospitals. Created to train medical students and midwives while providing skilled care to poor women, the maternity hospitals had incredibly high maternal mortality rates throughout much of the eighteenth and nineteenth centuries. Although physicians attending births at home in the mid-nineteenth century realized that they could transmit contagion, practitioners in lying-in hospitals paid little or no attention to their potential role in epidemics until the work of Lister. The use of antisepsis in obstetrics, explains Loudon, "was done in Lister’s name, it was due to Lister’s influence, and the method used was closer to that of Lister than of Semmelweis"(p. 131). Thus, Loudon argues that Lister and the antiseptic revolution of the 1880s saved the lying-in hospitals and the women who gave birth in...