In 1875, during an epidemic of puerperal or child-bed fever in England and Wales (fig. 1), Henry Hatherley, an obstetrician from Nottingham, published a defense of his and his colleagues' interests in the treatment of the illness. In this publication, which appeared in the the April issue of The British Medical Journal, Hatherley particularly questioned loose definitions of "puerperal fever," contending that the risk of infection from the attending physician was overblown:

I attended about this time nine labours (between January 5th and 22nd), all of which did well, although I took no special precautions to prevent infection. I think that, as far as any inference can be drawn from this isolated case, it is that the danger of infection to lying-in women from ordinary zymotic disease is less than is commonly supposed, and that a medical man is justified in fulfilling his midwifery engagements when attending infectious cases other than true puerperal fever. The question of responsibility for infection is a very serious and a very difficult one: to debar practitioners (morally, if not legally) from attending midwifery, whilst attending cases of scarlet fever, erysipelas, typhoid or typhus fever, diphtheria, etc., would not only mean ruin to many a medical man, but would so limit the number of medical men 'justified in practising' as seriously to inconvenience the public. I am one of those who believe that the term "puerperal fever" is applied too comprehensively, and that a more strict definition of this disease would shut out many so-called cases of 'puerperal fever.' (203)

Annual death rate per 1,000 births of women delivered of children in England and Wales 1850-1970. (Chamberlain, 590)

A hundred years earlier, the Scottish physician Alexander Gordon (1752-1799) had established that physicians could spread contagion in cases of puerperal fever (1795). Nevertheless Hatherley distorted "the question of responsibility for infection" to justify the retention of practices by means of which physicians, in the course of their daily rounds, transmitted infections to mothers-to-be from other patients suffering from the conditions he mentioned.

Determined to protect "medical men" from the consequences of their own actions, Hatherley was arguing for a cover-up. A loose definition of puerperal fever produced results prejudicial to his colleagues. Reasoning from what he admitted was an "isolated case" and an unsubstantiated statement about infectious diseases, Hatherley manufactured a general position concerned neither with the welfare of mothers-to-be nor with the convenience of the public. Hatherley's key concern was "ruin" (203), that is, the loss of status and income suffered by practitioners. Although a clearer definition might have failed to save practitioners from embarrassment, it would have been a major step forward in the epidemiology of the disease.

That same year, at a meeting of the Obstetrical Society of London held on April 17, Thomas Spencer Wells, surgeon to Queen Victoria and President of the Royal College of Surgeons, also questioned the definition of "puerperal fever." Although Wells' perspective differed from Hatherley's, his analysis similarly located the cause in the female body and made no allowance for imported infections such as erysipelas or typhus fever.

Wells suggested that the fever resulted from "the bruising or tearing of the parts concerned in childbirth, and the changes in the blood-vessels, blood, and lymphatics, following the injury." He asked his readers to suppose: that the uterus, veins and lymphatics become inflamed; that post-partum lochial discharge contained "pus with diffuse peritonitis"; and that the pus was found in the lymphatic vessels of the uterus and the cellular tissue. This hypothetical scenario provided the causal basis for equally hypothetical consequences that he nevertheless described as facts: "[T]he blood in the uterine veins clots, softens, breaks up, is the seat of chemical and vital change, is detained in or near the pelvis, or is carried away to distant parts, or alters the composition and properties of all the blood in the body." Consistent with the epidemiological difficulties practitioners faced, Wells offered a supposition based on observation but did not commit himself to a single explanation. Instead he asked his readers to decide whether a patient's symptoms indicated

purulent infection, or pyaemia, putrid infection, or septicaemia; whether all this will happen to a well-to-do healthy woman, unless she has been exposed to an infectious disease. Or whether puerperal fever could be a simple ever a simple traumatic fever modified by this puerperal condition. Does it always and necessarily depend on the action of a morbid poison?

Although he insisted that he was describing a purely internal matter, he was so reluctant to commit himself to a verifiable cause that he produced an excuse that brazenly contradicted the facts: "If all cases of contagions and infectious diseases under conditions other than that of childbirth are set aside, does there remain any such disease as puerperal fever?" (180) -- an astonishing question from the President of the Royal College of Surgeons.

Bibliography

Chamberlain, G. "British maternal mortality in the 19th and early 20th centuries." Journal of the Royal Society of Medicine 2006, 99 (11): 559-63.

Gordon, Alexander. book"> A Treatise on the Epidemic Puerperal Fever of Aberdeen. London: G.G. and J. Robinson, 1795.

Hatherley, H. "Erysipelas and Midwifery Practice." The British Medical Journal 1 (1875): 503.

Wells, T. Spencer. "An address on the Relation of Puerperal Fever to the Infective Diseases and Pyemia delivered before the Obstetrical Society of London." The British Medical Journal 1 (1875): 500-03.


Last modified 9 July 2020