Jannett Elizabeth Reid

   Cause of her death was Puerperal Peritonitis.

   Another name for Jannett was Jennett Elizabeth Reid.

  Medical Information:

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

CHRISTINE HALLETT, PhD*

*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

Introduction

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.

The purpose of this paper is to trace some of the ideas within those medical treatises on puerperal fever which were published during the period from 1760 to 1850. Previous historical writing, with the exception of Margaret DeLacy's overview of puerperal fever in eighteenth-century Britain, and George Lowis's paper considering the work of Alexander Gordon, has either focused on the innovations of the later nineteenth century or offered a broad overview of the subject which has tended to pass over the eighteenth and early nineteenth centuries with little comment, moving rapidly to the contributions of a later generation of physicians in the later nineteenth and twentieth centuries. Those contributions appeared to cast light on the infectious nature of puerperal fever. The disease is currently believed to be caused by a bacterial infection of the upper genital tract, in which the most common causative organism is the Beta haemolytic streptococcus, Lancefield Group A.

Death and disease caused by childbirth were a commonplace of early modern life. Pre-eclampsia, ante-partum and post-partum haemorrhage and cephalopelvic disproportion were only a few of the complications which could affect women and children at this most dangerous time. The Edinburgh physician William Campbell, in his treatise of 1822, observed that the symptoms of puerperal fever could be complex and difficult to interpret. In the majority of patients the disease appeared on the third day, and commenced with rigor, headache and the "cold fit" followed by extreme heat, perspiration and thirst. Abdominal pain was an almost ubiquitous feature and this began as a mild symptom, becoming increasingly severe over the duration of the disease. This pain-which was accompanied by abdominal distension-was usually located in the hypogastric and iliac regions, and any apparent remission tended to be dangerous, indicating mortification. There was "great derangement of the vascular system", the pulse rising to as much as 140 beats per minute, and the patient tended to lie on her back and appear listless and indifferent. The tongue was usually white, although it could become dark and furred in the face of impending death. Respiration was difficult due to the abdominal pain and distension, and the patient was prone to nausea and vomiting. The early stages of the disease could be characterized by constipation, which, however, soon gave way to diarrhoea. Urination was usually painful and the urine was "high coloured and turbid". The production of milk was usually suppressed, but the flow of lochia tended to continue. A minority of sufferers experienced delirium and mania.

It was not only the disturbing and extreme symptomatic presentation of puerperal fever that distressed practitioners, but also its intractable nature. Adding to the anxiety of physicians was the tendency of the disease to appear in "epidemic" form, in which the case fatality rate was high-70 to 80 per cent, as compared with 25 to 30 per cent in the sporadic form. John Clarke commented in his treatise of 1793 that the first useful account of a puerperal fever epidemic was the reference to an epidemic in the Paris Hôtel Dieu in 1745/6, which could be found in the Mémoires de l'Académie Royale des Sciences for the year 1746. In fact, it would appear that interest in the disease among British practitioners was first seriously aroused by what was probably the first British epidemic at the British Lying-in Hospital in 1760. According to Campbell, the term "puerperal fever" was first used by Edward Strother in his 1716 Criticon febrium.

John Mackintosh, writing in the 1820s, commented that "there is not a corner in Britain where this formidable disease has not made many mourners", but observed that a number of particular epidemics had become famous as a result of having been recorded and then repeatedly described in eighteenth- and early-nineteenth-century treatises on the subject. Alongside the Paris epidemic of 1745/6 and the London epidemic of 1760/1, he cited the 1768 and 1770 epidemics in London and other parts of England; the prolonged epidemic in Aberdeen from 1789-92 recorded by Alexander Gordon; and the epidemics in Leeds and Sunderland described respectively by William Hey and John Armstrong. Case fatality rates had varied enormously. For example, it was reported that, during the epidemic at the Westminster Lying-in Hospital in 1770, out of sixty-three women delivered, nineteen contracted the disease and thirteen of these died. In the Aberdeen epidemic, out of seventy-seven patients with the disease, twenty-eight died. However, Mackintosh also observed that, during an epidemic in the Lying-in Ward of the Edinburgh Infirmary "many years ago", all who contracted the disease died. The wide variations in the reports of eighteenth- and nineteenth-century authors make it impossible for a modern researcher to reconstruct accurately the incidence, mortality or case fatality rates for this disease. It is, however, clear that it was greatly feared by both patients and medical men. Once a woman contracted it, all recognized that she was likely to die. Emotions around the issue of puerperal fever therefore ran high, and the discovery of its nature and cure was a priority for the medical men of this time. A reading of the medical treatises of the later eighteenth-century creates the impression that this period was one of unprecedented confusion in the study of fevers. Nowhere is this impression stronger than in the writings on puerperal fever.

Man-midwifery was an uncertain but increasingly fashionable and sometimes quite lucrative area of practice for physicians; it may, for this reason, have been a field in which ideas about theory and practice were particularly strongly contested. Midwifery, formerly the preserve of women, was receiving increasing attention from medical men-both physicians and surgeons-during the eighteenth century. Prominent within this area of practice were the surgeons, for whom midwifery was seen as a natural extension of their activities. Surgeons had traditionally been called in to difficult births by midwives, usually when there was a need to extract an already dead foetus from the womb in order to save a mother's life. During the eighteenth century, surgeons were increasingly finding ways to extend their practice into the area of normal childbirth. Men-midwives, although recognized by society as holding respectable positions and possessing expertise, found their status limited by the "hands-on" nature of their work. Nevertheless, within broader social terms, man-midwifery could be seen as a field of financial and career opportunity. These ambiguities and uncertainties within the status of men-midwives may have contributed to the intensity and competitiveness of the debates which can be found in their writings.

The second half of the eighteenth century saw increasingly determined attempts by surgeons to raise their status. The formation of the Company of Surgeons in 1745 and then of the Royal College of Surgeons of London in 1800 permitted them to present themselves as "pure surgeons", practising at a level higher than that of the surgeon-apothecary. For this reason, surgeons were distancing themselves from man-midwifery, and élite men-midwives-particularly those who undertook some practice within lying-in hospitals-were often physician-accoucheurs. Individuals who wrote on puerperal fever were, therefore, likely to combine an interest in midwifery with one of the most important areas of a physician's practice-the treatment of fevers. The particular group of writers under study here contains individuals who possessed both surgical and medical qualifications and experience. Many had both experience as a surgeon and an MD degree.

This paper is based on an examination of literature on puerperal fever published in Britain between the years 1760 and 1850. Greater attention is paid to treatises than to journal articles, because these provide a more detailed insight into the theoretical perspectives guiding the work of physicians. Certain American texts which appear to have had a particularly strong influence on the British writers have also been included. Numerous French and other European physicians wrote on puerperal fever. Those of their works which were translated into English and published in Britain have been considered as part of the analysis, and the importance of their influence has been recognized.

The period between 1760 and 1850 can be seen as an important phase in the history of concepts of puerperal fever. Very few works dealing with the subject of fevers in puerperal women-and none on "puerperal fever" per se-were published in Britain before 1760. By 1850 a number of attempts had been made to offer extensive syntheses of knowledge, the most interesting of which were Robert Ferguson's theoretical overview of 1839, and Fleetwood Churchill's narrative history and compilation of 1849.

Medical men wrote as both practitioners and theorists; they saw their work as being grounded in practice, yet they also viewed their theoretical academic work as valuable in itself. Modern scholarship has identified a series of shifting emphases within medicine during the late eighteenth and early nineteenth centuries. This has been viewed as a period in which there was a move from rationalism to empiricism, from the authority of the ancients to a reliance on data, and from nosology to morbid anatomy and the localization of pathology. It has been seen also as the era of the "birth of the clinic"-the development of hospital-based medicine through, perhaps firstly, the advent of the British voluntary hospitals, and later the "revolution" in the Paris hospitals.

Physicians who wrote on puerperal fever identified themselves with what they saw as the ideas of "enlightened" science. They were drawing upon a complex of theories. Reason, based on experience, was claimed by most of the medical writers as the basis of their work. Yet a close reading of the eighteenth- and early-nineteenth-century texts reveals that physicians failed at every turn to extricate themselves from a priori assumptions.

The central controversy in the study of puerperal fever during the later eighteenth century remained firmly grounded in the central nosological issue of whether puerperal fever was fundamentally inflammatory or fundamentally putrid. If inflammatory, the fever was a pathological condition of the blood and circulation, which might have originated in the trauma of labour or in other sources of damage to the uterus or other internal organs. It was a disorder of the blood's composition, or of the rate and force with which the blood made its way through the vessels. Thus, it was believed that the most effective treatment would involve copious bleeding of the patient in the earliest stages of the disease.

If putrid, the fever was caused by acrid or morbific matter in the system, which might have been absorbed from outside, perhaps by contagion or as a result of putrid effluvium, or might simply be the result of the suppression of fluids or of obstructed perspiration. It could be part of a process of decay or mortification, or a manifestation of the body's attempt to throw off dangerous or poisonous matter.

Jannett married George Frederick Field on 13 Oct 1868 in Toronto, Ontario. (George Frederick Field was born on 10 Jun 1839 in England, died on 27 Apr 1926 in #56 Claremont Road, Toronto, Ontario and was buried on 29 Apr 1926 in The Necropolis, Toronto, Ontario.) The cause of his death was Old Age/Hardening of the Arteries.