Earlier this month I took a detour and posted a blog about Whit Stillman’s movie Love and Friendship, which is based on Jane Austen’s novella Lady Susan. With this blog I am returning to the ever-fascinating topic of Regency medicine and specifically to a discussion of miasma. Previously I discussed quinsy, a serious and sometimes fatal throat infection. During the Regency era, quinsy was thought to arise from an obstruction of the perspiration caused by walking into a chilly north wind or sitting near an open window—activities that decreased sweating and had the potential to cause a sore throat.1 Today we know that quinsy is the result of an acute bacterial infection. Here’s another bit of Regency medical moonshine: miasma caused childbed fever.
Regency Doctors Believed Miasma Caused Childbed Fever
Jane Austen was born in 1775. In that same year Dr. John Leake published a book on childbed fever, in which he lamented the current state of medicine regarding this deadly disease:
“There is not, perhaps, any malady…where powerful remedies of every kind have been tried with more diligence or less success.”2
The cause of this often fatal condition was not understood, but he believed, as did most physicians of his day, that childbed fever was partly a consequence of “a distemperature of the air”3 — a miasma. You may recall from my post of May 12th that miasma refers to putrid, noxious, foul-smelling air given off by marshes, swampy areas, rotting garbage, and decaying organic material (including human bodies, both dead and alive). “That women, after delivery, are more disposed to fever at one time than another, according to the constitution of the air, cannot be doubted,” Dr. Leake wrote.4
Symptoms of Childbed Fever
Childbed fever — what today is known as puerperal infections — was often fatal, the mother’s sudden death after delivery made all the more heartbreaking because the fever was unexpected and her newborn child was thriving. The mother’s feverish symptoms usually began on the second or third day after delivery, when both she and her child seemed to be in good health. It invariably started with the mother’s sudden shivering fit, which was the first alarm for the attending physician, surgeon or midwife. This first symptom was followed by others: a fierce headache, restlessness, stomach ache, nausea, and bilious vomiting. Some women complained of having a bitter taste in their mouth. A dull pain in their eyes could be detected, and their countenance was pale.5
Dr. Leake’s Perspective on Childbed Fever
Dr. John Leake was a member of the College of Physicians and well-situated to write about childbed fever. As Physician to London’s Westminster Lying-in Hospital, he lectured on the theory and practice of midwifery, managed obstetrical cases, and had ample opportunity for the “frequent inspection of morbid bodies” (translation: he dissected the dead).6 He took detailed notes on cases, writing down his patients’ symptoms, when the symptoms occurred, how violent the symptoms were, and whether the patients were improving or getting worse.
Because there was much confusion at that time about the principle of contagion, it was easier for Dr. Leake to describe what did not cause childbed fever. Based on the findings of his dissections, he wrote that childbed fever was not caused by absorption of corrupted milk from the breasts; it did not arise from an obstruction of the lochia (the normal vaginal discharge of mucus, tissue, and blood that occurs after delivery); it was not due to inflammation or any morbid condition of the uterus.7 It was a very peculiar disorder, in his opinion, and arose from breathing unwholesome air.8
Dr. White’s Thoughts on Childbed Fever
Some fifteen years after Leake published his book on childbed fever (when Jane Austen was a teenager — what a thought!), the physician Charles White published a fifth edition of his popular book, A Treatise on the Management of Pregnant and Lying-In Women. Dr. White reported similar symptoms in his patients with childbed fever: a shivering fit, followed by severe vomiting; pains in the loins and hips; a belly too tender to touch; a furred, white tongue. The patient was thirsty and hot and her milk and lochia had stopped flowing.9 He believed that many symptoms of childbed fever were due to putrid air:
“A true puerperal fever is originally caused by a putrid atmosphere or too long confinement of the patient in a horizontal position.”10
Unlike his colleague, Dr. White believed the lochia stagnated in the womb, growing acrid in the process and releasing noxious fumes that made the air in the birthing room putrid. This air was breathed in by the new mother and could produce childbed fever. Moreover, having too many people — gossips, presumably — breathing all together in the close birthing room only made matters worse.
Although he placed an emphasis on bad air as the cause of childbed fever, he also identified other factors that contributed to putrid fevers:11
- bad fashions — tight stays, petticoat bindings, the weight of pockets and petticoats
- a sedentary lifestyle, which caused excrements (particularly stools) to be retained
- improper diet, which also caused excrements to be retained
- too much strong liquor
- an overly warm room
- a hot regimen, which included drinking spicy caudle and volatile spirits, taking hot medicines, and the like
- guarding the windows and bed with curtains that excluded fresh air
Dr. White believed bad air contributed to disease in the homes of the poor, in jails, and in hospitals as well as in the luxurious mansions of the aristocracy. In hospitals, the disease hopped from ward to ward via the putrid miasma that lodged in furniture, curtains, and clothes and by the close proximity of the “necessary house” (the latrine or outhouse). Moreover, the nurses who directed the management of lying-in women were responsible for the “most important errors” related to this putrid fever.12
Of course he blamed the nurses! The doctors — those “modern possessors of the art” of midwifery13 — could not possibly contribute to the problem of childbed fever. Ha! The truth of that will be revealed in a later post.
Was Childbed Fever Caused by a Febrile Poison?
A review of several other 18th-century books on midwifery or childbirth, downloaded from Google Books, returned little new information. Mr. Chapman, for example, described several cases in which the midwife had accidentally thrust her hand through the vagina during delivery. One woman died immediately; another died a few days later; a third recovered completely. The fourth experienced “violent Pains in her Body, succeeded by a Putrid Fever, Vomitings, etc.”). Her symptoms sound very like those of childbed fever. The surgeon does not speculate on the etiology of her condition, although he wondered whether she would enjoy perfect health going forward.14
Dr. John Aitken went so far as to list several “remote causes” of childbed fever in his 1785 book on midwifery: febrile poison, heat, cold, moisture, passion. The febrile poison was considered the most powerful and frequently reported remote cause. The proximate cause was an “alteration of the animal structure or compound” produced by the remote causes.15
Confession: I find Dr. Aitken’s description of the proximate cause of childbed fever rather obtuse, but he wasn’t writing for a 21st-century retired nutritionist. He was using terminology that would have been understood by 18th-century doctors. I interpret his comment to mean that one or more of the remote causes (febrile poison, heat, cold, moisture, passion) caused a significant change in the mother’s body or organs (the “animal structure”) or changed the poison itself (the “compound”) in such a way as to produce childbed fever.
Interestingly, his first recommendation for curing childbed fever was to remove the exciting causes, with ventilation being at the top of the list (followed by bathing and cleanliness). Ventilation = air flow. Thus, his proposed cure was to replace foul-smelling air (miasma) with fresh air.
If Miasma Was the Cause … What Was the Cure?
Basically, 18th-century doctors were shooting in the dark. Let’s be honest: Dr. Aitken’s description of the cause of childbed fever is as nebulous as swamp gas. He and his colleagues were trying to build some structure around their understanding of disease processes, but it looks messy and mysterious. Who can blame them? They hadn’t a clue about the real cause of childbed fever. But they did have some ideas on treatments, which we’ll examine in my next blog.
1Buchan, William. Domestic Medicine (Boston, 1811), pp. 199-200.
2Leake, John. Practical Observations on the Child-bed Fever: and also on the Nature and Treatment of Uterine Hemorrhages, Convulsion, and such other Acute Diseases (London, 1775), p. 7 (PDF p. 12).
3Ibid., p. 98 (PDF p. 103).
4Ibid., p. 22 (PDF p. 27).
5Ibid., pp. 40-41 (PDF pp. 45-46).
6Ibid., p. 9 (PDF p. 14).
7Ibid., p. 10 (PDF p. 15).
8Ibid., pp. 32-33 (PDF pp. 37-38).
9White, Charles. A Treatise on the Management of Pregnant and Lying-In Women (London, 1791), pp. 286-287 (PDF pp. 312-313).
10Ibid., pp. 24-25 (PDF pp. 50-51).
11Ibid., pp. 1-7 (PDF pp. 27-33).
12Ibid., p. 8-12 (PDF pp. 34-38).
13Ibid., p. 12 (PDF p. 38).
14Chapman, Edmund. A Treatise on the Improvement of Midwifery; Chiefly with Regard to the Operation, To which are added, Fifty-seven CASES (London, 1759), pp. 169-170 (EPUB edition) or pp. 199-200 (PDF pp. 210-211) in the print edition.
15Aitken, John. Principles of Midwifery or Puerperal Medicine (Edinburgh, 1785), pp. 273-277 (EPUB edition).