The Power to Terrify: Eclampsia in 19th-Century American Practice

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PRINCIPLES & PRACTICE

The Power to Terrify: Eclampsia in 19th-Century American Practice Sandra W. Moss, MD

Throughout the 19th century, eclampsia was among the most dreaded complications of pregnancy. Conflicts arose over proposed etiologies and therapeutic modalities. Bloodletting and other harsh therapies reflected the prevailing humoral, neurovascular, and toxicologic theories. The role of untrained and professional nurses in the lying-in room of an eclamptic woman emerges from the literature of the time. An appreciation of the history of eclampsia provides context for the modern obstetric nurse. JOGNN, 31, 514–520; 2002. DOI: 10.1177/088421702237733 Keywords: Eclampsia—History of medicine (19th century, United States)—History of nursing— History of obstetrics—Phlebotomy—Toxemia of pregnancy Accepted: November 2001 Every 19th-century woman was acquainted with death in childbirth. “Nine months of gestation could mean nine months to prepare for death. . . . Women spent considerable time worrying and preparing for the probability of not surviving their confinements” (Leavitt, 1986, p. 20). Among the most dreaded complications of pregnancy were “flooding” (hemorrhage), puerperal fever, and eclamptic convulsions. Samuel Bard, professor of midwifery and the practice of medicine at King’s College in New York, considered eclamptic convulsions “among the most terrifying and dangerous symptoms of parturition” (Bard, 1817, p. 230). Nineteenth-century medical students received little or no practical instruction in obstetrics, and many graduated without conducting a normal delivery. Through textbooks, journal articles, professional meetings, and occasional postgraduate courses, 514 JOGNN

innovations in obstetric theory and practice trickled down from the major urban teaching centers in Europe and the United States to small-town and rural physicians, midwives, and nurses. Attended by female relatives or neighbors, women gave birth with the help of a nurse or midwife, trained or untrained, experienced or inexperienced, as circumstances permitted. Although informally trained nurses left few written records, their role in managing eclampsia may be surmised from instruction manuals of the day. During the late 19th century, attendance by women with formal training in obstetric nursing became an option for some parturients (Rinker, 2000). This article presents a bedside portrait of fullblown eclampsia in the years before routine prenatal care, blood pressure monitoring, magnesium sulfate, antisepsis, and safe options for timely delivery. Etiologic theories and resulting therapeutic rationales will be examined as they evolved during the 19th century. The role of the trained and untrained nurse at the bedside will be examined. This article will provide the modern obstetric nurse with historical perspective on a complication of pregnancy that has not quite lost its power to terrify.

A Terrifying Malady In 1900, less than 5% of births took place in maternity or lying-in hospitals (Wertz & Wertz, 1977). Childbirth occurred primarily in the parturient’s home. Physicians brought new theories, medications, and procedures to the bedside. They also brought their own fears, inexperience, and uncertainties. Most general practitioners were illequipped to deal with an obstetric crisis such as Volume 31, Number 5

eclampsia. As one historian observed, “Although every general practitioner was required to be an obstetrician, almost none acquired any practical experience before receiving his diploma” (Speert, 1963, p. 80). Physicians wrote about their own fears when called to attend a woman with eclampsia (Sproul, 1892); nurses surely shared those emotions. The first reported case of eclampsia in America appeared in the diary of judge Samuel Sewall of Massachusetts. On December 12, 1685, he wrote: “Esther Kein at her Time, falls into Convulsion Fits, and dyes last Thorsday [sic]; No likelihood of the Child’s being born” (Sewall, 1973, p. 87). In his 1833 Compendious System of Midwifery, William P. Dewees of the University of Pennsylvania referred to eclampsia as “one of the most ferocious complaints in the whole catalogue of human diseases” (Dewees, 1833, p. 460). In 1851, Charles D. Meigs of Jefferson Medical College in Philadelphia told his students, Gentlemen: Among the numerous sources of that anxiety to which the practitioner of midwifery is exposed, is the dread that he often feels lest his pregnant or parturient patient should be attacked with eclampsia, or puerperal convulsions . . . a malady . . . so horrible in appearance, so deadly in its tendency, so embarrassing sometimes in its treatment, that, although, as I said, it is not met with every day, it is solicitously expected. (Meigs, 1851, p. 653) When a laboring woman began convulsing, nurses, midwives, and physicians requested consultation whenever possible. In 1912, newly trained nurses were instructed: “Should the attending physician live too far away or be delayed in coming, the nearest physician should be sent for” (Fullerton, 1912, p. 69). Outside larger cities, assistance often was hours away. Between 1866 and 1890, in rural Flemington, NJ, Obadiah H. Sproul encountered six cases of “this dreaded accident,” with one maternal death, in his 1,500 deliveries. Sproul observed, I know of few situations more appalling than to be in attendance upon a case of confinement, probably miles from any one who could be summoned to your assistance, when the occurrence of a violent convulsion alarms all in attendance. The life of the parturient is at stake and what is to be done must be done promptly. (pp. 140-141) Incidence and mortality estimates vary. According to an 1863 English textbook, the incidence of eclampsia was about 1 in 600 pregnancies, with a mortality rate of 20% to 25% (Churchill, 1863). A review of New York City records from 1867 to 1875 revealed that deaths from eclampsia occurred in 1 of 700 pregnancies (Lusk, 1899, p. 567). Martha Ballard, a Massachusetts midwife, attended approximately 800 deliveries between September/October 2002

1785 and 1812. Of the five maternal deaths she recorded, one occurred in a woman with “fitts” (Ulrich, 1990, p. 192). During the 18th century, the term “eclampsia parturientium” was introduced to distinguish convulsions during pregnancy from other, nonspecific convulsive disorders (Chesley, 1972). Although a cluster of premonitory signs

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n his 1833 Compendious System of Midwifery, Dewees referred to eclampsia as “one of the most ferocious complaints in the whole catalogue of human diseases.”

and symptoms could be identified in some women, eclamptic convulsions often occurred without warning pre-, intra-, or postpartum. Prenatal care was the exception rather than the rule; a physician’s first visit to the patient often was precipitated by the onset of convulsions. Each convulsion might last from 5 to 30 minutes, recurring at intervals for a day or more. A Philadelphia physician recorded “convulsive paroxysms” approximately every 20 minutes for 17 hours in one patient (Griscom, 1856, p. 546).

Obstetric Nursing In the 1845 American edition of a popular British handbook, The Domestic Management of the Sick-Room, young middle-class women were instructed in the duties of home nursing. The home nurse was expected to administer medications, douches, and enemas. She prepared, applied, and attended to blistering plasters, hot and cold applications, poultices, and dressings. A brief section on childbirth offered guidelines for preparing the lying-in chamber, including “articles for blood-letting.” The home nurse assisted the physician by applying compresses and dressings after phlebotomy (Thomson, 1845, p. 162). As the number of nursing schools in the United States expanded from a handful in the 1870s to some 400 by end of the 19th century, training in obstetrics became a standard component of the curriculum. Student nurses were viewed by hospital administrators and physicians as an inexpensive, compliant, trained, and disciplined workforce; upon graduation, most left the hospital to become private-duty nurses (Rosenberg, 1987). In most schools, limited formal instruction was overshadowed by practical experience on the wards. For example, in 1889, the Brooklyn Training School for Nurses offered 26 lectures by physicians, only one of which was devoted to obstetrics (Brooklyn Training School for Nurses, 1889). Lying-

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in and women’s hospitals in the larger cities had advantages over small nursing schools in community hospitals. The Training School for Nurses at the Women’s Hospital in Philadelphia observed in its 1876 report: “In obstetrical nursing . . . The Woman’s Hospital offers especial advantages to nurse-students” (Woman’s Hospital of Philadelphia, 1876, p. 4). Students from a number of nursing schools in New York rotated for 3 months through the Sloane Maternity Hospital (founded 1887) in Manhattan (Speert, 1980). With the professionalization of nursing late in the 19th century, nurse educators such as Clara S. Weeks, a graduate of the New York Hospital Training School, began to establish guidelines for nursing care. In 1885, Weeks published A Text-Book of Nursing (For the Use of Training Schools, Families, and Private Students). In addition to the usual duties of the lying-in room, the trained nurse administered medications by the oral, rectal, topical, and subcutaneous routes. She gave enemas and douches and inserted urinary catheters. A nurse trained in obstetrics was expected to perform vaginal examinations to determine the progress of labor and to conduct normal deliveries, as necessary, “before medical aid can arrive. . .” (Weeks, 1885, p. 261). In lengthy or “tedious” labors, as physicians were called to other patients, nurses were expected to observe the patient and carry out ongoing treatments. Case records kept by physicians often revealed that the newborn was delivered prior to the physician’s arrival. Such annotations imply that the newborn simply appeared; no doubt nurses conducted many normal and complicated deliveries. A nurse also might be called upon to administer anesthesia in the home. Home nursing required special skills. “At an operation in a private house, the nurse will be called upon to do a good many things which in a hospital fall to the lot of the junior surgeons, such as administering the anesthetic” (Weeks, 1885, p. 201). Principles of antisepsis or asepsis were as foreign to nurses as they were to physicians until the latter decades of the 19th century. Many women who survived eclampsia later died of puerperal sepsis, a complication of intrauterine manipulation with unclean hands or forceps. At the end of the century, trained nurses began to maintain antiseptic conditions at the bedside (Rinker, 2000).

19th Century Theories of Eclampsia Eclampsia has been called “the disease of theories,” and remains so today (Chesley, 1978, p. 445). All aspects of eclampsia have been contested. During the early 19th century, explanations centered on vague neurologic theories and the idea of vascular plethora, an overabundance of blood often ascribed to retention of the menses during pregnancy. Plethora was thought to lead to cerebral congestion and eclamptic convulsions in susceptible women. 516 JOGNN

In 1843, John Charles Lever of London contributed to the understanding of eclampsia by linking proteinuria to eclampsia (Lever, 1843). Debates about the interrelationships between proteinuria, renal function, and eclampsia followed. Attendees at the second meeting of the American Gynecological Society in 1877 were informed by Professor Otto Spiegelberg of Germany that the kidneys of eclamptics often looked pale and bloodless at autopsy, suggesting that spasm of small renal vessels was the likely mechanism (Speert, 1980; Spiegelberg, 1878). Others believed that eclampsia occurred only in women with underlying renal disease and was, in effect, a form of uremia or kidney failure (Chesley, 1978). The concept of a toxemia of pregnancy was based on the idea that convulsions arose from retention of urea by the affected kidneys. During the second half of the 19th century, a search for the postulated toxin of eclampsia focused on metabolic products, such as carbonate of ammonia, creatinine, bilirubin, lactic acid, globulins, unshed menstrual toxins, ferments of placental origin, and end products of fetal catabolism. Trained nurses were instructed in testing the urine for albumin. Elizabeth Xander, a member of the 1898 nursing class at Presbyterian Hospital in Philadelphia, recorded in her notebook the obstetric lecturer’s instructions for boiling urine and observing for the albuminous precipitate (Xander, 1898). Blood pressure measurement was not introduced into clinical practice until the first decade of the 20th century (Chesley, 1978).

The Therapies of Eclampsia Eighteenth-century European obstetric textbooks contained discussions of treatment for eclampsia, but no obstetric textbooks were published in the United States until the early 19th century. In general and obstetric practice, most American physicians favored the harsh remedies popularized by Benjamin Rush of Philadelphia in the late-18th century. The therapeutic armamentarium was based primarily on “heroic” therapies designed to deplete the overstimulated system. Although theories about eclampsia evolved rapidly, most of the therapies popular in 1800 lingered throughout the century. In 1842, Joseph Warrington, director of the Philadelphia Lying-In Charity, published The Obstetric Catechism, a handbook of obstetric practice for use at the bedside. On eclampsia, Warrington (1842) advised, Bleed, twenty, thirty, forty or fifty ounces, until you empty the blood vessels and relieve the plethora; then resort to the usual treatment for apoplexy—cold to the head—mercurial cathartics, &c. [etc.]—active enemata—cups and leeches may sometimes be employed after one free bleeding. When vascular depletion has been carried sufficiently far, sinapisms, blisters, &c., may be Volume 31, Number 5

used as revulsives or counter-irritants. When the congestion is thus relieved, opium or camphor may be given in combination with calomel and ipecacuanha, and after the system shall have been properly reduced, and the disease controlled, mild tonics, as valerian, &c., may be administered. (p. 325) Physicians, nurses, and patients viewed health and disease within the same framework. Illness reflected a disequilibrium or imbalance in the patient’s system rather than a specific disease with a defined etiology. Like the patients she treated, the nurse understood and usually accepted the theoretic basis for heroic therapies. As Charles Rosenberg, a social historian of medicine, observed, “The effectiveness of the system hinged to a significant extent on the fact that all the weapons in the physician’s normal armamentarium worked—‘worked,’ that is, by providing visible and predictable physiological effects” (Rosenberg, 1979, p. 8). In a cataclysmic disequilibrium such as eclampsia, vigorous bleeding, blistering, and purging were seen as the only course if there was to be any hope of saving the mother or newborn.

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loodletting was the logical therapy for eclampsia; it fit well with a wide spectrum of etiologic theories.

Bloodletting Bloodletting, commonly referred to as “the use of the lancet,” was prescribed during the first half of the 19th century for many complaints of pregnancy and complications of labor (Siddall, 1980). Bloodletting was the logical therapy for eclampsia; it fit well with a wide spectrum of etiologic theories including surcharged vessels, nervous system irritability, renal failure, and the newer theories of a toxemia specific to pregnancy. Those who favored a toxemic or uremic etiology reasoned that phlebotomy removed a portion of the postulated circulating toxins. Textbooks advised that “the pulse must be reduced into a state of mellowness and softness before the arm is allowed to be tied up” (Churchill, 1863, p. 477). Patients were bled “largely” or “to syncope.” Not only was blood taken from an arm vein to reduce the general plethora, but an eclamptic patient might also be bled from the jugular vein or temporal artery, the superficial vessels nearest the engorged brain. Leeching and dry cupping (the application of evacuated glass suction cups) were alternative methods of bloodletting, often used over local areas of inflammation. Leeches, applied to the skin over the presumed site of inflammation (usually the temples), drank September/October 2002

their fill before dropping off. Nursing students were expected to learn these procedures (Weeks, 1885). Wet cupping was performed by a physician and involved the application of the evacuated glass cups over small skin incisions. Nurses were not expected to perform phlebotomy. By the middle of the 19th century, some authorities began to question the practice of vigorous phlebotomy, although most continued to support modest bloodletting in difficult cases. Wrote one critic, “The constant teaching of the books, combined with the absence of positive knowledge of the true seat and etiology of the disease, has led to the blind and indiscriminate routine of bleeding every poor patient perchance to,—I had almost said to death,—or perchance to life, as chance alone decides, the chief guide of practice being the continuation or cessation of the fits. . . . Bleed is the rule, absolute and imperative,—bleed,—bleed,—no matter what the condition of the patient” (Lindsley, 1858, p. 601). Fordyce Barker, professor of midwifery at the Bellevue Hospital Medical College, disagreed. It was “chiefly in dreadful convulsions that it [bloodletting] does most good,” wrote Barker. There was “no remedy so swift in uraemia, as venesection” (Barker, 1871, p. 3).

Local Measures Sinapisms, irritant plasters applied over areas of inflammation to produce counterirritation, were a significant component of 19th-century therapeutics. Crushed mustard seeds, mustard oil, and cantharides (Spanish fly) were the usual blistering agents. Serous fluid or pus oozing from the blisters was believed to be toxic matter drawn away from diseased internal organs. In eclampsia, sinapisms usually were applied to the shaved scalp or the back of the neck. In most textbooks, ice, cold water, or cooling lotions to the head also were recommended to reduce inflammation and sedate the nervous centers. Professor Meigs of Philadelphia was dogmatic: “The head should be kept cool. This cannot be properly done if the patient have [sic] a great quantity of hair. The hair, then, ought to be sacrificed . . . . an objection will never be made when the physician speaks with the proper tone and authority” (Meigs, 1851, p. 665).

Purging Nineteenth-century physicians, who often referred to the excretory systems as the emunctories, believed that excretion through one system could relieve pressure on another. Purging was a dominant feature of medical therapeutics in the United States. In eclampsia, purging offered relief of surcharged vessels and an overstimulated system, aided in the excretory work of the kidney, rid the body of urea and other toxins, removed local irritations in the gastrointestinal tract that might irritate the uterus,

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and encouraged labor. For example, calomel (chloride of mercury) was considered a virtual panacea, widely used for most medical conditions, including eclampsia. Modest doses caused salivation (ptyalism) and violent diarrhea. Prolonged administration led to severe inflammation, erosion, or necrosis of the gums and loosening or loss of teeth. Jalap and croton oil, used alone or with calomel, were equally drastic cathartics. Diaphoretics, referred to as sudorifics, also were used to relieve stress on the overworked kidney. Some authorities recommended hot baths or warm wet sheets to induce perspiration. Late in the century, jaborandi or its active component, pilocarpine, enjoyed brief popularity. Within minutes of oral or hypodermic administration, the patient became flushed and diaphoretic; bronchial secretions increased dramatically. Fatalities from excessive pulmonary secretions and bronchospasm soon led to abandonment of pilocarpine therapy in eclampsia.

Anesthetics and Drug Therapies The first use of anesthetic gas in labor was attributed to James Simpson of Edinburgh in 1847. Almost immediately, ether and chloroform were tried in the treatment of eclampsia. For example, in 1847, ether was used successfully for “terrific puerperal convulsions” in a Pennsylvania woman (Clark, 1847, p. 83). In 1849, a Newark physician first bled his eclamptic patient and then left to “procure chloroform, (which though a new agent, I meant to use) and forceps . . . and the able assistance of my esteemed friend Dr. Abram Coles, whose opportunities for witnessing the operation of chloroform in the European Hospitals have been very great” (Dougherty, 1849–1850, p. 175). Laudanum (tincture of opium or opium in wine) was commonly used for a range of medical problems. Morphine injections were widely used after the invention of the hypodermic syringe late in the 19th century. An experienced practitioner observed in 1879: “not a few of us have learned that it [opium] is a blessed remedy in the disease under consideration [i.e., eclampsia], and fulfills its indication with the same certainty and safety as chloroform” (Oakley, 1879, p. 71). Chloral hydrate, introduced in 1869, quickly became popular in labor and eclampsia, as did potassium bromide, recognized by the middle of the 19th century as a sedative and nervous system depressant. It has been remarked that the drugs used in eclampsia “would include nearly all in the older pharmacopoeias” (Chesley, 1984, p. 808). Veratrum viride tincture had been used for centuries as a cardiac tonic and counterirritant in neuralgia. After 1860, obstetricians began to take advantage of veratrum’s new reputation as an arterial sedative (Chesley, 1978). Drugs, such as valerian, classified loosely as vascular and nervous system antispasmodics, also were recommended. On the basis of the theory 518 JOGNN

that retained urea decomposed to ammonium carbonate, which in turn caused the convulsions, some authorities advised the administration of tartaric acid, lemon juice, or benzoic acid (Braun, 1858).

The Question of Delivery Two philosophical viewpoints existed regarding intervention in the natural course of labor in the patient with eclampsia. Warrington’s 1842 handbook, aimed at the general practitioner attending patients at home, advised: “Attend to the convulsions alone and allow the uterus to take care of itself. This it will usually do, if the tranquility of the nervous and general muscular system can be restored.” Hastening delivery was to be avoided unless “all the usual means of treatment have been fully employed” (Warrington, 1842, p. 325). Later in the century, however, some authorities stressed prompt delivery. An 1899 textbook advised, “As convulsions which occur after the advent of labor have a tendency to recur so long as the labor continues, and in the larger proportion of cases ceases after the birth of the child, every obstetrical resource compatible with the safety of the mother should be employed to hasten delivery” (Lusk, 1899, p. 580). In home practice, options were limited; bold interventions often resulted in disaster for mother and fetus. At urban hospitals, more radical measures were possible, but mortality rates remained high. It was generally agreed that labor should not be induced in the patient with seizures who was not yet in active labor; in such cases, medical therapy was advised until labor began naturally. Common interventions in labor included the application of low forceps, manual rupture of the membranes through a partly dilated cervix, high forceps applied within the uterine cavity, and internal podalic version and extraction by the feet. Controversies arose in connection with the advisability, timing, and means of dilating the cervix by “art” and thus speeding natural labor. Various procedures were developed for accouchement forcé, a term which referred to forcible dilatation or incision of the intact or partially dilated cervix followed by immediate delivery. Perforation of the skull followed by piecemeal delivery of the cranium using the “crochet” (a blunt hook) was resorted to in undeliverable cases. If the head was too high, and the convulsions “be such as to make us despair of the woman’s recovery . . . it may be necessary, and perhaps justifiable, to have recourse to the perforator and crochet” (Bard, 1817, p. 236). Such destructive procedures remained in use throughout the 19th century. Specialized cranioclasts and cephalotribes were used in hospital practice. At the end of the century, so-called vaginal cesarean section, in which deep surgical incisions were made in the partially dilated cervix, was common in Europe. AbdomVolume 31, Number 5

inal cesarean section remained a rarely performed, highrisk procedure, with a mortality rate of about 50%. As yet unknown in the United States was “expectant treatment,” introduced in Russia during the late 1890s, which relied on heavy sedation, observation by trained nurses, and minimal sensory stimulation of the woman with eclampsia.

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n appreciation of the history of eclampsia provides context for the modern obstetric nurse. Bedside nursing of the patient with full-blown eclampsia is no less challenging today than it was in 1885.

Conclusion Eclampsia in the pregnant 19th-century woman was frightening. At a time when suffering and death in childbirth were common, physicians expressed anxiety about eclampsia. Midwives and nurses surely experienced similar emotions. Throughout the 19th century, therapies for eclampsia reflected evolving etiologic theories and prevailing medical practices. The therapeutic measures that made sense in 19th-century obstetric practice in the United States appear useless, cruel, and dangerous to a modern observer. Major improvements in maternal and newborn outcome would only come with 20th-century innovations, such as routine prenatal care, blood pressure monitoring, and the introduction of magnesium sulfate therapy. An appreciation of the history of eclampsia provides context for the modern obstetric nurse. Bedside nursing of full-blown eclampsia is no less challenging today than it was in 1885, when Clara Weeks reminded nursing students that “it is only within a comparatively short time that the importance of special and thorough training for such work has become generally appreciated” (Weeks, 1885, p. 11). Today, more than a century later, eclampsia remains a puzzling disorder. Its etiology is uncertain and therapy, though effective, is empiric. The understanding and management of eclampsia continue to evolve.

Acknowledgments Research assistance by archivist Lois Densky-Wolff, Special Collections, University of Medicine and Dentistry of New Jersey, and curator Gail E. Farr and administrative assistant Betsy Weiss, Center for the Study of the History of Nursing at the University of Pennsylvania, is gratefully acknowledged. September/October 2002

REFERENCES Bard, S. (1817). A compendium of the theory and practice of midwifery (4th ed.). New York: Collins. Barker, F. (1871). Blood-letting as a therapeutic resource in obstetric medicine. Medical and Surgical Reporter, 24, 1-4. Braun, C. (1858). The uraemic convulsions of pregnancy, parturition, and childbed. New York: Samuel S. & William Wood. Brooklyn Training School For Nurses. (1889). Ninth annual report. Brooklyn: George Tremlett. Charles E. Rosenberg Collection, Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania. Chesley, L. (1972). The origin of the word ‘eclampsia.’ Obstetrics and Gynecology, 39, 802-804. Chesley, L. (1978). Hypertensive disorders of pregnancy. New York: Appleton-Century-Crofts. Chesley, L. (1984). History and epidemiology of preeclampsiaeclampsia. Clinical Obstetrics and Gynecology, 27, 801-820. Churchill, F. (1863). On the theory and practice of midwifery (with additions by D. Francis Condie): A new American, from the fourth corrected and enlarged English edition. Philadelphia: Blanchard & Lea. Clark, J. (1847). Abstract of a report on the inhalation of ether in labor, by Jonathan Clark, M.D., of Lower Merion, near Philadelphia, taken from The Medical Examiner, of October, 1847. New Jersey Medical Reporter, 1, 83-84. Dewees, W. (1833). Compendious system of midwifery (6th ed.). Philadelphia: Carey, Lea & Blanchard. Dougherty, A. (1849-1850). Case of puerperal convulsions. New Jersey Medical Reporter, 2, 174-176. Fullerton, A. (1912). A handbook of obstetric nursing for nurses, students, and mothers (7th ed.). Philadelphia: P. Blakiston. Griscom (1856). Etherization in puerperal convulsions. In Summary of the Transactions of the College of Physicians of Philadelphia. New Jersey Medical Reporter, 9, 546. Leavitt, J. (1986). Brought to bed: Child-bearing in America, 1750-1950. New York: Oxford University Press. Lever, C. (1843). Cases of puerperal convulsions. Guys Hospital Reports (2nd series), 1, 495-517. Lindsley, C. (1858). Report of an address to the 1857 meeting of the Connecticut Medical Society. New Jersey Medical Reporter, 11, 598-602. Lusk, W. (1899). The science and art of midwifery. New York: D. Appleton. Meigs, C. (1851). Woman: Her disease and remedies: A series of letters to his class (2nd ed.). Philadelphia: Lea & Blanchard. Oakley, L. (1879). Puerperal convulsions. Transactions of the Medical Society of New Jersey, pp. 50-79. Rinker, S. (2000). To cultivate a feeling of confidence: The nursing of obstetric patients, 1890-1940. Nursing History Review, 8, 117-142. Rosenberg, C. (1979). The therapeutic revolution: Medicine, meaning, and social change in nineteenth-century America. In M. Vogel & C. Rosenberg (Eds.), The therapeutic revolution (pp. 3-25). Philadelphia: University of Pennsylvania. Rosenberg, C. (1987). The care of strangers: The rise of America’s hospital system. New York: Basic Books. Sewall, S. (1973). The diary of Samuel Sewall 1674-1729 (Vol. 1; edited by M. Halsey Thomas). New York: Farrar, Straus & Giroux.

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Siddall, A. (1980). Bloodletting in American obstetric practice. Bulletin of the History of Medicine, 54, 101-110. Speert, H. (1963). The Sloane Hospital chronicle: A history of the department of obstetrics and gynecology of the ColumbiaPresbyterian Medical Center. Philadelphia: F. A. Davis. Speert, H. (1980). Obstetrics and gynecology in America: A history. Baltimore: Waverly. Spiegelberg, O. (1878). The pathology and treatment of puerperal eclampsia. Transactions of the American Gynecological Society, 2, 161-174. Sproul, O. (1892). Record of obstetric practice. Transactions of the Medical Society of New Jersey, pp. 135-145. Thomson, A. (1845). The domestic management of the sickroom. Philadelphia: Lea & Blanchard. Ulrich, L. (1990). A midwife’s tale: The life of Martha Ballard, based on her diary, 1875-1812. New York: Alfred A. Knopf. Warrington, J. (1842). The obstetric catechism. Philadelphia: J. D. Auner. Weeks, C. (1885). A text-book of nursing, for the use of training schools, families, and private students. New York: D. Appleton. Wertz, R., & Wertz, D. (1977). Lying-in: A history of childbirth in America (expanded ed.). New Haven, CT: Yale University Press.

Woman’s Hospital of Philadelphia. (1876). Report of training school for nurses. Woman’s Hospital of Philadelphia Records, 1858-1976. Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania (MC 89, Box 3, Series 2, Folder 2). Philadelphia: Author. Xander, E. (1898). Lecture notebook, Training School for Nurses at the Presbyterian Hospital in Philadelphia. Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania (MC 35, Series 2, Box 113, Folder 314).

Sandra W. Moss is a retired attending physician, St. Peter’s University Hospital, New Brunswick, NJ, and a retired clinical associate professor of medicine, Robert Wood Johnson Medical School, New Brunswick, NJ. Currently she is in the Graduate Program in the History of Technology, Environment, and Medicine, Federated Department of History, New Jersey Institute of Technology, University Heights, Newark, NJ 07102-1982. Address for correspondence: Sandra W. Moss, MD, 33 Eggert Avenue, Metuchen, NJ 08840. E-mail: [email protected]. edu.

JOGNN Reviewer Panel: 2002 Erin Anderson, RN, MSN Debbie Askin, RN, MN Rebecca Attenborough, RN, MN Linda Bell, RN, PhD Lynn Clark Callister, RN, PhD Sandra K. Cesario, RNC, PhD Andrea Christian, RN, MS, CNS Elizabeth G. Damato, RNC, PhD Anita DeWeese, RNC, MSN Susan Fekety, MSN, CNM Robin G. Flescher, RNC, CNS, MSN Eileen R. Fowles, RNC, PhD Karen Harris, RNC, MSN Diane Holditch-Davis, RN, PhD, FAAN Lori Jackson, RNC, NNP Sheryd J. Jackson, RNC, MS, WHNP Linda J. Juretschke, RNC, PhD, NNP Anne Katz, RN, PhD Colleen Keenan, WHNP, PhD, FNP Virginia L. Kinnick, RN, CNM, EdD Cheryl P. Kish, EdD, WHNP Linda J. Kobokovich, RNC, MScN Lynne P. Lewallen, RN, PhD M. Cynthia Logsdon, DNS, ARNP Laura Mahlmeister, RN, PhD

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Louise K. Martell, RN, MN, PhD Linda J. Mayberry, RN, PhD Patricia R. McCartney, RNC, PhD Rebecca S. Miltner, RNC, MS Kristen Montgomery, RN, PhD Anne A. Moore, RNC, MSN Mary R. Nichols, RN, CS, FNP, PhD Susan A. Orshan, RNC, PhD Kristen D. Priddy, RNC, MSN, CNS Rebecca B. Saunders, RNC, PhD Maureen Shogan, RNC, MN Mary Ann Stark, RNC, PhD Deborah Steward, RN, PhD Marilyn Stringer, PhD, CRNP, RDMS Patricia Dunphy Suplee, CS, RNC, PhD Rosemary Theroux, RNC, PhD Suzanne Thoyre, RN, PhD Nancy Townsend, RN, MSN Leona VandeVusse, CNM, PhD Terrie Watkins, RNC, CNM, MSN Kathryn Wekselman, RN, PhD Candy Wilson, RNC, MSN Margaret R. Wood, RN, PhD Ruth York, RN, PhD, FAAN

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