The Harvard Classics Part 18

The practical point to be ill.u.s.trated is the following: THE DISEASE KNOWN AS PUERPERAL FEVER IS SO FAR CONTAGIOUS AS TO BE FREQUENTLY CARRIED FROM PATIENT TO PATIENT BY PHYSICIANS AND NURSES.

Let me begin by throwing out certain incidental questions, which, without being absolutely essential, would render the subject more complicated, and by making such concessions and a.s.sumptions as may be fairly supposed to be without the pale of discussion.

1. It is granted that all the forms of what is called puerperal fever may not be, and probably are not, equally contagious or infectious. I do not enter into the distinctions which have been drawn by authors, because the facts do not appear to me sufficient to establish any absolute line of demarcation between such forms as may be propagated by contagion and those which are never so propagated. This general result I shall only support by the authority of Dr. Ramsbotham, who gives, as the result of his experience, that the same symptoms belong to what he calls the infectious and the sporadic forms of the disease, and the opinion of Armstrong in his original Essay. If others can show any such distinction, I leave it to them to do it. But there are cases enough that show the prevalence of the disease among the patients of a single pract.i.tioner when it was in no degree epidemic; in the proper sense of the term. I may refer to those of Mr.

Roberton and of Dr. Peirson, hereafter to be cited, as examples.

2. I shall not enter into any dispute about the particular MODE of infection, whether it be by the atmosphere the physician carries about him into the sick-chamber, or by the direct application of the virus to the absorbing surfaces with which his hand comes in contact. Many facts and opinions are in favour of each of these modes of transmission. But it is obvious that, in the majority of cases, it must be impossible to decide by which of these channels the disease is conveyed, from the nature of the intercourse between the physician and the patient.

3. It is not pretended that the contagion of puerperal fever must always be followed by the disease. It is true of all contagious diseases that they frequently spare those who appear to be fully submitted to their influence. Even the vaccine virus, fresh from the subject, fails every day to produce its legitimate effect, though every precaution is taken to insure its action. This is still more remarkably the case with scarlet fever and some other diseases.

4. It is granted that the disease may be produced and variously modified by many causes besides contagion, and more especially by epidemic and endemic influences. But this is not peculiar to the disease in question. There is no doubt that smallpox is propagated to a great extent by contagion, yet it goes through the same records of periodical increase and diminution which have been remarked in puerperal fever. If the question is asked how we are to reconcile the great variations in the mortality of puerperal fever in different seasons and places with the supposition of contagion, I will answer it by another question from Mr. Farr's letter to the Registrar-General. He makes the statement that "FIVE die weekly of smallpox in the metropolis when the disease is not epidemic," and adds, "The problem for solution is, Why do the five deaths become 10, 15, 20, 31, 58, 88, weekly, and then progressively fall through the same measured steps?"

5. I take it for granted that if it can be shown that great numbers of lives have been and are sacrificed to ignorance or blindness on this point, no other error of which physicians or nurses may be occasionally suspected will be alleged in palliation of this; but that whenever and wherever they can be shown to carry disease and death instead of health and safety, the common instincts of humanity will silence every attempt to explain away their responsibility.

The treatise of Dr. Gordon, of Aberdeen, was published in the year 1795, being among the earlier special works upon the disease. A part of his testimony has been occasionally copied into other works, but his expressions are so clear, his experience is given with such manly distinctness and disinterested honesty, that it may be quoted as a model which might have been often followed with advantage.

"This disease seized such women only as were visited or delivered by a pract.i.tioner, or taken care of by a nurse, who had previously attended patients affected with the disease."

"I had evident proofs of its infectious nature, and that the infection was as readily communicated as that of the smallpox or measles, and operated more speedily than any other infection with which I am acquainted."

"I had evident proofs that every person who had been with a patient in the puerperal fever became charged with an atmosphere of infection, which was communicated to every pregnant woman who happened to come within its sphere. This is not an a.s.sertion, but a fact, admitting of demonstration, as may be seen by a perusal of the foregoing table"--referring to a table of seventy-seven cases, in many of which the channel of propagation was evident.

He adds: "It is a disagreeable declaration for me to mention, that I myself was the means of carrying the infection to a great number of women." He then enumerates a number of instances in which the disease was conveyed by midwives and others to the neighboring villages, and declares that "these facts fully prove that the cause of the puerperal fever, of which I treat, was a specific contagion, or infection, altogether unconnected with a noxious const.i.tution of the atmosphere."

But his most terrible evidence is given in these words: "I ARRIVED AT THAT CERTAINTY IN THE MATTER THAT I COULD VENTURE TO FORETELL WHAT WOMEN WOULD BE AFFECTED WITH THE DISEASE, UPON HEARING BY WHAT MIDWIFE THEY WERE TO BE DELIVERED, OR BY WHAT NURSE THEY WERE TO BE ATTENDED, DURING THEIR LYING-IN: AND ALMOST IN EVERY INSTANCE MY PREDICTION WAS VERIFIED."

Even previously to Gordon, Mr. White, of Manchester, had said: "I am acquainted with two gentlemen in another town, where the whole business of midwifery is divided betwixt them, and it is very remarkable that one of them loses several patients every year of the puerperal fever, and the other never so much as meets with the disorder"--a difference which he seems to attribute to their various modes of treatment. [Footnote: On the Management of Lying-in Women. p. 120.]

Dr. Armstrong has given a number of instances in his Essay on Puerperal Fever of the prevalence of the disease among the patients of a single pract.i.tioner. At Sunderland, "in all, forty- three cases occurred from the 1st of January to the 1st of October, when the disease ceased; and of this number, forty were witnessed by Mr. Gregson and his a.s.sistant, Mr. Gregory, the remainder having been separately seen by three accoucheurs."

There is appended to the London edition of this Essay a letter from Mr. Gregson, in which that gentleman says, in reference to the great number of cases occurring in his practice, "The cause of this I cannot pretend fully to explain, but I should be wanting in common liberality if I were to make any hesitation in a.s.serting that the disease which appeared in my practice was highly contagious, and communicable from one puerperal woman to another." "It is customary among the lower and middle ranks of people to make frequent personal visits to puerperal women resident in the same neighborhood, and I have ample evidence for affirming that the infection of the disease was often carried about in that manner; and, however painful to my feelings, I must in candour declare that it is very probable the contagion was conveyed, in some instances, by myself, though I took every possible care to prevent such a thing from happening the moment that I ascertained that the distemper was infectious." Dr.

Armstrong goes on to mention six other instances within his knowledge, in which the disease had at different times and places been limited, in the same singular manner, to the practice of individuals, while it existed scarcely, if at all, among the patients of others around them. Two of the gentlemen became so convinced of their conveying the contagion that they withdrew for a time from practice.

I find a brief notice, in an American journal, of another series of cases, first mentioned by Mr. Davies, in the "Medical Repository." This gentleman stated his conviction that the disease is contagious.

"In the autumn of 1822 he met with twelve cases, while his medical friends in the neighbourhood did not meet with any, 'or at least very few.' He could attribute this circ.u.mstance to no other cause than his having been present at the examination after death, of two cases, some time previous, and of his having imparted the disease to his patients, notwithstanding every precaution." [Footnote: Philad. Med. Journal for 1825, p. 408.]

Dr. Gooch says: "It is not uncommon for the greater number of cases to occur in the practice of one man, whilst the other pract.i.tioners of the neighborhood, who are not more skilful or more busy, meet with few or none. A pract.i.tioner opened the body of a woman who had died of puerperal fever, and continued to wear the same clothes. A lady whom he delivered a few days afterwards was attacked with and died of a similar disease; two more of his lying-in patients, in rapid succession, met with the same fate; struck by the thought that he might have carried contagion in his clothes, he instantly changed them, and met with no more cases of the kind. [Footnote: A similar anecdote is related by Sir Benjamin Brodie, of the late Dr. John Clark, Lancet, May 2, 1840.] A woman in the country who was employed as washerwoman and nurse washed the linen of one who had died of puerperal fever; the next lying-in patient she nursed died of the same disease; a third nursed by her met the same fate, till the neighbourhood, getting afraid of her, ceased to employ her." [Footnote: An Account of Some of the Most Important Diseases Peculiar to Women, p. 4].

In the winter of the year 1824, "several instances occurred of its prevalence among the patients of particular pract.i.tioners, whilst others who were equally busy met with few or none. One instance of this kind was very remarkable. A general pract.i.tioner, in large midwifery practice, lost so many patients from puerperal fever that he determined to deliver no more for some time, but that his partner should attend in his place. This plan was pursued for one month, during which not a case of the disease occurred in their practice. The elder pract.i.tioner, being then sufficiently recovered, returned to his practice, but the first patient he attended was attacked by the disease and died. A physician who met him in consultation soon afterwards, about a case of a different kind, and who knew nothing of his misfortune, asked him whether puerperal fever was at all prevalent in his neighbourhood, on which he burst into tears, and related the above circ.u.mstances.

"Among the cases which I saw this season in consultation, four occurred in one month in the practice of one medical man, and all of them terminated fatally." [Footnote: Gooch, op. cit., p. 71.]

Dr. Ramsbotham a.s.serted, in a lecture at the London Hospital, that he had known the disease spread through a particular district, or be confined to the practice of a particular person, almost every patient being attacked with it, while others had not a single case. It seemed capable, he thought, of conveyance, not only by common modes, but through the dress of the attendants upon the patient. [Footnote: Lond. Med. Gaz., May 2, 1835.]

In a letter to be found in the "London Medical Gazette" for January, 1840, Mr. Roberton, of Manchester, makes the statement which I here give in a somewhat condensed form.

A midwife delivered a woman on the 4th of December, 1830, who died soon after with the symptoms of puerperal fever. In one month from this date the same midwife delivered thirty women, residing in different parts of an extensive suburb, of which number sixteen caught the disease and all died. These were the only cases which had occurred for a considerable time in Manchester. The other midwives connected with the same charitable inst.i.tution as the woman already mentioned are twenty-five in number, and deliver, on an average, ninety women a week, or about three hundred and eighty a month. None of these women had a case of puerperal fever. "Yet all this time this woman was crossing the other midwives in every direction, scores of the patients of the charity being delivered by them in the very same quarters where her cases of fever were happening."

Mr. Roberton remarks that little more than half the women she delivered during this month took the fever; that on some days all escaped, on others only one or more out of three or four; a circ.u.mstance similar to what is seen in other infectious maladies.

Dr. Blundell says: "Those who have never made the experiment can have but a faint conception how difficult it is to obtain the exact truth respecting any occurrence in which feelings and interests are concerned. Omitting particulars, then, I content myself with remarking, generally, that from more than one district I have received accounts of the prevalence of puerperal fever in the practice of some individuals, while its occurrence in that of others, in the same neighborhood, was not observed.

Some, as I have been told, have lost ten, twelve, or a greater number of patients, in scarcely broken succession; like their evil genius, the puerperal fever has seemed to stalk behind them wherever they went. Some have deemed it prudent to retire for a time from practice. In fine, that this fever may occur spontaneously, I admit; that its infectious nature may be plausibly disputed, I do not deny; but I add, considerately, that in my own family I had rather that those I esteemed the most should be delivered, unaided, in a stable, by the mangerside, than that they should receive the best help, in the fairest apartment, but exposed to the vapors of this pitiless disease.

Gossiping friends, wet-nurses, monthly nurses, the pract.i.tioner himself, these are the channels by which, as I suspect, the infection is princ.i.p.ally conveyed." [Footnote: Lect. on Midwifery, p. 395.]

At a meeting of the Royal Medical and Chirurgical Society Dr.

King. mentioned that some years since a pract.i.tioner at Woolwich lost sixteen patients from puerperal fever in the same year. He was compelled to give up practice for one or two years, his business being divided among the neighboring pract.i.tioners. No case of puerperal fever occurred afterwards, neither had any of the neighboring surgeons any cases of this disease.

At the same meeting Mr. Hutchinson mentioned the occurrence of three consecutive cases of puerperal fever, followed subsequently by two others, all in the practice of one accoucheur. [Footnote: Lancet, May 3, 1840.] Dr. Lee makes the following statement: "In the last two weeks of September, 1827, five fatal cases of uterine inflammation came under our observation. All the individuals so attacked had been attended in labor by the same midwife, and no example of a febrile or inflammatory disease of a serious nature occurred during that period among the other patients of the Westminster General Dispensary, who had been attended by the other midwives belonging to that inst.i.tution."

[Footnote: Lond. Cyc. of Pract. Med., art., "Fever, Puerperal"]

The recurrence of long series of cases like those I have cited, reported by those most interested to disbelieve in contagion, scattered along through an interval of half a century, might have been thought sufficient to satisfy the minds of all inquirers that here was something more than a singular coincidence. But if, on a more extended observation, it should be found that the same ominous groups of cases cl.u.s.terings about individual pract.i.tioners were observed in a remote country, at different times, and in widely separated regions, it would seem incredible that any should be found too prejudiced or indolent to accept the solemn truth knelled into their ears by the funeral bells from both sides of the ocean--the plain conclusion that the physician and the disease entered, hand in hand, into the chamber of the unsuspecting patient.

That such series of cases have been observed in this country, and in this neighborhood, I proceed to show.

In Dr. Francis's "Notes to Denman's Midwifery" a pa.s.sage is cited from Dr. Hosack in which he refers to certain puerperal cases which proved fatal to several lying-in women, and in some of which the disease was supposed to be conveyed by the accoucheurs themselves. [Footnote: Denman's Midwifery, p. 673, third Am. ed.]

A writer in the "New York Medical and Physical Journal" for October, 1829, in speaking of the occurrence of puerperal fever confined to one man's practice, remarks: "We have known cases of this kind occur, though rarely, in New York."

I mention these little hints about the occurrence of such cases partly because they are the first I have met with in American medical literature, but more especially because they serve to remind us that behind the fearful array of published facts there lies a dark list of similar events, unwritten in the records of science, but long remembered by many a desolated fireside.

Certainly nothing can be more open and explicit than the account given by Dr. Peirson, of Salem, of the cases seen by him. In the first nineteen days of January, 1829, he had five consecutive cases of puerperal fever, every patient he attended being attacked, and the three first cases proving fatal. In March of the same year he had two moderate cases, in June, another case, and in July, another, which proved fatal. "Up to this period," he remarks, "I am not informed that a single case had occurred in the practice of any other physician. Since that period I have had no fatal case in my practice, although I have had several dangerous cases. I have attended in all twenty cases of this disease, of which four have been fatal. I am not aware that there has been any other case in the town of distinct puerperal peritonitis, although I am willing to admit my information may be very defective on this point. I have been told of some 'mixed cases,' and 'morbid affections after delivery.'" [Footnote: Remarks on Puerperal Fever, pp. 12 and 13.]

In the "Quarterly Summary of the Transactions of the College of Physicians of Philadelphia" [Footnote: For May, June, and July, 1842.] may be found some most extraordinary developments respecting a series of cases occurring in the practice of a member of that body.

Dr. Condie called the attention of the Society to the prevalence, at the present time, of puerperal fever of a peculiarly insidious and malignant character. "In the practice of one gentleman extensively engaged as an obstetrician nearly every female he has attended in confinement, during several weeks past, within the above limits" (the southern sections and neighboring districts), "had been attacked by the fever."

"An important query presents itself, the doctor observed, in reference to the particular form of fever now prevalent. Is it, namely, capable of being propagated by contagion, and is a physician who has been in attendance upon a case of the disease warranted in continuing, without interruption, his practice as an obstetrician? Dr. C., although not a believer in the contagious character of many of those affections generally supposed to be propagated in this manner, has, nevertheless, become convinced by the facts that have fallen under his notice that the puerperal fever now prevailing is capable of being communicated by contagion. How, otherwise, can be explained the very curious circ.u.mstance of the disease in one district being exclusively confined to the practice of a single physician, a Fellow of this College, extensively engaged in obstetrical practice, while no instance of the disease has occurred in the patients under the care of any other accoucheur practising within the same district; scarcely a female that has been delivered for weeks past has escaped an attack?"

Dr. Rutter, the pract.i.tioner referred to, "observed that, after the occurrence of a number of cases of the disease in his practice, he had left the city and remained absent for a week, but, on returning, no article of clothing he then wore having been used by him before, one of the very first cases of parturition he attended was followed by an attack of the fever and terminated fatally; he cannot readily, therefore, believe in the transmission of the disease from female to female in the person or clothes of the physician."

The meeting at which these remarks were made was held on the 3d of May, 1842. In a letter dated December 20, 1842, addressed to Dr. Meigs, and to be found in the "Medical Examiner," [Footnote: For January 21, 1843.] he speaks of "those horrible cases of puerperal fever, some of which you did me the favor to see with me during the past summer," and talks of his experience in the disease, "now numbering nearly seventy cases, all of which have occurred within less than a twelve-month past."

And Dr. Meigs a.s.serts, on the same page, "Indeed, I believe that his practice in that department of the profession was greater than that of any other gentleman, which was probably the cause of his seeing a greater number of the cases." This from a professor of midwifery, who some time ago a.s.sured a gentleman whom he met in consultation that the night on which they met was the eighteenth in succession that he himself had been summoned from his repose, [Footnote: Medical Examiner for December 10, 1842.]

seems hardly satisfactory.

I must call the attention of the inquirer most particularly to the Quarterly Report above referred to, and the letters of Dr.

Meigs and Dr. Rutter, to be found in the "Medical Examiner."

Whatever impression they may produce upon his mind, I trust they will at least convince him that there is some reason for looking into this apparently uninviting subject.

At a meeting of the College of Physicians just mentioned Dr.

Warrington stated that a few days after a.s.sisting at an autopsy of puerperal peritonitis, in which he laded out the contents of the abdominal cavity with his hands, he was called upon to deliver three women in rapid succession. All of these women were attacked with different forms of what is commonly called puerperal fever. Soon after these he saw two other patients, both on the same day, with the same disease. Of these five patients, two died.

At the same meeting Dr. West mentioned a fact related to him by Dr. Samuel Jackson, of Northumberland. Seven females, delivered by Dr. Jackson in rapid succession, while practising in Northumberland County, were all attacked with puerperal fever, and five of them died. "Women," he said, "who had expected me to attend upon them, now becoming alarmed, removed out of my reach, and others sent for a physician residing several miles distant.

These women, as well as those attended by midwives, all did well; nor did we hear of any deaths in child-bed within a radius of fifty miles, excepting two, and these I afterwards ascertained to have been caused by other diseases." He underwent, as he thought, a thorough purification, and still his next patient was attacked with the disease and died. He was led to suspect that the contagion might have been carried in the gloves which he had worn in attendance upon the previous cases. Two months or more after this he had two other cases. He could find nothing to account for these unless it were the instruments for giving enemata, which had been used in two of the former cases and were employed by these patients. When the first case occurred, he was attending and dressing a limb extensively mortified from erysipelas, and went immediately to the accouchement with his clothes and gloves most thoroughly imbued with its effluvia. And here I may mention that this very Dr. Samael Jackson, of Northumberland, is one of Dr. Dewees's authorities against contagion.

The three following statements are now for the first time given to the public. All of the cases referred to occurred within this State, and two of the three series in Boston and its immediate vicinity.

I. The first is a series of cases which took place during the last spring in a town at some distance from this neighborhood. A physician of that town, Dr. C, Had the following consecutive cases: