Introductory Note
Oliver Wendell Holmes was born in Cambridge, Massachusetts, August 29, 1809, and
educated at Phillips Academy, Andover, and Harvard College. After graduation, he entered
the Law School, but soon gave up law for medicine. He studied first in Boston, and later
spent two years in medical schools in Europe, mainly in Paris. On his return he began to
practise in Boston, but in two years he was appointed professor of anatomy at Dartmouth
College, a position which he held from 1838 to 1840, when he again took up his Boston
practice. It was soon after this, in 1843, that he published his essay on the
"Contagiousness of Puerperal Fever," his only contribution of high distinction
to medical science. From 1847 to 1882 he was Parkman professor of anatomy and physiology
in the Harvard Medical School. He died in Boston, October 7, 1894.
In spite of the importance of the paper here printed, Holmes' reputation as a
scientist was overshadowed by that won by him as a wit and a man of letters. When he was
only twenty-one his "Old Ironsides" brought him into notice; and through his
poetry and fiction, and the sparkling talk of the "Breakfast Table" series, he
took a high place among the most distinguished group of writers that America has yet
produced.
The Contagiousness Of Puerperal Fever
[Note: This essay appeared first in 1843, in The New England Quarterly Journal of
Medicine, and was reprinted in the "Medical Essays" in 1855.]
Part I
In collecting, enforcing and adding to the evidence accumulated upon this most serious
subject, I would not be understood to imply that there exists a doubt in the mind of any
well-informed member of the medical profession as to the fact that puerperal fever is
sometimes communicated from one person to another, both directly and indirectly. In the
present state of our knowledge upon this point I should consider such doubts merely as a
proof that the sceptic had either not examined the evidence, or, having examined it,
refused to accept its plain and unavoidable consequences. I should be sorry to think, with
Dr. Rigby, that it was a case of "oblique vision"; I should be unwilling to
force home the argumentum ad hominem of Dr. Blundell, but I would not consent to make a
question of a momentous fact which is no longer to be considered as a subject for trivial
discussions, but to be acted upon with silent promptitude. It signifies nothing that wise
and experienced practitioners have sometimes doubted the reality of the danger in
question; no man has the right to doubt it any longer. No negative facts, no opposing
opinions, be they what they may, or whose they may, can form any answer to the series of
cases now within the reach of all who choose to explore the records of medical science.
If there are some who conceive that any important end would be answered by recording
such opinions, or by collecting the history of all the cases they could find in which no
evidence of the influence of contagion existed, I believe they are in error. Suppose a few
writers of authority can be found to profess a disbelief in contagion, - and they are very
few compared with those who think differently, - is it quite clear that they formed their
opinions on a view of all the facts, or is it not apparent that they relied mostly on
their own solitary experience? Still further, of those whose names are quoted, is it not
true that scarcely a single one could, by any possibility, have known the half or the
tenth of the facts of bearing on the subject which have reached such a frightful amount
within the last few years? Again, as to the utility of negative facts, as we may briefly
call them, - instances, namely, in which exposure has not been followed by disease, -
although, like other truths, they may be worth knowing, I do not see that they are like to
shed any important light upon the subject before us. Every such instance requires a good
deal of circumstantial explanation before it can be accepted. It is not enough that a
practitioner should have had a single case of puerperal fever not followed by others. It
must be known whether he attended others while this case was in progress, whether he went
directly from one chamber to others, whether he took any, and what, precautions. It is
important to know that several women were exposed to infection derived from the patient,
so that allowance may be made for want of predisposition. Now if of negative facts so
sifted there could be accumulated a hundred for every one plain instance of communication
here recorded, I trust it need not be said that we are bound to guard and watch over the
hundredth tenant of our fold, though the ninety and nine may be sure of escaping the wolf
at its entrance. If any one is disposed, then, to take a hundred instances of lives,
endangered or sacrificed out of those I have mentioned, and make it reasonably clear that
within a similar time and compass ten thousand escaped the same exposure, I shall thank
him for his industry, but I must be permitted to hold to my own practical conclusions, and
beg him to adopt or at least to examine them also. Children that walk in calico before
open fires are not always burned to death; the instances to the contrary may be worth
recording; but by no means if they are to be used as arguments against woollen frocks and
high fenders.
I am not sure that this paper will escape another remark which it might be wished were
founded in justice. It may be said that the facts are too generally known and acknowledged
to require any formal argument or exposition, that there is nothing new in the positions
advanced, and no need of laying additional statements before the profession. But on
turning to two works, one almost universally, and the other extensively, appealed to as
authority in this country, I see ample reason to overlook this objection. In the last
edition of Dewees' Treatise on the "Diseases of Females" it is expressly said,
"In this country, under no circumstance that puerperal fever has appeared hitherto,
does it afford the slightest ground for the belief that it is contagious." In the
"Philadelphia Practice of Midwifery" not one word can be found in the chapter
devoted to this disease which would lead the reader to suspect that the idea of contagion
had ever been entertained. It seems proper, therefore, to remind those who are in the
habit of referring to the works for guidance that there may possibly be some sources of
danger they have slighted or omitted, quite as important as a trifling irregularity of
diet, or a confined state of the bowels, and that whatever confidence a physician may have
in his own mode of treatment, his services are of questionable value whenever he carries
the bane as well as the antidote about his person.
The practical point to be illustrated 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 assumptions 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 practitioner 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 if 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
practitioner, 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 assertion, 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 constitution 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.1
[Footnote 1: 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 practitioner. 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
assistant, 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 asserting 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
circumstance 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."2
Dr. Gooch says: "It is not uncommon for the greater number of cases to occur in
the practice of one man, whilst the other practitioners of the neighborhood, who are not
more skilful or more busy, meet with few or none. A practitioner 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.3 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."4
[Footnote 2: Philad. Med. Journal for 1825, p. 408.]
[Footnote 3: A similar anecdote is related by Sir Benjamin Brodie, of the late Dr. John
Clark, Lancet, May 2, 1840.]
[Footnote 4: An Account of Some of the Most Important Disease Peculiar to Women, p. 4.]
In the winter of the year 1824, "several instances occurred of its prevalence
among the patients of particular practitioners, whilst others who were equally busy met
with few or none. One instance of this kind was very remarkable. A general practitioner,
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 practitioner, 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
circumstances.
"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."5
[Footnote 5: Gooch, op. cit., p. 71.]
Dr. Ramsbotham asserted, 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.6
[Footnote 6: 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 institution 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 circumstance 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 practitioner himself, these are the channels by which, as I suspect, the
infection is principally conveyed."7
[Footnote 7: Lect. on Midwifery, p. 395.]
At a meeting of the Royal Medical and Chirurgical Society Dr. King mentioned that some
years since a practitioner 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 practitioners. 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.8
[Footnote 8: Lancet, May 2, 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 institution."9
[Footnote 9: 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 clustering about
individual practitioners 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' "Notes to Denman's Midwifery" a passage 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.10
[Footnote 10: Denman's Midwifery, p. 675, 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.'"11
[Footnote 11: Remarks on Puerperal Fever, pp. 12 and 13.]
In the "Quarterly Summary of the Transactions of the College of Physicians of
Philadelphia"12 may be found some most extraordinary developments
respecting a series of cases occurring in the practice of a member of that body.
[Footnote 12: For May, June, and July, 1842]
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
circumstance 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 practitioner 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,"13 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."
[Footnote 13: For January 21, 1843.]
And Dr. Meigs asserts, 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 assured 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,14 seems hardly satisfactory.
[Footnote 14: Medical Examiner for December 10, 1842.]
Part II.
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 assisting 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. Samuel Jackson, of Northumberland, is one of Dr.
Dewees' 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:
No. 1, delivered March 20, died March 24.
No. 2, delivered April 9, died April 14.
No. 3, delivered April 10, died April 14.
No. 4, delivered April 11, died April 18.
No. 5, delivered April 27, died May 3.
No. 6, delivered April 28, had some symptoms, recovered.
No. 7, delivered May 8, had some symptoms, also recovered.
These were the only cases attended by this physician during the period referred to.
"They were all attended by him until their termination, with the exception of the
patient No. 6, who fell into the hands of another physician on the 2d of May (Dr. C. left
town for a few days at this time.) Dr. C. attended cases immediately before and after the
above-named periods, none of which, however, presented any peculiar symptoms of the
disease."
About the 1st of July he attended another patient in a neighboring village, who died
two or three days after delivery.
The first patient, it is stated, was delivered on the 20th of March. "On the 19th
Dr. C. made the autopsy of a man who had died suddenly, sick only forty-eight hours' had
oedema of the thigh and gangrene extending from a little above the ankle into the cavity
of the abdomen." Dr. C. wounded himself very slightly in the right hand during the
autopsy. The hand was quite painful the night following, during his attendance on the
patient No. 1. He did not see this patient after the 20th, being confined to the house,
and very sick from the wound just mentioned, from this time until the 3d of April
Several cases of erysipelas occurred in the house where the autopsy mentioned above
took place, soon after the examination. There were also many cases of erysipelas in town
at the time of the fatal puerperal cases which have been mentioned.
The nurse who laid out the body of the patient No. 3 was taken on the evening of the
same day with sore throat and erysipelas, and died in ten days from the first attack.
The nurse who laid out the body of the patient No. 4 was taken on the day following
with symptoms like those of this patient, and died in a week, without any external marks
of erysipelas.
"No other cases of similar character with those of Dr. C. occurred in the practice
of any of the physicians in the town or vicinity at the time. Deaths following confinement
have occurred in the practice of other physicians during the past year, but they were not
cases of puerperal fever. No post-mortem examinations were held in any of these puerperal
cases."
Some additional statements in this letter are deserving of insertion:
"A physician attended a woman in the immediate neighborhood of the cases numbered
2, 3, and 4. This patient was confined the morning of March 1st, and died on the night of
March 7th. It is doubtful whether this should be considered a case of puerperal fever. She
had suffered from canker, indigestion, and diarrhoea for a year previous to her delivery.
Her complaints were much aggravated for two or three months previous to delivery; she had
become greatly emaciated, and weakened to such an extent that it had not been expected
that she would long survive her confinement, if indeed she reached that period. Her labor
was easy enough; she flowed a good deal, seemed exceedingly prostrated, had ringing in her
ears, and other symptoms of exhaustion; the pulse was quick and small. On the second and
third day there was some tenderness and tumefaction of the abdomen, which increased
somewhat on the fourth and fifth. He had cases in midwifery before and after this, which
presented nothing peculiar."
It is also mentioned in the same letter that another physician had a case during the
last summer and another last fall, both of which recovered.
Another gentleman reports a case last December, a second case five weeks, and another
three weeks, since. All these recovered. A case also occurred very recently in the
practice of a physician in the village where the eighth patient of Dr. C. resides, which
proved fatal. "This patient had some patches of erysipelas on the legs and arms. The
same physician has delivered three cases since, which have all done well. There have been
no other cases in this town or its vicinity recently. There have been some few cases of
erysipelas." It deserves notice that the partner of Dr. C., who attended the autopsy
of the man above mentioned and took an active part in it, who also suffered very slightly
from a prick under the thumb-nail received during the examination, had twelve cases of
midwifery between March 26th and April 12th all of which did well, and presented no
peculiar symptoms. It should also be stated that during these seventeen days he was in
attendance on all the cases of erysipelas in the house where the autopsy had been
performed. I owe these facts to the prompt kindness of a gentleman whose intelligence and
character are sufficient guaranty for their accuracy.
The two following letters were addressed to my friend Dr. Storer by the gentleman in
whose practice the cases of puerperal fever occurred. His name renders it unnecessary to
refer more particularly to these gentlemen, who on their part have manifested the most
perfect freedom and courtesy in affording these accounts of their painful experience.
"January 28, 1843.
II. . . . "The time to which you allude was in 1830. The first case was in
February, during a very cold time. She was confined the 4th, and died the 12th. Between
the 10th and 28th of this month I attended six women in labor, all of whom did well except
the last, as also two who were confined March 1st and 5th. Mrs. E., confined February
28th, sickened, and died March 8th. The next day, 9th, I inspected the body, and the night
after attended a lady, Mrs. B., who sickened, and died 16th. The 10th, I attended another,
Mrs. G., who sickened, but recovered. March 16th I went from Mrs. G.'s room to attend a
Mrs. H., who sickened, and died 21st. The 17th, I inspected Mrs. B. On 19th, I went
directly from Mrs. H.'s room to attend another lady, Mrs. G., who also sickened, and died
22d. While Mrs. B. was sick, on 15th, I went directly from her room a few rods, and
attended another woman, who was not sick. Up to 20th of this month I wore the same
clothes. I now refused to attend any labor, and did not till April 21st, when, having
thoroughly cleansed myself, I resumed my practice, and had no more puerperal fever.
"The cases were not confined to a narrow space. The two nearest were half a mile
from each other, and half that distance from my residence. The others were from two to
three miles apart, and nearly that distance from my residence. There were no other cases
in their immediate vicinity which came to my knowledge. The general health of all the
women was pretty good, and all the labors as good as common, except the first. This woman,
in consequence of my not arriving in season, and the child being half-born some time
before I arrived, was very much exposed to the cold at the time of confinement, and
afterwards, being confined in a very open, cold room. Of the six cases, you perceive only
one recovered.
"In the winter of 1817 two of my patients had puerperal fever, one very badly, the
other not so badly. Both recovered. One other had swelled leg or phlegmasia dolens, and
one or two others did not recover as well as usual.
"In the summer of 1835 another disastrous period occurred in my practice. July 1st
I attended a lady in labor, who was afterwards quite ill and feverish; but at the time I
did not consider her case a decided puerperal fever. On 8th I attended one who did well.
On 12th, one who was seriously sick. This was also an equivocal case, apparently arising
from constipation and irritation of the rectum. These women were ten miles apart and five
from my residence. On 15th and 20th, two who did well. On 25th I attended another. This
was a severe labor, and followed by unequivocal puerperal fever, or peritonitis. She
recovered. August 2d and 3d, in about twenty-four hours, I attended four persons. Two of
them did very well; one was attacked with some of the common symptoms, which, however,
subsided in a day or two, and the other had decided puerperal fever, but recovered. This
woman resided five miles from me. Up to this time I wore the same coat. All my other
clothes had frequently been changed. On 6th, I attended two women, one of whom was not
sick at all; but the other, Mrs. L., was afterwards taken ill. On 10th, I attended a lady,
who did very well. I had previously changed all my clothes, and had no garment on which
had been in a puerperal room. On 12th, I was called to Mrs. S., in labor. While she was
ill, I left her to visit Mrs. L., one of the ladies who was confined on 6th. Mrs. L. had
been more unwell than usual, but I had not considered her case anything more than common
till this visit. I had on a surtout at this visit, which, on my return to Mrs. S., I left
in another room. Mrs. S. was delivered on 13th with forceps. These women both died of
decided puerperal fever.
"While I attended these women in their fevers I changed my clothes, and washed my
hands in a solution of chloride of lime after each visit. I attended seven women in labor
during this period, all of whom recovered without sickness.
"In my practice I have had several single cases of puerperal fever, some of whom
have died and some have recovered. Until the year 1830 I had no suspicion that the disease
could be communicated from one patient to another by a nurse or midwife; but I now think
the foregoing facts strongly favor that idea. I was so much convinced of this fact that I
adopted the plan before related.
"I believe my own health was as good as usual at each of the above periods. I have
no recollection to the contrary.
"I believe I have answered all your questions. I have been more particular on some
points perhaps than necessary; but I thought you could form your own opinion better than
to take mine. In 1830 I wrote to Dr. Channing a more particular statement of my cases. If
I have not answered your questions sufficiently, perhaps Dr. C. may have my letter to him,
and you can find your answer there."15
[Footnote 15: In a letter to myself this gentleman also stated, "I do not
recollect that there was any erysipelas or any other disease particularly prevalent at the
time."]
Boston, February 3, 1843.
III. "My dear Sir: I received a note from you last evening requesting me to answer
certain questions therein proposed, touching the cases of puerperal fever which came under
my observation the past summer. It gives me pleasure to comply with your request, so far
as it is in my power so to do, but, owing to the hurry in preparing for a journey, the
notes of the cases I had then taken were lost or mislaid. The principal facts, however,
are too vivid upon my recollection to be soon forgotten. I think, therefore, that I shall
be able to give you all the information you may require.
"All the cases that occurred in my practice took place between the 7th of May and
the 17th of June, 1842.
"They were not confined to any particular part of the city. The first two cases
were patients residing at the South End, the next was at the extreme North End, one living
in Sea Street and the other in Roxbury. The following is the order in which they occurred:
"Case 1. - Mrs.___ was confined on the 7th of May, at 5 o'clock, p. m., after a
natural labor of six hours. At 12 o'clock at night, on the 9th (thirty-one hours after
confinement), she was taken with severe chill, previous to which she was as comfortable as
women usually are under the circumstances. She died on the 10th.
"Case 2. - Mrs.___ was confined on the 10th of June (four weeks after Mrs. C.), at
11 a. m., after a natural, but somewhat severe, labor of five hours. At 7 o'clock, on the
morning of the 11th, she had a chill. Died on the 12th.
"Case 3. - Mrs.___, confined on the 14th of June, was comfortable until the 18th,
when symptoms of puerperal fever were manifest. She died on the 20th.
"Case 4. - Mrs.___, confined June 17th, at 5 o'clock, a. m., was doing well until
the morning of the 19th. She died on the evening of the 21st.
"Case 5. - Mrs.___ was confined with her fifth child on the 17th of June, at 6
o'clock in the evening. This patient had been attacked with puerperal fever, at three of
her previous confinements, but the disease yielded to depletion and other remedies without
difficulty. This time, I regret to say, I was not so fortunate. She was not attacked, as
were the other patients, with a chill, but complained of extreme pain in the abdomen, and
tenderness on pressure, almost from the moment of her confinement. In this, as in the
other cases, the disease resisted all remedies, and she died in great distress on the 22d
of the same month. Owing to the extreme heat of the season and my own indisposition, none
of the subjects were examined after death. Dr. Channing, who was in attendance with me on
the three last cases, proposed to have a post-mortem examination of the subject of case
No. 5, but from some cause which I do not now recollect it was not obtained.
"You wish to know whether I wore the same clothes when attending the different
cases. I cannot positively say, but I should think I did not, as the weather became warmer
after the first two cases; I therefore think it probable that I made a change of at least
a part of my dress. I have had no other case of puerperal fever in my own practice for
three years, save those above related, and I do not remember to have lost a patient before
with this disease. While absent, last July, I visited two patients sick with puerperal
fever, with a friend of mine in the country. Both of them recovered.
"The cases that I have recorded were not confined to any particular constitution
or temperament, but it seized upon the strong and the weak, the old and the young-one
being over forty years, and the youngest under eighteen years of age. . . . If the disease
is of an erysipelatous nature, as many suppose, contagionists may perhaps find some ground
for their belief in the fact that, for two weeks previous to my first case of puerperal
fever, I had been attending a severe case of erysipelas, and the infection may have been
conveyed through me to the patient; but, on the other hand, why is not this the case with
other physicians, or with the same physician at all times, for since my return from the
country I have had a more inveterate case of erysipelas than ever before, and no
difficulty whatever has attended any of my midwifery cases?"
I am assured, on unquestionable authority, that "About three years since, a
gentleman in extensive midwifery business, in a neighboring State, lost in the course of a
few weeks eight patients in child-bed, seven of them being undoubted cases of puerperal
fever. No other physician of the town lost a single patient of this disease during the
same period." And from what I have heard in conversation with some of our most
experienced practitioners, I am inclined to think many cases of the kind might be brought
to light by extensive inquiry.
This long catalogue of melancholy histories assumes a still darker aspect when we
remember how kindly nature deals with the parturient female, when she is not immersed in
the virulent atmosphere of an impure lying-in hospital, or poisoned in her chamber by the
unsuspected breath of contagion. From all causes together not more than four deaths in a
thousand births and miscarriages happened in England and Wales during the period embraced
by the first Report of the Registrar-General.16 In the second Report the
mortality was shown to be about five in one thousand.17 In the Dublin Lying-in
Hospital, during the seven years of Dr. Collins' mastership, there was one case of
puerperal fever to 178 deliveries, or less than six to the thousand, and one death from
this disease in 278 cases, or between three and four to the thousand.18 Yet
during this period the disease was endemic in the hospital, and might have gone on to
rival the horrors of the pestilence of the Maternite, had not the poison been destroyed by
a thorough purification.
[Footnote 16: First Report, p. 105.]
[Footnote 17: Second Report, p. 73.]
[Footnote 18: Collins' Treatise on Midwifery, p. 228, etc.]
In private practice, leaving out of view the cases that are to be ascribed to the
self-acting system of propagation, it would seem that the disease must be far from common.
Mr. White, of Manchester, says: "Out of the whole number of lying - in patients whom
I have delivered (and I may safely call it a great one), I have never lost one, nor to the
best of my recollection has one been greatly endangered, by the puerperal, miliary, low
nervous, putrid malignant, or milk fever."19 Dr. Joseph Clarke informed
Dr. Collins that in the course of forty-five years' most extensive practice he lost but
four patients from this disease.20 One of the most eminent practitioners of
Glasgow who has been engaged in very extensive practice for upwards of a quarter of a
century testifies that he never saw more than twelve cases of real puerperal fever.21
[Footnote 19: Op. cit., p. 115.]
[Footnote 20: Op. cit., p. 228.]
[Footnote 21: Lancet, May 4, 1833.]
I have myself been told by two gentlemen practicing in this city, and having for many
years a large midwifery business, that they had neither of them lost a patient from this
disease, and by one of them that he had only seen it in consultation with other
physicians. In five hundred cases of midwifery, of which Dr. Storer has given an abstract
in the first number of this journal, there was only of instance and fatal puerperal
peritonitis.
In the view of these facts it does appear a singular coincidence that one man or woman
should have ten, twenty, thirty, or seventy cases of this rare disease following his or
her footsteps with the keenness of a beagle, through the streets and lanes of a crowded
city, while the scores that cross the same paths on the same errands know it only by name.
It is a series of similar coincidence which has led us to consider the dagger, the musket,
and certain innocent looking white powders as having some little claim to be regarded as
dangerous. It is the practical inattention to similar coincidences which has given rise to
the unpleasant but often necessary documents called indictments, which has sharpened a
form of the cephalotome sometimes employed in the case of adults, and adjusted that
modification of the fillet which delivers the world of those who happen to be too much in
the way while such striking coincidences are taking place.
I shall now mention a few instances in which the disease appears to have been conveyed
by the process of direct inoculation.
Dr. Campbell, of Edinburgh, states that in October, 1821, he assisted at the
post-mortem examination of a patient who died with puerperal fever. He carried the pelvic
viscera in his pocket to the class-room. The same evening he attended a woman in labor
without previously changing his clothes; this patient died. The next morning he delivered
a woman with the forceps; she died also, and of many others who were seized with the
disease within a few weeks, three shared the same fate in succession.
In June, 1823, he assisted some of his pupils at the autopsy of a case of puerperal
fever. He was unable to wash his hands with proper care, for want of the necessary
accommodations. On getting home he found that two patients required his assistance. He
went without further ablution or changing his clothes; both these patients died with
puerperal fever.22 This same Dr. Campbell is one of Dr. Churchill's authorities
against contagion.
[Footnote 22: Lond. Med. Gazette, December 10, 1831.]
Mr. Roberton says that in one instance within his knowledge a practitioner passed the
catheter for a patient with puerperal fever late in the evening; the same night he
attended a lady who had the symptoms of the disease on the second day. In another instance
a surgeon was called while in the act of inspecting the body of a woman who died of this
fever, to attend a labor; within forty-eight hours this patient was seized with the fever.23
[Footnote 23: Ibid. for January, 1832.]
On the 16th of March, 1831, a medical practitioner examined the body of a woman who had
died a few days after delivery, from puerperal peritonitis. On the evening of the 17th he
delivered a patient, who was seized with puerperal fever on the 19th, and died on the
24th. Between this period and the 6th of April the same practitioner attended two other
patients, both of whom were attacked with the same disease and died.24
[Footnote 24: London Cyc. of Pract. Med., art., "Fever, Puerperal."]
In the autumn of 1829 a physician was present at the examination of a case of puerperal
fever, dissected out the organs, and assisted in sewing up the body. He had scarcely
reached home when he was summoned to attend a young lady in labor. In sixteen hours she
was attacked with the symptoms of puerperal fever, and narrowly escaped with her life.25
[Footnote 25: Ibid.]
In December, 1830, a midwife, who had attended two fatal cases of puerperal fever at
the British Lying-in Hospital, examined a patient who had just been admitted, to ascertain
if labor had commenced. This patient remained two days in the expectation that labor would
come on, when she returned home and was then suddenly taken in labor and delivered before
she could set out for the hospital. She went on favorably for two days, and was then taken
with puerperal fever and died in thirty-six hours.26
[Footnote 26: Ibid.]
"A young practitioner, contrary to advice, examined the body of a patient who had
died from puerperal fever; there was no epidemic at the time; the case appeared to be
purely sporadic. He delivered three other women shortly afterwards; they all died with
puerperal fever, the symptoms of which broke out very soon after labor. The patients of
his colleague did well, except one, where he assisted to remove some coagula from the
uterus; she was attacked in the same manner as those whom he had attended, and died
also." The writer in the "British and Foreign Medical Review," from whom I
quote this statement, and who is no other than Dr. Rigby, - adds: "We trust that this
fact alone will forever silence such doubts, and stamp the well-merited epithet of
'criminal,' as above quoted, upon such attempts.27
[Footnote 27: Brit. and For. Medical Review for January, 1842, p. 112.]
From the cases given by Mr. Ingleby I select the following: Two gentlemen, after having
been engaged in conducting the postmortem examination of a case of puerperal fever, went
in the same dress, each respectively, to a case of midwifery. "The one patient was
seized with the rigor about thirty hours afterwards. The other patient was seized with a
rigor the third morning after delivery. One recovered, one died."28 One of
these same gentlemen attended another woman in the same clothes two days after the autopsy
referred to. "The rigor did not take place until the evening of the fifth day from
the first visit. Result fatal." These cases belonged to a series of seven, the first
of which was thought to have originated in a case of erysipelas. "Several cases of a
mild character followed the foregoing seven, and their nature being now most unequivocal,
my friend declined visiting all midwifery cases for a time, and there was no recurrence of
the disease." These cases occurred in 1833. Five of them proved fatal. Mr. Ingleby
gives another series of seven cases which occurred to a practitioner in 1836, the first of
which was also attributed to his having opened several erysipelatous abscesses a short
time previously.
[Footnote 28: Edin. Med. and Surg. Journal, April, 1838.]
I need not refer to the case lately read before this Society, in which a physician
went, soon after performing an autopsy of a case of puerperal fever, to a woman in labor,
who was seized with the same disease and perished. The forfeit of that error has been
already paid.
At a meeting of the Medical and Chirurgical Society before referred to, Dr. Merriman
related an instance occurring in his own practice, which excites a reasonable suspicion
that two lives were sacrificed to a still less dangerous experiment. He was at the
examination of a case of puerperal fever at two o'clock in the afternoon. He took care not
to touch the body. At nine o'clock the same evening he attended a woman in labor; she was
so nearly delivered that he had scarcely anything to do. The next morning she had severe
rigors, and in forty-eight hours she was a corpse. Her infant had erysipelas and died in
two days.29
[Footnote 29: Lancet, May 2, 1840.]
In connection with the facts which have been stated it seems proper to allude to the
dangerous and often fatal effects which have followed from wounds received in the
post-mortem examination of patients who have died of puerperal fever. The fact that such
wounds are attended with peculiar risk has been long noticed. I find that Chaussier was in
the habit of cautioning his students against the danger to which they were exposed in
these dissections.30 The head pharmacien of the Hotel Dieu, in his analysis of
the fluid effused in puerperal peritonitis, says that practitioners are convinced of its
deleterious qualities, and that it is very dangerous to apply it to the denuded skin.31 Sir Benjamin Brodie speaks of it as being well known that the inoculation of lymph or pus
from the peritoneum of a puerperal patient is often attended with dangerous and even fatal
symptoms. Three cases in confirmation of this statement, two of them fatal, have been
reported to this Society within a few months.
[Footnote 30: Stein, L'Art d' Accoucher, 1794; Dict. des Sciences Medicales, art.,
"Puerperal."]
[Footnote 31: Journal de Pharmacie, January 1836.]
Of about fifty cases of injuries of this kind, of various degrees of severity, which I
have collected from different sources, at least twelve were instances of infection from
puerperal peritonitis. Some of the others are so stated as to render it probable that they
may have been of the same nature. Five other cases were of peritoneal inflammation; three
in males. Three were what was called enteritis, in one instance complicated with
erysipelas; but it is well known that this term has been often used to signify
inflammation of the peritoneum covering the intestines. On the other hand, no case of
typhus or typhoid fever is mentioned as giving rise to dangerous consequences, with the
exception of the single instance of an undertaker mentioned by Mr. Travers, who seems to
have been poisoned by a fluid which exuded from the body. The other accidents were
produced by dissection, or some other mode of contact with bodies of patients who had died
of various affections. They also differed much in severity, the cases of puerperal origin
being among the most formidable and fatal. Now a moment's reflection will show that the
number of cases of serious consequences ensuing from the dissection of the bodies of those
who had perished of puerperal fever is so vastly disproportioned to the relatively small
number of autopsies made in this complaint as compared with typhus or pneumonia (from
which last disease not one case of poisoning happened), and still more from all diseases
put together, that the conclusion is irresistible that a most fearful morbid poison is
often generated in the course of this disease. Whether or not it is sui generis, confined
to this disease, or produced in some others, as, for instance, erysipelas, I need not stop
to inquire.
In connection with this may be taken the following statement of Dr. Rigby: "That
the discharges from a patient under puerperal fever are in the highest degree contagious
we have abundant evidence in the history of lying-in hospitals. The puerperal abscesses
are also contagious, and may be communicated to healthy lying-in women by washing with the
same sponge; this fact has been repeatedly proved in the Vienna Hospital; but they are
equally communicable to women not pregnant; on more than one occasion the women engaged in
washing the soiled bed-linen of the General Lying-in Hospital have been attacked with
abscesses in the fingers or hands, attended with rapidly spreading inflammation of the
cellular tissue."32
[Footnote 32: System of Midwifery, p. 292.]
Now add to all this the undisputed fact that within the walls of lying-in hospitals
there is often generated a miasm, palpable as the chlorine used to destroy it, tenacious
so as in some cases almost to defy extirpation, deadly in some institutions as the plague;
which has killed women in a private hospital of London so fast that they were buried two
in one coffin to conceal its horrors; which enabled Tonelle to record two hundred and
twenty-two autopsies at the Maternite of Paris; which has led Dr. Lee to express his
deliberate conviction that the loss of life occasioned by these institutions completely
defeats the objects of their founders; and out of this train of cumulative evidence, the
multiplied groups of cases clustering about individuals, the deadly results of autopsies,
the inoculation by fluids from the living patient, the murderous poison of hospitals -
does there not result a conclusion that laughs all sophistry to scorn, and renders all
argument an insult?
I have had occasion to mention some instances in which there was an apparent relation
between puerperal fever and erysipelas. The length to which this paper has extended does
not allow me to enter into the consideration of this most important subject. I will only
say that the evidence appears to me altogether satisfactory that some most fatal series of
puerperal fever have been produced by an infection originating in the matter or effluvia
of erysipelas. In evidence of some connection between the two diseases, I need not go back
to the older authors, as Pouteau or Gordon, but will content myself with giving the
following references, with their dates; from which it will be seen that the testimony has
been constantly coming before the profession for the last few years:
"London Cyclopaedia of Practical Medicine," article Puerperal Fever, 1833.
Mr. Ceeley's Account of the Puerperal Fever at Aylesbury, "Lancet," 1835.
Dr. Ramsbotham's Lecture, "London Medical Gazette," 1835.
Mr. Yates Ackerly's Letter in the same Journal, 1838.
Mr. Ingleby on Epidemic Puerperal Fever, "Edinburgh Medical and Surgical
Journal," 1838.
Mr. Paley's Letter, "London Medical Gazette," 1839.
Remarks at the Medical and Chirurgical Society, "Lancet," 1840.
Dr. Rigby's "System of Midwifery," 1841.
"Nunneley on Erysipelas," a work which contains a large number of references
on the subject, 1841.
"British and Foreign Quarterly Review," 1842.
Dr. S. Jackson, of Northumberland, as already quoted from the Summary of the College of
Physicians, 1842.
And, lastly, a startling series of cases by Mr. Storrs, of Doncaster, to be found in
the "American Journal of the Medical Sciences" for January, 1843.
The relation of puerperal fever with other continued fevers would seem to be remote and
rarely obvious. Hey refers to two cases of synochus occurring in the Royal Infirmary of
Edinburgh, in women who had attended upon puerperal patients. Dr. Collins refers to
several instances in which puerperal fever has appeared to originate from a continued
proximity to patients suffering with typhus.33
[Footnote 33: Treatise on Midwifery, p. 228.]
Such occurrences as those just mentioned, though most important to be remembered and
guarded against, hardly attract our notice in the midst of the gloomy facts by which they
are surrounded. Of these facts, at the risk of fatiguing repetitions, I have summoned a
sufficient number, as I believe, to convince the most incredulous that every attempt to
disguise the truth which underlies them all is useless.
Part III.
It is true that some of the historians of the disease, especially Hulme, Hull, and
Leake, in England; Tonelle, Duges, and Baudelocque, in France, profess not to have found
puerperal fever contagious. At the most they give us mere negative facts, worthless
against an extent of evidence which now overlaps the widest range of doubt, and doubles
upon itself in the redundancy of superfluous demonstration. Examined in detail, this and
much of the show of testimony brought up to stare the daylight of conviction out of
countenance, proves to be in a great measure unmeaning and inapplicable, as might be
easily shown were it necessary. Nor do I feel the necessity of enforcing the conclusion
which arises spontaneously from the facts which have been enumerated by formally citing
the opinions of those grave authorities who have for the last half-century been sounding
the unwelcome truth it has cost so many lives to establish.
"It is to the British practitioner," says Dr. Rigby, "that we are
indebted for strongly insisting upon this important and dangerous character of puerperal
fever."34
[Footnote 34: British and Foreign Med. Rev. for January, 1842.]
The names of Gordon, John Clarke, Denman, Burns, Young,35 Hamilton,36 Haighton,37 Good,38 Waller,39 Blundell, Gooch,
Ramsbotham, Douglas,40 Lee, Ingleby, Locock,41 Abercrombie,42 Alison,43 Travers,44 Rigby, and Watson45 many of whose
writings I have already referred to, may have some influence with those who prefer the
weight of authorities to the simple deductions of their own reason from the facts laid
before them. A few Continental writers have adopted similar conclusions.46 It
gives me pleasure to remember that, while the doctrine has been unceremoniously
discredited in one of the leading journals,47 and made very light of by
teachers in two of the principal medical schools of this country, Dr. Channing has for
many years inculcated, and enforced by examples, the danger to be apprehended and the
precautions to be taken in the disease under consideration.
[Footnote 35: Encyc. Britannica, xiii, 467, art., "Medicine."]
[Footnote 36: Outlines of Midwifery, p. 109.]
[Footnote 37: Oral Lectures, etc.]
[Footnote 38: Study of Medicine, ii, 195.]
[Footnote 39: Medical and Physical Journal, July, 1830.]
[Footnote 40: Dublin Hospital Reports for 1822.]
[Footnote 41: Library of Practical Medicine, i, 373.]
[Footnote 42: Researches on Diseases of the Stomach, etc., p. 181.]
[Footnote 43: Library of Practical Medicine, i, 96.]
[Footnote 44: Further Researches on Constitutional Irritation, p. 128.]
[Footnote 45: London Medical Gazette, February, 1842.]
[Footnote 46: See British and Foreign Medical Review, vol. iii, p. 525, and vol. iv, p.
517. Also Ed. Med. and Surg. Journal for July, 1824, and American Journal of Med. Sciences
for January, 1841.]
[Footnote 47: Phil. Med. Journal, vol. xii, p. 364.]
I have no wish to express any harsh feeling with regard to the painful subject which
has come before us. If there are any so far excited by the story of these dreadful events
that they ask for some word of indignant remonstrance to show that science does not turn
the hearts of its followers into ice or stone, let me remind them that such words have
been uttered by those who speak with an authority I could not claim.48 It is as
a lesson rather than as a reproach that I call up the memory of these irreparable errors
and wrongs. No tongue can tell the heart-breaking calamity they have caused; they have
closed the eyes just opened upon a new world of love and happiness; they have bowed the
strength of manhood into the dust; they have cast the helplessness of infancy into the
stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. There
is no tone deep enough for regret, and no voice loud enough for warning. The woman about
to become a mother or with her newborn infant upon her bosom, should be the object of
trembling care and sympathy wherever she bears her tender burden or stretches her aching
limbs. The very outcast of the streets has pity upon her sister in degradation when the
seal of promised maternity is impressed upon her. The remorseless vengeance of the law,
brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at
a word which reveals her transient claim for mercy. The solemn prayer of the liturgy
singles out her sorrows from the multiplied trials of life, to plead for her in the hour
of peril. God forbid that any member of the profession to which she trusts her life,
doubly precious at that eventful period, should hazard it negligently, unadvisedly, or
selfishly!
[Footnote 48: Dr. Blundell and Dr. Rigby in the works already cited.]
There may be some among those whom I address who are disposed to ask the question, What
course are we to follow in relation to this matter? The facts are before them, and the
answer must be left to their own judgment and conscience. If any should care to know my
own conclusions, they are the following; and in taking the liberty to state them very
freely and broadly, I would ask the inquirer to examine them as freely in the light of the
evidence which has been laid before him.
1. A physician holding himself in readiness to attend cases of midwifery should never
take any active part in the post-mortem examination of cases of puerperal fever.
2. If a physician is present at such autopsies, he should use thorough ablution, change
every article of dress, and allow twenty-four hours or more to elapse before attending to
any case of midwifery. It may be well to extend the same caution to cases of simple
peritonitis
3. Similar precautions should be taken after the autopsy or surgical treatment of cases
of erysipelas, if the physician is obliged to unite such offices with his obstetrical
duties, which is in the highest degree inexpedient.
4. On the occurrence of a single case of puerperal fever in his practice, the
physicianhis bound to consider the next female he attends in labor, unless some weeks at
least have elapsed, as in danger of being infected by him, and it is his duty to take
every precaution to diminish her risk of disease and death.
5. If within a short period two cases of puerperal fever happen close to each other, in
the practice of the same physician, the disease not existing or prevailing in the
neighborhood, he would do wisely to relinquish his obstetrical practice for at least one
month, and endeavor to free himself by every available means from any noxious influence he
may carry about with him
6. The occurrence of three or more closely connected cases, in the practice of one
individual, no others existing in the neighborhood, and no other sufficient cause being
alleged for the coincidence, is prima facie evidence that he is the vehicle of contagion.
7. It is the duty of the physician to take every precaution that the disease shall not
be introduced by nurses or other assistants, by making proper inquiries concerning them,
and giving timely warning of every suspected source of danger.
8. Whatever indulgence may be granted to those who have heretofore been the ignorant
causes of so much misery, the time has come when the existence of a private pestilence in
the sphere of a single physician should be looked upon, not as a misfortune, but a crime;
and in the knowledge of such occurrences the duties of the practitioner to his profession
should give way to his paramount obligations to society.
Additional References And Cases.
Fifth Annual Report of the Registrar-General of England, 1843. Appendix. Letter from
William Farr, Esq. - Several new series of cases are given in the letter of Mr. Storrs,
contained in the appendix to this report. Mr. Storrs suggests precautions similar to those
I have laid down, and these precautions are strongly enforced by Mr. Farr, who is,
therefore, obnoxious to the same criticisms as myself.
Hall and Dexter, in Am. Journal of Med. Sc. for January, 1844. - Cases of puerperal
fever seeming to originate in erysipelas.
Elkington, of Birmingham, in Provincial Med. Journal, cited in Am. Journ. Med. Sc. for
April, 1844. - Six cases in less than a fortnight, seeming to originate in a case of
erysipelas.
West's Reports, in Brit. and For. Med. Review for October, 1845, and January, 1847. -
Affection of the arm, resembling malignant pustule, after removing the placenta of a
patient who died from puerperal fever. Reference to cases at Wurzburg, as proving
contagion, and to Keiller's cases in the Monthly Journal for February, 1846, as showing
connection of puerperal fever and erysipelas.
Kneeland. - Contagiousness of Puerperal Fever. Am. Jour. Med. Sc., January, 1846. Also,
Connection between Puerperal Fever and Epidemic Erysipelas. Ibid., April, 1846.
Robert Storrs. - Contagious Effects of Puerperal Fever on the Male Subject; or on
Persons not Child-bearing. (From Provincial Med. and Surg. Journal.) Am. Jour. Med. Sc.,
January, 1846. Numerous cases. See also Dr. Reid's case in same journal for April, 1846.
Routh's paper in Proc. of Royal Med. Chir. Soc., Am. Jour. Med. Sc., April, 1849, also
in B. and F. Med. Chir. Review, April, 1850.
Hill, of Leuchars. - A Series of Cases Illustrating the Contagious Nature of Erysipelas
and Puerperal Fever, and their Intimate Pathological Connection. (From Monthly Journal of
Med. Sc.) Am. Jour. Med. Sc., July, 1850.
Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits, from inoculation with
different morbid secretions.) Am. Jour. Med. Sc., October, 1850.
Arneth. - Paper read before the National Academy of Medicine. Annales d'Hygiene, Tome
LXV. 2^e Partie. (Means of Disinfection proposed by M. "Semmeliveis."
Semmelweiss.) Lotions of chloride of lime and use of nail-brush before admission to
lying-in wards. Alleged sudden and great decrease of mortality from puerperal fever. Cause
of disease attributed to inoculation with cadaveric matters.) See also Routh's paper,
mentioned above.
Moir. - Remarks at a meeting of the Edinburgh Medico-chirurgical Society. Refers to
cases of Dr. Kellie, of Leith. Sixteen in succession, all fatal. Also to several instances
of individual pupils having had a succession of cases in various quarters of the town,
while others, practising as extensively in the same localities, had none. Also to several
special cases not mentioned elsewhere. Am. Jour. Med. Sc. for October, 1851. (From New
Monthly Journal of Med. Science.)
Simpson. - Observations at a Meeting of the Edinburgh Obstetrical Society. (An
"eminent gentleman," according to Dr. Meigs, whose "name is as well known
in America as in (his) native land," Obstetrics, Phil., 1852, pp. 368, 375.) The
student is referred to this paper for a valuable resume of many of the facts, and the
necessary inferences, relating to this subject. Also for another series of cases, Mr.
Sidey's, five or six in rapid succession. Dr. Simpson attended the dissection of two of
Dr. Sidey's cases, and freely handled the diseased parts. His next four child-bed patients
were affected with puerperal fever, and it was the first time he had seen it in practice.
As Dr. Simpson is a gentleman (Dr. Meigs, as above), and as "a gentleman's hands are
clean" (Dr. Meigs' sixth letter), it follows that a gentleman with clean hands may
carry the disease. Am. Jour. Med. Sc., October, 1851.
Peddie. - The five or six cases of Dr. Sidey, followed by the four of Dr. Simpson, did
not end the series. A practitioner in Leith having examined in Dr. Simpson's house, a
portion of the uterus obtained from one of the patients, had immediately afterwards three
fatal cases of puerperal fever. Dr. Peddie referred to two distinct series of consecutive
cases in his own practice. He had since taken precautions, and not met with any such
cases. Am. Jour. Med. Sc., October, 1851.
Copland. - Considers it proved that puerperal fever may be propagated by the hands and
the clothes, or either, of a third person, the bed-clothes or body-clothes of a patient.
Mentions a new series of cases, one of which he saw, with the practitioner who had
attended them. She was the sixth he had had within a few days. All died. Dr. Copland
insisted that contagion had caused these cases; advised precautionary measures, and the
practitioner had no other cases for a considerable time. Considers it criminal, after the
evidence adduced, - which he could have quadrupled, - and the weight of authority brought
forward, for a practitioner to be the medium of transmitting contagion and death to his
patients. Dr. Copland lays down rules similar to those suggested by myself, and is
therefore entitled to the same epithet for so doing. Medical Dictionary, New York, 1852.
Article, Puerperal States and Diseases.
If there is any appetite for facts so craving as to be yet unappeased, lassata, necdum
satiata, - more can be obtained. Dr. Hodge remarks that "the frequency and importance
of this singular circumstance (that the disease is occasionally more prevalent with one
practitioner than another) has been exceedingly overrated." More than thirty strings
of cases, more than two hundred and fifty sufferers from puerperal fever, more than one
hundred and thirty deaths, appear as the results of a sparing estimate of such among the
facts I have gleaned as could be numerically valued. These facts constitute, we may take
it for granted, but a small fraction of those that have actually occurred. The number of
them might be greater, but "'tis enough, 'twill serve," in Mercutio's modest
phrase, so far as frequency is concerned. For a just estimate of the importance of the
singular circumstance, it might be proper to consult the languid survivors, the widowed
husbands, and the motherless children, as well as "the unfortunate accoucheur."
Source:
Scientific papers; physiology, medicine, surgery, geology, with introductions,
notes and illustrations. New York, P. F. Collier & son [c1910] The Harvard
classics v. 38.
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