Medical Essays
by
Oliver Wendell Holmes, Sr. (The Physician and Poet)
Part 3 out of 7
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." I will devote seven lines
to these seven pages, which seven lines, if I may say it without
offence, are, as it seems to me, six more than are strictly
necessary.
The following authors are cited as sceptics by Dr. Meigs:
Dewees.--I cited the same passage. Did not know half the facts.
Robert Lee.--Believes the disease is sometimes communicable by
contagion. Tonnelle, Baudelocque. Both cited by me. Jacquemier.
--Published three years after my Essay. Kiwisch. Behindhand in
knowledge of Puerperal Fever." [B. & F. Med. Rev. Jan. 1842.]
Paul Dubois.--Scanzoni.
These Continental writers not well informed on this point.[See Dr.
Simpson's Remarks at Meeting of Edin. Med. Chir. Soc. (Am. Jour.
Oct. 1851.)]
The story of Von Busch is of interest and value, but there is nothing
in it which need perplex the student. It is not pretended that the
disease is always, or even, it may be, in the majority of cases,
carried about by attendants; only that it is so carried in certain
cases. That it may have local and epidemic causes, as well as that
depending on personal transmission, is not disputed. Remember how
small-pox often disappears from a community in spite of its
contagious character, and the necessary exposure of many persons to
those suffering from it; in both diseases contagion is only one of
the coefficients of the disease.
I have already spoken of the possibility that Dr. Meigs may have been
the medium of transfer of puerperal fever in some of the cases he has
briefly catalogued. Of Dr. Rutter's cases I do not know how to
speak. I only ask the student to read the facts stated by Dr.
Condie, as given in my Essay, and say whether or not a man should
allow his wife to be attended by a practitioner in whose hands
"scarcely a female that has been delivered for weeks past has escaped
an attack," "while no instance of the disease has occurred in the
patients of any other accoucheur practising in the same district."
If I understand Dr. Meigs and Dr. Hodge, they would not warn the
physician or spare the patient under such circumstances. They would
"go on," if I understand them, not to seven, or seventy, only, but to
seventy times seven, if they could find patients. If this is not
what they mean, may we respectfully ask them to state what they do
mean, to their next classes, in the name of humanity, if not of
science!
I might repeat the question asked concerning Dr. Rutter's cases, with
reference to those reported by Dr. Roberton. Perhaps, however, the
student would like to know the opinion of a person in the habit of
working at matters of this kind in a practical point of view. To
satisfy him on this ground, I addressed the following question to the
President of one of our principal Insurance Companies, leaving Dr.
Meigs's book and my Essay in his hands at the same time.
Question. "If such facts as Roberton's cases were before you, and
the attendant had had ten, or even five fatal cases, or three, or two
even, would you, or would you not, if insuring the life of the next
patient to be taken care of by that attendant, expect an extra
premium over that of an average case of childbirth?"
Answer. "Of course I should require a very large extra premium, if
I would take take risk at all."
But I do not choose to add the expressions of indignation which the
examination of the facts before him called out. I was satisfied from
the effect they produced on him, that if all the hideous catalogues
of cases now accumulated were fully brought to the knowledge of the
public, nothing, since the days of Burke and Hare, has raised such a
cry of horror as would be shrieked in the ears of the Profession.
Dr. Meigs has elsewhere invoked "Providence" as the alternative of
accident, to account for the "coincidences." ("Obstetrics," Phil.
1852, p. 631.) If so, Providence either acts through the agency of
secondary causes, as in other diseases, or not. If through such
causes, let us find out what they are, as we try to do in other
cases. It may be true that offences, or diseases, will come, but
"woe unto him through whom they come," if we catch him in the
voluntary or careless act of bringing them! But if Providence does
not act through secondary causes in this particular sphere of
etiology, then why does Dr. Meigs take such pains to reason so
extensively about the laws of contagion, which, on that supposition,
have no more to do with this case than with the plague which
destroyed the people after David had numbered them? Above all, what
becomes of the theological aspect of the question, when he asserts
that a practitioner was "only unlucky in meeting with the epidemic
cases?" (Op. cit. p. 633.) We do not deny that the God of battles
decides the fate of nations; but we like to have the biggest
squadrons on our side, and we are particular that our soldiers should
not only say their prayers, but also keep their powder dry. We do
not deny the agency of Providence in the disaster at Norwalk, but we
turn off the engineer, and charge the Company five thousand dollars
apiece for every life that is sacrificed.
Why a grand jury should not bring in a bill against a physician who
switches off a score of women one after the other along his private
track, when he knows that there is a black gulf at the end of it,
down which they are to plunge, while the great highway is clear, is
more than I can answer. It is not by laying the open draw to
Providence that he is to escape the charge of manslaughter.
To finish with all these lesser matters of question, I am unable to
see why a female must necessarily be unattended in her confinement,
because she declines the services of a particular practitioner. In
all the series of cases mentioned, the death-carrying attendant was
surrounded by others not tracked by disease and its consequences.
Which, I would ask, is worse,--to call in another, even a rival
practitioner, or to submit an unsuspecting female to a risk which an
Insurance Company would have nothing to do with?
I do not expect ever to return to this subject. There is a point of
mental saturation, beyond which argument cannot be forced without
breeding impatient, if not harsh, feelings towards those who refuse
to be convinced. If I have so far manifested neither, it is well to
stop here, and leave the rest to those younger friends who may have
more stomach for the dregs of a stale argument.
The extent of my prefatory remarks may lead some to think that I
attach too much importance to my own Essay. Others may wonder that I
should expend so many words upon the two productions referred to, the
Letter and the Lecture. I do consider my Essay of much importance so
long as the doctrine it maintains is treated as a question, and so
long as any important part of the defence of that doctrine is thought
to rest on its evidence or arguments. I cannot treat as
insignificant any opinions bearing on life, and interests dearer than
life, proclaimed yearly to hundreds of young men, who will carry them
to their legitimate results in practice.
The teachings of the two Professors in the great schools of
Philadelphia are sure to be listened to, not only by their immediate
pupils, but by the Profession at large. I am too much in earnest for
either humility or vanity, but I do entreat those who hold the keys
of life and death to listen to me also for this once. I ask no
personal favor; but I beg to be heard in behalf of the women whose
lives are at stake, until some stronger voice shall plead for them.
I trust that I have made the issue perfectly distinct and
intelligible. And let it be remembered that this is no subject to be
smoothed over by nicely adjusted phrases of half-assent and half-
censure divided between the parties. The balance must be struck
boldly and the result declared plainly. If I have been hasty,
presumptuous, ill-informed, illogical; if my array of facts means
nothing; if there is no reason for any caution in the view of these
facts; let me be told so on such authority that I must believe it,
and I will be silent henceforth, recognizing that my mind is in a
state of disorganization. If the doctrine I have maintained is a
mournful truth; if to disbelieve it, and to practise on this
disbelief, and to teach others so to disbelieve and practise, is to
carry desolation, and to charter others to carry it, into confiding
families, let it be proclaimed as plainly what is to be thought of
the teachings of those who sneer at the alleged dangers, and scout
the very idea of precaution. Let it be remembered that persons are
nothing in this matter; better that twenty pamphleteers should be
silenced, or as many professors unseated, than that one mother's life
should be taken. There is no quarrel here between men, but there is
deadly incompatibility and exterminating warfare between doctrines.
Coincidences, meaning nothing, though a man have a monopoly of the
disease for weeks or months; or cause and effect, the cause being in
some way connected with the person; this is the question. If I am
wrong, let me be put down by such a rebuke as no rash declaimer has
received since there has been a public opinion in the medical
profession of America; if I am right, let doctrines which lead to
professional homicide be no longer taught from the chairs of those
two great Institutions. Indifference will not do here; our
Journalists and Committees have no right to take up their pages with
minute anatomy and tediously detailed cases, while it is a question
whether or not the "blackdeath" of child-bed is to be scattered
broadcast by the agency of the mother's friend and adviser. Let the
men who mould opinions look to it; if there is any voluntary
blindness, any interested oversight, any culpable negligence, even,
in such a matter, and the facts shall reach the public ear; the
pestilence-carrier of the lying-in chamber must look to God for
pardon, for man will never forgive him.
THE CONTAGIOUSNESS OF PUERPERAL FEVER.
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 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's 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 these 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 favor 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 small-pox is propagated
to a great extent by contagion, yet it goes through the same periods
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 small-pox
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. Apart
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 small-pox 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. [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
candor 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 neighborhood 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."
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.' 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 with the
same fate, till the neighborhood, getting afraid of her, ceased to
employ her."
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 neighborhood, 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." [Lond. Med. Gaz. May 2, 1835.]
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.
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
manger-side, 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."
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.[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."
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's "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.
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 I 'mixed cases,' and 'morbid affections after delivery.'"
In the "Quarterly Summary of the Transactions of the College of
Physicians of Philadelphia" 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 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," 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 twelvemonth past."
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, 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 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 efluvia. And here I may
mention, that this very Dr. Samuel 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.
No. 1, delivered March 20, died March 24.
" 2, " April 9, " April 14.
" 3, " " 10, " " 14.
" 4, " " 11, " " 18.
" 5, " " 27, " May 3.
" 6, " " 28, had some symptoms,(recovered.)
" 7, " 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 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 the 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. Scorer, 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 the 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 at 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 the 8th, I attended one who did well.
On the 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 recollections 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. Charming 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." [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 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." In the second Report the mortality was shown
to be about five in one thousand. In the Dublin Lying-in Hospital,
during the seven years of Dr. Collins's 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 a 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.
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."
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. 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.[Lancet, May 4, 1833]
I have myself been told by two gentlemen practising 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 one
instance of 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 coincidences 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. This same Dr. Campbell is one of Dr.
Churchill's authorities against contagion.
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 had died of this fever, to attend a labor; within forty-eight
hours this patient was seized with the fever.'
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.
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.
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.
"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."
[Brit. and For. Medical Review for Jan. 1842, p. 112.]
From the cases given by Mr. Ingleby, I select the following. Two
gentlemen, after having been engaged in conducting the post-mortem
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." [Edin. Med. and Surg. Journal, April,
1838.]
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 eases 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.
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. [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. [Stein, L'Art
d'Accoucher, 1794; Dict. des Sciences Medicales, art. "Puerperal."]
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. [Journal de Pharmacie, January,
1836.] 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.
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 abscess in the fingers or hands, attended with rapidly spreading
inflammation of the cellular tissue."
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
Tonnelle 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.
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.
It is true that some of the historians of the disease, especially
Hulme, Hull, and Leake, in England; Tonnelle, 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."
The names of Gordon, John Clarke, Denman, Burns, Young, Hamilton,
Haighton, Good, Waller; Blundell, Gooch, Ramsbotham, Douglas, Lee,
Ingleby, Locock, Abercrombie, Alison; Travers, Rigby, and Watson,
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. It
gives me pleasure to remember, that while the doctrine has been
unceremoniously discredited in one of the leading Journals, 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.
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. 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 new-born 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!
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 physician is 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. Stows, contained in the
Appendix to this Report. Mr. Stows 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. Se. 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.
Se., 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, 184,6. 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 of Puerperal Fever, and their Intimate
Pathological Connection. (From Monthly Journal of Med. Sc.) Am.
Jour. Med. Se., July, 1850.
Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits,
from inoculation with different morbid secretions.) Am. Jour. Med.
Se., October, 1850.
Arneth. Paper read before the National Academy of Medicine. Annales
d'Hygiene, Tome LXV. 2e 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. Se. 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.
Peddle.--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. Veddie 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 maybe 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,--Lesotho, 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 "'t is enough, 't will 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."
III
CURRENTS AND COUNTER-CURRENTS IN MEDICAL SCIENCE
An Address delivered before the Massachusetts Medical Society, at the
Annual Meeting, May 30, 1860.
"Facultate magis quam violentia."
HIPPOCRATES.
Our Annual Meeting never fails to teach us at least one lesson. The
art whose province it is to heal and to save cannot protect its own
ranks from the inroads of disease and the waste of the Destroyer.
Seventeen of our associates have been taken from us since our last
Anniversary. Most of them followed their calling in the villages or
towns that lie among the hills or along the inland streams. Only
those who have lived the kindly, mutually dependent life of the
country, can tell how near the physician who is the main reliance in
sickness of all the families throughout a thinly settled region comes
to the hearts of the people among whom he labors, how they value him
while living, how they cherish his memory when dead. For these
friends of ours who have gone before, there is now no more toil; they
start from their slumbers no more at the cry of pain; they sally
forth no more into the storms; they ride no longer over the lonely
roads that knew them so well; their wheels are rusting on their axles
or rolling with other burdens; their watchful eyes are closed to all
the sorrows they lived to soothe. Not one of these was famous in the
great world; some were almost unknown beyond their own immediate
circle. But they have left behind them that loving remembrance which
is better than fame, and if their epitaphs are chiselled briefly in
stone, they are written at full length on living tablets in a
thousand homes to which they carried their ever-welcome aid and
sympathy.
One whom we have lost, very widely known and honored, was a leading
practitioner of this city. His image can hardly be dimmed in your
recollection, as he stood before you only three years ago, filling
the same place with which I am now honored. To speak of him at all
worthily, would be to write the history of professional success, won
without special aid at starting, by toil, patience, good sense, pure
character, and pleasing manners; won in a straight uphill ascent,
without one breathing-space until he sat down, not to rest, but to
die. If prayers could have shielded him from the stroke, if love
could have drawn forth the weapon, and skill could have healed the
wound, this passing tribute might have been left to other lips and to
another generation.
Let us hope that our dead have at last found that rest which neither
summer nor winter, nor day nor night, had granted to their unending
earthly labors! And let us remember that our duties to our brethren
do not cease when they become unable to share our toils, or leave
behind them in want and woe those whom their labor had supported. It
is honorable to the Profession that it has organized an Association a
for the relief of its suffering members and their families; it owes
this tribute to the ill-rewarded industry and sacrifices of its less
fortunate brothers who wear out health and life in the service of
humanity. I have great pleasure in referring to this excellent
movement, which gives our liberal profession a chance to show its
liberality, and serves to unite us all, the successful and those whom
fortune has cast down, in the bonds of a true brotherhood.
A medical man, as he goes about his daily business after twenty years
of practice, is apt to suppose that he treats his patients according
to the teachings of his experience. No doubt this is true to some
extent; to what extent depending much on the qualities of the
individual. But it is easy to prove that the prescriptions of even
wise physicians are very commonly founded on something quite
different from experience. Experience must be based on the permanent
facts of nature. But a glance at the prevalent modes of treatment of
any two successive generations will show that there is a changeable
as well as a permanent element in the art of healing; not merely
changeable as diseases vary, or as new remedies are introduced, but
changeable by the going out of fashion of special remedies, by the
decadence of a popular theory from which their fitness was deduced,
or other cause not more significant. There is no reason to suppose
that the present time is essentially different in this respect from
any other. Much, therefore, which is now very commonly considered to
be the result of experience, will be recognized in the next, or in
some succeeding generation, as no such result at all, but as a
foregone conclusion, based on some prevalent belief or fashion of the
time.
There are, of course, in every calling, those who go about the work
of the day before them, doing it according to the rules of their
craft, and asking no questions of the past or of the future, or of
the aim and end to which their special labor is contributing. These
often consider and call themselves practical men. They pull the oars
of society, and have no leisure to watch the currents running this or
that way; let theorists and philosophers attend to them. In the mean
time, however, these currents are carrying the practical men, too,
and all their work may be thrown away, and worse than thrown away, if
they do not take knowledge of them and get out of the wrong ones and
into the right ones as soon as they may. Sir Edward Parry and his
party were going straight towards the pole in one of their arctic
expeditions, travelling at the rate of ten miles a day. But the ice
over which they travelled was drifting straight towards the equator,
at the rate of twelve miles a day, and yet no man among them would
have known that he was travelling two miles a day backward unless he
had lifted his eyes from the track in which he was plodding. It is
not only going backward that the plain practical workman is liable
to, if he will not look up and look around; he may go forward to ends
he little dreams of. It is a simple business for a mason to build up
a niche in a wall; but what if, a hundred years afterwards when the
wall is torn down, the skeleton of a murdered man drop out of the
niche? It was a plain practical piece of carpentry for a Jewish
artisan to fit two pieces of timber together according to the legal
pattern in the time of Pontius Pilate; he asked no questions,
perhaps, but we know what burden the cross bore on the morrow! And
so, with subtler tools than trowels or axes, the statesman who works
in policy without principle, the theologian who works in forms
without a soul, the physician who, calling himself a practical man,
refuses to recognize the larger laws which govern his changing
practice, may all find that they have been building truth into the
wall, and hanging humanity upon the cross.
The truth is, that medicine, professedly founded on observation, is
as sensitive to outside influences, political, religious,
philosophical, imaginative, as is the barometer to the changes of
atmospheric density. Theoretically it ought to go on its own
straightforward inductive path, without regard to changes of
government or to fluctuations of public opinion. But look a moment
while I clash a few facts together, and see if some sparks do not
reveal by their light a closer relation between the Medical Sciences
and the conditions of Society and the general thought of the time,
than would at first be suspected.
Observe the coincidences between certain great political and
intellectual periods and the appearance of illustrious medical
reformers and teachers. It was in the age of Pericles, of Socrates,
of Plato, of Phidias, that Hippocrates gave to medical knowledge the
form which it retained for twenty centuries. With the world-
conquering Alexander, the world-embracing Aristotle, appropriating
anatomy and physiology, among his manifold spoils of study, marched
abreast of his royal pupil to wider conquests. Under the same
Ptolemies who founded the Alexandrian Library and Museum, and ordered
the Septuagint version of the Hebrew Scriptures, the infallible
Herophilus ["Contradicere Herophilo in anatomicis, est contradicere
evangelium," was a saying of Fallopius.] made those six hundred
dissections of which Tertullian accused him, and the sagacious
Erasistratus introduced his mild antiphlogistic treatment in
opposition to the polypharmacy and antidotal practice of his time.
It is significant that the large-minded Galen should have been the
physician and friend of the imperial philosopher Marcus Aurelius.
The Arabs gave laws in various branches of knowledge to those whom
their arms had invaded, or the terror of their spreading dominion had
reached, and the point from which they started was, as Humboldt
acknowledges, "the study of medicine, by which they long ruled the
Christian Schools," and to which they added the department of
chemical pharmacy.
Look at Vesalius, the contemporary of Luther. Who can fail to see
one common spirit in the radical ecclesiastic and the reforming
court-physician? Both still to some extent under the dominion of the
letter: Luther holding to the real presence; Vesalius actually
causing to be drawn and engraved two muscles which he knew were not
found in the human subject, because they had been described by Galen,
from dissections of the lower animals. Both breaking through old
traditions in the search of truth; one, knife in hand, at the risk of
life and reputation, the other at the risk of fire and fagot, with
that mightier weapon which all the devils could not silence, though
they had been thicker than the tiles on the house-tops. How much the
physician of the Catholic Charles V. had in common with the great
religious destructive, may be guessed by the relish with which he
tells the story how certain Pavian students exhumed the body of an
"elegans scortum," or lovely dame of ill repute, the favorite of a
monk of the order of St. Anthony, who does not seem to have resisted
temptation so well as the founder of his order. We have always
ranked the physician Rabelais among the early reformers, but I do not
know that Vesalius has ever been thanked for his hit at the morals of
the religious orders, or for turning to the good of science what was
intended for the "benefit of clergy."
Our unfortunate medical brother, Michael Servetus, the spiritual
patient to whom the theological moxa was applied over the entire
surface for the cure of his heresy, came very near anticipating
Harvey. The same quickened thought of the time which led him to
dispute the dogma of the Church, opened his mind to the facts which
contradicted the dogmas of the Faculty.
Harvey himself was but the posthumous child of the great Elizabethan
period. Bacon was at once his teacher and his patient. The founder
of the new inductive philosophy had only been dead two years when the
treatise on the Circulation, the first-fruit of the Restoration of
Science, was given to the world.
And is it to be looked at as a mere accidental coincidence, that
while Napoleon was modernizing the political world, Bichat was
revolutionizing the science of life and the art that is based upon
it; that while the young general was scaling the Alps, the young
surgeon was climbing the steeper summits of unexplored nature; that
the same year read the announcement of those admirable "Researches on
Life and Death," and the bulletins of the battle of Marengo?
If we come to our own country, who can fail to recognize that
Benjamin Rush, the most conspicuous of American physicians, was the
intellectual offspring of the movement which produced the Revolution?
"The same hand," says one of his biographers," which subscribed the
declaration of the political independence of these States,
accomplished their emancipation from medical systems formed in
foreign countries, and wholly unsuitable to the state of diseases in
America."
Following this general course of remark, I propose to indicate in a
few words the direction of the main intellectual current of the time,
and to point out more particularly some of the eddies which tend to
keep the science and art of medicine from moving with it, or even to
carry them backwards.
The two dominant words of our time are law and average, both pointing
to the uniformity of the order of being in which we live. Statistics
have tabulated everything,--population, growth, wealth, crime,
disease. We have shaded maps showing the geographical distribution
of larceny and suicide. Analysis and classification have been at
work upon all tangible and visible objects. The Positive Philosophy
of Comte has only given expression to the observing and computing
mind of the nineteenth century.
In the mean time, the great stronghold of intellectual conservatism,
traditional belief, has been assailed by facts which would have been
indicted as blasphemy but a few generations ago. Those new tables of
the law, placed in the hands of the geologist by the same living God
who spoke from Sinai to the Israelites of old, have remodelled the
beliefs of half the civilized world. The solemn scepticism of
science has replaced the sneering doubts of witty philosophers. The
more positive knowledge we gain, the more we incline to question all
that has been received without absolute proof.
As a matter of course, this movement has its partial reactions. The
province of faith is claimed as a port free of entry to unsupported
individual convictions. The tendency to question is met by the
unanalyzing instinct of reverence. The old church calls back its
frightened truants. Some who have lost their hereditary religious
belief find a resource in the revelations of Spiritualism. By a
parallel movement, some of those who have become medical infidels
pass over to the mystic band of believers in the fancied miracles of
Homoeopathy.
Under these influences transmitted to, or at least shared by, the
medical profession, the old question between "Nature," so called, and
"Art," or professional tradition, has reappeared with new interest.
I say the old question, for Hippocrates stated the case on the side
of "Nature" more than two thousand years ago. Miss Florence
Nightingale,--and if I name her next to the august Father of the
Healing Art, its noblest daughter well deserves that place of honor,
--Miss Florence Nightingale begins her late volume with a paraphrase
of his statement. But from a very early time to this there has
always been a strong party against "Nature." Themison called the
practice of Hippocrates "a meditation upon death." Dr. Rush says:
"It is impossible to calculate the mischief which Hippocrates, has
done, by first marking Nature with his name and afterwards letting
her loose upon sick people. Millions have perished by her hands in
all ages and countries." Sir John Forbes, whose defence of "Nature"
in disease you all know, and to the testimonial in whose honor four
of your Presidents have contributed, has been recently greeted, on
retiring from the profession, with a wish that his retirement had
been twenty years sooner, and the opinion that no man had done so
much to destroy the confidence of the public in the medical
profession.
In this Society we have had the Hippocratic and the Themisonic side
fairly represented. The treatise of one of your early Presidents on
the Mercurial Treatment is familiar to my older listeners. Others
who have held the same office have been noted for the boldness of
their practice, and even for partiality to the use of complex
medication.
On the side of "Nature" we have had, first of all, that remarkable
discourse on Self-Limited Diseases, [On Self-Limited Diseases. A
Discourse delivered before the Massachusetts Medical Society, at
their Annual Meeting, May 27, 1835. By Jacob Bigelow, M. D.] which
has given the key-note to the prevailing medical tendency of this
neighborhood, at least, for the quarter of a century since it was
delivered. Nor have we forgotten the address delivered at
Springfield twenty years later, [Search out the Secrets, of Nature.
By Augustus A. Gould, M. D. Read at the Annual Meeting, June 27,
1855.] full of good sense and useful suggestions, to one of which
suggestions we owe the learned, impartial, judicious, well-written
Prize Essay of Dr. Worthington Hooker. [Rational Therapeutics. A
Prize Essay. By Worthington Hooker, M. D., of New Haven. Boston.
1857.] We should not omit from the list the important address of
another of our colleagues, [On the Treatment of Compound and
Complicated Fractures. By William J. Walker, M. D. Read at the
Annual Meeting, May 29, 1845.] showing by numerous cases the power of
Nature in healing compound fractures to be much greater than is
frequently supposed,--affording, indeed, more striking illustrations
than can be obtained from the history of visceral disease, of the
supreme wisdom, forethought, and adaptive dexterity of that divine
Architect, as shown in repairing the shattered columns which support
the living temple of the body.
We who are on the side of "Nature" please ourselves with the idea
that we are in the great current in which the true intelligence of
the time is moving. We believe that some who oppose, or fear, or
denounce our movement are themselves caught in various eddies that
set back against the truth. And we do most earnestly desire and most
actively strive, that Medicine, which, it is painful to remember, has
been spoken of as "the withered branch of science" at a meeting of
the British Association, shall be at length brought fully to share,
if not to lead, the great wave of knowledge which rolls with the
tides that circle the globe.
If there is any State or city which might claim to be the American
headquarters of the nature-trusting heresy, provided it be one, that
State is Massachusetts, and that city is its capital. The effect
which these doctrines have upon the confidence reposed in the
profession is a matter of opinion. For myself, I do not believe this
confidence can be impaired by any investigations which tend to limit
the application of troublesome, painful, uncertain, or dangerous
remedies. Nay, I will venture to say this, that if every specific
were to fail utterly, if the cinchona trees all died out, and the
arsenic mines were exhausted, and the sulphur regions were burned up,
if every drug from the vegetable, animal, and mineral kingdom were to
disappear from the market, a body of enlightened men, organized as a
distinct profession, would be required just as much as now, and
respected and trusted as now, whose province should be to guard
against the causes of disease, to eliminate them if possible when
still present, to order all the conditions of the patient so as to
favor the efforts of the system to right itself, and to give those
predictions of the course of disease which only experience can
warrant, and which in so many cases relieve the exaggerated fears of
sufferers and their friends, or warn them in season of impending
danger. Great as the loss would be if certain active remedies could
no longer be obtained, it would leave the medical profession the most
essential part of it's duties, and all, and more than all, its
present share of honors; for it would be the death-blow to
charlatanism, which depends for its success almost entirely on drugs,
or at least on a nomenclature that suggests them.
There is no offence, then, or danger in expressing the opinion, that,
after all which has been said, the community is still overdosed: The
best proof of it is, that "no families take so little medicine as
those of doctors, except those of apothecaries, and that old
practitioners are more sparing of active medicines than younger
ones." [Dr. James Jackson has kindly permitted me to make the
following extract from a letter just received by him from Sir James
Clark, and dated May 26, 1860: "As a physician advances in age, he
generally, I think, places less confidence in the ordinary medical
treatment than he did, not only during his early, but even his middle
period of life."] The conclusion from these facts is one which the
least promising of Dr. Howe's pupils in the mental department could
hardly help drawing.
Part of the blame of over-medication must, I fear, rest with the
profession, for yielding to the tendency to self-delusion, which
seems inseparable from the practice of the art of healing. I need
only touch on the common modes of misunderstanding or misapplying the
evidence of nature.
First, there is the natural incapacity for sound observation, which
is like a faulty ear in music. We see this in many persons who know
a good deal about books, but who are not sharp-sighted enough to buy
a horse or deal with human diseases.
Secondly, there is in some persons a singular inability to weigh the
value of testimony; of which, I think, from a pretty careful
examination of his books, Hahnemann affords the best specimen outside
the walls of Bedlam.
The inveterate logical errors to which physicians have always been
subject are chiefly these:
The mode of inference per enumerationem simplicem, in scholastic
phrase; that is, counting only their favorable cases. This is the
old trick illustrated in Lord Bacon's story of the gifts of the
shipwrecked people, hung up in the temple.--Behold! they vowed these
gifts to the altar, and the gods saved them. Ay, said a doubting
bystander, but how many made vows of gifts and were shipwrecked
notwithstanding? The numerical system is the best corrective of this
and similar errors. The arguments commonly brought against its
application to all matters of medical observation, treatment
included, seem to apply rather to the tabulation of facts ill
observed, or improperly classified, than to the method itself.
The post hoc ergo propter hoc error: he got well after taking my
medicine; therefore in consequence of taking it.
The false induction from genuine facts of observation, leading to the
construction of theories which are then deductively applied in the
face of the results of direct observation. The school of Broussais
has furnished us with a good example of this error.
And lastly, the error which Sir Thomas Browne calls giving "a reason
of the golden tooth;" that is, assuming a falsehood as a fact, and
giving reasons for it, commonly fanciful ones, as is constantly done
by that class of incompetent observers who find their "golden tooth"
in the fabulous effects of the homoeopathie materia medica,--which
consists of sugar of milk and a nomenclature.
Another portion of the blame rests with the public itself, which
insists on being poisoned. Somebody buys all the quack medicines
that build palaces for the mushroom, say rather, the toadstool
millionaires. Who is it? These people have a constituency of
millions. The popular belief is all but universal that sick persons
should feed on noxious substances. One of our members was called not
long since to a man with a terribly sore mouth. On inquiry he found
that the man had picked up a box of unknown pills, in Howard Street,
and had proceeded to take them, on general principles, pills being
good for people. They happened to contain mercury, and hence the
trouble for which he consulted our associate.
The outside pressure, therefore, is immense upon the physician,
tending to force him to active treatment of some kind. Certain old
superstitions, still lingering in the mind of the public, and not yet
utterly expelled from that of the profession, are at the bottom of
this, or contribute to it largely. One of the most ancient is, that
disease is a malignant agency, or entity, to be driven out of the
body by offensive substances, as the smoke of the fish's heart and
liver drove the devil out of Tobit's bridal chamber, according to the
Apochrypha. Epileptics used to suck the blood from the wounds of
dying gladiators. [Plinii Hist. Mundi. lib. xxviii. c. 4.] The
Hon. Robert Boyle's little book was published some twenty or thirty
years before our late President, Dr. Holyoke, was born. [A Collection
of Choice and Safe Remedies. The Fifth Edition, corrected. London,
1712. Dr. Holyoke was born in 1728.] In it he recommends, as
internal medicines, most of the substances commonly used as
fertilizers of the soil. His "Album Graecum" is best left
untranslated, and his "Zebethum Occidentale" is still more
transcendentally unmentionable except in a strange dialect. It
sounds odiously to us to hear him recommend for dysentery a powder
made from "the sole of an old shoe worn by some man that walks much."
Perhaps nobody here ever heard of tying a stocking, which had been
worn during the day, round the neck at night for a sore throat. The
same idea of virtue in unlovely secretions! [The idea is very
ancient. "Sordes hominis" "Sudore et oleo medicinam facientibus."
--Plin. xxviii. 4.]
Even now the Homoeopathists have been introducing the venom of
serpents, under the learned title of Lachesis, and outraging human
nature with infusions of the pediculus capitis; that is, of course,
as we understand their dilutions, the names of these things; for if a
fine-tooth-comb insect were drowned in Lake Superior, we cannot agree
with them in thinking that every drop of its waters would be
impregnated with all the pedicular virtues they so highly value.
They know what they are doing. They are appealing to the detestable
old superstitious presumption in favor of whatever is nauseous and
noxious as being good for the sick.
Again, we all occasionally meet persons stained with nitrate of
silver, given for epilepsy. Read what Dr. Martin says, about the way
in which it came to be used, in his excellent address before the
Norfolk County Medical Society, and the evidence I can show, but have
not time for now, and then say what you think of the practice which
on such presumptions turns a white man as blue as the double-tattooed
King of the Cannibal Islands! [Note A.]
If medical superstitions have fought their way down through all the
rationalism and scepticism of the nineteenth century, of course the
theories of the schools, supported by great names, adopted into the
popular belief and incorporated with the general mass of
misapprehension with reference to disease, must be expected to meet
us at every turn in the shape of bad practice founded on false
doctrine. A French patient complains that his blood heats him, and
expects his doctor to bleed him. An English or American one says he
is bilious, and will not be easy without a dose of calomel. A doctor
looks at a patient's tongue, sees it coated, and says the stomach is
foul; his head full of the old saburral notion which the extreme
inflammation-doctrine of Broussais did so much to root out, but which
still leads, probably, to much needless and injurious wrong of the
stomach and bowels by evacuants, when all they want is to be let
alone. It is so hard to get anything out of the dead hand of medical
tradition! The mortmain of theorists extinct in science clings as
close as that of ecclesiastics defunct in law.
One practical hint may not be out of place here. It seems to be
sometimes forgotten, by those who must know the fact, that the tongue
is very different, anatomically and physiologically, from the
stomach. Its condition does not in the least imply a similar one of
the stomach, which is a very different structure, covered with a
different kind of epithelium, and furnished with entirely different
secretions. A silversmith will, for a dollar, make a small hoe, of
solid silver, which will last for centuries, and will give a patient
more comfort, used for the removal of the accumulated epithelium and
fungous growths which constitute the "fur," than many a prescription
with a split-footed Rx before it, addressed to the parts out of
reach.
I think more of this little implement on account of its agency in
saving the Colony at Plymouth in the year 1623. Edward Winslow heard
that Massasoit was sick and like to die. He found him with a
houseful of people about him, women rubbing his arms and legs, and
friends "making such a hellish noise" as they probably thought would
scare away the devil of sickness. Winslow gave him some conserve,
washed his mouth, scraped his tongue, which was in a horrid state,
got down some drink, made him some broth, dosed him with an infusion
of strawberry leaves and sassafras root, and had the satisfaction of
seeing him rapidly recover. Massasoit, full of gratitude, revealed
the plot which had been formed to destroy the colonists, whereupon
the Governor ordered Captain Miles Standish to see to them; who
thereupon, as everybody remembers, stabbed Pecksuot with his own
knife, broke up the plot, saved the colony, and thus rendered
Massachusetts and the Massachusetts Medical Society a possibility, as
they now are a fact before us. So much for this parenthesis of the
tongue-scraper, which helped to save the young colony from a much
more serious scrape, and may save the Union yet, if a Presidential
candidate should happen to be taken sick as Massasoit was, and his
tongue wanted cleaning,--which process would not hurt a good many
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