The Complete PG Works of Oliver Wendell Holmes, Sr.
by
Oliver Wendell Holmes, Sr. (The Physician and Poet)
Part 43 out of 51
And Dr. Fielitz, in the "Homoeopathic Gazette" of Leipsic, after
saying, in a good-natured way, that Psora is the Devil in medicine,
and that physicians are divided on this point into diabolists and
exorcists, declares that, according to a remark of Hahnemann, the
whole civilized world is affected with Psora. I must therefore
disappoint any advocate of Hahnemann who may honor me with his
presence, by not attacking a doctrine on which some of the disciples
of his creed would be very happy to have its adversaries waste their
time and strength. I will not meddle with this excrescence, which,
though often used in time of peace, would be dropped, like the limb
of a shell-fish, the moment it was assailed; time is too precious,
and the harvest of living extravagances nods too heavily to my
sickle, that I should blunt it upon straw and stubble.
I will close the subject with a brief examination of some of the
statements made in Homoeopathic works, and more particularly in the
brilliant Manifesto of the "Examiner," before referred to. And
first, it is there stated under the head of "Homoeopathic
Literature," that "SEVEN HUNDRED volumes have been issued from the
press developing the peculiarities of the system, and many of them
possessed of a scientific character that savans know well how to
respect." If my assertion were proper evidence in the case, I should
declare, that, having seen a good many of these publications, from
the year 1834, when I bought the work of the Rev. Thomas Everest,"
[Dr. Curie speaks of this silly pamphlet as having been published in
1835.] to within a few weeks, when I received my last importation of
Homaeopathic literature, I have found that all, with a very few
exceptions, were stitched pamphlets varying from twenty or thirty
pages to somewhat less than a hundred, and generally resembling each
other as much as so many spelling-books.
But not being evidence in the case, I will give you the testimony of
Dr. Trinks, of Dresden, who flourishes on the fifteenth page of the
same Manifesto as one of the most distinguished among the
Homoeopathists of Europe. I translate the sentence literally from
the "Archives de la Medecine Homoeopathique."
"The literature of Homoeopathy, if that honorable name must be
applied to all kinds of book-making, has been degraded to the
condition of the humblest servitude. Productions without talent,
without spirit, without discrimination, flat and pitiful eulogies,
exaggerations surpassing the limits of the most robust faith,
invectives against such as dared to doubt the dogmas which had been
proclaimed, or catalogues of remedies; of such materials is it
composed! From distance to distance only, have appeared some memoirs
useful to science or practice, which appear as so many green oases in
the midst of this literary desert."
It is a very natural as well as a curious question to ask, What has
been the success of Homoeopathy in the different countries of Europe,
and what is its present condition?
The greatest reliance of the advocates of Homoeopathy is of course on
Germany. We know very little of its medical schools, its medical
doctrines, or its medical men, compared with those of England and
France. And, therefore, when an intelligent traveller gives a direct
account from personal inspection of the miserable condition of the
Homoeopathic hospital at Leipsic, the first established in Europe,
and the first on the list of the ever-memorable Manifesto, it is easy
enough answer or elude the fact by citing various hard names of
"distinguished" practitioners, which sound just as well to the
uninformed public as if they were Meckel, or Tiedemann, or
Langenbeck. Dr. Leo-Wolf, who, to be sure, is opposed to
Homoeopathy, but who is a scholar, and ought to know something
of his own countrymen, assures us that "Dr. Kopp is the only German
Homoeopathist, if we can call him so, who has been distinguished as
an author and practitioner before he examined this method." And Dr.
Lee, the same gentleman in whose travels the paragraph relating to
the Leipsic Hospital is to be found, says the same thing. And I will
cheerfully expose myself to any impertinent remark which it might
suggest, to assure my audience that I never heard or saw one
authentic Homoeopathic name of any country in Europe, which I had
ever heard mentioned before as connected with medical science by a
single word or deed sufficient to make it in any degree familiar to
my ears, unless Arnold of Heidelberg is the anatomist who discovered
a little nervous centre, called the otic ganglion. But you need ask
no better proof of who and what the German adherents of this doctrine
must be, than the testimony of a German Homoeopathist as to the
wretched character of the works they manufacture to enforce its
claims.
As for the act of this or that government tolerating or encouraging
Homoeopathy, every person of common intelligence knows that it is a
mere form granted or denied according to the general principles of
policy adopted in different states, or the degree of influence which
some few persons who have adopted it may happen to have at court.
What may be the value of certain pompous titles with which many of
the advocates of Homoeopathy are honored, it might be disrespectful
to question. But in the mean time the judicious inquirer may ponder
over an extract which I translate from a paper relating to a
personage well known to the community as Williams the Oculist, with
whom I had the honor of crossing the Atlantic some years since, and
who himself handed me two copies of the paper in question.
"To say that he was oculist of Louis XVIII. and of Charles X., and
that he now enjoys the same title with respect to His Majesty, Louis
Philippe, and the King of the Belgians, is unquestionably to say a
great deal; and yet it is one of the least of his titles to public
confidence. His reputation rests upon a basis more substantial even
than the numerous diplomas with which he is provided, than the
membership of the different medical societies which have chosen him
as their associate," etc., etc.
And as to one more point, it is time that the public should fully
understand that the common method of supporting barefaced imposture
at the present day, both in Europe and in this country, consists in
trumping up "Dispensaries," "Colleges of Health," and other
advertising charitable clap-traps, which use the poor as decoy-ducks
for the rich, and the proprietors of which have a strong predilection
for the title of "Professor." These names, therefore, have come to
be of little or no value as evidence of the good character, still
less of the high pretensions of those who invoke their authority.
Nor does it follow, even when a chair is founded in connection with a
well-known institution, that it has either a salary or an occupant;
so that it may be, and probably is, a mere harmless piece of
toleration on the part of the government if a Professorship of
Homoeopathy is really in existence at Jena or Heidelberg. And
finally, in order to correct the error of any who might suppose that
the whole Medical Profession of Germany has long since fallen into
the delusions of Hahnemann, I will quote two lines which a celebrated
anatomist and surgeon (whose name will occur again in this lecture in
connection with a very pleasing letter) addressed to the French
Academy of Medicine in 1835. "I happened to be in Germany some
months since, at a meeting of nearly six hundred physicians; one of
them wished to bring up the question of Homoeopathy; they would not
even listen to him." This may have been very impolite and bigoted,
but that is not precisely the point in reference to which I mention
the circumstance.
But if we cannot easily get at Germany, we can very easily obtain
exact information from France and England. I took the trouble to
write some months ago to two friends in Paris, in whom I could place
confidence, for information upon the subject. One of them answered
briefly to the effect that nothing was said about it. When the late
Curator of the Lowell Institute, at his request, asked about the
works upon the subject, he was told that they had remained a long
time on the shelves quite unsalable, and never spoken of.
The other gentleman, [Dr. Henry T. Bigelow, now Professor of
Surgery in Harvard University] whose name is well known to my
audience, and who needs no commendation of mine, had the kindness to
procure for me many publications upon the subject, and some
information which sets the whole matter at rest, so far as Paris is
concerned. He went directly to the Baillieres, the principal and
almost the only publishers of all the Homoeopathic books and journals
in that city. The following facts were taken by him from the
account-books of this publishing firm. Four Homoeopathic Journals
have been published in Paris; three of them by the Baillieres.
The reception they met with may be judged of by showing the number of
subscribers to each on the books of the publishing firm.
A Review published by some other house, which lasted one year, and
had about fifty subscribers, appeared in 1834, 1835.
There were only four Journals of Homoeopathy ever published in Paris.
The Baillieres informed my correspondent that the sale of
Homoeopathic books was much less than formerly, and that consequently
they should undertake to publish no new books upon the subject,
except those of Jahr or Hahnemann. "This man," says my
correspondent,--referring to one of the brothers,--"the publisher and
headquarters of Homoeopathy in Paris, informs me that it is going
down in England and Germany as well as in Paris." For all the facts
he had stated he pledged himself as responsible.
Homoeopathy was in its prime in Paris, he said, in 1836 and 1837, and
since then has been going down.
Louis told my correspondent that no person of distinction in Paris
had embraced Homoeopathy, and that it was declining. If you ask who
Louis is, I refer you to the well-known Homoeopathist, Peschier of
Geneva, who says, addressing him, "I respect no one more than
yourself; the feeling which guides your researches, your labors, and
your pen, is so honorable and rare, that I could not but bow down
before it; and I own, if there were any allopathist who inspired me
with higher veneration, it would be him and not yourself whom I
should address."
Among the names of "Distinguished Homoeopathists," however, displayed
in imposing columns, in the index of the "Homoeopathic Examiner," are
those of MARJOLIN, AMUSSAT, and BRESCHET, names well known to the
world of science, and the last of them identified with some of the
most valuable contributions which anatomical knowledge has received
since the commencement of the present century. One Dr. Chrysaora,
who stands sponsor for many facts in that Journal, makes the
following statement among the rest: "Professors, who are esteemed
among the most distinguished of the Faculty (Faculty de Medicine),
both as to knowledge and reputation, have openly confessed the power
of Homoeopathia in forms of disease where the ordinary method of
practice proved totally insufficient. It affords me the highest
pleasure to select from among these gentlemen, Marjolin, Amussat, and
Breschet."
Here is a literal translation of an original letter, now in my
possession, from one of these Homoeopathists to my correspondent:--
"DEAR SIR, AND RESPECTED PROFESSIONAL BROTHER:
"You have had the kindness to inform me in your letter that a new
American Journal, the 'New World,' has made use of my name in
support of the pretended Homoeopathic doctrines, and that I am
represented as one of the warmest partisans of Homoeopathy in France.
"I am vastly surprised at the reputation manufactured for me upon the
new continent; but I am obliged, in deference to truth, to reject it
with my whole energy. I spurn far from me everything which relates
to that charlatanism called Homoeopathy, for these pretended
doctrines cannot endure the scrutiny of wise and enlightened persons,
who are guided by honorable sentiments in the practice of the noblest
of arts.
"PARIS, 3d November, 1841
"I am, etc., etc.,
"G. BRESCHET,
"Professor in the Faculty of Medicine, Member of the Institute,
Surgeon of Hotel Dieu, and Consulting Surgeon to the King, etc."
[I first saw M. Breschet's name mentioned in that Journal]
Concerning Amussat, my correspondent writes, that he was informed by
Madame Hahnemann, who converses in French more readily than her
husband, and therefore often speaks for him, that "he was not a
physician, neither Homoeopathist nor Allopathist, but that he was the
surgeon of their own establishment; that is, performed as a surgeon
all the operations they had occasion for in their practice."
I regret not having made any inquiries as to Marjolin, who, I doubt
not, would strike his ponderous snuff-box until it resounded like the
Grecian horse, at hearing such a doctrine associated with his
respectable name. I was not aware, when writing to Paris, that this
worthy Professor, whose lectures I long attended, was included in
these audacious claims; but after the specimens I have given of the
accuracy of the foreign correspondence of the "Homoeopathic
Examiner," any further information I might obtain would seem so
superfluous as hardly to be worth the postage.
Homoeopathy may be said, then, to be in a sufficiently miserable
condition in Paris. Yet there lives, and there has lived for years,
the illustrious Samuel Hahnemann, who himself assured my
correspondent that no place offered the advantages of Paris in its
investigation, by reason of the attention there paid to it.
In England, it appears by the statement of Dr. Curie in October,
1839, about eight years after its introduction into the country, that
there were eighteen Homoeopathic physicians in the United Kingdom, of
whom only three were to be found out of London, and that many of
these practised Homoeopathy in secret.
It will be seen, therefore, that, according to the recent statement
of one of its leading English advocates, Homoeopathy had obtained not
quite half as many practical disciples in England as Perkinism could
show for itself in a somewhat less period from the time of its first
promulgation in that country.
Dr. Curie's letter, dated London, October 30, 1839, says there is
"one in Dublin, Dr. Luther; at Glasgow, Dr. Scott." The
"distinguished" Chrysaora writes from Paris, dating October 20, 1839,
"On the other hand, Homoeopathy is commencing to make an inroad into
England by the way of Ireland. At Dublin, distinguished physicians
have already embraced the new system, and a great part of the
nobility and gentry of that city have emancipated themselves from the
English fashion and professional authority."
But the Marquis of Anglesea and Sir Edward Lytton Bulwer patronize
Homoeopathy; the Queen Dowager Adelaide has been treated by a
Homoeopathic physician. "Jarley is the delight of the nobility and
gentry." "The Royal Family are the patrons of Jarley."
Let me ask if a Marquis and a Knight are better than two Lords, and
if the Dowager of Royalty is better than Royalty itself, all of which
illustrious dignities were claimed in behalf of Benjamin Douglass
Perkins?
But if the balance is thought too evenly suspended in this case,
another instance can be given in which the evidence of British
noblemen and their ladies is shown to be as valuable in establishing
the character of a medical man or doctrine, as would be the testimony
of the Marquis of Waterford concerning the present condition and
prospects of missionary enterprise. I have before me an octavo
volume of more than four hundred pages, in which, among much similar
matter, I find highly commendatory letters from the Marchioness of
Ormond, Lady Harriet Kavanagh, the Countess of Buckinghamshire, the
Right Hon. Viscount Ingestre, M. P., and the Most Noble, the Marquis
of Sligo,--all addressed to "John St. John Long, Esq," a wretched
charlatan, twice tried for, and once convicted of, manslaughter at
the Old Bailey.
This poor creature, too, like all of his tribe, speaks of the medical
profession as a great confederation of bigoted monopolists. He, too,
says that "If an innovator should appear, holding out hope to those
in despair, and curing disorders which the faculty have recorded as
irremediable, he is at once, and without inquiry, denounced as an
empiric and an impostor." He, too, cites the inevitable names of
Galileo and Harvey, and refers to the feelings excited by the great
discovery of Jenner. From the treatment of the great astronomer who
was visited with the punishment of other heretics by the
ecclesiastical authorities of a Catholic country some centuries
since, there is no very direct inference to be drawn to the medical
profession of the present time. His name should be babbled no
longer, after having been placarded for the hundredth time in the
pages of St. John Long. But if we are doomed to see constant
reference to the names of Harvey and Jenner in every worthless
pamphlet containing the prospectus of some new trick upon the public,
let us, once for all, stare the facts in the face, and see how the
discoveries of these great men were actually received by the medical
profession.
In 1628, Harvey published his first work upon the circulation. His
doctrines were a complete revolution of the prevailing opinions of
all antiquity. They immediately found both champions and opponents;
of which last, one only, Riolanus, seemed to Harvey worthy of an
answer, on account of his "rank, fame, and learning." Controversy in
science, as in religion, was not, in those days, carried on with all
the courtesy which our present habits demand, and it is possible that
some hard words may have been applied to Harvey, as it is very
certain that he used the most contemptuous expressions towards
others.
Harvey declares in his second letter to Riolanus, "Since the first
discovery of the circulation, hardly a day, or a moment, has passed
without my hearing it both well and ill spoken of; some attack it
with great hostility, others defend it with high encomiums; one party
believe that I have abundantly proved the truth of the doctrine
against all the weight of opposing arguments, by experiments,
observations, and dissections; others think it not yet sufficiently
cleared up, and free from objections." Two really eminent
Professors, Plempius of Louvain, and Walaeus of Leyden, were among
its early advocates.
The opinions sanctioned by the authority of long ages, and the names
of Hippocrates and Galen, dissolved away, gradually, but certainly,
before the demonstrations of Harvey. Twenty-four years after the
publication of his first work, and six years before his death, his
bust in marble was placed in the Hall of the College of Physicians,
with a suitable inscription recording his discoveries.
Two years after this he was unanimously invited to accept the
Presidency of that body; and he lived to see his doctrine
established, and all reputable opposition withdrawn.
There were many circumstances connected with the discovery of Dr.
Jenner which were of a nature to excite repugnance and opposition.
The practice of inoculation for the small-pox had already disarmed
that disease of many of its terrors. The introduction of a
contagious disease from a brute creature into the human system
naturally struck the public mind with a sensation of disgust and
apprehension, and a part of the medical public may have shared these
feelings. I find that Jenner's discovery of vaccination was made
public in June, 1798. In July of the same year the celebrated
surgeon, Mr. Cline, vaccinated a child with virus received from Dr.
Jenner, and in communicating the success of this experiment, he
mentions that Dr. Lister, formerly of the Small-Pox Hospital, and
himself, are convinced of the efficacy of the cow-pox. In November
of the same year, Dr. Pearson published his "Inquiry," containing the
testimony of numerous practitioners in different parts of the
kingdom, to the efficacy of the practice. Dr. HAYGARTH, who was so
conspicuous in exposing the follies of Perkinism, was among the very
earliest to express his opinion in favor of vaccination. In 1801,
Dr. Lettsom mentions the circumstance "as being to the honor of the
medical professors, that they have very generally encouraged this
salutary practice, although it is certainly calculated to lessen
their pecuniary advantages by its tendency to extirpate a fertile
source of professional practice."
In the same year the Medical Committee of Paris spoke of vaccination
in a public letter, as "the most brilliant and most important
discovery of the eighteenth century." The Directors of a Society for
the Extermination of the Small-Pox, in a Report dated October 1st,
1807, "congratulate the public on the very favorable opinion which
the Royal College of Physicians of London, after a most minute and
laborious investigation made by the command of his Majesty, have a
second time expressed on the subject of vaccination, in their Report
laid before the House of Commons, in the last session of Parliament;
in consequence of which the sum of twenty thousand pounds was voted
to Dr. Jenner, as a remuneration for his discovery, in addition to
ten thousand pounds before granted." (In June, 1802.)
These and similar accusations, so often brought up against the
Medical Profession, are only one mode in which is manifested a spirit
of opposition not merely to medical science, but to all science, and
to all sound knowledge. It is a spirit which neither understands
itself nor the object at which it is aiming. It gropes among the
loose records of the past, and the floating fables of the moment, to
glean a few truths or falsehoods tending to prove, if they prove
anything, that the persons who have passed their lives in the study
of a branch of knowledge the very essence of which must always
consist in long and accurate observation, are less competent to judge
of new doctrines in their own department than the rest of the
community. It belongs to the clown in society, the destructive in
politics, and the rogue in practice.
The name of Harvey, whose great discovery was the legitimate result
of his severe training and patient study, should be mentioned only to
check the pretensions of presumptuous ignorance. The example of
Jenner, who gave his inestimable secret, the result of twenty-two
years of experiment and researches, unpurchased, to the public,--
when, as was said in Parliament, he might have made a hundred
thousand pounds by it as well as any smaller sum,--should be referred
to only to rebuke the selfish venders of secret remedies, among whom
his early history obliges us reluctantly to record Samuel Hahnemann.
Those who speak of the great body of physicians as if they were
united in a league to support the superannuated notions of the past
against the progress of improvement, have read the history of
medicine to little purpose. The prevalent failing of this profession
has been, on the contrary, to lend a too credulous ear to ambitious
and plausible innovators. If at the present time ten years of public
notoriety have passed over any doctrine professing to be of
importance in medical science, and if it has not succeeded in raising
up a powerful body of able, learned, and ingenious advocates for its
claims, the fault must be in the doctrine and not in the medical
profession.
Homoeopathy has had a still more extended period of trial than this,
and we have seen with what results. It only remains to throw out a
few conjectures as to the particular manner in which it is to break
up and disappear.
1. The confidence of the few believers in this delusion will never
survive the loss of friends who may die of any acute disease, under a
treatment such as that prescribed by Homoeopathy. It is doubtful how
far cases of this kind will be trusted to its tender mercies, but
wherever it acquires any considerable foothold, such cases must come,
and with them the ruin of those who practise it, should any highly
valued life be thus sacrificed.
2. After its novelty has worn out, the ardent and capricious
individuals who constitute the most prominent class of its patrons
will return to visible doses, were it only for the sake of a change.
3. The Semi-Homoeopathic practitioner will gradually withdraw from
the rotten half of his business and try to make the public forget his
connection with it.
4. The ultra Homoeopathist will either recant and try to rejoin the
medical profession; or he will embrace some newer and if possible
equally extravagant doctrine; or he will stick to his colors and go
down with his sinking doctrine. Very few will pursue the course last
mentioned.
A single fact may serve to point out in what direction there will
probably be a movement of the dissolving atoms of Homoeopathy. On
the 13th page of the too frequently cited Manifesto of the "Examiner"
I read the following stately paragraph:
"Bigelius, M. D., physician to the Emperor of Russia, whose elevated
reputation is well known in Europe, has been an acknowledged advocate
of Hahnemann's doctrines for several years. He abandoned Allopathia
for Homoeopathia." The date of this statement is January, 1840. I
find on looking at the booksellers' catalogues that one Bigel, or
Bigelius, to speak more classically, has been at various times
publishing Homoeopathic books for some years.
Again, on looking into the "Encyclographie des Sciences Medicales"
for April, 1840, I find a work entitled "Manual of HYDROSUDOPATHY,
or the Treatment of Diseases by Cold Water, etc., etc., by Dr. Bigel,
Physician of the School of Strasburg, Member of the Medico-
Chirurgical Institute of Naples, of the Academy of St. Petersburg,--
Assessor of the College of the Empire of Russia, Physician of his
late Imperial Highness the Grand Duke Constantine, Chevalier of the
Legion of Honor, etc." Hydrosudopathy or Hydropathy, as it is
sometimes called, is a new medical doctrine or practice which has
sprung up in Germany since Homoeopathy, which it bids fair to drive
out of the market, if, as Dr. Bigel says, fourteen physicians
afflicted with diseases which defied themselves and their colleagues
came to Graefenberg, in the year 1836 alone, and were cured. Now Dr.
Bigel, "whose elevated reputation is well known in Europe," writes as
follows: "The reader will not fail to see in this defence of the
curative method of Graefenberg a profession of medical faith, and he
will be correct in so doing." And his work closes with the following
sentence, worthy of so distinguished an individual: "We believe, with
religion, that the water of baptism purifies the soul from its
original sin; let us believe also, with experience, that it is for
our corporeal sins the redeemer of the human body." If Bigel,
Physician to the late Grand Duke Constantine, is identical with Bigel
whom the "Examiner" calls Physician to the Emperor of Russia, it
appears that he is now actively engaged in throwing cold water at
once upon his patients and the future prospects of Homoeopathy.
If, as must be admitted, no one of Hahnemann's doctrines is received
with tolerable unanimity among his disciples, except the central
axiom, Similia similibus curantur; if this axiom itself relies mainly
for its support upon the folly and trickery of Hahnemann, what can we
think of those who announce themselves ready to relinquish all the
accumulated treasures of our art, to trifle with life upon the
strength of these fantastic theories? What shall we think of
professed practitioners of medicine, if, in the words of Jahr, "from
ignorance, for their personal convenience, or through charlatanism,
they treat their patients one day Homoeopathically and the next
Allopathically;" if they parade their pretended new science before
the unguarded portion of the community; if they suffer their names to
be coupled with it wherever it may gain a credulous patient; and deny
all responsibility for its character, refuse all argument for its
doctrines, allege no palliation for the ignorance and deception
interwoven with every thread of its flimsy tissue, when they are
questioned by those competent to judge and entitled to an answer?
Such is the pretended science of Homoeopathy, to which you are asked
to trust your lives and the lives of those dearest to you. A mingled
mass of perverse ingenuity, of tinsel erudition, of imbecile
credulity, and of artful misrepresentation, too often mingled in
practice, if we may trust the authority of its founder, with
heartless and shameless imposition. Because it is suffered so often
to appeal unanswered to the public, because it has its journals, its
patrons, its apostles, some are weak enough to suppose it can escape
the inevitable doom of utter disgrace and oblivion. Not many years
can pass away before the same curiosity excited by one of Perkins's
Tractors will be awakened at the sight of one of the Infinitesimal
Globules. If it should claim a longer existence, it can only be by
falling into the hands of the sordid wretches who wring their bread
from the cold grasp of disease and death in the hovels of ignorant
poverty.
As one humble member of a profession which for more than two thousand
years has devoted itself to the pursuit of the best earthly interests
of mankind, always assailed and insulted from without by such as are
ignorant of its infinite perplexities and labors, always striving in
unequal contest with the hundred-armed giant who walks in the
noonday, and sleeps not in the midnight, yet still toiling, not
merely for itself and the present moment, but for the race and the
future, I have lifted my voice against this lifeless delusion,
rolling its shapeless bulk into the path of a noble science it is too
weak to strike, or to injure.
THE CONTAGIOUSNESS OF PUERPERAL FEVER
Printed in 1843; reprinted with additions, 1855.
THE POINT AT ISSUE.
THE AFFIRMATIVE.
"The disease known as Puerperal Fever is so far contagious as to be
frequently carried from patient to patient by physicians and nurses."
O. W. Holmes, 1843.
THE NEGATIVE.
"The result of the whole discussion will, I trust, serve, not only to
exalt your views of the value and dignity of our profession, but to
divest your minds of the overpowering dread that you can ever become,
especially to woman, under the extremely interesting circumstances of
gestation and parturition, the minister of evil; that you can ever
convey, in any possible manner, a horrible virus, so destructive in
its effects, and so mysterious in its operations as that attributed
to puerperal fever."--Professor Hodge,
1852.
"I prefer to attribute them to accident, or Providence, of which I
can form a conception, rather than to a contagion of which I cannot
form any clear idea, at least as to this particular malady."--
Professor Meigs, 1852.
" . . . in the propagation of which they have no more to do, than
with the propagation of cholera from Jessore to San Francisco, and
from Mauritius to St. Petersburg."--Professor Meigs, 1854.
---------------------
"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."--Gordon, 1795.
"A certain number of deaths is caused every year by the contagion of
puerperal fever, communicated by the nurses and medical attendants."
Farr, in Fifth Annual Report of Registrar-General of England, 1843.
". . . boards of health, if such exist, or, without them, the
medical institutions of a country, should have the power of coercing,
or of inflicting some kind of punishment on those who recklessly go
from cases of puerperal fevers to parturient or puerperal females,
without using due precaution; and who, having been shown the risk,
criminally encounter it, and convey pestilence and death to the
persons they are employed to aid in the most interesting and
suffering period of female existence."--Copland's Medical
Dictionary, Art. Puerperal States and Diseases, 1852.
"We conceive it unnecessary to go into detail to prove the contagious
nature of this disease, as there are few, if any, American
practitioners who do not believe in this doctrine."--Dr. Lee, in
Additions to Article last cited.
-----------------------
[INTRODUCTORY NOTE.] It happened, some years ago, that a discussion
arose in a Medical Society of which I was a member, involving the
subject of a certain supposed cause of disease, about which something
was known, a good deal suspected, and not a little feared. The
discussion was suggested by a case, reported at the preceding
meeting, of a physician who made an examination of the body of a
patient who had died with puerperal fever, and who himself died in
less than a week, apparently in consequence of a wound received at
the examination, having attended several women in confinement in the
mean time, all of whom, as it was alleged, were attacked with
puerperal fever.
Whatever apprehensions and beliefs were entertained, it was plain
that a fuller knowledge of the facts relating to the subject would be
acceptable to all present. I therefore felt that it would be doing a
good service to look into the best records I could find, and inquire
of the most trustworthy practitioners I knew, to learn what
experience had to teach in the matter, and arrived at the results
contained in the following pages.
The Essay was read before the Boston Society for Medical Improvement,
and, at the request of the Society, printed in the "New England
Quarterly Journal of Medicine and Surgery" for April, 1843. As this
Journal never obtained a large circulation, and ceased to be
published after a year's existence, and as the few copies I had
struck off separately were soon lost sight of among the friends to
whom they were sent, the Essay can hardly be said to have been fully
brought before the Profession.
The subject of this Paper has the same profound interest for me at
the present moment as it had when I was first collecting the terrible
evidence out of which, as it seems to me, the commonest exercise of
reason could not help shaping the truth it involved. It is not
merely on account of the bearing of the question,--if there is a
question,--on all that is most sacred in human life and happiness,
that the subject cannot lose its interest. It is because it seems
evident that a fair statement of the facts must produce its proper
influence on a very large proportion of well-constituted and
unprejudiced minds. Individuals may, here and there, resist the
practical bearing of the evidence on their own feelings or interests;
some may fail to see its meaning, as some persons may be found who
cannot tell red from green; but I cannot doubt that most readers will
be satisfied and convinced, to loathing, long before they have
finished the dark obituary calendar laid before them.
I do not know that I shall ever again have so good an opportunity of
being useful as was granted me by the raising of the question which
produced this Essay. For I have abundant evidence that it has made
many practitioners more cautious in their relations with puerperal
females, and I have no doubt it will do so still, if it has a chance
of being read, though it should call out a hundred counterblasts,
proving to the satisfaction of their authors that it proved nothing.
And for my part, I had rather rescue one mother from being poisoned
by her attendant, than claim to have saved forty out of fifty
patients to whom I had carried the disease. Thus, I am willing to
avail myself of any hint coming from without to offer this paper once
more to the press. The occasion has presented itself, as will be
seen, in a convenient if not in a flattering form.
I send this Essay again to the MEDICAL PROFESSION, without the change
of a word or syllable. I find, on reviewing it, that it anticipates
and eliminates those secondary questions which cannot be entertained
for a moment until the one great point of fact is peremptorily
settled. In its very statement of the doctrine maintained it avoids
all discussion of the nature of the disease "known as puerperal
fever," and all the somewhat stale philology of the word contagion.
It mentions, fairly enough, the names of sceptics, or unbelievers as
to the reality of personal transmission; of Dewees, of Tonnelle, of
Duges, of Baudelocque, and others; of course, not including those
whose works were then unwritten or unpublished; nor enumerating all
the Continental writers who, in ignorance of the great mass of
evidence accumulated by British practitioners, could hardly be called
well informed on this subject. It meets all the array of negative
cases,--those in which disease did not follow exposure,--by the
striking example of small-pox, which, although one of the most
contagious of diseases, is subject to the most remarkable
irregularities and seeming caprices in its transmission. It makes
full allowance for other causes besides personal transmission,
especially for epidemic influences. It allows for the possibility of
different modes of conveyance of the destructive principle. It
recognizes and supports the belief that a series of cases may
originate from a single primitive source which affects each new
patient in turn; and especially from cases of Erysipelas. It does
not undertake to discuss the theoretical aspect of the subject; that
is a secondary matter of consideration. Where facts are numerous,
and unquestionable, and unequivocal in their significance, theory
must follow them as it best may, keeping time with their step, and
not go before them, marching to the sound of its own drum and
trumpet. Having thus narrowed its area to a limited practical
platform of discussion, a matter of life and death, and not of
phrases or theories, it covers every inch of it with a mass of
evidence which I conceive a Committee of Husbands, who can count
coincidences and draw conclusions as well as a Synod of Accoucheurs,
would justly consider as affording ample reasons for an unceremonious
dismissal of a practitioner (if it is conceivable that such a step
could be waited for), after five or six funerals had marked the path
of his daily visits, while other practitioners were not thus
escorted. To the Profession, therefore, I submit the paper in its
original form, and leave it to take care of itself.
To the MEDICAL STUDENTS, into whose hands this Essay may fall, some
words of introduction may be appropriate, and perhaps, to a small
number of them, necessary. There are some among them who, from
youth, or want of training, are easily bewildered and confused in any
conflict of opinions into which their studies lead them. They are
liable to lose sight of the main question in collateral issues, and
to be run away with by suggestive speculations. They confound belief
with evidence, often trusting the first because it is expressed with
energy, and slighting the latter because it is calm and
unimpassioned. They are not satisfied with proof; they cannot
believe a point is settled so long as everybody is not silenced.
They have not learned that error is got out of the minds that cherish
it, as the taenia is removed from the body, one joint, or a few
joints at a time, for the most part, rarely the whole evil at once.
They naturally have faith in their instructors, turning to them for
truth, and taking what they may choose to give them; babes in
knowledge, not yet able to tell the breast from the bottle, pumping
away for the milk of truth at all that offers, were it nothing better
than a Professor's shrivelled forefinger.
In the earliest and embryonic stage of professional development, any
violent impression on the instructor's mind is apt to be followed by
some lasting effect on that of the pupil. No mother's mark is more
permanent than the mental naevi and moles, and excrescences, and
mutilations, that students carry with them out of the lecture-room,
if once the teeming intellect which nourishes theirs has been scared
from its propriety by any misshapen fantasy. Even an impatient or
petulant expression, which to a philosopher would be a mere index of
the low state of amiability of the speaker at the moment of its
utterance, may pass into the young mind as an element of its future
constitution, to injure its temper or corrupt its judgment. It is a
duty, therefore, which we owe to this younger class of students, to
clear any important truth which may have been rendered questionable
in their minds by such language, or any truth-teller against whom
they may have been prejudiced by hasty epithets, from the impressions
such words have left. Until this is done, they are not ready for the
question, where there is a question, for them to decide. Even if we
ourselves are the subjects of the prejudice, there seems to be no
impropriety in showing that this prejudice is local or personal, and
not an acknowledged conviction with the public at large. It may be
necessary to break through our usual habits of reserve to do this,
but this is the fault of the position in which others have placed us.
Two widely-known and highly-esteemed practitioners, Professors in two
of the largest Medical Schools of the Union, teaching the branch of
art which includes the Diseases of Women, and therefore speaking with
authority; addressing in their lectures and printed publications
large numbers of young men, many of them in the tenderest immaturity
of knowledge, have recently taken ground in a formal way against the
doctrine maintained in this paper:
On the Non-Contagious Character of Puerperal Fever: An Introductory
Lecture. By Hugh L. Hodge, M. D., Professor of Obstetrics in the
University of Pennsylvania. Delivered Monday, October 11, 1852.
Philadelphia, 1852.
On the Nature, Signs, and Treatment of Childbed Fevers : in a Series
of Letters addressed to the Students of his Class. By Charles D.
Meigs, M. D., Professor of Midwifery and the Diseases of Women and
Children in Jefferson Medical College, Philadelphia, etc., etc.
Philadelphia, 1854. Letter VI.
The first of the two publications, Dr. Hodge's Lecture, while its
theoretical considerations and negative experiences do not seem to me
to require any further notice than such as lay ready for them in my
Essay written long before, is, I am pleased to say, unobjectionable
in tone and language, and may be read without offence.
This can hardly be said of the chapter of Dr. Meigs's volume which
treats of Contagion in Childbed Fever. There are expressions used in
it which might well put a stop to all scientific discussions, were
they to form the current coin in our exchange of opinions. I leave
the "very young gentlemen," whose careful expositions of the results
of practice in more than six thousand cases are characterized as "the
jejune and fizenless dreamings of sophomore writers," to the
sympathies of those "dear young friends," and "dear young gentlemen,"
who will judge how much to value their instructor's counsel to think
for themselves, knowing what they are to expect if they happen not to
think as he does.
One unpalatable expression I suppose the laws of construction oblige
me to appropriate to myself, as my reward for a certain amount of
labor bestowed on the investigation of a very important question of
evidence, and a statement of my own practical conclusions. I take no
offence, and attempt no retort. No man makes a quarrel with me over
the counterpane that covers a mother, with her new-born infant at her
breast. There is no epithet in the vocabulary of slight and sarcasm
that can reach my personal sensibilities in such a controversy. Only
just so far as a disrespectful phrase may turn the student aside from
the examination of the evidence, by discrediting or dishonoring the
witness, does it call for any word of notice.
I appeal from the disparaging language by which the Professor in the
Jefferson School of Philadelphia world dispose of my claims to be
listened to. I appeal, not to the vote of the Society for Medical
Improvement, although this was an unusual evidence of interest in the
paper in question, for it was a vote passed among my own townsmen;
nor to the opinion of any American, for none know better than the
Professors in the great Schools of Philadelphia how cheaply the
praise of native contemporary criticism is obtained. I appeal to the
recorded opinions of those whom I do not know, and who do not know
me, nor care for me, except for the truth that I may have uttered; to
Copland, in his "Medical Dictionary," who has spoken of my Essay in
phrases to which the pamphlets of American "scribblers" are seldom
used from European authorities; to Ramsbotham, whose compendious
eulogy is all that self-love could ask; to the "Fifth Annual Report"
of the Registrar-General of England, in which the second-hand
abstract of my Essay figures largely, and not without favorable
comment, in an important appended paper. These testimonies, half
forgotten until this circumstance recalled them, are dragged into the
light, not in a paroxysm of vanity, but to show that there may be
food for thought in the small pamphlet which the Philadelphia Teacher
treats so lightly. They were at least unsought for, and would never
have been proclaimed but for the sake of securing the privilege of a
decent and unprejudiced hearing.
I will take it for granted that they have so far counterpoised the
depreciating language of my fellow-countryman and fellow-teacher as
to gain me a reader here and there among the youthful class of
students I am now addressing. It is only for their sake that I think
it necessary to analyze, or explain, or illustrate, or corroborate
any portion of the following Essay. But I know that nothing can be
made too plain for beginners; and as I do not expect the
practitioner, or even the more mature student, to take the trouble to
follow me through an Introduction which I consider wholly unnecessary
and superfluous for them, I shall not hesitate to stoop to the most
elementary simplicity for the benefit of the younger student. I do
this more willingly because it affords a good opportunity, as it
seems to me, of exercising the untrained mind in that medical logic
which does not seem to have been either taught or practised in our
schools of late, to the extent that might be desired.
I will now exhibit, in a series of propositions reduced to their
simplest expression, the same essential statements and conclusions as
are contained in the Essay, with such commentaries and explanations
as may be profitable to the inexperienced class of readers addressed.
I. It has been long believed, by many competent observers, that
Puerperal Fever (so called) is sometimes carried from patient to
patient by medical assistants.
II. The express object of this Essay is to prove that it is so
carried.
III. In order to prove this point, it is not necessary to consult
any medical theorist as to whether or not it is consistent with his
preconceived notions that such a mode of transfer should exist.
IV. If the medical theorist insists on being consulted, and we see
fit to indulge him, he cannot be allowed to assume that the alleged
laws of contagion, deduced from observation in other diseases, shall
be cited to disprove the alleged laws deduced from observation in
this. Science would never make progress under such conditions.
Neither the long incubation of hydrophobia, nor the protecting power
of vaccination, would ever have been admitted, if the results of
observation in these affections had been rejected as contradictory to
the previously ascertained laws of contagion.
V. The disease in question is not a common one; producing, on the
average, about three deaths in a thousand births, according to the
English Registration returns which I have examined.
VI. When an unusually large number of cases of this disease occur
about the same time, it is inferred, therefore, that there exists
some special cause for this increased frequency. If the disease
prevails extensively over a wide region of country, it is attributed
without dispute to an epidemic influence. If it prevails in a single
locality, as in a hospital, and not elsewhere, this is considered
proof that some local cause is there active in its production.
VII. When a large number of cases of this disease occur in rapid
succession, in one individual's ordinary practice, and few or none
elsewhere, these cases appearing in scattered localities, in patients
of the same average condition as those who escape under the care of
others, there is the same reason for connecting the cause of the
disease with the person in this instance, as with the place in that
last mentioned.
VIII. Many series of cases, answering to these conditions, are given
in this Essay, and many others will be referred to which have
occurred since it was written.
IX. The alleged results of observation may be set aside; first,
because the so-called facts are in their own nature equivocal;
secondly, because they stand on insufficient authority; thirdly,
because they are not sufficiently numerous. But, in this case, the
disease is one of striking and well-marked character; the witnesses
are experts, interested in denying and disbelieving the facts; the
number of consecutive cases in many instances frightful, and the
number of series of cases such that I have no room for many of them
except by mere reference.
X. These results of observation, being admitted, may, we will
suppose, be interpreted in different methods. Thus the coincidences
may be considered the effect of chance. I have had the chances
calculated by a competent person, that a given practitioner, A.,
shall have sixteen fatal cases in a month, on the following data:
A. to average attendance upon two hundred and fifty births in a year;
three deaths in one thousand births to be assumed as the average from
puerperal fever; no epidemic to be at the time prevailing. It
follows, from the answer given me, that if we suppose every one of
the five hundred thousand annual births of England to have been
recorded during the last half-century, there would not be one chance
in a million million million millions that one such series should be
noted. No possible fractional error in this calculation can render
the chance a working probability. Applied to dozens of series of
various lengths, it is obviously an absurdity. Chance, therefore, is
out of the question as an explanation of the admitted coincidences.
XI. There is, therefore, some relation of cause and effect between
the physician's presence and the patient's disease.
XII. Until it is proved to what removable condition attaching to the
attendant the disease is owing, he is bound to stay away from his
patients so soon as he finds himself singled out to be tracked by the
disease. How long, and with what other precautions, I have
suggested, without dictating, at the close of my Essay. If the
physician does not at once act on any reasonable suspicion of his
being the medium of transfer, the families where he is engaged, if
they are allowed to know the facts, should decline his services for
the time. His feelings on the occasion, however interesting to
himself, should not be even named in this connection. A physician
who talks about ceremony and gratitude, and services rendered, and
the treatment he got, surely forgets himself; it is impossible that
he should seriously think of these small matters where there is even
a question whether he may not carry disease, and death, and
bereavement into any one of "his families," as they are sometimes
called.
I will now point out to the young student the mode in which he may
relieve his mind of any confusion, or possibly, if very young, any
doubt, which the perusal of Dr. Meigs's Sixth Letter may have raised
in his mind.
The most prominent ideas of the Letter are, first, that the
transmissible nature of puerperal fever appears improbable, and,
secondly, that it would be very inconvenient to the writer.
Dr. Woodville, Physician to the Small-Pox and Inoculation Hospital in
London, found it improbable, and exceedingly inconvenient to himself,
that cow pox should prevent small-pox; but Dr. Jenner took the
liberty to prove the fact, notwithstanding.
I will first call the young student's attention to the show of
negative facts (exposure without subsequent disease), of which much
seems to be thought. And I may at the same time refer him to Dr.
Hodge's Lecture, where he will find the same kind of facts and
reasoning. Let him now take up Watson's Lectures, the good sense and
spirit of which have made his book a universal favorite, and open to
the chapter on Continued Fever. He will find a paragraph containing
the following sentence: "A man might say, 'I was in the battle of
Waterloo, and saw many men around me fall down and die, and it was
said that they were struck down by musket-balls; but I know better
than that, for I was there all the time, and so were many of my
friends, and we were never hit by any musket-balls. Musket-balls,
therefore, could not have been the cause of the deaths we witnessed.'
And if, like contagion, they were not palpable to the senses, such a
person might go on to affirm that no proof existed of there being any
such thing as musket-balls." Now let the student turn back to the
chapter on Hydrophobia in the same volume. He will find that John
Hunter knew a case in which, of twenty-one persons bitten, only one
died of the disease. He will find that one dog at Charenton was
bitten at different times by thirty different mad dogs, and outlived
it all. Is there no such thing, then, as hydrophobia? Would one
take no especial precautions if his wife, about to become a mother,
had been bitten by a rabid animal, because so many escape? Or let
him look at "Underwood on Diseases of Children,"[Philadelphia, 1842,
p. 244, note.] and he will find the case of a young woman who was
inoculated eight times in thirty days, at the same time attending
several children with smallpox, and yet was not infected. But seven
weeks afterwards she took the disease and died.
It would seem as if the force of this argument could hardly fail to
be seen, if it were granted that every one of these series of cases
were so reported as to prove that there could have been no transfer
of disease. There is not one of them so reported, in the Lecture or
the Letter, as to prove that the disease may not have been carried by
the practitioner. I strongly suspect that it was so carried in some
of these cases, but from the character of the very imperfect evidence
the question can never be settled without further disclosures.
Although the Letter is, as I have implied, principally taken up with
secondary and collateral questions, and might therefore be set aside
as in the main irrelevant, I am willing, for the student's sake, to
touch some of these questions briefly, as an illustration of its
logical character.
The first thing to be done, as I thought when I wrote my Essay, was
to throw out all discussions of the word contagion, and this I did
effectually by the careful wording of my statement of the subject to
be discussed. My object was not to settle the etymology or
definition of a word, but to show that women had often died in
childbed, poisoned in some way by their medical attendants. On the
other point, I, at least, have no controversy with anybody, and I
think the student will do well to avoid it in this connection. If I
must define my position, however, as well as the term in question, I
am contented with Worcester's definition; provided always this avowal
do not open another side controversy on the merits of his Dictionary,
which Dr. Meigs has not cited, as compared with Webster's, which he
has.
I cannot see the propriety of insisting that all the laws of the
eruptive fevers must necessarily hold true of this peculiar disease
of puerperal women. If there were any such propriety, the laws of
the eruptive fevers must at least be stated correctly. It is not
true, for instance, as Dr. Meigs states, that contagion is "no
respecter of persons;" that "it attacks all individuals alike." To
give one example: Dr. Gregory, of the Small-Pox Hospital, who ought
to know, says that persons pass through life apparently insensible to
or unsusceptible of the small-pox virus, and that the same persons do
not take the vaccine disease.
As to the short time of incubation, of which so much is made, we have
no right to decide beforehand whether it shall be long or short, in
the cases we are considering. A dissection wound may produce
symptoms of poisoning in six hours; the bite of a rabid animal may
take as many months.
After the student has read the case in Dr. Meigs's 136th paragraph,
and the following one, in which he exclaims against the idea of
contagion, because the patient, delivered on the 26th of December,
was attacked in twenty-four hours, and died on the third day, let him
read what happened at the "Black Assizes" of 1577 and 1750. In the
first case, six hundred persons sickened the same night of the
exposure, and three hundred more in three days. [Elliotson's
Practice, p. 298.] Of those attacked in the latter year, the
exposure being on the 11th of May, Alderman Lambert died on the 13th,
Under-Sheriff Cox on the 14th, and many of note before the
20th. But these are old stories. Let the student listen then to Dr.
Gerhard, whose reputation as a cautious observer he may be supposed
to know. "The nurse was shaving a man, who died in a few hours after
his entrance; he inhaled his breath, which had a nauseous taste, and
in an hour afterwards was taken with nausea, cephalalgia, and singing
of the ears. From that moment the attack began, and assumed a severe
character. The assistant was supporting another patient, who died
soon afterwards; he felt the pungent heat upon his skin, and was
taken immediately with the symptoms of typhus."[Am. Jour. Med.
Sciences, Feb. 1837, p. 299.] It is by notes of cases, rather
than notes of admiration, that we must be guided, when we study the
Revised Statutes of Nature, as laid down from the curule chairs of
Medicine.
Let the student read Dr. Meigs's 140th paragraph soberly, and then
remember, that not only does he infer, suspect, and surmise, but he
actually asserts (page 154), "there was poison in the house," because
three out of five patients admitted into a ward had puerperal fever
and died. Have I not as much right to draw a positive inference from
"Dr. A.'s" seventy exclusive cases as he from the three cases in the
ward of the Dublin Hospital? All practical medicine, and all action
in common affairs, is founded on inferences. How does Dr. Meigs know
that the patients he bled in puerperal fever would not have all got
well if he had not bled them?
"You see a man discharge a gun at another; you see the flash, you
hear the report, you see the person fall a lifeless corpse; and you
infer, from all these circumstances, that there was a ball discharged
from the gun, which entered his body and caused his death, because
such is the usual and natural cause of such an effect. But you did
not see the ball leave the gun, pass through the air, and enter the
body of the slain; and your testimony to the fact of killing is,
therefore, only inferential,--in other words, circumstantial. It is
possible that no ball was in the gun; and we infer that there was,
only because we cannot account for death on any other supposition."
[Chief Justice Gibson, in Am. Law Journal, vol. vi. p. 123.]
"The question always comes to this: Is the circumstance of
intercourse with the sick followed by the appearance of the disease
in a proportion of cases so much greater than any other circumstance
common to any portion of the inhabitants of the place under
observation, as to make it inconceivable that the succession of cases
occurring in persons having that intercourse should have been the
result of chance? If so, the inference is unavoidable, that that
intercourse must have acted as a cause of the disease. All
observations which do not bear strictly on that point are irrelevant,
and, in the case of an epidemic first appearing in a town or
district, a succession of two cases is sometimes sufficient to
furnish evidence which, on the principle I have stated, is nearly
irresistible."
Possibly an inexperienced youth may be awe-struck by the quotation
from Cuvier. These words, or their equivalent, are certainly to be
found in his Introduction. So are the words "top not come down"!
to be found in the Bible, and they were as much meant for the ladies'
head-dresses as the words of Cuvier were meant to make clinical
observation wait for a permit from anybody to look with its eyes and
count on its fingers. Let the inquiring youth read the whole
Introduction, and he will see what they mean.
I intend no breach of courtesy, but this is a proper place to warn
the student against skimming the prefaces and introductions of works
for mottoes and embellishments to his thesis. He cannot learn
anatomy by thrusting an exploring needle into the body. He will be
very liable to misquote his author's meaning while he is picking off
his outside sentences. He may make as great a blunder as that simple
prince who praised the conductor of his orchestra for the piece just
before the overture; the musician was too good a courtier to tell him
that it was only the tuning of the instruments.
To the six propositions in the 142d paragraph, and the remarks about
"specific" diseases, the answer, if any is necessary, seems very
simple. An inflammation of a serous membrane may give rise to
secretions which act as a poison, whether that be a "specific" poison
or not, as Dr. Homer has told his young readers, and as dissectors
know too well; and that poison may produce its symptoms in a few
hours after the system has received it, as any may see in Druitt's
"Surgery," if they care to look. Puerperal peritonitis may produce
such a poison, and puerperal women may be very sensible to its
influences, conveyed by contact or exhalation. Whether this is so or
not, facts alone can determine, and to facts we have had recourse to
settle it.
The following statement is made by Dr. Meigs in his 142d paragraph,
and developed more at length, with rhetorical amplifications, in the
134th. "No human being, save a pregnant or parturient woman, is
susceptible to the poison." This statement is wholly incorrect, as I
am sorry to have to point out to a Teacher in Dr. Meigs's position.
I do not object to the erudition which quotes Willis and Fernelius,
the last of whom was pleasantly said to have "preserved the dregs of
the Arabs in the honey of his Latinity." But I could wish that more
modern authorities had not been overlooked. On this point, for
instance, among the numerous facts disproving the statement, the
"American Journal of Medical Sciences," published not far from his
lecture-room, would have presented him with a respectable catalog of
such cases. Thus he might refer to Mr. Storrs's paper "On the
Contagious Effects of Puerperal Fever on the Male Subject; or on
Persons not Childbearing"(Jan. 1846), or to Dr. Reid's case (April,
1846), or to Dr. Barron's statement of the children's dying of
peritonitis in an epidemic of puerperal fever at the Philadelphia
Hospital (Oct. 1842), or to various instances cited in Dr.
Kneeland's article (April, 186). Or, if he would have referred to
the "New York Journal," he might have seen Prof. Austin Flint's
cases. Or, if he had honored my Essay so far, he might have found
striking instances of the same kind in the first of the new series of
cases there reported and elsewhere. I do not see the bearing of his
proposition, if it were true. But it is one of those assertions that
fall in a moment before a slight examination of the facts; and I
confess my surprise, that a professor who lectures on the Diseases of
Women should have ventured to make it.
Nearly seven pages are devoted to showing that I was wrong in saying
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." 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.
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