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 would 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.