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.