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 '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.