the 19th, Dr. C. made the autopsy of a man who died suddenly, sick only
forty-eight hours; had oedema of the thigh, and gangrene extending from
a little above the ankle into the cavity of the abdomen.” Dr. C. wounded
himself, very slightly, in the right hand during the autopsy. The hand
was quite painful the night following, during his attendance on the
patient No. 1. He did not see this patient after the 20th, being
confined to the house, and very sick from the wound just mentioned, from
this time until the 3d of April.
Several cases of erysipelas occurred in the house where the autopsy
mentioned above took place, soon after the examination. There were also
many cases of erysipelas in town at the time of the fatal puerperal
cases which have been mentioned.
The nurse who laid out the body of the patient No. 3 was taken on the
evening of the same day with sore throat and erysipelas, and died in ten
days from the first attack.
The nurse who laid out the body of the patient No. 4 was taken on the
day following with symptoms like those of this patient, and died in a
week, without any external marks of erysipelas.
“No other cases of similar character with those of Dr. C. occurred in
the practice of any of the physicians in the town or vicinity at the
time. Deaths following confinement have occurred in the practice of
other physicians during the past year, but they were not cases of
puerperal fever. No post-mortem examinations were held in any of these
puerperal cases.”
Some additional statements in this letter are deserving of insertion.
“A physician attended a woman in the immediate neighborhood of the cases
numbered 2, 3, and 4. This patient was confined the morning of March
1st, and died on the night of March 7th. It is doubtful whether this
should be considered a case of puerperal fever. She had suffered from
canker, indigestion, and diarrhoea for a year previous to her delivery.
Her complaints were much aggravated for two or three months previous
to delivery; she had become greatly emaciated, and weakened to such an
extent that it had not been expected that she would long survive her
confinement, if indeed she reached that period. Her labor was easy
enough; she flowed a good deal, seemed exceedingly prostrated, had
ringing in the ears, and other symptoms of exhaustion; the pulse was
quick and small. On the second and third day there was some tenderness
and tumefaction of the abdomen, which increased somewhat on the fourth
and fifth. He had cases in midwifery before and after this, which
presented nothing peculiar.”
It is also mentioned in the same letter, that another physician had
a case during the last summer and another last fall, both of which
recovered.
Another gentleman reports a case last December, a second case five
weeks, and another three weeks since. All these recovered. A case also
occurred very recently in the practice of a physician in the village
where the eighth patient of Dr. C. resides, which proved fatal. “This
patient had some patches of erysipelas on the legs and arms. The same
physician has delivered three cases since, which have all done well.
There have been no other cases in this town or its vicinity recently.
There have been some few cases of erysipelas.” It deserves notice
that the partner of Dr. C., who attended the autopsy of the man above
mentioned and took an active part in it; who also suffered very slightly
from a prick under the thumb-nail received during the examination, had
twelve cases of midwifery between March 26th and April 12th, all of
which did well, and presented no peculiar symptoms. It should also be
stated, that during these seventeen days he was in attendance on all the
cases of erysipelas in the house where the autopsy had been performed.
I owe these facts to the prompt kindness of a gentleman whose
intelligence and character are sufficient guaranty for their accuracy.
The two following letters were addressed to my friend Dr. Scorer, by the
gentleman in whose practice the cases of puerperal fever occurred.
His name renders it unnecessary to refer more particularly to these
gentlemen, who on their part have manifested the most perfect freedom
and courtesy in affording these accounts of their painful experience.
“January 28, 1843.
II.... “The time to which you allude was in 1830. The first case was in
February, during a very cold time. She was confined the 4th, and died
the 12th. Between the 10th and 28th of this month, I attended six women
in labor, all of whom did well except the last, as also two who were
confined March 1st and 5th. Mrs. E., confined February 28th, sickened,
and died March 8th. The next day, 9th, I inspected the body, and the
night after attended a lady, Mrs. B., who sickened, and died 16th. The
10th, I attended another, Mrs. G., who sickened, but recovered. March
16th, I went from Mrs. G.'s room to attend a Mrs. H., who sickened, and
died 21st. The 17th, I inspected Mrs. B. On the 19th, I went directly
from Mrs. H.'s room to attend another lady, Mrs. G., who also sickened,
and died 22d. While Mrs. B. was sick, on 15th, I went directly from her
room a few rods, and attended another woman, who was not sick. Up to
20th of this month I wore the same clothes. I now refused to attend any
labor, and did not till April 21st, when, having thoroughly cleansed
myself, I resumed my practice, and had no more puerperal fever.
“The cases were not confined to a narrow space. The two nearest were
half a mile from each other, and half that distance from my residence.
The others were from two to three miles apart, and nearly that distance
from my residence. There were no other cases in their immediate vicinity
which came to my knowledge. The general health of all the women was
pretty good, and all the labors as good as common, except the first.
This woman, in consequence of my not arriving in season, and the child
being half-born at some time before I arrived, was very much exposed to
the cold at the time of confinement, and afterwards, being confined in a
very open, cold room. Of the six cases you perceive only one recovered.
“In the winter of 1817 two of my patients had puerperal fever, one very
badly, the other not so badly. Both recovered. One other had swelled
leg, or phlegmasia dolens, and one or two others did not recover as well
as usual.
“In the summer of 1835 another disastrous period occurred in my
practice. July 1st, I attended a lady in labor, who was afterwards quite
ill and feverish; but at the time I did not consider her case a decided
puerperal fever. On the 8th, I attended one who did well. On the 12th,
one who was seriously sick. This was also an equivocal case, apparently
arising from constipation and irritation of the rectum. These women were
ten miles apart and five from my residence. On 15th and 20th, two who
did well. On 25th, I attended another. This was a severe labor, and
followed by unequivocal puerperal fever, or peritonitis. She recovered.
August 2d and 3d, in about twenty-four hours I attended four persons.
Two of them did very well; one was attacked with some of the common
symptoms, which however subsided in a day or two, and the other had
decided puerperal fever, but recovered. This woman resided five miles
from me. Up to this time I wore the same coat. All my other clothes had
frequently been changed. On 6th, I attended two women, one of whom was
not sick at all; but the other, Mrs. L., was afterwards taken ill. On
10th, I attended a lady, who did very well. I had previously changed all
my clothes, and had no garment on which had been in a puerperal room. On
12th, I was called to Mrs. S., in labor. While she was ill, I left her
to visit Mrs. L., one of the ladies who was confined on 6th. Mrs. L. had
been more unwell than usual, but I had not considered her case anything
more than common till this visit. I had on a surtout at this visit,
which, on my return to Mrs. S., I left in another room. Mrs. S. was
delivered on 13th with forceps. These women both died of decided
puerperal fever.
“While I attended these women in their fevers, I changed my clothes, and
washed my hands in a solution of chloride of lime after each visit. I
attended seven women in labor during this period, all of whom recovered
without sickness.
“In my practice I have had several single cases of puerperal fever, some
of whom have died and some have recovered. Until the year 1830 I had
no suspicion that the disease could be communicated from one patient
to another by a nurse or midwife; but I now think the foregoing facts
strongly favor that idea. I was so much convinced of this fact, that I
adopted the plan before related.
“I believe my own health was as good as usual at each of the above
periods. I have no recollections to the contrary.
“I believe I have answered all your questions. I have been more
particular on some points perhaps than necessary; but I thought you
could form your own opinion better than to take mine. In 1830 I wrote
to Dr. Charming a more particular statement of my cases. If I have not
answered your questions sufficiently, perhaps Dr. C. may have my letter
to him, and you can find your answer there.” [In a letter to myself,
this gentleman also stated, “I do not recollect that there was any
erysipelas or any other disease particularly prevalent at the time.”]
“BOSTON, February 3, 1843.
III. “MY DEAR SIR,--I received a note from you last evening, requesting
me to answer certain questions therein proposed, touching the cases
of puerperal fever which came under my observation the past summer. It
gives me pleasure to comply with your request, so far as it is in my
power so to do, but, owing to the hurry in preparing for a journey, the
notes of the cases I had then taken were lost or mislaid. The principal
facts, however, are too vivid upon my recollection to be soon forgotten.
I think, therefore, that I shall be able to give you all the information
you may require.
“All the cases that occurred in my practice took place between the 7th
of May and the 17th of June 1842.
“They were not confined to any particular part of the city. The first
two cases were patients residing at the South End, the next was at the
extreme North End, one living in Sea Street and the other in Roxbury.
The following is the order in which they occurred:
“Case 1. Mrs.______ was confined on the 7th of May, at 5 o'clock, P. M.,
after a natural labor of six hours. At 12 o'clock at night, on the 9th
(thirty-one hours after confinement), she was taken with severe chill,
previous to which she was as comfortable as women usually are under the
circumstances. She died on the 10th.
“Case 2. Mrs.______ was confined on the 10th of June (four weeks after
Mrs. C.), at 11 A. M., after a natural, but somewhat severe labor of
five hours. At 7 o'clock, on the morning of the 11th, she had a chill.
Died on the 12th.
“Case 3. Mrs.______, confined on the 14th of June, was comfortable until
the 18th, when symptoms of puerperal fever were manifest. She died on
the 20th.
“Case 4. Mrs.______, confined June 17th, at 5 o'clock, A. M., was doing
well until the morning of the 19th. She died on the evening of the 21st.
“Case 5. Mrs.______ was confined with her fifth child on the 17th of
June, at 6 o'clock in the evening. This patient had been attacked with
puerperal fever, at three of her previous confinements, but the disease
yielded to depletion and other remedies without difficulty. This time, I
regret to say, I was not so fortunate. She was not attacked, as were the
other patients, with a chill, but complained of extreme pain in abdomen,
and tenderness on pressure, almost from the moment of her confinement.
In this as in the other cases, the disease resisted all remedies, and
she died in great distress on the 22d of the same month. Owing to
the extreme heat of the season, and my own indisposition, none of the
subjects were examined after death. Dr. Channing, who was in attendance
with me on the three last cases, proposed to have a post-mortem
examination of the subject of case No. 5, but from some cause which I do
not now recollect it was not obtained.
“You wish to know whether I wore the same clothes when attending the
different cases. I cannot positively say, but I should think I did not,
as the weather became warmer after the first two cases; I therefore
think it probable that I made a change of at least a part of my dress.
I have had no other case of puerperal fever in my own practice for three
years, save those above related, and I do not remember to have lost a
patient before with this disease. While absent, last July, I visited
two patients sick with puerperal fever, with a friend of mine in the
country. Both of them recovered.
“The cases that I have recorded were not confined to any particular
constitution or temperament, but it seized upon the strong and the weak,
the old and the young,--one being over forty years, and the youngest
under eighteen years of age.... If the disease is of an erysipelatous
nature, as many suppose, contagionists may perhaps find some ground for
their belief in the fact, that, for two weeks previous to my first case
of puerperal fever, I had been attending a severe case of erysipelas,
and the infection may have been conveyed through me to the patient; but,
on the other hand, why is not this the case with other physicians,
or with the same physician at all times, for since my return from
the country I have had a more inveterate case of erysipelas than ever
before, and no difficulty whatever has attended any of my midwifery
cases?”
I am assured, on unquestionable authority, that “About three years
since, a gentleman in extensive midwifery business, in a neighboring
State, lost in the course of a few weeks eight patients in child-bed,
seven of them being undoubted cases of puerperal fever. No other
physician of the town lost a single patient of this disease during the
same period.” And from what I have heard in conversation with some of
our most experienced practitioners, I am inclined to think many cases of
the kind might be brought to light by extensive inquiry.
This long catalogue of melancholy histories assumes a still darker
aspect when we remember how kindly nature deals with the parturient
female, when she is not immersed in the virulent atmosphere of an impure
lying-in hospital, or poisoned in her chamber by the unsuspected breath
of contagion. From all causes together, not more than four deaths in a
thousand births and miscarriages happened in England and Wales during
the period embraced by the first “Report of the Registrar-General.”
In the second Report the mortality was shown to be about five in one
thousand. In the Dublin Lying-in Hospital, during the seven years of
Dr. Collins's mastership, there was one case of puerperal fever to 178
deliveries, or less than six to the thousand, and one death from this
disease in 278 cases, or between three and four to the thousand a yet
during this period the disease was endemic in the hospital, and might
have gone on to rival the horrors of the pestilence of the Maternite,
had not the poison been destroyed by a thorough purification.
In private practice, leaving out of view the cases that are to be
ascribed to the self-acting system of propagation, it would seem that
the disease must be far from common. Mr. White of Manchester says, “Out
of the whole number of lying-in patients whom I have delivered (and I
may safely call it a great one), I have never lost one, nor to the best
of my recollection has one been greatly endangered, by the puerperal,
miliary, low nervous, putrid malignant, or milk fever.” Dr. Joseph
Clarke informed Dr. Collins, that in the course of forty-five years'
most extensive practice he lost but four patients from this disease. One
of the most eminent practitioners of Glasgow, who has been engaged in
very extensive practice for upwards of a quarter of a century, testifies
that he never saw more than twelve cases of real puerperal fever.
[Lancet, May 4, 1833]
I have myself been told by two gentlemen practising in this city, and
having for many years a large midwifery business, that they had neither
of them lost a patient from this disease, and by one of them that he
had only seen it in consultation with other physicians. In five hundred
cases of midwifery, of which Dr. Storer has given an abstract in the
first number of this Journal, there was only one instance of fatal
puerperal peritonitis.
In the view of these facts, it does appear a singular coincidence, that
one man or woman should have ten, twenty, thirty, or seventy cases of
this rare disease following his or her footsteps with the keenness of
a beagle, through the streets and lanes of a crowded city, while the
scores that cross the same paths on the same errands know it only
by name. It is a series of similar coincidences which has led us to
consider the dagger, the musket, and certain innocent-looking white
powders as having some little claim to be regarded as dangerous. It is
the practical inattention to similar coincidences which has given rise
to the unpleasant but often necessary documents called indictments,
which has sharpened a form of the cephalotome sometimes employed in
the case of adults, and adjusted that modification of the fillet which
delivers the world of those who happen to be too much in the way while
such striking coincidences are taking place.
I shall now mention a few instances in which the disease appears to have
been conveyed by the process of direct inoculation.
Dr. Campbell of Edinburgh states that in October, 1821, he assisted at
the post-mortem examination of a patient who died with puerperal fever.
He carried the pelvic viscera in his pocket to the class-room. The same
evening he attended a woman in labor without previously changing his
clothes; this patient died. The next morning he delivered a woman with
the forceps; she died also, and of many others who were seized with the
disease within a few weeks, three shared the same fate in succession.
In June, 1823, he assisted some of his pupils at the autopsy of a case
of puerperal fever. He was unable to wash his hands with proper care,
for want of the necessary accommodations. On getting home he found that
two patients required his assistance. He went without further ablution,
or changing his clothes; both these patients died with puerperal fever.
This same Dr. Campbell is one of Dr. Churchill's authorities against
contagion.
Mr. Roberton says that in one instance within his knowledge a
practitioner passed the catheter for a patient with puerperal fever late
in the evening; the same night he attended a lady who had the symptoms
of the disease on the second day. In another instance a surgeon was
called while in the act of inspecting the body of a woman who had died
of this fever, to attend a labor; within forty-eight hours this patient
was seized with the fever.'
On the 16th of March, 1831, a medical practitioner examined the body
of a woman who had died a few days after delivery, from puerperal
peritonitis. On the evening of the 17th he delivered a patient, who was
seized with puerperal fever on the 19th, and died on the 24th. Between
this period and the 6th of April, the same practitioner attended two
other patients, both of whom were attacked with the same disease and
died.
In the autumn of 1829 a physician was present at the examination of
a case of puerperal fever, dissected out the organs, and assisted in
sewing up the body. He had scarcely reached home when he was summoned to
attend a young lady in labor. In sixteen hours she was attacked with the
symptoms of puerperal fever, and narrowly escaped with her life.
In December, 1830, a midwife, who had attended two fatal cases of
puerperal fever at the British Lying-in Hospital, examined a patient
who had just been admitted, to ascertain if labor had commenced. This
patient remained two days in the expectation that labor would come
on, when she returned home and was then suddenly taken in labor and
delivered before she could set out for the hospital. She went on
favorably for two days, and was then taken with puerperal fever and died
in thirty-six hours.
“A young practitioner, contrary to advice, examined the body of a
patient who had died from puerperal fever; there was no epidemic at the
time; the case appeared to be purely sporadic. He delivered three
other women shortly afterwards; they all died with puerperal fever, the
symptoms of which broke out very soon after labor. The patients of his
colleague did well, except one, where he assisted to remove some coagula
from the uterus; she was attacked in the same manner as those whom he
had attended, and died also.” The writer in the “British and Foreign
Medical Review,” from whom I quote this statement,--and who is no
other than Dr. Rigby, adds, “We trust that this fact alone will forever
silence such doubts, and stamp the well-merited epithet of 'criminal,'
as above quoted, upon such attempts.” [Brit. and For. Medical Review for
Jan. 1842, p. 112.]
From the cases given by Mr. Ingleby, I select the following. Two
gentlemen, after having been engaged in conducting the post-mortem
examination of a case of puerperal fever, went in the same dress, each
respectively, to a case of midwifery. “The one patient was seized with
the rigor about thirty hours afterwards. The other patient was seized
with a rigor the third morning after delivery. One recovered, one died.”
[Edin. Med. and Surg. Journal, April, 1838.] One of these same gentlemen
attended another woman in the same clothes two days after the autopsy
referred to. “The rigor did not take place until the evening of the
fifth day from the first visit. Result fatal.” These cases belonged to a
series of seven, the first of which was thought to have originated in
a case of erysipelas. “Several cases of a mild character followed the
foregoing seven, and their nature being now most unequivocal, my friend
declined visiting all midwifery cases for a time, and there was no
recurrence of the disease.” These cases occurred in 1833. Five of them
proved fatal. Mr. Ingleby gives another series of seven cases which
occurred to a practitioner in 1836, the first of which was also
attributed to his having opened several erysipelatous abscesses a short
time previously.
I need not refer to the case lately read before this Society, in which a
physician went, soon after performing an autopsy of a case of puerperal
fever, to a woman in labor, who was seized with the same disease and
perished. The forfeit of that error has been already paid.
At a meeting of the Medical and Chirurgical Society before referred to,
Dr. Merriman related an instance occurring in his own practice, which
excites a reasonable suspicion that two lives were sacrificed to a
still less dangerous experiment. He was at the examination of a case
of puerperal fever at two o'clock in the afternoon. He took care not to
touch the body. At nine o'clock the same evening he attended a woman in
labor; she was so nearly delivered that he had scarcely anything to do.
The next morning she had severe rigors, and in forty-eight hours she was
a corpse. Her infant had erysipelas and died in two days. [Lancet, May
2, 1840.]