allude to the dangerous and often fatal effects which have followed from
wounds received in the post-mortem examination of patients who have died
of puerperal fever. The fact that such wounds are attended with peculiar
risk has been long noticed. I find that Chaussier was in the habit of
cautioning his students against the danger to which they were exposed in
these dissections. [Stein, L'Art d'Accoucher, 1794; Dict. des Sciences
Medicales, art. “Puerperal.”] The head pharmacien of the Hotel Dieu, in
his analysis of the fluid effused in puerperal peritonitis, says that
practitioners are convinced of its deleterious qualities, and that it is
very dangerous to apply it to the denuded skin. [Journal de Pharmacie,
January, 1836.] Sir Benjamin Brodie speaks of it as being well known
that the inoculation of lymph or pus from the peritoneum of a puerperal
patient is often attended with dangerous and even fatal symptoms. Three
cases in confirmation of this statement, two of them fatal, have been
reported to this Society within a few months.
Of about fifty cases of injuries of this kind, of various degrees of
severity, which I have collected from different sources, at least twelve
were instances of infection from puerperal peritonitis. Some of the
others are so stated as to render it probable that they may have been of
the same nature. Five other cases were of peritoneal inflammation;
three in males. Three were what was called enteritis, in one instance
complicated with erysipelas; but it is well known that this term has
been often used to signify inflammation of the peritoneum covering the
intestines. On the other hand, no case of typhus or typhoid fever is
mentioned as giving rise to dangerous consequences, with the exception
of the single instance of an undertaker mentioned by Mr. Travers, who
seems to have been poisoned by a fluid which exuded from the body.
The other accidents were produced by dissection, or some other mode of
contact with bodies of patients who had died of various affections.
They also differed much in severity, the cases of puerperal origin being
among the most formidable and fatal. Now a moment's reflection will
show that the number of cases of serious consequences ensuing from the
dissection of the bodies of those who had perished of puerperal fever
is so vastly disproportioned to the relatively small number of autopsies
made in this complaint as compared with typhus or pneumonia (from which
last disease not one case of poisoning happened), and still more from
all diseases put together, that the conclusion is irresistible that
a most fearful morbid poison is often generated in the course of this
disease. Whether or not it is sui generis, confined to this disease, or
produced in some others, as, for instance, erysipelas, I need, not stop
to inquire.
In connection with this may be taken the following statement of Dr.
Rigby. “That the discharges from a patient under puerperal fever are in
the highest degree contagious we have abundant evidence in the history
of lying-in hospitals. The puerperal abscesses are also contagious, and
may be communicated to healthy lying-in women by washing with the same
sponge; this fact has been repeatedly proved in the Vienna Hospital; but
they are equally communicable to women not pregnant; on more than
one occasion the women engaged in washing the soiled bed-linen of the
General Lying-in Hospital have been attacked with abscess in the fingers
or hands, attended with rapidly spreading inflammation of the cellular
tissue.”
Now add to all this the undisputed fact, that within the walls of
lying-in hospitals there is often generated a miasm, palpable as the
chlorine used to destroy it, tenacious so as in some cases almost to
defy extirpation, deadly in some institutions as the plague; which has
killed women in a private hospital of London so fast that they were
buried two in one coffin to conceal its horrors; which enabled Tonnelle
to record two hundred and twenty-two autopsies at the Maternite of
Paris; which has led Dr. Lee to express his deliberate conviction that
the loss of life occasioned by these institutions completely defeats the
objects of their founders; and out of this train of cumulative evidence,
the multiplied groups of cases clustering about individuals, the deadly
results of autopsies, the inoculation by fluids from the living patient,
the murderous poison of hospitals,--does there not result a conclusion
that laughs all sophistry to scorn, and renders all argument an insult?
I have had occasion to mention some instances in which there was an
apparent relation between puerperal fever and erysipelas. The length
to which this paper has extended does not allow me to enter into the
consideration of this most important subject. I will only say, that
the evidence appears to me altogether satisfactory that some most fatal
series of puerperal fever have been produced by an infection originating
in the matter or effluvia of erysipelas. In evidence of some connection
between the two diseases, I need not go back to the older authors, as
Pouteau or Gordon, but will content myself with giving the following
references, with their dates; from which it will be seen that the
testimony has been constantly coming before the profession for the last
few years.
“London Cyclopaedia of Practical Medicine,” article Puerperal Fever,
1833.
Mr. Ceeley's Account of the Puerperal Fever at Aylesbury. “Lancet,”
1835.
Dr. Ramsbotham's Lecture. “London Medical Gazette,” 1835.
Mr. Yates Ackerly's Letter in the same Journal, 1838.
Mr. Ingleby on Epidemic Puerperal Fever. “Edinburgh Medical and Surgical
Journal,” 1838.
Mr. Paley's Letter. “London Medical Gazette,” 1839.
Remarks at the Medical and Chirurgical Society. “Lancet,” 1840.
Dr. Rigby's “System of Midwifery.” 1841.
“Nunneley on Erysipelas,”--a work which contains a large number of
references on the subject. 1841.
“British and Foreign Quarterly Review,” 1842.
Dr. S. Jackson of Northumberland, as already quoted from the Summary of
the College of Physicians, 1842.
And lastly, a startling series of cases by Mr. Storrs of Doncaster, to
be found in the “American Journal of the Medical Sciences” for January,
1843.
The relation of puerperal fever with other continued fevers would seem
to be remote and rarely obvious. Hey refers to two cases of synochus
occurring in the Royal Infirmary of Edinburgh, in women who had attended
upon puerperal patients. Dr. Collins refers to several instances
in which puerperal fever has appeared to originate from a continued
proximity to patients suffering with typhus.
Such occurrences as those just mentioned, though most important to be
remembered and guarded against, hardly attract our notice in the midst
of the gloomy facts by which they are surrounded. Of these facts, at the
risk of fatiguing repetitions, I have summoned a sufficient number, as I
believe, to convince the most incredulous that every attempt to disguise
the truth which underlies them all is useless.
It is true that some of the historians of the disease, especially
Hulme, Hull, and Leake, in England; Tonnelle, Duges, and Baudelocque,
in France, profess not to have found puerperal fever contagious. At the
most they give us mere negative facts, worthless against an extent of
evidence which now overlaps the widest range of doubt, and doubles
upon itself in the redundancy of superfluous demonstration. Examined in
detail, this and much of the show of testimony brought up to stare
the daylight of conviction out of countenance, proves to be in a great
measure unmeaning and inapplicable, as might be easily shown were it
necessary. Nor do I feel the necessity of enforcing the conclusion
which arises spontaneously from the facts which have been enumerated, by
formally citing the opinions of those grave authorities who have for the
last half-century been sounding the unwelcome truth it has cost so many
lives to establish.
“It is to the British practitioner,” says Dr. Rigby, “that we are
indebted for strongly insisting upon this important and dangerous
character of puerperal fever.”
The names of Gordon, John Clarke, Denman, Burns, Young, Hamilton,
Haighton, Good, Waller; Blundell, Gooch, Ramsbotham, Douglas, Lee,
Ingleby, Locock, Abercrombie, Alison, Travers, Rigby, and Watson, many
of whose writings I have already referred to, may have some influence
with those who prefer the weight of authorities to the simple deductions
of their own reason from the facts laid before them. A few Continental
writers have adopted similar conclusions. It gives me pleasure to
remember, that while the doctrine has been unceremoniously discredited
in one of the leading Journals, and made very light of by teachers in
two of the principal Medical Schools, of this country, Dr. Channing has
for many years inculcated, and enforced by examples, the danger to
be apprehended and the precautions to be taken in the disease under
consideration.
I have no wish to express any harsh feeling with regard to the painful
subject which has come before us. If there are any so far excited by the
story of these dreadful events that they ask for some word of indignant
remonstrance to show that science does not turn the hearts of its
followers into ice or stone, let me remind them that such words have
been uttered by those who speak with an authority I could not claim. It
is as a lesson rather than as a reproach that I call up the memory
of these irreparable errors and wrongs. No tongue can tell the
heart-breaking calamity they have caused; they have closed the eyes
just opened upon a new world of love and happiness; they have bowed the
strength of manhood into the dust; they have cast the helplessness of
infancy into the stranger's arms, or bequeathed it, with less cruelty,
the death of its dying parent. There is no tone deep enough for regret,
and no voice loud enough for warning. The woman about to become a
mother, or with her new-born infant upon her bosom, should be the object
of trembling care and sympathy wherever she bears her tender burden,
or stretches her aching limbs. The very outcast of the streets has pity
upon her sister in degradation, when the seal of promised maternity is
impressed upon her. The remorseless vengeance of the law, brought down
upon its victim by a machinery as sure as destiny, is arrested in its
fall at a word which reveals her transient claim for mercy. The solemn
prayer of the liturgy singles out her sorrows from the multiplied trials
of life, to plead for her in the hour of peril. God forbid that any
member of the profession to which she trusts her life, doubly precious
at that eventful period, should hazard it negligently, unadvisedly, or
selfishly!
There may be some among those whom I address who are disposed to ask the
question, What course are we to follow in relation to this matter? The
facts are before them, and the answer must be left to their own judgment
and conscience. If any should care to know my own conclusions, they are
the following; and in taking the liberty to state them very freely and
broadly, I would ask the inquirer to examine them as freely in the light
of the evidence which has been laid before him.
1. A physician holding himself in readiness to attend cases of midwifery
should never take any active part in the post-mortem examination of
cases of puerperal fever.
2. If a physician is present at such autopsies, he should use thorough
ablution, change every article of dress, and allow twenty-four hours or
more to elapse before attending to any case of midwifery. It may be well
to extend the same caution to cases of simple peritonitis.
3. Similar precautions should be taken after the autopsy or surgical
treatment of cases of erysipelas, if the physician is obliged to unite
such offices with his obstetrical duties, which is in the highest degree
inexpedient.
4. On the occurrence of a single case of puerperal fever in his
practice, the physician is bound to consider the next female he attends
in labor, unless some weeks at least have elapsed, as in danger of being
infected by him, and it is his duty to take every precaution to diminish
her risk of disease and death.
5. If within a short period two cases of puerperal fever happen close
to each other, in the practice of the same physician, the disease
not existing or prevailing in the neighborhood, he would do wisely to
relinquish his obstetrical practice for at least one month, and endeavor
to free himself by every available means from any noxious influence he
may carry about with him.
6. The occurrence of three or more closely connected cases, in the
practice of one individual, no others existing in the neighborhood, and
no other sufficient cause being alleged for the coincidence, is prima
facie evidence that he is the vehicle of contagion.
7. It is the duty of the physician to take every precaution that the
disease shall not be introduced by nurses or other assistants, by making
proper inquiries concerning them, and giving timely warning of every
suspected source of danger.
8. Whatever indulgence may be granted to those who have heretofore
been the ignorant causes of so much misery, the time has come when the
existence of a private pestilence in the sphere of a single physician
should be looked upon, not as a misfortune, but a crime; and in the
knowledge of such occurrences the duties of the practitioner to his
profession should give way to his paramount obligations to society.
ADDITIONAL REFERENCES AND CASES.
Fifth Annual Report of the Registrar-General of England.
1843. Appendix. Letter from William Farr, Esq.--Several new series of
cases are given in the Letter of Mr. Stows, contained in the Appendix to
this Report. Mr. Stows suggests precautions similar to those I have laid
down, and these precautions are strongly enforced by Mr. Farr, who is,
therefore, obnoxious to the same criticisms as myself.
Hall and Dexter, in Am. Journal of Med. Sc. for January, 1844.--Cases of
puerperal fever seeming to originate in erysipelas.
Elkington, of Birmingham, in Provincial Med. Journal, cited in Am.
Journ. Med. Sc. for April, 1844.--Six cases in less than a fortnight,
seeming to originate in a case of erysipelas.
West's Reports, in Brit. and For. Med. Review for October, 1845, and
January, 1847.--Affection of the arm, resembling malignant pustule,
after removing the placenta of a patient who died from puerperal fever.
Reference to cases at Wurzburg, as proving contagion, and to Keiller's
cases in the Monthly Journal for February, 1846, as showing connection
of puerperal fever and erysipelas.
Kneeland.--Contagiousness of Puerperal Fever. Am. Jour. Med. Se.,
January, 1846. Also, Connection between Puerperal Fever and Epidemic
Erysipelas. Ibid., April, 1846.
Robert Storrs.--Contagious Effects of Puerperal Fever on the Male
Subject; or on Persons not Child-bearing. (From Provincial Med. and
Surg. Journal.) Am. Jour. Med. Sc., January, 1846. Numerous cases. See
also Dr. Reid's case in same Journal for April, 1846.
Routh's paper in Proc. of Royal Med. Chir. Soc., Am. Jour. Med. Sc.,
April, 1849, also in B. and F. Med. Chir. Review, April, 1850.
Hill, of Leuchars.--A Series of Cases illustrating the Contagious Nature
of Erysipelas and of Puerperal Fever, and their Intimate Pathological
Connection. (From Monthly Journal of Med. Sc.) Am. Jour. Med. Se., July,
1850.
Skoda on the Causes of Puerperal Fever. (Peritonitis in rabbits, from
inoculation with different morbid secretions.) Am. Jour. Med. Se.,
October, 1850.
Arneth. Paper read before the National Academy of Medicine. Annales
d'Hygiene, Tome LXV. 2e Partie. (Means of Disinfection proposed by M.
“Semmeliveis” (Semmelweiss.) Lotions of chloride of lime and use of
nail-brush before admission to lying-in wards. Alleged sudden and great
decrease of mortality from puerperal fever. Cause of disease attributed
to inoculation with cadaveric matters.) See also Routh's paper,
mentioned above.
Moir. Remarks at a meeting of the Edinburgh Medico-Chirurgical Society.
Refers to cases of Dr. Kellie, of Leith. Sixteen in succession, all
fatal. Also to several instances of individual pupils having had a
succession of cases in various quarters of the town, while others,
practising as extensively in the same localities, had none. Also to
several special cases not mentioned elsewhere. Am. Jour. Med. Se. for
October, 1851. (From New Monthly Journal of Med. Science.)
Simpson.--Observations at a Meeting of the Edinburgh Obstetrical
Society. (An “eminent gentleman,” according to Dr. Meigs, whose “name
is as well known in America as in (his) native land.” Obstetrics.
Phil. 1852, pp. 368, 375.) The student is referred to this paper for
a valuable resume of many of the facts, and the necessary inferences,
relating to this subject. Also for another series of cases, Mr. Sidey's,
five or six in rapid succession. Dr. Simpson attended the dissection
of two of Dr. Sidey's cases, and freely handled the diseased parts. His
next four child-bed patients were affected with puerperal fever, and
it was the first time he had seen it in practice. As Dr. Simpson is a
gentleman (Dr. Meigs, as above), and as “a gentleman's hands are clean”
(Dr. Meigs' Sixth Letter), it follows that a gentleman with clean hands
may carry the disease. Am. Jour. Med. Sc., October, 1851.
Peddle.--The five or six cases of Dr. Sidey, followed by the four of Dr.
Simpson, did not end the series. A practitioner in Leith having examined
in Dr. Simpson's house, a portion of the uterus obtained from one of
the patients, had immediately afterwards three fatal cases of puerperal
fever. Dr. Veddie referred to two distinct series of consecutive cases
in his own practice. He had since taken precautions, and not met with
any such cases. Am. Jour. Med. Sc., October, 1851.
Copland. Considers it proved that puerperal fever maybe propagated by
the hands and the clothes, or either, of a third person, the bed-clothes
or body-clothes of a patient. Mentions a new series of cases, one of
which he saw, with the practitioner who had attended them. She was the
sixth he had had within a few days. All died. Dr. Copland insisted that
contagion had caused these cases; advised precautionary measures, and
the practitioner had no other cases for a considerable time. Considers
it criminal, after the evidence adduced,--which he could have
quadrupled,--and the weight of authority brought forward, for a
practitioner to be the medium of transmitting contagion and death to
his patients. Dr. Copland lays down rules similar to those suggested
by myself, and is therefore entitled to the same epithet for so doing.
Medical Dictionary, New York, 1852. Article, Puerperal States and
Diseases.
If there is any appetite for facts so craving as to be yet
unappeased,--Lesotho, necdum satiata,--more can be obtained. Dr. Hodge
remarks that “the frequency and importance of this singular circumstance
(that the disease is occasionally more prevalent with one practitioner
than another) has been exceedingly overrated.” More than thirty strings
of cases, more than two hundred and fifty sufferers from puerperal
fever, more than one hundred and thirty deaths appear as the results of
a sparing estimate of such among the facts I have gleaned as could be
numerically valued. These facts constitute, we may take it for granted,
but a small fraction of those that have actually occurred. The number of
them might be greater, but “'t is enough, 't will serve,” in Mercutio's
modest phrase, so far as frequency is concerned. For a just estimate
of the importance of the singular circumstance, it might be proper to
consult the languid survivors, the widowed husbands, and the motherless
children, as well as “the unfortunate accoucheur.”
CURRENTS AND COUNTER-CURRENTS IN MEDICAL SCIENCE
An Address delivered before the Massachusetts Medical Society, at the
Annual Meeting, May 30, 1860.
“Facultate magis quam violentia.”
HIPPOCRATES.
Our Annual Meeting never fails to teach us at least one lesson. The art
whose province it is to heal and to save cannot protect its own ranks
from the inroads of disease and the waste of the Destroyer.
Seventeen of our associates have been taken from us since our last
Anniversary. Most of them followed their calling in the villages or
towns that lie among the hills or along the inland streams. Only those
who have lived the kindly, mutually dependent life of the country, can
tell how near the physician who is the main reliance in sickness of all
the families throughout a thinly settled region comes to the hearts of
the people among whom he labors, how they value him while living, how
they cherish his memory when dead. For these friends of ours who have
gone before, there is now no more toil; they start from their slumbers
no more at the cry of pain; they sally forth no more into the storms;
they ride no longer over the lonely roads that knew them so well; their
wheels are rusting on their axles or rolling with other burdens; their
watchful eyes are closed to all the sorrows they lived to soothe. Not
one of these was famous in the great world; some were almost unknown
beyond their own immediate circle. But they have left behind them that
loving remembrance which is better than fame, and if their epitaphs are
chiselled briefly in stone, they are written at full length on living
tablets in a thousand homes to which they carried their ever-welcome aid
and sympathy.
One whom we have lost, very widely known and honored, was a leading
practitioner of this city. His image can hardly be dimmed in your
recollection, as he stood before you only three years ago, filling the
same place with which I am now honored. To speak of him at all worthily,
would be to write the history of professional success, won without
special aid at starting, by toil, patience, good sense, pure character,
and pleasing manners; won in a straight uphill ascent, without one
breathing-space until he sat down, not to rest, but to die. If prayers
could have shielded him from the stroke, if love could have drawn forth
the weapon, and skill could have healed the wound, this passing tribute
might have been left to other lips and to another generation.
Let us hope that our dead have at last found that rest which neither
summer nor winter, nor day nor night, had granted to their unending
earthly labors! And let us remember that our duties to our brethren do
not cease when they become unable to share our toils, or leave behind
them in want and woe those whom their labor had supported. It is
honorable to the Profession that it has organized an Association for the
relief of its suffering members and their families; it owes this tribute
to the ill-rewarded industry and sacrifices of its less fortunate
brothers who wear out health and life in the service of humanity. I have
great pleasure in referring to this excellent movement, which gives our
liberal profession a chance to show its liberality, and serves to unite
us all, the successful and those whom fortune has cast down, in the
bonds of a true brotherhood.
A medical man, as he goes about his daily business after twenty years of
practice, is apt to suppose that he treats his patients according to the
teachings of his experience. No doubt this is true to some extent; to
what extent depending much on the qualities of the individual. But it
is easy to prove that the prescriptions of even wise physicians are
very commonly founded on something quite different from experience.
Experience must be based on the permanent facts of nature. But a glance
at the prevalent modes of treatment of any two successive generations
will show that there is a changeable as well as a permanent element in
the art of healing; not merely changeable as diseases vary, or as new
remedies are introduced, but changeable by the going out of fashion of
special remedies, by the decadence of a popular theory from which their
fitness was deduced, or other cause not more significant. There is no
reason to suppose that the present time is essentially different in
this respect from any other. Much, therefore, which is now very commonly
considered to be the result of experience, will be recognized in the
next, or in some succeeding generation, as no such result at all, but as
a foregone conclusion, based on some prevalent belief or fashion of the
time.