Medical Essays, 1842-1882 Part 11

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 doc.u.ments 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 a.s.sisted at the post-mortem examination of a patient who died with puerperal fever.

He carried the pelvic viscera in his pocket to the cla.s.s-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 a.s.sisted 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 a.s.sistance. 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 pract.i.tioner pa.s.sed 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 pract.i.tioner 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 pract.i.tioner 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 a.s.sisted 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 pract.i.tioner, 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 a.s.sisted 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 eases which occurred to a pract.i.tioner 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.]

In connection with the facts which have been stated, it seems proper to 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 a.n.a.lysis of the fluid effused in puerperal peritonitis, says that pract.i.tioners 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 was.h.i.+ng 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 was.h.i.+ng 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 inst.i.tutions 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 inst.i.tutions completely defeats the objects of their founders; and out of this train of c.u.mulative evidence, the multiplied groups of cases cl.u.s.tering 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 repet.i.tions, 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 pract.i.tioner," 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, Loc.o.c.k, 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 princ.i.p.al 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. G.o.d 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 a.s.sistants, by making proper inquiries concerning them, and giving timely warning of every suspected source of danger.