Oliver Wendell Holmes (1809–1894). The Contagiousness of Puerperal Fever.
The Harvard Classics. 1909–14.
The Contagiousness of Puerperal Fever
I
Note.—This essay appeared first in 1843, in The New England Quarterly Journal of Medicine, and was reprinted in the “Medical Essays” in 1855.
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 the 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.
1. It is granted that all the forms of what is called puerperal fever 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 favour 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 smallpox is propagated to a great extent by contagion, yet it goes through the same records 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 smallpox 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. A part 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 smallpox 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
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.
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 candour 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 neighbourhood 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 the same fate, till the neighbourhood, 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 neighbourhood, 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.”
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 mangerside, 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.
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 twelve-month 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 effluvia. 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.
The first patient, it is stated, was delivered on the 20th of March. “On the 19th Dr. C. made the autopsy of a man who had died suddenly, sick only forty-eight hours; had œdema 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 diarrhœa 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 her 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. Storer 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.
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 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 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 8th I attended one who did well. On 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 recollection 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. Channing 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.”
III. “M
“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:
“C
“C
“C
“Case 4.—Mrs.——, confined June 17th, at 5 o’clock,
“C
“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. 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 Maternité, 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.
I have myself been told by two gentlemen practicing 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 fortyeight 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.
From the cases given by Mr. Ingleby I select the following: Two gentlemen, after having been engaged in conducting the postmortem 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.” 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.
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. The head pharmacien of the Hôtel 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. 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 abscesses 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 Tonellé to record two hundred and twenty-two autopsies at the Maternité 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 orginating 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 Cyclopædia 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; Tonellé, Dugès, 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 primâ 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.