The Harvard Classics Part 19

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 oedema of the thigh and gangrene extending from a little above the ankle into the cavity of the abdomen." Dr. C. wounded himself very slightly in the right hand during the autopsy. The hand was quite painful the night following, during his attendance on the patient No. 1. He did not see this patient after the 20th, being confined to the house, and very sick from the wound just mentioned, from this time until the 3d of April.

Several cases of erysipelas occurred in the house where the autopsy mentioned above took place, soon after the examination.

There were also many cases of erysipelas in town at the time of the fatal puerperal cases which have been mentioned.

The nurse who laid out the body of the patient No. 3 was taken on the evening of the same day with sore throat and erysipelas, and died in ten days from the first attack.

The nurse who laid out the body of the patient No. 4 was taken on the day following with symptoms like those of this patient, and died in a week, without any external marks of erysipelas.

"No other cases of similar character with those of Dr. C.

occurred in the practice of any of the physicians in the town or vicinity at the time. Deaths following confinement have occurred in the practice of other physicians during the past year, but they were not cases of puerperal fever. No post-mortem examinations were held in any of these puerperal cases."

Some additional statements in this letter are deserving of insertion:

"A physician attended a woman in the immediate neighborhood of the cases numbered 2, 3, and 4. This patient was confined the morning of March 1st, and died on the night of Match 7th. It is doubtful whether this should be considered a case of puerperal fever. She had suffered from canker, indigestion, and diarrhoea for a year previous to her delivery. Her complaints were much aggravated for two or three months previous to delivery; she had become greatly emaciated, and weakened to such an extent that it had not been expected that she would long survive her confinement, if indeed she reached that period. Her labor was easy enough; she flowed a good deal, seemed exceedingly prostrated, had ringing in 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 p.r.i.c.k 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.

"January 38, 1843.

II ... "The time to which you allude was in 1830. The first case was in February, during a very cold time. She was confined the 4th, and died the 12th. Between the 10th and 28th of this month I attended six women in labor, all of whom did well except the last, as also two who were confined March 1st and 5th. Mrs. E., confined February 28th, sickened, and died March 8th. The next day, 9th, I inspected the body, and the night after attended a lady, Mrs. B., who sickened, and died 16th. The 10th, I attended another, Mrs. G., who sickened, but recovered. March 16th I went from Mrs. G.'s room to attend a Mrs. H., who sickened, and died 21st. The 17th, I inspected Mrs. B. On the 19th, I went directly from Mrs. H.'s room to attend another lady, Mrs. G., who also sickened, and died 22d. While Mrs. B. was sick, on 15th, I went directly from her room a few rods, and attended another woman, who was not sick. Up to 20th of this month I wore the same clothes. I now refused to attend any labor, and did not till April 21st, when, having thoroughly cleansed myself, I resumed my practice, and had no more puerperal fever.

"The cases were not confined to a narrow s.p.a.ce. The two nearest were half a mile from each other, and half that distance from my residence. The others were from two to three miles apart, and nearly that distance from my residence. There were no other cases in their immediate vicinity which came to my knowledge. The general health of all the women was pretty good, and all the labors as good as common, except the first. This woman, in consequence of my not arriving in season, and the child being half-born at some time before I arrived, was very much exposed to the cold at the time of confinement, and afterwards, being confined in a very open, cold room. Of the six cases, you perceive only one recovered.

"In the winter of 1817 two of my patients had puerperal fever, one very badly, the other not so badly. Both recovered. One other had swelled leg or phlegmasia dolens, and one or two others did not recover as well as usual.

"In the summer of 1835 another disastrous period occurred in my practice. July 1st I attended a lady in labor, who was afterwards quite ill and feverish; but at the time I did not consider her case a decided puerperal fever. On the 8th I attended one who did well. On the 12th, one who was seriously sick. This was also an equivocal case, apparently arising from constipation and irritation of the r.e.c.t.u.m. These women were ten miles apart and five from my residence. On 15th and 2Oth 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 2nd and 3rd, 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." [Footnote: In a letter to myself this gentleman also stated," I do not recollect that there was any erysipelas or any other disease particularly prevalent at the time."]

"Boston, February 3, 1843.

III. "My Dear Sir: I received a note from you last evening requesting me to answer certain questions therein proposed, touching the cases of puerperal fever which came under my observation the past summer. It gives me pleasure to comply with your request, so far as it is in my power so to do, but, owing to the hurry in preparing for a journey, the notes of the cases I had then taken were lost or mislaid. The princ.i.p.al facts, however, are too vivid upon my recollection to be soon forgotten.

I think, therefore, that I shall be able to give you all the information you may require.

"All the cases that occurred in my practice took place between the 7th of May and the 17th of June, 1842.

They were not confined to any particular part of the city. The first two cases were patients residing at the South End, the next was at the extreme North End, one living in Sea Street and the other in Roxbury. The following is the order in which they occurred:

"CASE 1.--Mrs.-- was confined on the 7th of May, at 5 o'clock, P.

M., after a natural labor of six hours. At 12 o'clock at night, on the 9th (thirty-one hours after confinement), she was taken with severe chill, previous to which she was as comfortable as women usually are under the circ.u.mstances. She died on the 10th.

"CASE 2.--Mrs.-- was confined on the 10th of June (four weeks after Mrs. C), at 11 A. M., after a natural, but somewhat severe, labor of five hours. At 7 o'clock, on the morning of the 11th, she had a chill. Died on the 12th.

"CASE 3.--Mrs.--, confined on the 14th of June, was comfortable until the 18th, when symptoms of puerperal fever were manifest.

She died on the 20th.

"CASE 4.--Mrs.--, confined June 17th, at 5 o'clock, A. M., was doing well until the morning of the 19th. She died on the evening of the 21st.

"CASE 5.--Mrs.--was confined with her FIFTH child on the 17th of June, at 6 o'clock in the evening. This patient had been attacked with puerperal fever, at three of her previous confinements, but the disease yielded to depletion and other remedies without difficulty. This time, I regret to say, I was not so fortunate.

She was not attacked, as were the other patients, with a chill, but complained of extreme pain in the abdomen, and tenderness on pressure, almost from the moment of her confinement. In this, as in the other cases, the disease resisted all remedies, and she died in great distress on the 22d of the same month. Owing to the extreme heat of the season and my own indisposition, none of the subjects were examined after death. Dr. Channing, who was in attendance with me on the three last cases, proposed to have a post-mortem examination of the subject of case No. 5, but from some cause which I do not now recollect it was not obtained.

"You wish to know whether I wore the same clothes when attending the different cases. I cannot positively say, but I should think I did not, as the weather became warmer after, the first two cases; I therefore think it probable that I made a change of at least a PART of my dress. I have had no other case of puerperal fever in my own practice for three years, save those above related, and I do not remember to have lost a patient before with this disease. While absent, last July, I visited two patients sick with puerperal fever, with a friend of mine in the country.

Both of them recovered.

"The cases that I have recorded were not confined to any particular const.i.tution 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 a.s.sured, 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 pract.i.tioners, I am inclined to think many cases of the kind might be brought to light by extensive inquiry.

This long catalogue of melancholy histories a.s.sumes 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. [Footnote: First Report, p. 105.] In the second Report the mortality was shown to be about five in one thousand. [Footnote: Second Report, p. 73.] In the Dublin Lying-in Hospital, during the seven years of Dr. Collins's masters.h.i.+p, 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. [Footnote: Collins's Treatise on Midwifery, p. 228, etc.] Yet during this period the disease was endemic in the hospital, and might have gone on to rival the horrors of the pestilence of the Maternite, had not the poison been destroyed by a thorough purification.

In private practice, leaving out of view the cases that are to be ascribed to the self-acting system of propagation, it would seem that the disease must be far from common. Mr. White, of Manchester, says: "Out of the whole number of lying-in patients whom I have delivered (and I may safely call it a great one), I have never lost one, nor to the best of my recollection has one been greatly endangered, by the puerperal, miliary, low nervous, putrid malignant, or milk fever." [Footnote: Op. cit., p. 115.]

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. [Footnote: Op. cit., p.228.] One of the most eminent pract.i.tioners 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. [Footnote: Lancet, May 4, 1833.]

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 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.