Part 12

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 neighborhood 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 with the same fate, till the neighborhood, 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 neighborhood, 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.” [Lond. Med. Gaz. May 2, 1835.]

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 manger-side, 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.[Lancet, May 2, 1840.]

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

Several cases of erysipelas occurred in the house where the autopsy mentioned above took place, soon after the examination. There were also many cases of erysipelas in town at the time of the fatal puerperal cases which have been mentioned.

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

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

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

Some additional statements in this letter are deserving of insertion.

“A physician attended a woman in the immediate neighborhood of the cases numbered 2, 3, and 4. This patient was confined the morning of March 1st, and died on the night of March 7th. It is doubtful whether this should be considered a case of puerperal fever. She had suffered from canker, indigestion, and diarrhoea for a year previous to her delivery. Her complaints were much aggravated for two or three months previous to delivery; she had become greatly emaciated, and weakened to such an extent that it had not been expected that she would long survive her confinement, if indeed she reached that period. Her labor was easy enough; she flowed a good deal, seemed exceedingly prostrated, had ringing in the ears, and other symptoms of exhaustion; the pulse was quick and small. On the second and third day there was some tenderness and tumefaction of the abdomen, which increased somewhat on the fourth and fifth. He had cases in midwifery before and after this, which presented nothing peculiar.”

It is also mentioned in the same letter, that another physician had a case during the last summer and another last fall, both of which recovered.

Another gentleman reports a case last December, a second case five weeks, and another three weeks since. All these recovered. A case also occurred very recently in the practice of a physician in the village where the eighth patient of Dr. C. resides, which proved fatal. “This patient had some patches of erysipelas on the legs and arms. The same physician has delivered three cases since, which have all done well. There have been no other cases in this town or its vicinity recently. There have been some few cases of erysipelas.” It deserves notice that the partner of Dr. C., who attended the autopsy of the man above mentioned and took an active part in it; who also suffered very slightly from a prick under the thumb-nail received during the examination, had twelve cases of midwifery between March 26th and April 12th, all of which did well, and presented no peculiar symptoms. It should also be stated, that during these seventeen days he was in attendance on all the cases of erysipelas in the house where the autopsy had been performed.

I owe these facts to the prompt kindness of a gentleman whose intelligence and character are sufficient guaranty for their accuracy.

The two following letters were addressed to my friend Dr. Scorer, by the gentleman in whose practice the cases of puerperal fever occurred. His name renders it unnecessary to refer more particularly to these gentlemen, who on their part have manifested the most perfect freedom and courtesy in affording these accounts of their painful experience.

“January 28, 1843.

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

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

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