medical essays-第22章

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ly　of　the　disease　for　weeks　or　months；　or　cause　and　effect；　the　cause　being　in　some　way　connected　with　the　person；　this　is　the　question。　　If　I　am　wrong；　let　me　be　put　down　by　such　a　rebuke　as　no　rash　declaimer　has　received　since　there　has　been　a　public　opinion　in　the　medical　profession　of　America；　if　I　am　right；　let　doctrines　which　lead　to　professional　homicide　be　no　longer　taught　from　the　chairs　of　those　two　great　Institutions。　　Indifference　will　not　do　here；　our　Journalists　and　Committees　have　no　right　to　take　up　their　pages　with　minute　anatomy　and　tediously　detailed　cases；　while　it　is　a　question　whether　or　not　the　〃blackdeath〃　of　child…bed　is　to　be　scattered　broadcast　by　the　agency　of　the　mother's　friend　and　adviser。　　Let　the　men　who　mould　opinions　look　to　it；　if　there　is　any　voluntary　blindness；　any　interested　oversight；　any　culpable　negligence；　even；　in　such　a　matter；　and　the　facts　shall　reach　the　public　ear；　the　pestilence…carrier　of　the　lying…in　chamber　must　look　to　God　for　pardon；　for　man　will　never　forgive　him。


　　　　　　　　　　　　　　　THE　CONTAGIOUSNESS　OF　PUERPERAL　FEVER。

In　collecting；　enforcing；　and　adding　to　the　evidence　accumulated　upon　this　most　serious　subject；　I　would　not　be　understood　to　imply　that　there　exists　a　doubt　in　the　mind　of　any　well…informed　member　of　the　medical　profession　as　to　the　fact　that　puerperal　fever　is　sometimes　communicated　from　one　person　to　another；　both　directly　and　indirectly。　　In　the　present　state　of　our　knowledge　upon　this　point　I　should　consider　such　doubts　merely　as　a　proof　that　the　sceptic　had　either　not　examined　the　evidence；　or；　having　examined　it；　refused　to　accept　its　plain　and　unavoidable　consequences。　　I　should　be　sorry　to　think；　with　Dr。　Rigby；　that　it　was　a　case　of　〃oblique　vision；〃　I　should　be　unwilling　to　force　home　the　argumentum　ad　hominem　of　Dr。　Blundell；　but　I　would　not　consent　to　make　a　question　of　a　momentous　fact　which　is　no　longer　to　be　considered　as　a　subject　for　trivial　discussions；　but　to　be　acted　upon　with　silent　promptitude。　　It　signifies　nothing　that　wise　and　experienced　practitioners　have　sometimes　doubted　the　reality　of　the　danger　in　question；　no　man　has　the　right　to　doubt　it　any　longer。　　No　negative　facts；　no　opposing　opinions；　be　they　what　they　may；　or　whose　they　may；　can　form　any　answer　to　the　series　of　cases　now　within　the　reach　of　all　who　choose　to　explore　the　records　of　medical　science。

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　these　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　favor　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　small…pox　is　propagated　to　a　great　extent　by　contagion；　yet　it　goes　through　the　same　periods　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　small…pox　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。　　Apart　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　small…pox　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