medical essays-第27章

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uerperal　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　abscess　in　the　fingers　or　hands；　attended　with　rapidly　spreading　inflammation　of　the　cellular　tissue。〃

Now　add　to　all　this　the　undisputed　fact；　that　within　the　walls　of　lying…in　hospitals　there　is　often　generated　a　miasm；　palpable　as　the　chlorine　used　to　destroy　it；　tenacious　so　as　in　some　cases　almost　to　defy　extirpation；　deadly　in　some　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　Tonnelle　to　record　two　hundred　and　twenty…two　autopsies　at　the　Maternite　of　Paris；　which　has　led　Dr。　Lee　to　express　his　deliberate　conviction　that　the　loss　of　life　occasioned　by　these　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　originating　in　the　matter　or　effluvia　of　erysipelas。　　In　evidence　of　some　connection　between　the　two　diseases；　I　need　not　go　back　to　the　older　authors；　as　Pouteau　or　Gordon；　but　will　content　myself　with　giving　the　following　references；　with　their　dates；　from　which　it　will　be　seen　that　the　testimony　has　been　constantly　coming　before　the　profession　for　the　last　few　years。

〃London　Cyclopaedia　of　Practical　Medicine；〃　article　Puerperal　Fever；　1833。

Mr。　Ceeley's　Account　of　the　Puerperal　Fever　at　Aylesbury。　　〃Lancet；〃　1835。

Dr。　Ramsbotham's　Lecture。　　〃London　Medical　Gazette；〃　1835。

Mr。　Yates　Ackerly's　Letter　in　the　same　Journal；　1838。

Mr。　Ingleby　on　Epidemic　Puerperal　Fever。　　〃Edinburgh　Medical　and　Surgical　Journal；〃　1838。

Mr。　Paley's　Letter。　　〃London　Medical　Gazette；〃　1839。

Remarks　at　the　Medical　and　Chirurgical　Society。　〃Lancet；〃　1840。

Dr。　Rigby's　〃System　of　Midwifery。〃　　1841。

〃Nunneley　on　Erysipelas；〃a　work　which　contains　a　large　number　of　references　on　the　subject。　　1841。

〃British　and　Foreign　Quarterly　Review；〃　1842。

Dr。　S。　　Jackson　of　Northumberland；　as　already　quoted　from　the　Summary　of　the　College　of　Physicians；　1842。

And　lastly；　a　startling　series　of　cases　by　Mr。　Storrs　of　Doncaster；　to　be；　found　in　the　〃American　Journal　of　the　Medical　Sciences〃　for　January；　1843。

The　relation　of　puerperal　fever　with　other　continued　fevers　would　seem　to　be　remote　and　rarely　obvious。　　Hey　refers　to　two　cases　of　synochus　occurring　in　the　Royal　Infirmary　of　Edinburgh；　in　women　who　had　attended　upon　puerperal　patients。　　Dr。　Collins　refers　to　several　instances　in　which　puerperal　fever　has　appeared　to　originate　from　a　continued　proximity　to　patients　suffering　with　typhus。

Such　occurrences　as　those　just　mentioned；　though　most　important　to　be　remembered　and　guarded　against；　hardly　attract　our　notice　in　the　midst　of　the　gloomy　facts　by　which　they　are　surrounded。　　Of　these　facts；　at　the　risk　of　fatiguing　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；　Tonnelle；　Duges；　and　Baudelocque；　in　France；　profess　not　to　have　found　puerperal　fever　contagious。　　At　the　most　they　give　us　mere　negative　facts；　worthless　against　an　extent　of　evidence　which　now　overlaps　the　widest　range　of　doubt；　and　doubles　upon　itself　in　the　redundancy　of　superfluous　demonstration。　Examined　in　detail；　this　and　much　of　the　show　of　testimony　brought　up　to　stare　the　daylight　of　conviction　out　of　countenance；　proves　to　be　in　a　great　measure　unmeaning　and　inapplicable；　as　might　be　easily　shown　were　it　necessary。　　Nor　do　I　feel　the　necessity　of　enforcing　the　conclusion　which　arises　spontaneously　from　the　facts　which　have　been　enumerated；　by　formally　citing　the　opinions　of　those　grave　authorities　who　have　for　the　last　half…century　been　sounding　the　unwelcome　truth　it　has　cost　so　many　lives　to　establish。

〃It　is　to　the　British　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