Medical Essays, 1842-1882 Part 8

VII. When a large number of cases of this disease occur in rapid succession, in one individual's ordinary practice, and few or none elsewhere, these cases appearing in scattered localities, in patients of the same average condition as those who escape under the care of others, there is the same reason for connecting the cause of the disease with the person in this instance, as with the place in that last mentioned.

VIII. Many series of cases, answering to these conditions, are given in this Essay, and many others will be referred to which have occurred since it was written.

IX. The alleged results of observation may be set aside; first, because the so-called facts are in their own nature equivocal; secondly, because they stand on insufficient authority; thirdly, because they are not sufficiently numerous. But, in this case, the disease is one of striking and well-marked character; the witnesses are experts, interested in denying and disbelieving the facts; the number of consecutive cases in many instances frightful, and the number of series of cases such that I have no room for many of them except by mere reference.

X. These results of observation, being admitted, may, we will suppose, be interpreted in different methods. Thus the coincidences may be considered the effect of chance. I have had the chances calculated by a competent person, that a given pract.i.tioner, A., shall have sixteen fatal cases in a month, on the following data: A. to average attendance upon two hundred and fifty births in a year; three deaths in one thousand births to be a.s.sumed as the average from puerperal fever; no epidemic to be at the time prevailing. It follows, from the answer given me, that if we suppose every one of the five hundred thousand annual births of England to have been recorded during the last half-century, there would not be one chance in a million million million millions that one such series should be noted. No possible fractional error in this calculation can render the chance a working probability. Applied to dozens of series of various lengths, it is obviously an absurdity.

Chance, therefore, is out of the question as an explanation of the admitted coincidences.

XI. There is, therefore, some relation of cause and effect between the physician's presence and the patient's disease.

XII. Until it is proved to what removable condition attaching to the attendant the disease is owing, he is bound to stay away from his patients so soon as he finds himself singled out to be tracked by the disease. How long, and with what other precautions, I have suggested, without dictating, at the close of my Essay. If the physician does not at once act on any reasonable suspicion of his being the medium of transfer, the families where he is engaged, if they are allowed to know the facts, should decline his services for the time. His feelings on the occasion, however interesting to himself, should not be even named in this connection. A physician who talks about ceremony and grat.i.tude, and services rendered, and the treatment he got, surely forgets himself; it is impossible that he should seriously think of these small matters where there is even a question whether he may not carry disease, and death, and bereavement into any one of "his families," as they are sometimes called.

I will now point out to the young student the mode in which he may relieve his mind of any confusion, or possibly, if very young, any doubt, which the perusal of Dr. Meigs's Sixth Letter may have raised in his mind.

The most prominent ideas of the Letter are, first, that the transmissible nature of puerperal fever appears improbable, and, secondly, that it would be very inconvenient to the writer. Dr.

Woodville, Physician to the Small-Pox and Inoculation Hospital in London, found it improbable, and exceedingly inconvenient to himself, that cow pox should prevent small-pox; but Dr. Jenner took the liberty to prove the fact, notwithstanding.

I will first call the young student's attention to the show of negative facts (exposure without subsequent disease), of which much seems to be thought. And I may at the same time refer him to Dr. Hodge's Lecture, where he will find the same kind of facts and reasoning. Let him now take up Watson's Lectures, the good sense and spirit of which have made his book a universal favorite, and open to the chapter on Continued Fever. He will find a paragraph containing the following sentence: "A man might say, 'I was in the battle of Waterloo, and saw many men around me fall down and die, and it was said that they were struck down by musket-b.a.l.l.s; but I know better than that, for I was there all the time, and so were many of my friends, and we were never hit by any musket-b.a.l.l.s. Musket-b.a.l.l.s, therefore, could not have been the cause of the deaths we witnessed.' And if, like contagion, they were not palpable to the senses, such a person might go on to affirm that no proof existed of there being any such thing as musket-b.a.l.l.s." Now let the student turn back to the chapter on Hydrophobia in the same volume. He will find that John Hunter knew a case in which, of twenty-one persons bitten, only one died of the disease. He will find that one dog at Charenton was bitten at different times by thirty different mad dogs, and outlived it all.

Is there no such thing, then, as hydrophobia? Would one take no especial precautions if his wife, about to become a mother, had been bitten by a rabid animal, because so many escape? Or let him look at "Underwood on Diseases of Children," [Philadelphia, 1842, p. 244, note.] and he will find the case of a young woman who was inoculated eight times in thirty days, at the same time attending several children with smallpox, and yet was not infected. But seven weeks afterwards she took the disease and died.

It would seem as if the force of this argument could hardly fail to be seen, if it were granted that every one of these series of cases were so reported as to prove that there could have been no transfer of disease.

There is not one of them so reported, in the Lecture or the Letter, as to prove that the disease may not have been carried by the pract.i.tioner.

I strongly suspect that it was so carried in some of these cases, but from the character of the very imperfect evidence the question can never be settled without further disclosures.

Although the Letter is, as I have implied, princ.i.p.ally taken up with secondary and collateral questions, and might therefore be set aside as in the main irrelevant, I am willing, for the student's sake, to touch some of these questions briefly, as an ill.u.s.tration of its logical character.

The first thing to be done, as I thought when I wrote my Essay, was to throw out all discussions of the word contagion, and this I did effectually by the careful wording of my statement of the subject to be discussed. My object was not to settle the etymology or definition of a word, but to show that women had often died in childbed, poisoned in some way by their medical attendants. On the other point, I, at least, have no controversy with anybody, and I think the student will do well to avoid it in this connection. If I must define my position, however, as well as the term in question, I am contented with Worcester's definition; provided always this avowal do not open another side controversy on the merits of his Dictionary, which Dr. Meigs has not cited, as compared with Webster's, which he has.

I cannot see the propriety of insisting that all the laws of the eruptive fevers must necessarily hold true of this peculiar disease of puerperal women. If there were any such propriety, the laws of the eruptive fevers must at least be stated correctly. It is not true, for instance, as Dr. Meigs states, that contagion is "no respecter of persons;" that "it attacks all individuals alike." To give one example: Dr. Gregory, of the Small-Pox Hospital, who ought to know, says that persons pa.s.s through life apparently insensible to or unsusceptible of the small-pox virus, and that the same persons do not take the vaccine disease.

As to the short time of incubation, of which so much is made, we have no right to decide beforehand whether it shall be long or short, in the cases we are considering. A dissection wound may produce symptoms of poisoning in six hours; the bite of a rabid animal may take as many months.

After the student has read the case in Dr. Meigs's 136th paragraph, and the following one, in which he exclaims against the idea of contagion, because the patient, delivered on the 26th of December, was attacked in twenty-four hours, and died on the third day, let him read what happened at the "Black a.s.sizes" of 1577 and 1750. In the first case, six hundred persons sickened the same night of the exposure, and three hundred more in three days. [Elliotson's Practice, p. 298.] Of those attacked in the latter year, the exposure being on the 11th of May, Alderman Lambert died on the 13th, Under-Sheriff c.o.x on the 14th, and many of note before the 20th. But these are old stories. Let the student listen then to Dr.

Gerhard, whose reputation as a cautious observer he may be supposed to know. "The nurse was shaving a man, who died in a few hours after his entrance; he inhaled his breath, which had a nauseous taste, and in an hour afterwards was taken with nausea, cephalalgia, and singing of the ears. From that moment the attack began, and a.s.sumed a severe character.

The a.s.sistant was supporting another patient, who died soon afterwards; he felt the pungent heat upon his skin, and was taken immediately with the symptoms of typhus." [Am. Jour. Med. Sciences, Feb. 1837, p. 299.]

It is by notes of cases, rather than notes of admiration, that we must be guided, when we study the Revised Statutes of Nature, as laid down from the curule chairs of Medicine.

Let the student read Dr. Meigs's 140th paragraph soberly, and then remember, that not only does he infer, suspect, and surmise, but he actually a.s.serts (page 154), "there was poison in the house," because three out of five patients admitted into a ward had puerperal fever and died. Have I not as much right to draw a positive inference from "Dr.

A.'s" seventy exclusive cases as he from the three cases in the ward of the Dublin Hospital? All practical medicine, and all action in common affairs, is founded on inferences. How does Dr. Meigs know that the patients he bled in puerperal fever would not have all got well if he had not bled them?

"You see a man discharge a gun at another; you see the flash, you hear the report, you see the person fall a lifeless corpse; and you infer, from all these circ.u.mstances, that there was a ball discharged from the gun, which entered his body and caused his death, because such is the usual and natural cause of such an effect. But you did not see the ball leave the gun, pa.s.s through the air, and enter the body of the slain; and your testimony to the fact of killing is, therefore, only inferential,--in other words, circ.u.mstantial. It is possible that no ball was in the gun; and we infer that there was, only because we cannot account for death on any other supposition." [Chief Justice Gibson, in Am. Law Journal, vol. vi. p. 123.]

"The question always comes to this: Is the circ.u.mstance of intercourse with the sick followed by the appearance of the disease in a proportion of cases so much greater than any other circ.u.mstance common to any portion of the inhabitants of the place under observation, as to make it inconceivable that the succession of cases occurring in persons having that intercourse should have been the result of chance? If so, the inference is unavoidable, that that intercourse must have acted as a cause of the disease. All observations which do not bear strictly on that point are irrelevant, and, in the case of an epidemic first appearing in a town or district, a succession of two cases is sometimes sufficient to furnish evidence which, on the principle I have stated, is nearly irresistible."

Possibly an inexperienced youth may be awe-struck by the quotation from Cuvier. These words, or their equivalent, are certainly to be found in his Introduction. So are the words "top not come down"! to be found in the Bible, and they were as much meant for the ladies' head-dresses as the words of Cuvier were meant to make clinical observation wait for a permit from anybody to look with its eyes and count on its fingers. Let the inquiring youth read the whole Introduction, and he will see what they mean.

I intend no breach of courtesy, but this is a proper place to warn the student against skimming the prefaces and introductions of works for mottoes and embellishments to his thesis. He cannot learn anatomy by thrusting an exploring needle into the body. He will be very liable to misquote his author's meaning while he is picking off his outside sentences. He may make as great a blunder as that simple prince who praised the conductor of his orchestra for the piece just before the overture; the musician was too good a courtier to tell him that it was only the tuning of the instruments.

To the six propositions in the 142d paragraph, and the remarks about "specific" diseases, the answer, if any is necessary, seems very simple.

An inflammation of a serous membrane may give rise to secretions which act as a poison, whether that be a "specific" poison or not, as Dr.

Homer has told his young readers, and as dissectors know too well; and that poison may produce its symptoms in a few hours after the system has received it, as any may see in Druitt's "Surgery," if they care to look.

Puerperal peritonitis may produce such a poison, and puerperal women may be very sensible to its influences, conveyed by contact or exhalation.

Whether this is so or not, facts alone can determine, and to facts we have had recourse to settle it.

The following statement is made by Dr. Meigs in his 142d paragraph, and developed more at length, with rhetorical amplifications, in the 134th.

"No human being, save a pregnant or parturient woman, is susceptible to the poison." This statement is wholly incorrect, as I am sorry to have to point out to a Teacher in Dr. Meigs's position. I do not object to the erudition which quotes Willis and Fernelius, the last of whom was pleasantly said to have "preserved the dregs of the Arabs in the honey of his Latinity." But I could wish that more modern authorities had not been overlooked. On this point, for instance, among the numerous facts disproving the statement, the "American Journal of Medical Sciences,"

published not far from his lecture-room, would have presented him with a respectable catalog of such cases. Thus he might refer to Mr. Storrs's paper "On the Contagious Effects of Puerperal Fever on the Male Subject; or on Persons not Childbearing" (Jan. 1846), or to Dr. Reid's case (April, 1846), or to Dr. Barron's statement of the children's dying of peritonitis in an epidemic of puerperal fever at the Philadelphia Hospital (Oct. 1842), or to various instances cited in Dr. Kneeland's article (April, 186). Or, if he would have referred to the "New York Journal," he might have seen Prof. Austin Flint's cases. Or, if he had honored my Essay so far, he might have found striking instances of the same kind in the first of the new series of cases there reported and elsewhere. I do not see the bearing of his proposition, if it were true.

But it is one of those a.s.sertions that fall in a moment before a slight examination of the facts; and I confess my surprise, that a professor who lectures on the Diseases of Women should have ventured to make it.

Nearly seven pages are devoted to showing that I was wrong in saying 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." I will devote seven lines to these seven pages, which seven lines, if I may say it without offence, are, as it seems to me, six more than are strictly necessary.

The following authors are cited as sceptics by Dr. Meigs: Dewees.--I cited the same pa.s.sage. Did not know half the facts. Robert Lee.--Believes the disease is sometimes communicable by contagion.

Tonnelle, Baudelocque. Both cited by me. Jacquemier.--Published three years after my Essay. Kiwisch. "Behindhand in knowledge of Puerperal Fever." [B. & F. Med. Rev. Jan. 1842.] Paul Dubois.--Scanzoni.

These Continental writers not well informed on this point.[See Dr.

Simpson's Remarks at Meeting of Edin. Med. Chir. Soc. (Am. Jour. Oct.

1851.)]

The story of Von Busch is of interest and value, but there is nothing in it which need perplex the student. It is not pretended that the disease is always, or even, it may be, in the majority of cases, carried about by attendants; only that it is so carried in certain cases. That it may have local and epidemic causes, as well as that depending on personal transmission, is not disputed. Remember how small-pox often disappears from a community in spite of its contagious character, and the necessary exposure of many persons to those suffering from it; in both diseases contagion is only one of the coefficients of the disease.

I have already spoken of the possibility that Dr. Meigs may have been the medium of transfer of puerperal fever in some of the cases he has briefly catalogued. Of Dr. Rutter's cases I do not know how to speak. I only ask the student to read the facts stated by Dr. Condie, as given in my Essay, and say whether or not a man should allow his wife to be attended by a pract.i.tioner in whose hands "scarcely a female that has been delivered for weeks past has escaped an attack," "while no instance of the disease has occurred in the patients of any other accoucheur practising in the same district." If I understand Dr. Meigs and Dr.

Hodge, they would not warn the physician or spare the patient under such circ.u.mstances. They would "go on," if I understand them, not to seven, or seventy, only, but to seventy times seven, if they could find patients. If this is not what they mean, may we respectfully ask them to state what they do mean, to their next cla.s.ses, in the name of humanity, if not of science!

I might repeat the question asked concerning Dr. Rutter's cases, with reference to those reported by Dr. Roberton. Perhaps, however, the student would like to know the opinion of a person in the habit of working at matters of this kind in a practical point of view. To satisfy him on this ground, I addressed the following question to the President of one of our princ.i.p.al Insurance Companies, leaving Dr. Meigs's book and my Essay in his hands at the same time.

Question. "If such facts as Roberton's cases were before you, and the attendant had had ten, or even five fatal cases, or three, or two even, would you, or would you not, if insuring the life of the next patient to be taken care of by that attendant, expect an extra premium over that of an average case of childbirth?"

Answer. "Of course I should require a very large extra premium, if I would take take risk at all."

But I do not choose to add the expressions of indignation which the examination of the facts before him called out. I was satisfied from the effect they produced on him, that if all the hideous catalogues of cases now acc.u.mulated were fully brought to the knowledge of the public, nothing, since the days of Burke and Hare, has raised such a cry of horror as would be shrieked in the ears of the Profession.

Dr. Meigs has elsewhere invoked "Providence" as the alternative of accident, to account for the "coincidences." ("Obstetrics," Phil. 1852, p. 631.) If so, Providence either acts through the agency of secondary causes, as in other diseases, or not. If through such causes, let us find out what they are, as we try to do in other cases. It may be true that offences, or diseases, will come, but "woe unto him through whom they come," if we catch him in the voluntary or careless act of bringing them! But if Providence does not act through secondary causes in this particular sphere of etiology, then why does Dr. Meigs take such pains to reason so extensively about the laws of contagion, which, on that supposition, have no more to do with this case than with the plague which destroyed the people after David had numbered them? Above all, what becomes of the theological aspect of the question, when he a.s.serts that a pract.i.tioner was "only unlucky in meeting with the epidemic cases?" (Op. cit. p. 633.) We do not deny that the G.o.d of battles decides the fate of nations; but we like to have the biggest squadrons on our side, and we are particular that our soldiers should not only say their prayers, but also keep their powder dry. We do not deny the agency of Providence in the disaster at Norwalk, but we turn off the engineer, and charge the Company five thousand dollars apiece for every life that is sacrificed.

Why a grand jury should not bring in a bill against a physician who switches off a score of women one after the other along his private track, when he knows that there is a black gulf at the end of it, down which they are to plunge, while the great highway is clear, is more than I can answer. It is not by laying the open draw to Providence that he is to escape the charge of manslaughter.

To finish with all these lesser matters of question, I am unable to see why a female must necessarily be unattended in her confinement, because she declines the services of a particular pract.i.tioner. In all the series of cases mentioned, the death-carrying attendant was surrounded by others not tracked by disease and its consequences. Which, I would ask, is worse,--to call in another, even a rival pract.i.tioner, or to submit an unsuspecting female to a risk which an Insurance Company would have nothing to do with?

I do not expect ever to return to this subject. There is a point of mental saturation, beyond which argument cannot be forced without breeding impatient, if not harsh, feelings towards those who refuse to be convinced. If I have so far manifested neither, it is well to stop here, and leave the rest to those younger friends who may have more stomach for the dregs of a stale argument.

The extent of my prefatory remarks may lead some to think that I attach too much importance to my own Essay. Others may wonder that I should expend so many words upon the two productions referred to, the Letter and the Lecture. I do consider my Essay of much importance so long as the doctrine it maintains is treated as a question, and so long as any important part of the defence of that doctrine is thought to rest on its evidence or arguments. I cannot treat as insignificant any opinions bearing on life, and interests dearer than life, proclaimed yearly to hundreds of young men, who will carry them to their legitimate results in practice.

The teachings of the two Professors in the great schools of Philadelphia are sure to be listened to, not only by their immediate pupils, but by the Profession at large. I am too much in earnest for either humility or vanity, but I do entreat those who hold the keys of life and death to listen to me also for this once. I ask no personal favor; but I beg to be heard in behalf of the women whose lives are at stake, until some stronger voice shall plead for them.

I trust that I have made the issue perfectly distinct and intelligible.

And let it be remembered that this is no subject to be smoothed over by nicely adjusted phrases of half-a.s.sent and half-censure divided between the parties. The balance must be struck boldly and the result declared plainly. If I have been hasty, presumptuous, ill-informed, illogical; if my array of facts means nothing; if there is no reason for any caution in the view of these facts; let me be told so on such authority that I must believe it, and I will be silent henceforth, recognizing that my mind is in a state of disorganization. If the doctrine I have maintained is a mournful truth; if to disbelieve it, and to practise on this disbelief, and to teach others so to disbelieve and practise, is to carry desolation, and to charter others to carry it, into confiding families, let it be proclaimed as plainly what is to be thought of the teachings of those who sneer at the alleged dangers, and scout the very idea of precaution. Let it be remembered that persons are nothing in this matter; better that twenty pamphleteers should be silenced, or as many professors unseated, than that one mother's life should be taken. There is no quarrel here between men, but there is deadly incompatibility and exterminating warfare between doctrines.

Coincidences meaning nothing, though a man have a monopoly 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 Inst.i.tutions. 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 G.o.d for pardon, for man will never forgive him.

THE CONTAGIOUSNESS OF PUERPERAL FEVER.