第15章

Intheearliestandembryonicstageofprofessionaldevelopment，anyviolentimpressionontheinstructor’smindisapttobefollowedbysomelastingeffectonthatofthepupil。Nomother’smarkismorepermanentthanthementalnaeviandmoles，andexcrescences，andmutilations，thatstudentscarrywiththemoutofthelecture-room，ifoncetheteemingintellectwhichnourishestheirshasbeenscaredfromitsproprietybyanymisshapenfantasy。Evenanimpatientorpetulantexpression，whichtoaphilosopherwouldbeamereindexofthelowstateofamiabilityofthespeakeratthemomentofitsutterance，maypassintotheyoungmindasanelementofitsfutureconstitution，toinjureitstemperorcorruptitsjudgment。Itisaduty，therefore，whichweowetothisyoungerclassofstudents，toclearanyimportanttruthwhichmayhavebeenrenderedquestionableintheirmindsbysuchlanguage，oranytruth-telleragainstwhomtheymayhavebeenprejudicedbyhastyepithets，fromtheimpressionssuchwordshaveleft。Untilthisisdone，theyarenotreadyforthequestion，wherethereisaquestion，forthemtodecide。Evenifweourselvesarethesubjectsoftheprejudice，thereseemstobenoimproprietyinshowingthatthisprejudiceislocalorpersonal，andnotanacknowledgedconvictionwiththepublicatlarge。Itmaybenecessarytobreakthroughourusualhabitsofreservetodothis，butthisisthefaultofthepositioninwhichothershaveplacedus。

Twowidely-knownandhighly-esteemedpractitioners，ProfessorsintwoofthelargestMedicalSchoolsoftheUnion，teachingthebranchofartwhichincludestheDiseasesofWomen，andthereforespeakingwithauthority；addressingintheirlecturesandprintedpublicationslargenumbersofyoungmen，manyoftheminthetenderestimmaturityofknowledge，haverecentlytakengroundinaformalwayagainstthedoctrinemaintainedinthispaper：

OntheNon-ContagiousCharacterofPuerperalFever：AnIntroductoryLecture。ByHughL。Hodge，M。D。，ProfessorofObstetricsintheUniversityofPennsylvania。DeliveredMonday，October11，1852。

Philadelphia，1852。

OntheNature，Signs，andTreatmentofChildbedFevers：inaSeriesofLettersaddressedtotheStudentsofhisClass。ByCharlesD。

Meigs，M。D。，ProfessorofMidwiferyandtheDiseasesofWomenandChildreninJeffersonMedicalCollege，Philadelphia，etc。，etc。

Philadelphia，1854。LetterVI。

Thefirstofthetwopublications，Dr。Hodge’sLecture，whileitstheoreticalconsiderationsandnegativeexperiencesdonotseemtometorequireanyfurthernoticethansuchaslayreadyfortheminmyEssaywrittenlongbefore，is，Iampleasedtosay，unobjectionableintoneandlanguage，andmaybereadwithoutoffence。

ThiscanhardlybesaidofthechapterofDr。Meigs’svolumewhichtreatsofContagioninChildbedFever。Thereareexpressionsusedinitwhichmightwellputastoptoallscientificdiscussions，weretheytoformthecurrentcoininourexchangeofopinions。Ileavethe“veryyounggentlemen，“whosecarefulexpositionsoftheresultsofpracticeinmorethansixthousandcasesarecharacterizedas“thejejuneandfizenlessdreamingsofsophomorewriters，“tothesympathiesofthose“dearyoungfriends，“and“dearyounggentlemen，“

whowilljudgehowmuchtovaluetheirinstructor’scounseltothinkforthemselves，knowingwhattheyaretoexpectiftheyhappennottothinkashedoes。

OneunpalatableexpressionIsupposethelawsofconstructionobligemetoappropriatetomyself，asmyrewardforacertainamountoflaborbestowedontheinvestigationofaveryimportantquestionofevidence，andastatementofmyownpracticalconclusions。Itakenooffence，andattemptnoretort。Nomanmakesaquarrelwithmeoverthecounterpanethatcoversamother，withhernew-borninfantatherbreast。Thereisnoepithetinthevocabularyofslightandsarcasmthatcanreachmypersonalsensibilitiesinsuchacontroversy。Onlyjustsofarasadisrespectfulphrasemayturnthestudentasidefromtheexaminationoftheevidence，bydiscreditingordishonoringthewitness，doesitcallforanywordofnotice。

IappealfromthedisparaginglanguagebywhichtheProfessorintheJeffersonSchoolofPhiladelphiaworlddisposeofmyclaimstobelistenedto。Iappeal，nottothevoteoftheSocietyforMedicalImprovement，althoughthiswasanunusualevidenceofinterestinthepaperinquestion，foritwasavotepassedamongmyowntownsmen；

nortotheopinionofanyAmerican，fornoneknowbetterthantheProfessorsinthegreatSchoolsofPhiladelphiahowcheaplythepraiseofnativecontemporarycriticismisobtained。IappealtotherecordedopinionsofthosewhomIdonotknow，andwhodonotknowme，norcareforme，exceptforthetruththatImayhaveuttered；toCopland，inhis“MedicalDictionary，“whohasspokenofmyEssayinphrasestowhichthepamphletsofAmerican“scribblers“areseldomusedfromEuropeanauthorities；toRamsbotham，whosecompendiouseulogyisallthatself-lovecouldask；tothe“FifthAnnualReport“

oftheRegistrar-GeneralofEngland，inwhichthesecond-handabstractofmyEssayfigureslargely，andnotwithoutfavorablecomment，inanimportantappendedpaper。Thesetestimonies，halfforgottenuntilthiscircumstancerecalledthem，aredraggedintothelight，notinaparoxysmofvanity，buttoshowthattheremaybefoodforthoughtinthesmallpamphletwhichthePhiladelphiaTeachertreatssolightly。Theywereatleastunsoughtfor，andwouldneverhavebeenproclaimedbutforthesakeofsecuringtheprivilegeofadecentandunprejudicedhearing。

Iwilltakeitforgrantedthattheyhavesofarcounterpoisedthedepreciatinglanguageofmyfellow-countrymanandfellow-teacherastogainmeareaderhereandthereamongtheyouthfulclassofstudentsIamnowaddressing。ItisonlyfortheirsakethatIthinkitnecessarytoanalyze，orexplain，orillustrate，orcorroborateanyportionofthefollowingEssay。ButIknowthatnothingcanbemadetooplainforbeginners；andasIdonotexpectthepractitioner，oreventhemorematurestudent，totakethetroubletofollowmethroughanIntroductionwhichIconsiderwhollyunnecessaryandsuperfluousforthem，Ishallnothesitatetostooptothemostelementarysimplicityforthebenefitoftheyoungerstudent。Idothismorewillinglybecauseitaffordsagoodopportunity，asitseemstome，ofexercisingtheuntrainedmindinthatmedicallogicwhichdoesnotseemtohavebeeneithertaughtorpractisedinourschoolsoflate，totheextentthatmightbedesired。

Iwillnowexhibit，inaseriesofpropositionsreducedtotheirsimplestexpression，thesameessentialstatementsandconclusionsasarecontainedintheEssay，withsuchcommentariesandexplanationsasmaybeprofitabletotheinexperiencedclassofreadersaddressed。

I。Ithasbeenlongbelieved，bymanycompetentobservers，thatPuerperalFever(socalled)issometimescarriedfrompatienttopatientbymedicalassistants。

II。TheexpressobjectofthisEssayistoprovethatitissocarried。

III。Inordertoprovethispoint，itisnotnecessarytoconsultanymedicaltheoristastowhetherornotitisconsistentwithhispreconceivednotionsthatsuchamodeoftransfershouldexist。

IV。Ifthemedicaltheoristinsistsonbeingconsulted，andweseefittoindulgehim，hecannotbeallowedtoassumethattheallegedlawsofcontagion，deducedfromobservationinotherdiseases，shallbecitedtodisprovetheallegedlawsdeducedfromobservationinthis。Sciencewouldnevermakeprogressundersuchconditions。

Neitherthelongincubationofhydrophobia，northeprotectingpowerofvaccination，wouldeverhavebeenadmitted，iftheresultsofobservationintheseaffectionshadbeenrejectedascontradictorytothepreviouslyascertainedlawsofcontagion。

V。Thediseaseinquestionisnotacommonone；producing，ontheaverage，aboutthreedeathsinathousandbirths，accordingtotheEnglishRegistrationreturnswhichIhaveexamined。

VI。Whenanunusuallylargenumberofcasesofthisdiseaseoccuraboutthesametime，itisinferred，therefore，thatthereexistssomespecialcauseforthisincreasedfrequency。Ifthediseaseprevailsextensivelyoverawideregionofcountry，itisattributedwithoutdisputetoanepidemicinfluence。Ifitprevailsinasinglelocality，asinahospital，andnotelsewhere，thisisconsideredproofthatsomelocalcauseisthereactiveinitsproduction。

VII。Whenalargenumberofcasesofthisdiseaseoccurinrapidsuccession，inoneindividual’sordinarypractice，andfewornoneelsewhere，thesecasesappearinginscatteredlocalities，inpatientsofthesameaverageconditionasthosewhoescapeunderthecareofothers，thereisthesamereasonforconnectingthecauseofthediseasewiththepersoninthisinstance，aswiththeplaceinthatlastmentioned。

VIII。Manyseriesofcases，answeringtotheseconditions，aregiveninthisEssay，andmanyotherswillbereferredtowhichhaveoccurredsinceitwaswritten。

IX。Theallegedresultsofobservationmaybesetaside；first，becausetheso-calledfactsareintheirownnatureequivocal；

secondly，becausetheystandoninsufficientauthority；thirdly，becausetheyarenotsufficientlynumerous。But，inthiscase，thediseaseisoneofstrikingandwell-markedcharacter；thewitnessesareexperts，interestedindenyinganddisbelievingthefacts；thenumberofconsecutivecasesinmanyinstancesfrightful，andthenumberofseriesofcasessuchthatIhavenoroomformanyofthemexceptbymerereference。

X。Theseresultsofobservation，beingadmitted，may，wewillsuppose，beinterpretedindifferentmethods。Thusthecoincidencesmaybeconsideredtheeffectofchance。Ihavehadthechancescalculatedbyacompetentperson，thatagivenpractitioner，A。，shallhavesixteenfatalcasesinamonth，onthefollowingdata：

A。toaverageattendanceupontwohundredandfiftybirthsinayear；

threedeathsinonethousandbirthstobeassumedastheaveragefrompuerperalfever；noepidemictobeatthetimeprevailing。Itfollows，fromtheanswergivenme，thatifwesupposeeveryoneofthefivehundredthousandannualbirthsofEnglandtohavebeenrecordedduringthelasthalf-century，therewouldnotbeonechanceinamillionmillionmillionmillionsthatonesuchseriesshouldbenoted。Nopossiblefractionalerrorinthiscalculationcanrenderthechanceaworkingprobability。Appliedtodozensofseriesofvariouslengths，itisobviouslyanabsurdity。Chance，therefore，isoutofthequestionasanexplanationoftheadmittedcoincidences。

XI。Thereis，therefore，somerelationofcauseandeffectbetweenthephysician’spresenceandthepatient’sdisease。

XII。Untilitisprovedtowhatremovableconditionattachingtotheattendantthediseaseisowing，heisboundtostayawayfromhispatientssosoonashefindshimselfsingledouttobetrackedbythedisease。Howlong，andwithwhatotherprecautions，Ihavesuggested，withoutdictating，atthecloseofmyEssay。Ifthephysiciandoesnotatonceactonanyreasonablesuspicionofhisbeingthemediumoftransfer，thefamilieswhereheisengaged，iftheyareallowedtoknowthefacts，shoulddeclinehisservicesforthetime。Hisfeelingsontheoccasion，howeverinterestingtohimself，shouldnotbeevennamedinthisconnection。Aphysicianwhotalksaboutceremonyandgratitude，andservicesrendered，andthetreatmenthegot，surelyforgetshimself；itisimpossiblethatheshouldseriouslythinkofthesesmallmatterswherethereisevenaquestionwhetherhemaynotcarrydisease，anddeath，andbereavementintoanyoneof“hisfamilies，“astheyaresometimescalled。

Iwillnowpointouttotheyoungstudentthemodeinwhichhemayrelievehismindofanyconfusion，orpossibly，ifveryyoung，anydoubt，whichtheperusalofDr。Meigs’sSixthLettermayhaveraisedinhismind。

ThemostprominentideasoftheLetterare，first，thatthetransmissiblenatureofpuerperalfeverappearsimprobable，and，secondly，thatitwouldbeveryinconvenienttothewriter。

Dr。Woodville，PhysiciantotheSmall-PoxandInoculationHospitalinLondon，founditimprobable，andexceedinglyinconvenienttohimself，thatcowpoxshouldpreventsmall-pox；butDr。Jennertookthelibertytoprovethefact，notwithstanding。

Iwillfirstcalltheyoungstudent’sattentiontotheshowofnegativefacts(exposurewithoutsubsequentdisease)，ofwhichmuchseemstobethought。AndImayatthesametimereferhimtoDr。

Hodge’sLecture，wherehewillfindthesamekindoffactsandreasoning。LethimnowtakeupWatson’sLectures，thegoodsenseandspiritofwhichhavemadehisbookauniversalfavorite，andopentothechapteronContinuedFever。Hewillfindaparagraphcontainingthefollowingsentence：“Amanmightsay，’IwasinthebattleofWaterloo，andsawmanymenaroundmefalldownanddie，anditwassaidthattheywerestruckdownbymusket-balls；butIknowbetterthanthat，forIwasthereallthetime，andsoweremanyofmyfriends，andwewereneverhitbyanymusket-balls。Musket-balls，therefore，couldnothavebeenthecauseofthedeathswewitnessed。’