第16章

Andif，likecontagion，theywerenotpalpabletothesenses，suchapersonmightgoontoaffirmthatnoproofexistedoftherebeinganysuchthingasmusket-balls。“NowletthestudentturnbacktothechapteronHydrophobiainthesamevolume。HewillfindthatJohnHunterknewacaseinwhich，oftwenty-onepersonsbitten，onlyonediedofthedisease。HewillfindthatonedogatCharentonwasbittenatdifferenttimesbythirtydifferentmaddogs，andoutliveditall。Istherenosuchthing，then，ashydrophobia？Wouldonetakenoespecialprecautionsifhiswife，abouttobecomeamother，hadbeenbittenbyarabidanimal，becausesomanyescape？Orlethimlookat“UnderwoodonDiseasesofChildren，“[Philadelphia，1842，p。244，note。]andhewillfindthecaseofayoungwomanwhowasinoculatedeighttimesinthirtydays，atthesametimeattendingseveralchildrenwithsmallpox，andyetwasnotinfected。Butsevenweeksafterwardsshetookthediseaseanddied。

Itwouldseemasiftheforceofthisargumentcouldhardlyfailtobeseen，ifitweregrantedthateveryoneoftheseseriesofcasesweresoreportedastoprovethattherecouldhavebeennotransferofdisease。Thereisnotoneofthemsoreported，intheLectureortheLetter，astoprovethatthediseasemaynothavebeencarriedbythepractitioner。Istronglysuspectthatitwassocarriedinsomeofthesecases，butfromthecharacteroftheveryimperfectevidencethequestioncanneverbesettledwithoutfurtherdisclosures。

AlthoughtheLetteris，asIhaveimplied，principallytakenupwithsecondaryandcollateralquestions，andmightthereforebesetasideasinthemainirrelevant，Iamwilling，forthestudent’ssake，totouchsomeofthesequestionsbriefly，asanillustrationofitslogicalcharacter。

Thefirstthingtobedone，asIthoughtwhenIwrotemyEssay，wastothrowoutalldiscussionsofthewordcontagion，andthisIdideffectuallybythecarefulwordingofmystatementofthesubjecttobediscussed。Myobjectwasnottosettletheetymologyordefinitionofaword，buttoshowthatwomenhadoftendiedinchildbed，poisonedinsomewaybytheirmedicalattendants。Ontheotherpoint，I，atleast，havenocontroversywithanybody，andI

thinkthestudentwilldowelltoavoiditinthisconnection。IfI

mustdefinemyposition，however，aswellastheterminquestion，I

amcontentedwithWorcester’sdefinition；providedalwaysthisavowaldonotopenanothersidecontroversyonthemeritsofhisDictionary，whichDr。Meigshasnotcited，ascomparedwithWebster’s，whichhehas。

Icannotseetheproprietyofinsistingthatallthelawsoftheeruptivefeversmustnecessarilyholdtrueofthispeculiardiseaseofpuerperalwomen。Iftherewereanysuchpropriety，thelawsoftheeruptivefeversmustatleastbestatedcorrectly。Itisnottrue，forinstance，asDr。Meigsstates，thatcontagionis“norespecterofpersons；“that“itattacksallindividualsalike。“Togiveoneexample：Dr。Gregory，oftheSmall-PoxHospital，whooughttoknow，saysthatpersonspassthroughlifeapparentlyinsensibletoorunsusceptibleofthesmall-poxvirus，andthatthesamepersonsdonottakethevaccinedisease。

Astotheshorttimeofincubation，ofwhichsomuchismade，wehavenorighttodecidebeforehandwhetheritshallbelongorshort，inthecasesweareconsidering。Adissectionwoundmayproducesymptomsofpoisoninginsixhours；thebiteofarabidanimalmaytakeasmanymonths。

AfterthestudenthasreadthecaseinDr。Meigs’s136thparagraph，andthefollowingone，inwhichheexclaimsagainsttheideaofcontagion，becausethepatient，deliveredonthe26thofDecember，wasattackedintwenty-fourhours，anddiedonthethirdday，lethimreadwhathappenedatthe“BlackAssizes“of1577and1750。Inthefirstcase，sixhundredpersonssickenedthesamenightoftheexposure，andthreehundredmoreinthreedays。[Elliotson’sPractice，p。298。]Ofthoseattackedinthelatteryear，theexposurebeingonthe11thofMay，AldermanLambertdiedonthe13th，Under-SheriffCoxonthe14th，andmanyofnotebeforethe20th。Buttheseareoldstories。LetthestudentlistenthentoDr。

Gerhard，whosereputationasacautiousobserverhemaybesupposedtoknow。“Thenursewasshavingaman，whodiedinafewhoursafterhisentrance；heinhaledhisbreath，whichhadanauseoustaste，andinanhourafterwardswastakenwithnausea，cephalalgia，andsingingoftheears。Fromthatmomenttheattackbegan，andassumedaseverecharacter。Theassistantwassupportinganotherpatient，whodiedsoonafterwards；hefeltthepungentheatuponhisskin，andwastakenimmediatelywiththesymptomsoftyphus。“[Am。Jour。Med。

Sciences，Feb。1837，p。299。]Itisbynotesofcases，ratherthannotesofadmiration，thatwemustbeguided，whenwestudytheRevisedStatutesofNature，aslaiddownfromthecurulechairsofMedicine。

LetthestudentreadDr。Meigs’s140thparagraphsoberly，andthenremember，thatnotonlydoesheinfer，suspect，andsurmise，butheactuallyasserts(page154，“therewaspoisoninthehouse，“becausethreeoutoffivepatientsadmittedintoawardhadpuerperalfeveranddied。HaveInotasmuchrighttodrawapositiveinferencefrom“Dr。A。’s“seventyexclusivecasesashefromthethreecasesinthewardoftheDublinHospital？Allpracticalmedicine，andallactionincommonaffairs，isfoundedoninferences。HowdoesDr。Meigsknowthatthepatientshebledinpuerperalfeverwouldnothaveallgotwellifhehadnotbledthem？

“Youseeamandischargeagunatanother；youseetheflash，youhearthereport，youseethepersonfallalifelesscorpse；andyouinfer，fromallthesecircumstances，thattherewasaballdischargedfromthegun，whichenteredhisbodyandcausedhisdeath，becausesuchistheusualandnaturalcauseofsuchaneffect。Butyoudidnotseetheballleavethegun，passthroughtheair，andenterthebodyoftheslain；andyourtestimonytothefactofkillingis，therefore，onlyinferential，——inotherwords，circumstantial。Itispossiblethatnoballwasinthegun；andweinferthattherewas，onlybecausewecannotaccountfordeathonanyothersupposition。“

[ChiefJusticeGibson，inAm。LawJournal，vol。vi。p。123。]

“Thequestionalwayscomestothis：Isthecircumstanceofintercoursewiththesickfollowedbytheappearanceofthediseaseinaproportionofcasessomuchgreaterthananyothercircumstancecommontoanyportionoftheinhabitantsoftheplaceunderobservation，astomakeitinconceivablethatthesuccessionofcasesoccurringinpersonshavingthatintercourseshouldhavebeentheresultofchance？Ifso，theinferenceisunavoidable，thatthatintercoursemusthaveactedasacauseofthedisease。Allobservationswhichdonotbearstrictlyonthatpointareirrelevant，and，inthecaseofanepidemicfirstappearinginatownordistrict，asuccessionoftwocasesissometimessufficienttofurnishevidencewhich，ontheprincipleIhavestated，isnearlyirresistible。“

Possiblyaninexperiencedyouthmaybeawe-struckbythequotationfromCuvier。Thesewords，ortheirequivalent，arecertainlytobefoundinhisIntroduction。Soarethewords“topnotcomedown“！

tobefoundintheBible，andtheywereasmuchmeantfortheladies’

head-dressesasthewordsofCuvierweremeanttomakeclinicalobservationwaitforapermitfromanybodytolookwithitseyesandcountonitsfingers。LettheinquiringyouthreadthewholeIntroduction，andhewillseewhattheymean。

Iintendnobreachofcourtesy，butthisisaproperplacetowarnthestudentagainstskimmingtheprefacesandintroductionsofworksformottoesandembellishmentstohisthesis。Hecannotlearnanatomybythrustinganexploringneedleintothebody。Hewillbeveryliabletomisquotehisauthor’smeaningwhileheispickingoffhisoutsidesentences。Hemaymakeasgreatablunderasthatsimpleprincewhopraisedtheconductorofhisorchestraforthepiecejustbeforetheoverture；themusicianwastoogoodacourtiertotellhimthatitwasonlythetuningoftheinstruments。

Tothesixpropositionsinthe142dparagraph，andtheremarksabout“specific“diseases，theanswer，ifanyisnecessary，seemsverysimple。Aninflammationofaserousmembranemaygiverisetosecretionswhichactasapoison，whetherthatbea“specific“poisonornot，asDr。Homerhastoldhisyoungreaders，andasdissectorsknowtoowell；andthatpoisonmayproduceitssymptomsinafewhoursafterthesystemhasreceivedit，asanymayseeinDruitt’s“Surgery，“iftheycaretolook。Puerperalperitonitismayproducesuchapoison，andpuerperalwomenmaybeverysensibletoitsinfluences，conveyedbycontactorexhalation。Whetherthisissoornot，factsalonecandetermine，andtofactswehavehadrecoursetosettleit。

ThefollowingstatementismadebyDr。Meigsinhis142dparagraph，anddevelopedmoreatlength，withrhetoricalamplifications，inthe134th。“Nohumanbeing，saveapregnantorparturientwoman，issusceptibletothepoison。“Thisstatementiswhollyincorrect，asI

amsorrytohavetopointouttoaTeacherinDr。Meigs’sposition。

IdonotobjecttotheeruditionwhichquotesWillisandFernelius，thelastofwhomwaspleasantlysaidtohave“preservedthedregsoftheArabsinthehoneyofhisLatinity。“ButIcouldwishthatmoremodernauthoritieshadnotbeenoverlooked。Onthispoint，forinstance，amongthenumerousfactsdisprovingthestatement，the“AmericanJournalofMedicalSciences，“publishednotfarfromhislecture-room，wouldhavepresentedhimwitharespectablecatalogofsuchcases。ThushemightrefertoMr。Storrs’spaper“OntheContagiousEffectsofPuerperalFeverontheMaleSubject；oronPersonsnotChildbearing“(Jan。1846)，ortoDr。Reid’scase(April，1846)，ortoDr。Barron’sstatementofthechildren’sdyingofperitonitisinanepidemicofpuerperalfeveratthePhiladelphiaHospital(Oct。1842)，ortovariousinstancescitedinDr。

Kneeland’sarticle(April，186)。Or，ifhewouldhavereferredtothe“NewYorkJournal，“hemighthaveseenProf。AustinFlint’scases。Or，ifhehadhonoredmyEssaysofar，hemighthavefoundstrikinginstancesofthesamekindinthefirstofthenewseriesofcasestherereportedandelsewhere。Idonotseethebearingofhisproposition，ifitweretrue。Butitisoneofthoseassertionsthatfallinamomentbeforeaslightexaminationofthefacts；andI

confessmysurprise，thataprofessorwholecturesontheDiseasesofWomenshouldhaveventuredtomakeit。

NearlysevenpagesaredevotedtoshowingthatIwaswronginsayingIwouldnotbe“understoodtoimplythatthereexistsadoubtinthemindofanywell-informedmemberofthemedicalprofessionastothefactthatpuerperalfeverissometimescommunicatedfromonepersontoanother，bothdirectlyandindirectly。“Iwilldevotesevenlinestothesesevenpages，whichsevenlines，ifImaysayitwithoutoffence，are，asitseemstome，sixmorethanarestrictlynecessary。

ThefollowingauthorsarecitedasscepticsbyDr。Meigs：

Dewees——Icitedthesamepassage。Didnotknowhalfthefacts。

RobertLee——Believesthediseaseissometimescommunicablebycontagion。Tonnelle，Baudelocque。Bothcitedbyme。Jacquemier——

PublishedthreeyearsaftermyEssay。Kiwisch。BehindhandinknowledgeofPuerperalFever。“[B。&F。Med。Rev。Jan。1842。]

PaulDubois——Scanzoni。

TheseContinentalwritersnotwellinformedonthispoint。[SeeDr。

Simpson’sRemarksatMeetingofEdin。Med。Chir。Soc。(Am。Jour。

Oct。1851。)]

ThestoryofVonBuschisofinterestandvalue，butthereisnothinginitwhichneedperplexthestudent。Itisnotpretendedthatthediseaseisalways，oreven，itmaybe，inthemajorityofcases，carriedaboutbyattendants；onlythatitissocarriedincertaincases。Thatitmayhavelocalandepidemiccauses，aswellasthatdependingonpersonaltransmission，isnotdisputed。Rememberhowsmall-poxoftendisappearsfromacommunityinspiteofitscontagiouscharacter，andthenecessaryexposureofmanypersonstothosesufferingfromit；inbothdiseasescontagionisonlyoneofthecoefficientsofthedisease。

IhavealreadyspokenofthepossibilitythatDr。Meigsmayhavebeenthemediumoftransferofpuerperalfeverinsomeofthecaseshehasbrieflycatalogued。OfDr。Rutter’scasesIdonotknowhowtospeak。IonlyaskthestudenttoreadthefactsstatedbyDr。

Condie，asgiveninmyEssay，andsaywhetherornotamanshouldallowhiswifetobeattendedbyapractitionerinwhosehands“scarcelyafemalethathasbeendeliveredforweekspasthasescapedanattack，““whilenoinstanceofthediseasehasoccurredinthepatientsofanyotheraccoucheurpractisinginthesamedistrict。“

IfIunderstandDr。MeigsandDr。Hodge，theywouldnotwarnthephysicianorsparethepatientundersuchcircumstances。Theywould“goon，“ifIunderstandthem，nottoseven，orseventy，only，buttoseventytimesseven，iftheycouldfindpatients。Ifthisisnotwhattheymean，maywerespectfullyaskthemtostatewhattheydomean，totheirnextclasses，inthenameofhumanity，ifnotofscience！

ImightrepeatthequestionaskedconcerningDr。Rutter’scases，withreferencetothosereportedbyDr。Roberton。Perhaps，however，thestudentwouldliketoknowtheopinionofapersoninthehabitofworkingatmattersofthiskindinapracticalpointofview。Tosatisfyhimonthisground，IaddressedthefollowingquestiontothePresidentofoneofourprincipalInsuranceCompanies，leavingDr。

Meigs’sbookandmyEssayinhishandsatthesametime。

Question。“IfsuchfactsasRoberton’scaseswerebeforeyou，andtheattendanthadhadten，orevenfivefatalcases，orthree，ortwoeven，wouldyou，orwouldyounot，ifinsuringthelifeofthenextpatienttobetakencareofbythatattendant，expectanextrapremiumoverthatofanaveragecaseofchildbirth？“