第18章

3。Itisnotpretendedthatthecontagionofpuerperalfevermustalwaysbefollowedbythedisease。Itistrueofallcontagiousdiseases，thattheyfrequentlysparethosewhoappeartobefullysubmittedtotheirinfluence。Eventhevaccinevirus，freshfromthesubject，failseverydaytoproduceitslegitimateeffect，thougheveryprecautionistakentoinsureitsaction。Thisisstillmoreremarkablythecasewithscarletfeverandsomeotherdiseases。

4。Itisgrantedthatthediseasemaybeproducedandvariouslymodifiedbymanycausesbesidescontagion，andmoreespeciallybyepidemicandendemicinfluences。Butthisisnotpeculiartothediseaseinquestion。Thereisnodoubtthatsmall-poxispropagatedtoagreatextentbycontagion，yetitgoesthroughthesameperiodsofperiodicalincreaseanddiminutionwhichhavebeenremarkedinpuerperalfever。Ifthequestionisaskedhowwearetoreconcilethegreatvariationsinthemortalityofpuerperalfeverindifferentseasonsandplaceswiththesuppositionofcontagion，IwillansweritbyanotherquestionfromMr。Farr’slettertotheRegistrar-

General。Hemakesthestatementthat“fivedieweeklyofsmall-poxinthemetropoliswhenthediseaseisnotepidemic，“——andadds，“Theproblemforsolutionis，——Whydothefivedeathsbecome10，15，20，31，58，88，weekly，andthenprogressivelyfallthroughthesamemeasuredsteps？“

5。Itakeitforgranted，thatifitcanbeshownthatgreatnumbersofliveshavebeenandaresacrificedtoignoranceorblindnessonthispoint，noothererrorofwhichphysiciansornursesmaybeoccasionallysuspectedwillbeallegedinpalliationofthis；butthatwheneverandwherevertheycanbeshowntocarrydiseaseanddeathinsteadofhealthandsafety，thecommoninstinctsofhumanitywillsilenceeveryattempttoexplainawaytheirresponsibility。

ThetreatiseofDr。GordonofAberdeenwaspublishedintheyear1795，beingamongtheearlierspecialworksuponthedisease。Apartofhistestimonyhasbeenoccasionallycopiedintootherworks，buthisexpressionsaresoclear，hisexperienceisgivenwithsuchmanlydistinctnessanddisinterestedhonesty，thatitmaybequotedasamodelwhichmighthavebeenoftenfollowedwithadvantage。

“Thisdiseaseseizedsuchwomenonlyaswerevisited，ordeliveredbyapractitioner，ortakencareofbyanurse，whohadpreviouslyattendedpatientsaffectedwiththedisease。“

“Ihadevidentproofsofitsinfectiousnature，andthattheinfectionwasasreadilycommunicatedasthatofthesmall-poxormeasles，andoperatedmorespeedilythananyotherinfectionwithwhichIamacquainted。“

“Ihadevidentproofsthateverypersonwhohadbeenwithapatientinthepuerperalfeverbecamechargedwithanatmosphereofinfection，whichwascommunicatedtoeverypregnantwomanwhohappenedtocomewithinitssphere。Thisisnotanassertion，butafact，admittingofdemonstration，asmaybeseenbyaperusaloftheforegoingtable，“——referringtoatableofseventy-sevencases，inmanyofwhichthechannelofpropagationwasevident。

Headds，“Itisadisagreeabledeclarationformetomention，thatI

myselfwasthemeansofcarryingtheinfectiontoagreatnumberofwomen。“Hethenenumeratesanumberofinstancesinwhichthediseasewasconveyedbymidwivesandotherstotheneighboringvillages，anddeclaresthat“thesefactsfullyprovethatthecauseofthepuerperalfever，ofwhichItreat，wasaspecificcontagion，orinfection，altogetherunconnectedwithanoxiousconstitutionoftheatmosphere。“

Buthismostterribleevidenceisgiveninthesewords：“IARRIVEDAT

THATCERTAINTYINTHEMATTER，THATICOULDVENTURETOFORETELLWHAT

WOMENWOULDBEAFFECTEDWITHTHEDISEASE，UPONHEARINGBYWHAT

MIDWIFETHEYWERETOBEDELIVERED，ORBYWHATNURSETHEYWERETOBE

ATTENDED，DURINGTHEIRLYING-IN：ANDALMOSTINEVERYINSTANCE，MY

PREDICTIONWASVERIFIED。“

EvenpreviouslytoGordon，Mr。WhiteofManchesterhadsaid，“Iamacquaintedwithtwogentlemeninanothertown，wherethewholebusinessofmidwiferyisdividedbetwixtthem，anditisveryremarkablethatoneofthemlosesseveralpatientseveryyearofthepuerperalfever，andtheotherneversomuchasmeetswiththedisorder，“——adifferencewhichheseemstoattributetotheirvariousmodesoftreatment。[OntheManagementofLying-inWomen，p。120。]

Dr。ArmstronghasgivenanumberofinstancesinhisEssayonPuerperalFever，oftheprevalenceofthediseaseamongthepatientsofasinglepractitioner。AtSunderland，“inall，forty-threecasesoccurredfromthe1stofJanuarytothe1stofOctober，whenthediseaseceased；andofthisnumberfortywerewitnessedbyMr。

Gregsonandhisassistant，Mr。Gregory，theremainderhavingbeenseparatelyseenbythreeaccoucheurs。“ThereisappendedtotheLondoneditionofthisEssay，aletterfromMr。Gregson，inwhichthatgentlemansays，inreferencetothegreatnumberofcasesoccurringinhispractice，“ThecauseofthisIcannotpretendfullytoexplain，butIshouldbewantingincommonliberalityifIweretomakeanyhesitationinasserting，thatthediseasewhichappearedinmypracticewashighlycontagious，andcommunicablefromonepuerperalwomantoanother。““Itiscustomaryamongthelowerandmiddleranksofpeopletomakefrequentpersonalvisitstopuerperalwomenresidentinthesameneighborhood，andIhaveampleevidenceforaffirmingthattheinfectionofthediseasewasoftencarriedaboutinthatmanner；and，howeverpainfultomyfeelings，Imustincandordeclare，thatitisveryprobablethecontagionwasconveyed，insomeinstances，bymyself，thoughItookeverypossiblecaretopreventsuchathingfromhappening，themomentthatIascertainedthatthedistemperwasinfectious。“Dr。Armstronggoesontomentionsixotherinstanceswithinhisknowledge，inwhichthediseasehadatdifferenttimesandplacesbeenlimited，inthesamesingularmanner，tothepracticeofindividuals，whileitexistedscarcelyifatallamongthepatientsofothersaroundthem。Twoofthegentlemenbecamesoconvincedoftheirconveyingthecontagion，thattheywithdrewforatimefrompractice。

Ifindabriefnotice，inanAmericanJournal，ofanotherseriesofcases，firstmentionedbyMr。Davies，inthe“MedicalRepository。“

Thisgentlemanstatedhisconvictionthatthediseaseiscontagious。

“Intheautumnof1822hemetwithtwelvecases，whilehismedicalfriendsintheneighborhooddidnotmeetwithany，’oratleastveryfew。’Hecouldattributethiscircumstancetonoothercausethanhishavingbeenpresentattheexamination，afterdeath，oftwocases，sometimeprevious，andofhishavingimpartedthediseasetohispatients，notwithstandingeveryprecaution。’“

Dr。Goochsays，“Itisnotuncommonforthegreaternumberofcasestooccurinthepracticeofoneman，whilsttheotherpractitionersoftheneighborhood，whoarenotmoreskilfulormorebusy，meetwithfewornone。Apractitioneropenedthebodyofawomanwhohaddiedofpuerperalfever，andcontinuedtowearthesameclothes。Aladywhomhedeliveredafewdaysafterwardswasattackedwithanddiedofasimilardisease；twomoreofhislying-inpatients，inrapidsuccession，metwiththesamefate；struckbythethought，thathemighthavecarriedcontagioninhisclothes，heinstantlychangedthem，andmetwithnomorecasesofthekind。’Awomaninthecountry，whowasemployedaswasherwomanandnurse，washedthelinenofonewhohaddiedofpuerperalfever；thenextlying-inpatientshenurseddiedofthesamedisease；athirdnursedbyhermetwiththesamefate，tilltheneighborhood，gettingafraidofher，ceasedtoemployher。“

Inthewinteroftheyear1824，“Severalinstancesoccurredofitsprevalenceamongthepatientsofparticularpractitioners，whilstotherswhowereequallybusymetwithfewornone。Oneinstanceofthiskindwasveryremarkable。Ageneralpractitioner，inlargemidwiferypractice，lostsomanypatientsfrompuerperalfever，thathedeterminedtodelivernomoreforsometime，butthathispartnershouldattendinhisplace。Thisplanwaspursuedforonemonth，duringwhichnotacaseofthediseaseoccurredintheirpractice。

Theelderpractitioner，beingthensufficientlyrecovered，returnedtohispractice，butthefirstpatientheattendedwasattackedbythediseaseanddied。Aphysician，whomethiminconsultationsoonafterwards，aboutacaseofadifferentkind，andwhoknewnothingofhismisfortune，askedhimwhetherpuerperalfeverwasatallprevalentinhisneighborhood，onwhichheburstintotears，andrelatedtheabovecircumstances。

“AmongthecaseswhichIsawthisseasoninconsultation，fouroccurredinonemonthinthepracticeofonemedicalman，andallofthemterminatedfatally。“[Lond。Med。Gaz。May2，1835。]

Dr。Ramsbothamasserted，inaLectureattheLondonHospital，thathehadknownthediseasespreadthroughaparticulardistrict，orbeconfinedtothepracticeofaparticularperson，almosteverypatientbeingattackedwithit，whileothershadnotasinglecase。Itseemedcapable，hethought，ofconveyance，notonlybycommonmodes；

butthroughthedressoftheattendantsuponthepatient。

Inalettertobefoundinthe“LondonMedicalGazette“forJanuary，1840，Mr。RobertonofManchestermakesthestatementwhichIheregiveinasomewhatcondensedform。

Amidwifedeliveredawomanonthe4thofDecember，1830，whodiedsoonafterwiththesymptomsofpuerperalfever。Inonemonthfromthisdatethesamemidwifedeliveredthirtywomen，residingindifferentpartsofanextensivesuburb，ofwhichnumbersixteencaughtthediseaseandalldied。TheseweretheonlycaseswhichhadoccurredforaconsiderabletimeinManchester。Theothermidwivesconnectedwiththesamecharitableinstitutionasthewomanalreadymentionedaretwenty-fiveinnumber，anddeliver，onanaverage，ninetywomenaweek，oraboutthreehundredandeightyamonth。Noneofthesewomenhadacaseofpuerperalfever。“Yetallthistimethiswomanwascrossingtheothermidwivesineverydirection，scoresofthepatientsofthecharitybeingdeliveredbythemintheverysamequarterswherehercasesoffeverwerehappening。“

Mr。Robertonremarks，thatlittlemorethanhalfthewomenshedeliveredduringthismonthtookthefever；thatonsomedaysallescaped，onothersonlyoneormoreoutofthreeorfour；acircumstancesimilartowhatisseeninotherinfectiousmaladies。

Dr。Blundellsays，“Thosewhohavenevermadetheexperimentcanhavebutafaintconceptionhowdifficultitistoobtaintheexacttruthrespectinganyoccurrenceinwhichfeelingsandinterestsareconcerned。Omittingparticulars，then，Icontentmyselfwithremarking，generally，thatfrommorethanonedistrictIhavereceivedaccountsoftheprevalenceofpuerperalfeverinthepracticeofsomeindividuals，whileitsoccurrenceinthatofothers，inthesameneighborhood，wasnotobserved。Some，asIhavebeentold，havelostten，twelve，oragreaternumberofpatients，inscarcelybrokensuccession；liketheirevilgenius，thepuerperalfeverhasseemedtostalkbehindthemwherevertheywent。Somehavedeemeditprudenttoretireforatimefrompractice。Infine，thatthisfevermayoccurspontaneously，Iadmit；thatitsinfectiousnaturemaybeplausiblydisputed，Idonotdeny；butIadd，considerately，thatinmyownfamilyIhadratherthatthoseI

esteemedthemostshouldbedelivered，unaided，inastable，bythemanger-side，thanthattheyshouldreceivethebesthelp，inthefairestapartment，butexposedtothevaporsofthispitilessdisease。Gossipingfriends，wet-nurses，monthlynurses，thepractitionerhimself，thesearethechannelsbywhich，asIsuspect，theinfectionisprincipallyconveyed。“

AtameetingoftheRoyalMedicalandChirurgicalSociety，Dr。KingmentionedthatsomeyearssinceapractitioneratWoolwichlostsixteenpatientsfrompuerperalfeverinthesameyear。Hewascompelledtogiveuppracticeforoneortwoyears，hisbusinessbeingdividedamongtheneighboringpractitioners。Nocaseofpuerperalfeveroccurredafterwards，neitherhadanyoftheneighboringsurgeonsanycasesofthisdisease。

AtthesamemeetingMr。Hutchinsonmentionedtheoccurrenceofthreeconsecutivecasesofpuerperalfever，followedsubsequentlybytwoothers，allinthepracticeofoneaccoucheur。[Lancet，May2，1840。]

Dr。Leemakesthefollowingstatement：“InthelasttwoweeksofSeptember，1827，fivefatalcasesofuterineinflammationcameunderourobservation。Alltheindividualssoattackedhadbeenattendedinlaborbythesamemidwife，andnoexampleofafebrileorinflammatorydiseaseofaseriousnatureoccurredduringthatperiodamongtheotherpatientsoftheWestminsterGeneralDispensary，whohadbeenattendedbytheothermidwivesbelongingtothatinstitution。“

TherecurrenceoflongseriesofcaseslikethoseIhavecited，reportedbythosemostinterestedtodisbelieveincontagion，scatteredalongthroughanintervalofhalfacentury，mighthavebeenthoughtsufficienttosatisfythemindsofallinquirersthatherewassomethingmorethanasingularcoincidence。Butif，onamoreextendedobservation，itshouldbefoundthatthesameominousgroupsofcasesclusteringaboutindividualpractitionerswereobservedinaremotecountry，atdifferenttimes，andinwidelyseparatedregions，itwouldseemincrediblethatanyshouldbefoundtooprejudicedorindolenttoacceptthesolemntruthknelledintotheirearsbythefuneralbellsfrombothsidesoftheocean，——theplainconclusionthatthephysicianandthediseaseentered，handinhand，intothechamberoftheunsuspectingpatient。