第20章

inspectedthebody，andthenightafterattendedalady，Mrs。B。，whosickened，anddied16th。The10th，Iattendedanother，Mrs。G。，whosickened，butrecovered。March16th，IwentfromMrs。G。’sroomtoattendaMrs。H。，whosickened，anddied21st。The17th，IinspectedMrs。B。Onthe19th，IwentdirectlyfromMrs。H。’sroomtoattendanotherlady，Mrs。G。，whoalsosickened，anddied22d。WhileMrs。

B。wassick，on15th，Iwentdirectlyfromherroomafewrods，andattendedanotherwoman，whowasnotsick。Upto20thofthismonthI

worethesameclothes。Inowrefusedtoattendanylabor，anddidnottillApril21st，when，havingthoroughlycleansedmyself，I

resumedmypractice，andhadnomorepuerperalfever。

“Thecaseswerenotconfinedtoanarrowspace。Thetwonearestwerehalfamilefromeachother，andhalfthatdistancefrommyresidence。Theotherswerefromtwotothreemilesapart，andnearlythatdistancefrommyresidence。Therewerenoothercasesintheirimmediatevicinitywhichcametomyknowledge。Thegeneralhealthofallthewomenwasprettygood，andallthelaborsasgoodascommon，exceptthefirst。Thiswoman，inconsequenceofmynotarrivinginseason，andthechildbeinghalf-bornatsometimebeforeIarrived，wasverymuchexposedtothecoldatthetimeofconfinement，andafterwards，beingconfinedinaveryopen，coldroom。Ofthesixcasesyouperceiveonlyonerecovered。

“Inthewinterof1817twoofmypatientshadpuerperalfever，oneverybadly，theothernotsobadly。Bothrecovered。Oneotherhadswelledleg，orphlegmasiadolens，andoneortwoothersdidnotrecoveraswellasusual。

“Inthesummerof1835anotherdisastrousperiodoccurredinmypractice。July1st，Iattendedaladyinlabor，whowasafterwardsquiteillandfeverish；butatthetimeIdidnotconsiderhercaseadecidedpuerperalfever。Onthe8th，Iattendedonewhodidwell。

Onthe12th，onewhowasseriouslysick。Thiswasalsoanequivocalcase，apparentlyarisingfromconstipationandirritationoftherectum。Thesewomenweretenmilesapartandfivefrommyresidence。

On15thand20th，twowhodidwell。On25th，Iattendedanother。

Thiswasaseverelabor，andfollowedbyunequivocalpuerperalfever，orperitonitis。Sherecovered。August2dand3d，inabouttwenty-

fourhoursIattendedfourpersons。Twoofthemdidverywell；onewasattackedwithsomeofthecommonsymptoms，whichhoweversubsidedinadayortwo，andtheotherhaddecidedpuerperalfever，butrecovered。Thiswomanresidedfivemilesfromme。UptothistimeI

worethesamecoat。Allmyotherclotheshadfrequentlybeenchanged。On6th，Iattendedtwowomen，oneofwhomwasnotsickatall；buttheother，Mrs。L。，wasafterwardstakenill。On10th，I

attendedalady，whodidverywell。Ihadpreviouslychangedallmyclothes，andhadnogarmentonwhichhadbeeninapuerperalroom。

On12th，IwascalledtoMrs。S。，inlabor。Whileshewasill，I

lefthertovisitMrs。L。，oneoftheladieswhowasconfinedon6th。

Mrs。L。hadbeenmoreunwellthanusual，butIhadnotconsideredhercaseanythingmorethancommontillthisvisit。Ihadonasurtoutatthisvisit，which，onmyreturntoMrs。S。，Ileftinanotherroom。Mrs。S。wasdeliveredon13thwithforceps。Thesewomenbothdiedofdecidedpuerperalfever。

“WhileIattendedthesewomenintheirfevers，Ichangedmyclothes，andwashedmyhandsinasolutionofchlorideoflimeaftereachvisit。Iattendedsevenwomeninlaborduringthisperiod，allofwhomrecoveredwithoutsickness。

“InmypracticeIhavehadseveralsinglecasesofpuerperalfever，someofwhomhavediedandsomehaverecovered。Untiltheyear1830

Ihadnosuspicionthatthediseasecouldbecommunicatedfromonepatienttoanotherbyanurseormidwife；butInowthinktheforegoingfactsstronglyfavorthatidea。Iwassomuchconvincedofthisfact，thatIadoptedtheplanbeforerelated。

“Ibelievemyownhealthwasasgoodasusualateachoftheaboveperiods。Ihavenorecollectionstothecontrary。

“IbelieveIhaveansweredallyourquestions。Ihavebeenmoreparticularonsomepointsperhapsthannecessary；butIthoughtyoucouldformyourownopinionbetterthantotakemine。In1830I

wrotetoDr。Charmingamoreparticularstatementofmycases。IfI

havenotansweredyourquestionssufficiently，perhapsDr。C。mayhavemylettertohim，andyoucanfindyouranswerthere。“[Inalettertomyself，thisgentlemanalsostated，“Idonotrecollectthattherewasanyerysipelasoranyotherdiseaseparticularlyprevalentatthetime。“]

“BOSTON，February3，1843。

III。“MYDEARSIR，——Ireceivedanotefromyoulastevening，requestingmetoanswercertainquestionsthereinproposed，touchingthecasesofpuerperalfeverwhichcameundermyobservationthepastsummer。Itgivesmepleasuretocomplywithyourrequest，sofarasitisinmypowersotodo，but，owingtothehurryinpreparingforajourney，thenotesofthecasesIhadthentakenwerelostormislaid。Theprincipalfacts，however，aretoovividuponmyrecollectiontobesoonforgotten。Ithink，therefore，thatIshallbeabletogiveyoualltheinformationyoumayrequire。

“Allthecasesthatoccurredinmypracticetookplacebetweenthe7thofMayandthe17thofJune1842。

“Theywerenotconfinedtoanyparticularpartofthecity。ThefirsttwocaseswerepatientsresidingattheSouthEnd，thenextwasattheextremeNorthEnd，onelivinginSeaStreetandtheotherinRoxbury。Thefollowingistheorderinwhichtheyoccurred：

“Case1。Mrs。_____wasconfinedonthe7thofMay，at5o’clock，P。M。，afteranaturallaborofsixhours。At12o’clockatnight，onthe9th(thirty-onehoursafterconfinement)，shewastakenwithseverechill，previoustowhichshewasascomfortableaswomenusuallyareunderthecircumstances。Shediedonthe10th。

“Case2。Mrs。_____wasconfinedonthe10thofJune(fourweeksafterMrs。C。)，at11A。M。，afteranatural，butsomewhatseverelaboroffivehours。At7o’clock，onthemorningofthe11th，shehadachill。Diedonthe12th。

“Case3。Mrs。_____，confinedonthe14thofJune，wascomfortableuntilthe18th，whensymptomsofpuerperalfeverweremanifest。Shediedonthe20th。

“Case4。Mrs。_____，confinedJune17th，at5o’clock，A。M。，wasdoingwelluntilthemorningofthe19th。Shediedontheeveningofthe21st。

“Case5。Mrs。_____wasconfinedwithherfifthchildonthe17thofJune，at6o’clockintheevening。Thispatienthadbeenattackedwithpuerperalfever，atthreeofherpreviousconfinements，butthediseaseyieldedtodepletionandotherremedieswithoutdifficulty。

Thistime，Iregrettosay，Iwasnotsofortunate。Shewasnotattacked，asweretheotherpatients，withachill，butcomplainedofextremepaininabdomen，andtendernessonpressure，almostfromthemomentofherconfinement。Inthisasintheothercases，thediseaseresistedallremedies，andshediedingreatdistressonthe22dofthesamemonth。Owingtotheextremeheatoftheseason，andmyownindisposition，noneofthesubjectswereexaminedafterdeath。

Dr。Channing，whowasinattendancewithmeonthethreelastcases，proposedtohaveapost-mortemexaminationofthesubjectofcaseNo。

5，butfromsomecausewhichIdonotnowrecollectitwasnotobtained。

“YouwishtoknowwhetherIworethesameclotheswhenattendingthedifferentcases。Icannotpositivelysay，butIshouldthinkIdidnot，astheweatherbecamewarmerafterthefirsttwocases；I

thereforethinkitprobablethatImadeachangeofatleastapartofmydress。Ihavehadnoothercaseofpuerperalfeverinmyownpracticeforthreeyears，savethoseaboverelated，andIdonotremembertohavelostapatientbeforewiththisdisease。Whileabsent，lastJuly，Ivisitedtwopatientssickwithpuerperalfever，withafriendofmineinthecountry。Bothofthemrecovered。

“ThecasesthatIhaverecordedwerenotconfinedtoanyparticularconstitutionortemperament，butitseizeduponthestrongandtheweak，theoldandtheyoung，——onebeingoverfortyyears，andtheyoungestundereighteenyearsofage……Ifthediseaseisofanerysipelatousnature，asmanysuppose，contagionistsmayperhapsfindsomegroundfortheirbeliefinthefact，that，fortwoweeksprevioustomyfirstcaseofpuerperalfever，Ihadbeenattendingaseverecaseoferysipelas，andtheinfectionmayhavebeenconveyedthroughmetothepatient；but，ontheotherhand，whyisnotthisthecasewithotherphysicians，orwiththesamephysicianatalltimes，forsincemyreturnfromthecountryIhavehadamoreinveteratecaseoferysipelasthaneverbefore，andnodifficultywhateverhasattendedanyofmymidwiferycases？“

Iamassured，onunquestionableauthority，that“Aboutthreeyearssince，agentlemaninextensivemidwiferybusiness，inaneighboringState，lostinthecourseofafewweekseightpatientsinchild-bed，sevenofthembeingundoubtedcasesofpuerperalfever。Nootherphysicianofthetownlostasinglepatientofthisdiseaseduringthesameperiod。“AndfromwhatIhaveheardinconversationwithsomeofourmostexperiencedpractitioners，Iaminclinedtothinkmanycasesofthekindmightbebroughttolightbyextensiveinquiry。

Thislongcatalogueofmelancholyhistoriesassumesastilldarkeraspectwhenwerememberhowkindlynaturedealswiththeparturientfemale，whensheisnotimmersedinthevirulentatmosphereofanimpurelying-inhospital，orpoisonedinherchamberbytheunsuspectedbreathofcontagion。Fromallcausestogether，notmorethanfourdeathsinathousandbirthsandmiscarriageshappenedinEnglandandWalesduringtheperiodembracedbythefirstReportoftheRegistrar-General。“InthesecondReportthemortalitywasshowntobeaboutfiveinonethousand。IntheDublinLying-inHospital，duringthesevenyearsofDr。Collins’smastership，therewasonecaseofpuerperalfeverto178deliveries，orlessthansixtothethousand，andonedeathfromthisdiseasein278cases，orbetweenthreeandfourtothethousandayetduringthisperiodthediseasewasendemicinthehospital，andmighthavegoneontorivalthehorrorsofthepestilenceoftheMaternite，hadnotthepoisonbeendestroyedbyathoroughpurification。

Inprivatepractice，leavingoutofviewthecasesthataretobeascribedtotheself-actingsystemofpropagation，itwouldseemthatthediseasemustbefarfromcommon。Mr。WhiteofManchestersays，“Outofthewholenumberoflying-inpatientswhomIhavedelivered(andImaysafelycallitagreatone)，Ihaveneverlostone，nortothebestofmyrecollectionhasonebeengreatlyendangered，bythepuerperal，miliary，lownervous，putridmalignant，ormilkfever。“

Dr。JosephClarkeinformedDr。Collins，thatinthecourseofforty-

fiveyears’mostextensivepracticehelostbutfourpatientsfromthisdisease。OneofthemosteminentpractitionersofGlasgow，whohasbeenengagedinveryextensivepracticeforupwardsofaquarterofacentury，testifiesthatheneversawmorethantwelvecasesofrealpuerperalfever。[Lancet，May4，1833]

Ihavemyselfbeentoldbytwogentlemenpractisinginthiscity，andhavingformanyyearsalargemidwiferybusiness，thattheyhadneitherofthemlostapatientfromthisdisease，andbyoneofthemthathehadonlyseenitinconsultationwithotherphysicians。Infivehundredcasesofmidwifery，ofwhichDr。StorerhasgivenanabstractinthefirstnumberofthisJournal，therewasonlyoneinstanceoffatalpuerperalperitonitis。

Intheviewofthesefacts，itdoesappearasingularcoincidence，thatonemanorwomanshouldhaveten，twenty，thirty，orseventycasesofthisrarediseasefollowinghisorherfootstepswiththekeennessofabeagle，throughthestreetsandlanesofacrowdedcity，whilethescoresthatcrossthesamepathsonthesameerrandsknowitonlybyname。Itisaseriesofsimilarcoincidenceswhichhasledustoconsiderthedagger，themusket，andcertaininnocent-

lookingwhitepowdersashavingsomelittleclaimtoberegardedasdangerous。Itisthepracticalinattentiontosimilarcoincidenceswhichhasgivenrisetotheunpleasantbutoftennecessarydocumentscalledindictments，whichhassharpenedaformofthecephalotomesometimesemployedinthecaseofadults，andadjustedthatmodificationofthefilletwhichdeliverstheworldofthosewhohappentobetoomuchinthewaywhilesuchstrikingcoincidencesaretakingplace。

Ishallnowmentionafewinstancesinwhichthediseaseappearstohavebeenconveyedbytheprocessofdirectinoculation。

Dr。CampbellofEdinburghstatesthatinOctober，1821，heassistedatthepost-mortemexaminationofapatientwhodiedwithpuerperalfever。Hecarriedthepelvicviscerainhispockettotheclass-