medical essays-第28部分

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〃In　my　practice　I　have　had　several　single　cases　of　puerperal　fever；　some　of　whom　have　died　and　some　have　recovered。　　Until　the　year　1830　I　had　no　suspicion　that　the　disease　could　be　communicated　from　one　patient　to　another　by　a　nurse　or　midwife；　but　I　now　think　the　foregoing　facts　strongly　favor　that　idea。　　I　was　so　much　convinced　of　this　fact；　that　I　adopted　the　plan　before　related。

〃I　believe　my　own　health　was　as　good　as　usual　at　each　of　the　above　periods。　　I　have　no　recollections　to　the　contrary。

〃I　believe　I　have　answered　all　your　questions。　　I　have　been　more　particular　on　some　points　perhaps　than　necessary；　but　I　thought　you　could　form　your　own　opinion　better　than　to　take　mine。　　In　1830　I　wrote　to　Dr。　Charming　a　more　particular　statement　of　my　cases。　　If　I　have　not　answered　your　questions　sufficiently；　perhaps　Dr。　C。　　may　have　my　letter　to　him；　and　you　can　find　your　answer　there。〃　＇In　a　letter　to　myself；　this　gentleman　also　stated；　〃I　do　not　recollect　that　there　was　any　erysipelas　or　any　other　disease　particularly　prevalent　at　the　time。〃＇


〃BOSTON；　February　3；　1843。

III。　　〃MY　DEAR　SIR；I　received　a　note　from　you　last　evening；　requesting　me　to　answer　certain　questions　therein　proposed；　touching　the　cases　of　puerperal　fever　which　came　under　my　observation　the　past　summer。　　It　gives　me　pleasure　to　comply　with　your　request；　so　far　as　it　is　in　my　power　so　to　do；　but；　owing　to　the　hurry　in　preparing　for　a　journey；　the　notes　of　the　cases　I　had　then　taken　were　lost　or　mislaid。　　The　principal　facts；　however；　are　too　vivid　upon　my　recollection　to　be　soon　forgotten。　　I　think；　therefore；　that　I　shall　be　able　to　give　you　all　the　information　you　may　require。

〃All　the　cases　that　occurred　in　my　practice　took　place　between　the　7th　of　May　and　the　17th　of　June　1842。

〃They　were　not　confined　to　any　particular　part　of　the　city。　　The　first　two　cases　were　patients　residing　at　the　South　End；　the　next　was　at　the　extreme　North　End；　one　living　in　Sea　Street　and　the　other　in　Roxbury。　　The　following　is　the　order　in　which　they　occurred：

〃Case　1。　　Mrs。_____　　was　confined　on　the　7th　of　May；　at　5　o'clock；　P。　M。；　after　a　natural　labor　of　six　hours。　　At　12　o'clock　at　night；　on　the　9th　（thirty…one　hours　after　confinement）；　she　was　taken　with　severe　chill；　previous　to　which　she　was　as　comfortable　as　women　usually　are　under　the　circumstances。　　She　died　on　the　10th。

〃Case　2。　　Mrs。_____　　was　confined　on　the　10th　of　June　（four　weeks　after　Mrs。　　C。）；　at　11　A。　M。；　after　a　natural；　but　somewhat　severe　labor　of　five　hours。　　At　7　o'clock；　on　the　morning　of　the　11th；　she　had　a　chill。　　Died　on　the　12th。

〃Case　3。　　Mrs。_____　；　confined　on　the　14th　of　June；　was　comfortable　until　the　18th；　when　symptoms　of　puerperal　fever　were　manifest。　　She　died　on　the　20th。

〃Case　4。　　Mrs。_____　；　confined　June　17th；　at　5　o'clock；　A。　　M。；　was　doing　well　until　the　morning　of　the　19th。　　She　died　on　the　evening　of　the　21st。

〃Case　5。　　Mrs。_____　　was　confined　with　her　fifth　child　on　the　17th　of　June；　at　6　o'clock　in　the　evening。　　This　patient　had　been　attacked　with　puerperal　fever；　at　three　of　her　previous　confinements；　but　the　disease　yielded　to　depletion　and　other　remedies　without　difficulty。　This　time；　I　regret　to　say；　I　was　not　so　fortunate。　　She　was　not　attacked；　as　were　the　other　patients；　with　a　chill；　but　complained　of　extreme　pain　in　abdomen；　and　tenderness　on　pressure；　almost　from　the　moment　of　her　confinement。　　In　this　as　in　the　other　cases；　the　disease　resisted　all　remedies；　and　she　died　in　great　distress　on　the　22d　of　the　same　month。　　Owing　to　the　extreme　heat　of　the　season；　and　my　own　indisposition；　none　of　the　subjects　were　examined　after　death。　Dr。　Channing；　who　was　in　attendance　with　me　on　the　three　last　cases；　proposed　to　have　a　post…mortem　examination　of　the　subject　of　case　No。　5；　but　from　some　cause　which　I　do　not　now　recollect　it　was　not　obtained。

〃You　wish　to　know　whether　I　wore　the　same　clothes　when　attending　the　different　cases。　　I　cannot　positively　say；　but　I　should　think　I　did　not；　as　the　weather　became　warmer　after　the　first　two　cases；　I　therefore　think　it　probable　that　I　made　a　change　of　at　least　a　part　of　my　dress。　　I　have　had　no　other　case　of　puerperal　fever　in　my　own　practice　for　three　years；　save　those　above　related；　and　I　do　not　remember　to　have　lost　a　patient　before　with　this　disease。　　While　absent；　last　July；　I　visited　two　patients　sick　with　puerperal　fever；　with　a　friend　of　mine　in　the　country。　　Both　of　them　recovered。

〃The　cases　that　I　have　recorded　were　not　confined　to　any　particular　constitution　or　temperament；　but　it　seized　upon　the　strong　and　the　weak；　the　old　and　the　young；one　being　over　forty　years；　and　the　youngest　under　eighteen　years　of　age　。　　。　　。　　。　　If　the　disease　is　of　an　erysipelatous　nature；　as　many　suppose；　contagionists　may　perhaps　find　some　ground　for　their　belief　in　the　fact；　that；　for　two　weeks　previous　to　my　first　case　of　puerperal　fever；　I　had　been　attending　a　severe　case　of　erysipelas；　and　the　infection　may　have　been　conveyed　through　me　to　the　patient；　but；　on　the　other　hand；　why　is　not　this　the　case　with　other　physicians；　or　with　the　same　physician　at　all　times；　for　since　my　return　from　the　country　I　have　had　a　more　inveterate　case　of　erysipelas　than　ever　before；　and　no　difficulty　whatever　has　attended　any　of　my　midwifery　cases？〃


I　am　assured；　on　unquestionable　authority；　that　〃About　three　years　since；　a　gentleman　in　extensive　midwifery　business；　in　a　neighboring　State；　lost　in　the　course　of　a　few　weeks　eight　patients　in　child…bed；　seven　of　them　being　undoubted　cases　of　puerperal　fever。　　No　other　physician　of　the　town　lost　a　single　patient　of　this　disease　during　the　same　period。〃　　And　from　what　I　have　heard　in　conversation　with　some　of　our　most　experienced　practitioners；　I　am　inclined　to　think　many　cases　of　the　kind　might　be　brought　to　light　by　extensive　inquiry。


This　long　catalogue　of　melancholy　histories　assumes　a　still　darker　aspect　when　we　remember　how　kindly　nature　deals　with　the　parturient　female；　when　she　is　not　immersed　in　the　virulent　atmosphere　of　an　impure　lying…in　hospital；　or　poisoned　in　her　chamber　by　the　unsuspected　breath　of　contagion。　　From　all　causes　together；　not　more　than　four　deaths　in　a　thousand　births　and　miscarriages　happened　in　England　and　Wales　during　the　period　embraced　by　the　first　Report　of　the　Registrar…General。〃　　In　the　second　Report　the　mortality　was　shown　to　be　about　five　in　one　thousand。　In　the　Dublin　Lying…in　Hospital；　during　the　seven　years　of　Dr。　Collins's　mastership；　there　was　one　case　of　puerperal　fever　to　178　deliveries；　or　less　than　six　to　the　thousand；　and　one　death　from　this　disease　in　278　cases；　or　between　three　and　four　to　the　thousand　a　yet　during　this　period　the　disease　was　endemic　in　the　hospital；　and　might　have　gone　on　to　rival　the　horrors　of　the　pestilence　of　the　Maternite；　had　not　the　poison　been　destroyed　by　a　thorough　purification。

In　private　practice；　leaving　out　of　view　the　cases　that　are　to　be　ascribed　to　the　self…acting　system　of　propagation；　it　would　seem　that　the　disease　must　be　far　from　common。　　Mr。　White　of　Manchester　says；　〃Out　of　the　whole　number　of　lying…in　patients　whom　I　have　delivered　（and　I　may　safely　call　it　a　great　one）；　I　have　never　lost　one；　nor　to　the　best　of　my　recollection　has　one　been　greatly　endangered；　by　the　puerperal；　miliary；　low　nervous；　putrid　malignant；　or　milk　fever。〃　Dr。　Joseph　Clarke　informed　Dr。　Collins；　that　in　the　course　of　forty…　five　years'　most　extensive　practice　he　lost　but　four　patients　from　this　disease。　　One　of　the　most　eminent　practitioners　of　Glasgow；　who　has　been　engaged　in　very　extensive　practice　for　upwards　of　a　quarter　of　a　century；　testifies　that　he　never　saw　more　than　twelve　cases　of　real　puerperal　fever。＇Lancet；　May　4；　1833＇

I　have　myself　been　told　by　two　gentlemen　practising　in　this　city；　and　having　for　many　years　a　large　midwifery　business；　that　they　had　neither　of　them　lost　a　patient　from　this　disease；　and　by　one　of　them　that　he　had　only　seen　it　in　consultation　with　other　physicians。　　In　five　hundred　cases　of　midwifery；　of　which　Dr。　Storer　has　given　an　abstract　in　the　first　number　of　this　Journal；　there　was　only　one　instance　of　fatal　puerperal　peritonitis。

In　the　view　of　these　facts；　it　does　appear　a　singular　coincidence；　that　one　man　or　woman　should　have　ten；　twenty；　thirty；　or　seventy　cases　of　this　rare　disease　following　his　or　her　footsteps　with　the　keenness　of　a　beagle；　through　the　streets　and　lanes　of　a　crowded　city；　while　the　scores　that　cross　the　same　paths　on　the　same　errands　know　it　only　by　name。　　It　is　a　series　of　similar　coincidences　which　has　led　us　to　consider　the　dagger；　the　musket；　and　certain　innocent…　looking　white　powders　as　having　some　little　claim　to　be　regarded　as　dangerous。　　It　is　the　practical　inattention　to　similar　coincidences　which　has　given　rise　to　the　unpleasant　but　often　necessary　documents　called　indictments；　which　has　sharpened　a　form　of　the　cephalotome　sometimes　employed　in　the　case　of　adults；　and　adjusted　that　modification　of　the　fillet　which　delivers　the　world　of　those　who　happen　to　be　too　much　in　the　way　while　such　striking　coincidences　are　taking　place。

I　shall　now　mention　a　few　instances　in　which　the　disease　appears　to　have　been　conveyed　by　the　process　of　direct　inoculation。

Dr。　Campbell　of　Edinburgh　states　that　in　October；　1821；　he　assisted　at　the　post…mortem　examination　of　a　patient　who　died　with　puerperal　fever。　　He　carried　the　pelvic　viscera　in　his　pocket　to　the　class…　room。　　The　same　evening　he　attended　a　woman　in　labor　without　previously　changing　his　clothes；　this　patient　died。　　The　next　morning　he　delivered　a　woman　with　the　forceps；　she　died　also；　and　of　many　others　who　were　seized　with　the　disease　within　a　few　weeks；　three　shared　the　same　fate　in　succession。

In　June；　1823；　he　assisted　some　of　his　pupils　at　the　autopsy　of　a　case　of　puerperal　fever。　　He　was　unable　to　wash　his　hands　with　proper　care；　for　want　of　the　necessary　accommodations。　　On　getting　home　he　found　that　two　patients　required　his　assistance。　　He　went　without　further　ablution；　or　changing　his　clothes；　both　these　patients　died　with　puerperal　fever。　　This　same　Dr。　Campbell　is　one　of　Dr。　Churchill's　authorities　against　contagion。

Mr。　Roberton　says　that　in　one　instance