medical essays-第35章
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〃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 within his knowledge
