Part 8 (1/2)

VII. When a large number of cases of this disease occur in rapid succession, in one individual's ordinary practice, and few or none elsewhere, these cases appearing in scattered localities, in patients of the same average condition as those who escape under the care of others, there is the same reason for connecting the cause of the disease with the person in this instance, as with the place in that last mentioned.

VIII. Many series of cases, answering to these conditions, are given in this Essay, and many others will be referred to which have occurred since it was written.

IX. The alleged results of observation may be set aside; first, because the so-called facts are in their own nature equivocal; secondly, because they stand on insufficient authority; thirdly, because they are not sufficiently numerous. But, in this case, the disease is one of striking and well-marked character; the witnesses are experts, interested in denying and disbelieving the facts; the number of consecutive cases in many instances frightful, and the number of series of cases such that I have no room for many of them except by mere reference.

X. These results of observation, being admitted, may, we will suppose, be interpreted in different methods. Thus the coincidences may be considered the effect of chance. I have had the chances calculated by a competent person, that a given pract.i.tioner, A., shall have sixteen fatal cases in a month, on the following data: A. to average attendance upon two hundred and fifty births in a year; three deaths in one thousand births to be a.s.sumed as the average from puerperal fever; no epidemic to be at the time prevailing. It follows, from the answer given me, that if we suppose every one of the five hundred thousand annual births of England to have been recorded during the last half-century, there would not be one chance in a million million million millions that one such series should be noted. No possible fractional error in this calculation can render the chance a working probability. Applied to dozens of series of various lengths, it is obviously an absurdity.

Chance, therefore, is out of the question as an explanation of the admitted coincidences.

XI. There is, therefore, some relation of cause and effect between the physician's presence and the patient's disease.

XII. Until it is proved to what removable condition attaching to the attendant the disease is owing, he is bound to stay away from his patients so soon as he finds himself singled out to be tracked by the disease. How long, and with what other precautions, I have suggested, without dictating, at the close of my Essay. If the physician does not at once act on any reasonable suspicion of his being the medium of transfer, the families where he is engaged, if they are allowed to know the facts, should decline his services for the time. His feelings on the occasion, however interesting to himself, should not be even named in this connection. A physician who talks about ceremony and grat.i.tude, and services rendered, and the treatment he got, surely forgets himself; it is impossible that he should seriously think of these small matters where there is even a question whether he may not carry disease, and death, and bereavement into any one of ”his families,” as they are sometimes called.

I will now point out to the young student the mode in which he may relieve his mind of any confusion, or possibly, if very young, any doubt, which the perusal of Dr. Meigs's Sixth Letter may have raised in his mind.

The most prominent ideas of the Letter are, first, that the transmissible nature of puerperal fever appears improbable, and, secondly, that it would be very inconvenient to the writer. Dr.

Woodville, Physician to the Small-Pox and Inoculation Hospital in London, found it improbable, and exceedingly inconvenient to himself, that cow pox should prevent small-pox; but Dr. Jenner took the liberty to prove the fact, notwithstanding.

I will first call the young student's attention to the show of negative facts (exposure without subsequent disease), of which much seems to be thought. And I may at the same time refer him to Dr. Hodge's Lecture, where he will find the same kind of facts and reasoning. Let him now take up Watson's Lectures, the good sense and spirit of which have made his book a universal favorite, and open to the chapter on Continued Fever. He will find a paragraph containing the following sentence: ”A man might say, 'I was in the battle of Waterloo, and saw many men around me fall down and die, and it was said that they were struck down by musket-b.a.l.l.s; but I know better than that, for I was there all the time, and so were many of my friends, and we were never hit by any musket-b.a.l.l.s. Musket-b.a.l.l.s, therefore, could not have been the cause of the deaths we witnessed.' And if, like contagion, they were not palpable to the senses, such a person might go on to affirm that no proof existed of there being any such thing as musket-b.a.l.l.s.” Now let the student turn back to the chapter on Hydrophobia in the same volume. He will find that John Hunter knew a case in which, of twenty-one persons bitten, only one died of the disease. He will find that one dog at Charenton was bitten at different times by thirty different mad dogs, and outlived it all.

Is there no such thing, then, as hydrophobia? Would one take no especial precautions if his wife, about to become a mother, had been bitten by a rabid animal, because so many escape? Or let him look at ”Underwood on Diseases of Children,” [Philadelphia, 1842, p. 244, note.] and he will find the case of a young woman who was inoculated eight times in thirty days, at the same time attending several children with smallpox, and yet was not infected. But seven weeks afterwards she took the disease and died.

It would seem as if the force of this argument could hardly fail to be seen, if it were granted that every one of these series of cases were so reported as to prove that there could have been no transfer of disease.

There is not one of them so reported, in the Lecture or the Letter, as to prove that the disease may not have been carried by the pract.i.tioner.

I strongly suspect that it was so carried in some of these cases, but from the character of the very imperfect evidence the question can never be settled without further disclosures.

Although the Letter is, as I have implied, princ.i.p.ally taken up with secondary and collateral questions, and might therefore be set aside as in the main irrelevant, I am willing, for the student's sake, to touch some of these questions briefly, as an ill.u.s.tration of its logical character.

The first thing to be done, as I thought when I wrote my Essay, was to throw out all discussions of the word contagion, and this I did effectually by the careful wording of my statement of the subject to be discussed. My object was not to settle the etymology or definition of a word, but to show that women had often died in childbed, poisoned in some way by their medical attendants. On the other point, I, at least, have no controversy with anybody, and I think the student will do well to avoid it in this connection. If I must define my position, however, as well as the term in question, I am contented with Worcester's definition; provided always this avowal do not open another side controversy on the merits of his Dictionary, which Dr. Meigs has not cited, as compared with Webster's, which he has.

I cannot see the propriety of insisting that all the laws of the eruptive fevers must necessarily hold true of this peculiar disease of puerperal women. If there were any such propriety, the laws of the eruptive fevers must at least be stated correctly. It is not true, for instance, as Dr. Meigs states, that contagion is ”no respecter of persons;” that ”it attacks all individuals alike.” To give one example: Dr. Gregory, of the Small-Pox Hospital, who ought to know, says that persons pa.s.s through life apparently insensible to or unsusceptible of the small-pox virus, and that the same persons do not take the vaccine disease.

As to the short time of incubation, of which so much is made, we have no right to decide beforehand whether it shall be long or short, in the cases we are considering. A dissection wound may produce symptoms of poisoning in six hours; the bite of a rabid animal may take as many months.

After the student has read the case in Dr. Meigs's 136th paragraph, and the following one, in which he exclaims against the idea of contagion, because the patient, delivered on the 26th of December, was attacked in twenty-four hours, and died on the third day, let him read what happened at the ”Black a.s.sizes” of 1577 and 1750. In the first case, six hundred persons sickened the same night of the exposure, and three hundred more in three days. [Elliotson's Practice, p. 298.] Of those attacked in the latter year, the exposure being on the 11th of May, Alderman Lambert died on the 13th, Under-Sheriff c.o.x on the 14th, and many of note before the 20th. But these are old stories. Let the student listen then to Dr.

Gerhard, whose reputation as a cautious observer he may be supposed to know. ”The nurse was shaving a man, who died in a few hours after his entrance; he inhaled his breath, which had a nauseous taste, and in an hour afterwards was taken with nausea, cephalalgia, and singing of the ears. From that moment the attack began, and a.s.sumed a severe character.

The a.s.sistant was supporting another patient, who died soon afterwards; he felt the pungent heat upon his skin, and was taken immediately with the symptoms of typhus.” [Am. Jour. Med. Sciences, Feb. 1837, p. 299.]

It is by notes of cases, rather than notes of admiration, that we must be guided, when we study the Revised Statutes of Nature, as laid down from the curule chairs of Medicine.

Let the student read Dr. Meigs's 140th paragraph soberly, and then remember, that not only does he infer, suspect, and surmise, but he actually a.s.serts (page 154), ”there was poison in the house,” because three out of five patients admitted into a ward had puerperal fever and died. Have I not as much right to draw a positive inference from ”Dr.

A.'s” seventy exclusive cases as he from the three cases in the ward of the Dublin Hospital? All practical medicine, and all action in common affairs, is founded on inferences. How does Dr. Meigs know that the patients he bled in puerperal fever would not have all got well if he had not bled them?

”You see a man discharge a gun at another; you see the flash, you hear the report, you see the person fall a lifeless corpse; and you infer, from all these circ.u.mstances, that there was a ball discharged from the gun, which entered his body and caused his death, because such is the usual and natural cause of such an effect. But you did not see the ball leave the gun, pa.s.s through the air, and enter the body of the slain; and your testimony to the fact of killing is, therefore, only inferential,--in other words, circ.u.mstantial. It is possible that no ball was in the gun; and we infer that there was, only because we cannot account for death on any other supposition.” [Chief Justice Gibson, in Am. Law Journal, vol. vi. p. 123.]

”The question always comes to this: Is the circ.u.mstance of intercourse with the sick followed by the appearance of the disease in a proportion of cases so much greater than any other circ.u.mstance common to any portion of the inhabitants of the place under observation, as to make it inconceivable that the succession of cases occurring in persons having that intercourse should have been the result of chance? If so, the inference is unavoidable, that that intercourse must have acted as a cause of the disease. All observations which do not bear strictly on that point are irrelevant, and, in the case of an epidemic first appearing in a town or district, a succession of two cases is sometimes sufficient to furnish evidence which, on the principle I have stated, is nearly irresistible.”

Possibly an inexperienced youth may be awe-struck by the quotation from Cuvier. These words, or their equivalent, are certainly to be found in his Introduction. So are the words ”top not come down”! to be found in the Bible, and they were as much meant for the ladies' head-dresses as the words of Cuvier were meant to make clinical observation wait for a permit from anybody to look with its eyes and count on its fingers. Let the inquiring youth read the whole Introduction, and he will see what they mean.

I intend no breach of courtesy, but this is a proper place to warn the student against skimming the prefaces and introductions of works for mottoes and embellishments to his thesis. He cannot learn anatomy by thrusting an exploring needle into the body. He will be very liable to misquote his author's meaning while he is picking off his outside sentences. He may make as great a blunder as that simple prince who praised the conductor of his orchestra for the piece just before the overture; the musician was too good a courtier to tell him that it was only the tuning of the instruments.

To the six propositions in the 142d paragraph, and the remarks about ”specific” diseases, the answer, if any is necessary, seems very simple.

An inflammation of a serous membrane may give rise to secretions which act as a poison, whether that be a ”specific” poison or not, as Dr.