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。