|
Part I.
Part I.
Introductory Note
Oliver Wendell Holmes was born in Cambridge, Massachusetts, August 29,
1809, and educated at Phillips Academy, Andover, and Harvard College. After
graduation, he entered the Law School, but soon gave up law for medicine. He
studied first in Boston, and later spent two years in medical schools in
Europe, mainly in Paris. On his return he began to practise in Boston, but in
two years he was appointed professor of anatomy at Dartmouth College, a
position which he held from 1838 to 1840, when he again took up his Boston
practice. It was soon after this, in 1843, that he published his essay on the
"Contagiousness of Puerperal Fever," his only contribution of high distinction
to medical science. From 1847 to 1882 he was Parkman professor of anatomy and
physiology in the Harvard Medical School. He died in Boston, October 7, 1894.
In spite of the importance of the paper here printed, Holmes` reputation
as a scientist was overshadowed by that won by him as a wit and a man of
letters. When he was only twenty-one his "Old Ironsides" brought him into
notice; and through his poetry and fiction, and the sparkling talk of the
"Breakfast Table" series, he took a high place among the most distinguished
group of writers that America has yet produced.
The Contagiousness Of Puerperal Fever
In collecting, enforcing and adding to the evidence accumulated upon this
most serious subject, I would not be understood to imply that there exists a
doubt in the mind of any well-informed member of the medical profession as to
the fact that puerperal fever is sometimes communicated from one person to
another, both directly and indirectly. In the present state of our knowledge
upon this point I should consider such doubts merely as a proof that the
sceptic had either not examined the evidence, or, having examined it, refused
to accept its plain and unavoidable consequences. I should be sorry to think,
with Dr. Rigby, that it was a case of "oblique vision"; I should be unwilling
to force home the argumentum ad hominem of Dr. Blundell, but I would not
consent to make a question of a momentous fact which is no longer to be
considered as a subject for trivial discussions, but to be acted upon with
silent promptitude. It signifies nothing that wise and experienced
practitioners have sometimes doubted the reality of the danger in question; no
man has the right to doubt it any longer. No negative facts, no opposing
opinions, be they what they may, or whose they may, can form any answer to the
series of cases now within the reach of all who choose to explore the records
of medical science.
[Note: This essay appeared first in 1843, in The New England Quarterly Journal
of Medicine, and was reprinted in the "Medical Essays" in 1855.]
If there are some who conceive that any important end would be answered
by recording such opinions, or by collecting the history of all the cases they
could find in which no evidence of the influence of contagion existed, I
believe they are in error. Suppose a few writers of authority can be found to
profess a disbelief in contagion, - and they are very few compared with those
who think differently, - is it quite clear that they formed their opinions on
a view of all the facts, or is it not apparent that they relied mostly on
their own solitary experience? Still further, of those whose names are quoted,
is it not true that scarcely a single one could, by any possibility, have
known the half or the tenth of the facts of bearing on the subject which have
reached such a frightful amount within the last few years? Again, as to the
utility of negative facts, as we may briefly call them, - instances, namely,
in which exposure has not been followed by disease, - although, like other
truths, they may be worth knowing, I do not see that they are like to shed any
important light upon the subject before us. Every such instance requires a
good deal of circumstantial explanation before it can be accepted. It is not
enough that a practitioner should have had a single case of puerperal fever
not followed by others. It must be known whether he attended others while this
case was in progress, whether he went directly from one chamber to others,
whether he took any, and what, precautions. It is important to know that
several women were exposed to infection derived from the patient, so that
allowance may be made for want of predisposition. Now if of negative facts so
sifted there could be accumulated a hundred for every one plain instance of
communication here recorded, I trust it need not be said that we are bound to
guard and watch over the hundredth tenant of our fold, though the ninety and
nine may be sure of escaping the wolf at its entrance. If any one is disposed,
then, to take a hundred instances of lives, endangered or sacrificed out of
those I have mentioned, and make it reasonably clear that within a similar
time and compass ten thousand escaped the same exposure, I shall thank him for
his industry, but I must be permitted to hold to my own practical conclusions,
and beg him to adopt or at least to examine them also. Children that walk in
calico before open fires are not always burned to death; the instances to the
contrary may be worth recording; but by no means if they are to be used as
arguments against woollen frocks and high fenders.
I am not sure that this paper will escape another remark which it might
be wished were founded in justice. It may be said that the facts are too
generally known and acknowledged to require any formal argument or exposition,
that there is nothing new in the positions advanced, and no need of laying
additional statements before the profession. But on turning to two works, one
almost universally, and the other extensively, appealed to as authority in
this country, I see ample reason to overlook this objection. In the last
edition of Dewees` Treatise on the "Diseases of Females" it is expressly
said, "In this country, under no circumstance that puerperal fever has
appeared hitherto, does it afford the slightest ground for the belief that it
is contagious." In the "Philadelphia Practice of Midwifery" not one word can
be found in the chapter devoted to this disease which would lead the reader to
suspect that the idea of contagion had ever been entertained. It seems proper,
therefore, to remind those who are in the habit of referring to the works for
guidance that there may possibly be some sources of danger they have slighted
or omitted, quite as important as a trifling irregularity of diet, or a
confined state of the bowels, and that whatever confidence a physician may
have in his own mode of treatment, his services are of questionable value
whenever he carries the bane as well as the antidote about his person.
The practical point to be illustrated is the following: The disease
known as Puerperal Fever is so far contagious as to be frequently carried from
patient to patient by physicians and nurses.
Let me begin by throwing out certain incidental questions, which, without
being absolutely essential, would render the subject more complicated, and by
making such concessions and assumptions as may be fairly supposed to be
without the pale of discussion.
1. It is granted that all the forms of what is called puerperal fever may
not be, and probably are not, equally contagious or infectious. I do not enter
into the distinctions which have been drawn by authors, because the facts do
not appear to me sufficient to establish any absolute line of demarcation
between such forms as may be propagated by contagion and those which are never
so propagated. This general result I shall only support by the authority of
Dr. Ramsbotham, who gives, as the result of his experience, that the same
symptoms belong to what he calls the infectious and the sporadic forms of the
disease, and the opinion of Armstrong in his original Essay. If others can
show any such distinction, I leave it to them to do it. But there are cases
enough that show the prevalence of the disease among the patients of a single
practitioner when it was in no degree epidemic, in the proper sense of the
term. I may refer to those of Mr. Roberton and of Dr. Peirson, hereafter to
be cited, as examples.
2. I shall not enter into any dispute about the particular mode of
infection, whether it be by the atmosphere the physician carries about him
into the sick-chamber, or by the direct application of the virus to the
absorbing surfaces with which his hand comes in contact. Many facts and
opinions are in favour of each of these modes of transmission. But it is
obvious that, in the majority of cases, it must be impossible to decide by
which of these channels the disease is conveyed, from the nature of the
intercourse between the physician and the patient.
3. It is not pretended that the contagion of puerperal fever must always
be followed by the disease. It is true of all contagious diseases that they
frequently spare those who appear to be fully submitted to their influence.
Even the vaccine virus, fresh from the subject, fails every day to produce
its legitimate effect, though every precaution is taken to insure its action.
This is still more remarkably the case with scarlet fever and some other
diseases.
4. It is granted that the disease may be produced and variously modified
by many causes besides contagion, and more especially by epidemic and endemic
influences. But this is not peculiar to the disease in question. There is no
doubt that smallpox is propagated to a great extent by contagion, yet it goes
through the same records of periodical increase and diminution which have
been remarked in puerperal fever. If the question is asked how we are to
reconcile the great variations in the mortality of puerperal fever in
different seasons and places with the supposition of contagion, I will answer
it by another question from Mr. Farr`s letter to the Registrar-General. He
makes the statement that "five die weekly of smallpox in the metropolis when
the disease is not epidemic," and adds, "The problem for solution is, - Why
do the five deaths become 10, 15, 20, 31, 58, 88, weekly, and then
progressively fall through the same measured steps?"
5. I take if for granted that if it can be shown that great numbers of
lives have been and are sacrificed to ignorance or blindness on this point,
no other error of which physicians or nurses may be occasionally suspected
will be alleged in palliation of this; but that whenever and wherever they
can be shown to carry disease and death instead of health and safety, the
common instincts of humanity will silence every attempt to explain away
their responsibility.
The treatise of Dr. Gordon, of Aberdeen, was published in the year 1795,
being among the earlier special works upon the disease. A part of his
testimony has been occasionally copied into other works, but his expressions
are so clear, his experience is given with such manly distinctness and
disinterested honesty, that it may be quoted as a model which might have been
often followed with advantage.
"This disease seized such women only as were visited or delivered by a
practitioner, or taken care of by a nurse, who had previously attended
patients affected with the disease."
"I had evident proofs of its infectious nature, and that the infection
was as readily communicated as that of the smallpox or measles, and operated
more speedily than any other infection with which I am acquainted."
"I had evident proofs that every person who had been with a patient in
the puerperal fever became charged with an atmosphere of infection, which was
communicated to every pregnant woman who happened to come within its sphere.
This is not an assertion, but a fact, admitting of demonstration, as may be
seen by a perusal of the foregoing table"-referring to a table of
seventy-seven cases, in many of which the channel of propagation was evident.
He adds: "It is a disagreeable declaration for me to mention, that I
myself was the means of carrying the infection to a great number of women."
He then enumerates a number of instances in which the disease was conveyed
by midwives and others to the neighboring villages, and declares that "these
facts fully prove that the cause of the puerperal fever, of which I treat,
was a specific contagion, or infection, altogether unconnected with a
noxious constitution of the atmosphere."
But his most terrible evidence is given in these words: "I arrived at
that certainty in the matter that I could venture to foretell what women
would be affected with the disease, upon hearing by what midwife they were
to be delivered, or by what nurse they were to be attended, during their
lying-in: and almost in every instance my prediction was verified."
Even previously to Gordon, Mr. White, of Manchester, had said: "I am
acquainted with two gentlemen in another town, where the whole business of
midwifery is divided betwixt them, and it is very remarkable that one of
them loses several patients every year of the puerperal fever, and the other
never so much as meets with the disorder" - a difference which he seems to
attribute to their various modes of treatment.^1
[Footnote 1: On the Management of Lying-in Women, p. 120.]
Dr. Armstrong has given a number of instances in his Essay on Puerperal
Fever of the prevalence of the disease among the patients of a single
practitioner. At Sunderland, "in all, forty-three cases occurred from the 1st
of January to the 1st of October, when the disease ceased; and of this
number, forty were witnessed by Mr. Gregson and his assistant, Mr. Gregory,
the remainder having been separately seen by three accoucheurs." There is
appended to the London edition of this Essay a letter from Mr. Gregson, in
which that gentleman says, in reference to the great number of cases
occurring in his practice, "The cause of this I cannot pretend fully to
explain, but I should be wanting in common liberality if I were to make any
hesitation in asserting that the disease which appeared in my practice was
highly contagious, and communicable from one puerperal woman to another."
"It is customary among the lower and middle ranks of people to make frequent
personal visits to puerperal women resident in the same neighborhood, and I
have ample evidence for affirming that the infection of the disease was often
carried about in that manner; and, however painful to my feelings, I must
in candour declare that it is very probable the contagion was conveyed, in
some instances, by myself, though I took every possible care to prevent such
a thing from happening the moment that I ascertained that the distemper was
infectious." Dr. Armstrong goes on to mention six other instances within his
knowledge, in which the disease had at different times and places been
limited, in the same singular manner, to the practice of individuals, while
it existed scarcely, if at all, among the patients of others around them.
Two of the gentlemen became so convinced of their conveying the contagion
that they withdrew for a time from practice.
I find a brief notice, in an American journal, of another series of
cases, first mentioned by Mr. Davies, in the "Medical Repository." This
gentleman stated his conviction that the disease is contagious.
"In the autumn of 1822 he met with twelve cases, while his medical
friends in the neighbourhood did not meet with any, `or at least very few.` He
could attribute this circumstance to no other cause than his having been
present at the examination after death, of two cases, some time previous, and
of his having imparted the disease to his patients, notwithstanding every
precaution."^2
Dr. Gooch says: "It is not uncommon for the greater number of cases to
occur in the practice of one man, whilst the other practitioners of the
neighborhood, who are not more skilful or more busy, meet with few or none. A
practitioner opened the body of a woman who had died of puerperal fever, and
continued to wear the same clothes. A lady whom he delivered a few days
afterwards was attacked with and died of a similar disease; two more of his
lying-in patients, in rapid succession, met with the same fate; struck by the
thought that he might have carried contagion in his clothes, he instantly
changed them, and met with no more cases of the kind.^3 A woman in the country
who was employed as washerwoman and nurse washed the linen of one who had died
of puerperal fever; the next lying-in patient she nursed died of the same
disease; a third nursed by her met the same fate, till the neighbourhood,
getting afraid of her, ceased to employ her."^4
[Footnote 2: Philad. Med. Journal for 1825, p. 408.]
[Footnote 3: A similar anecdote is related by Sir Benjamin Brodie, of the late
Dr. John Clark, Lancet, May 2, 1840.]
[Footnote 4: An Account of Some of the Most Important Disease Peculiar to
Women, p. 4.]
In the winter of the year 1824, "several instances occurred of its
prevalence among the patients of particular practitioners, whilst others who
were equally busy met with few or none. One instance of this kind was very
remarkable. A general practitioner, in large midwifery practice, lost so many
patients from puerperal fever that he determined to deliver no more for some
time, but that his partner should attend in his place. This plan was pursued
for one month, during which not a case of the disease occurred in their
practice. The elder practitioner, being then sufficiently recovered, returned
to his practice, but the first patient he attended was attacked by the disease
and died. A physician who met him in consultation soon afterwards, about a
case of a different kind, and who knew nothing of his misfortune, asked him
whether puerperal fever was at all prevalent in his neighbourhood, on which he
burst into tears, and related the above circumstances.
"Among the cases which I saw this season in consultation, four occurred
in one month in the practice of one medical man, and all of them terminated
fatally."^5
[Footnote 5: Gooch, op. cit., p. 71.]
Dr. Ramsbotham asserted, in a lecture at the London Hospital, that he had
known the disease spread through a particular district, or be confined to the
practice of a particular person, almost every patient being attacked with it,
while others had not a single case. It seemed capable, he thought, of
conveyance, not only by common modes, but through the dress of the attendants
upon the patient.^6
[Footnote 6: Lond. Med. Gaz., May 2, 1835.]
In a letter to be found in the "London Medical Gazette" for January,
1840, Mr. Roberton, of Manchester, makes the statement which I here give in a
somewhat condensed form.
A midwife delivered a woman on the 4th of December, 1830, who died soon
after with the symptoms of puerperal fever. In one month from this date the
same midwife delivered thirty women, residing in different parts of an
extensive suburb, of which number sixteen caught the disease and all died.
These were the only cases which had occurred for a considerable time in
Manchester. The other midwives connected with the same charitable institution
as the woman already mentioned are twenty-five in number, and deliver, on an
average, ninety women a week, or about three hundred and eighty a month. None
of these women had a case of puerperal fever. "Yet all this time this woman
was crossing the other midwives in every direction, scores of the patients of
the charity being delivered by them in the very same quarters where her cases
of fever were happening."
Mr. Roberton remarks that little more than half the women she delivered
during this month took the fever; that on some days all escaped, on others
only one or more out of three or four; a circumstance similar to what is seen
in other infectious maladies.
Dr. Blundell says: "Those who have never made the experiment can have but
a faint conception how difficult it is to obtain the exact truth respecting
any occurrence in which feelings and interests are concerned. Omitting
particulars, then, I content myself with remarking, generally, that from more
than one district I have received accounts of the prevalence of puerperal
fever in the practice of some individuals, while its occurrence in that of
others, in the same neighborhood, was not observed. Some, as I have been told,
have lost ten, twelve, or a greater number of patients, in scarcely broken
succession; like their evil genius, the puerperal fever has seemed to stalk
behind them wherever they went. Some have deemed it prudent to retire for a
time from practice. In fine, that this fever may occur spontaneously, I admit;
that its infectious nature may be plausibly disputed, I do not deny; but I
add, considerately, that in my own family I had rather that those I esteemed
the most should be delivered, unaided, in a stable, by the mangerside, than
that they should receive the best help, in the fairest apartment, but exposed
to the vapors of this pitiless disease. Gossiping friends, wet-nurses, monthly
nurses, the practitioner himself, these are the channels by which, as I
suspect, the infection is principally conveyed."^7
[Footnote 7: Lect. on Midwifery, p. 395.]
At a meeting of the Royal Medical and Chirurgical Society Dr. King
mentioned that some years since a practitioner at Woolwich lost sixteen
patients from puerperal fever in the same year. He was compelled to give up
practice for one or two years, his business being divided among the
neighboring practitioners. No case of puerperal fever occurred afterwards,
neither had any of the neighboring surgeons any cases of this disease.
At the same meeting Mr. Hutchinson mentioned the occurrence of three
consecutive cases of puerperal fever, followed subsequently by two others, all
in the practice of one accoucheur.^8
[Footnote 8: Lancet, May 2, 1840.]
Dr. Lee makes the following statement: "In the last two weeks of
September, 1827, five fatal cases of uterine inflammation came under our
observation. All the individuals so attacked had been attended in labor by the
same midwife, and no example of a febrile or inflammatory disease of a serious
nature occurred during that period among the other patients of the Westminster
General Dispensary, who had been attended by the other midwives belonging to
that institution."^9
[Footnote 9: Lond. Cyc. of Pract. Med., art., "Fever, Puerperal."]
The recurrence of long series of cases like those I have cited, reported
by those most interested to disbelieve in contagion, scattered along through
an interval of half a century, might have been thought sufficient to satisfy
the minds of all inquirers that here was something more than a singular
coincidence. But if, on a more extended observation, it should be found that
the same ominous groups of cases clustering about individual practitioners
were observed in a remote country, at different times, and in widely separated
regions, it would seem incredible that any should be found too prejudiced or
indolent to accept the solemn truth knelled into their ears by the funeral
bells from both sides of the ocean - the plain conclusion that the physician
and the disease entered, hand in hand, into the chamber of the unsuspecting
patient.
That such series of cases have been observed in this country, and in this
neighborhood, I proceed to show.
In Dr. Francis` "Notes to Denman`s Midwifery" a passage is cited from
Dr. Hosack in which he refers to certain puerperal cases which proved fatal to
several lying-in women, and in some of which the disease was supposed to be
conveyed by the accoucheurs themselves.^10
[Footnote 10: Denman`s Midwifery, p. 675, third Am. ed.]
A writer in the "New York Medical and Physical Journal" for October,
1829, in speaking of the occurrence of puerperal fever confined to one man`s
practice, remarks: "We have known cases of this kind occur, though rarely, in
New York."
I mention these little hints about the occurrence of such cases partly
because they are the first I have met with in American medical literature, but
more especially because they serve to remind us that behind the fearful array
of published facts there lies a dark list of similar events, unwritten in the
records of science, but long remembered by many a desolated fireside.
Certainly nothing can be more open and explicit than the account given by
Dr. Peirson, of Salem, of the cases seen by him. In the first nineteen days of
January, 1829, he had five consecutive cases of puerperal fever, every patient
he attended being attacked, and the three first cases proving fatal. In March
of the same year he had two moderate cases, in June, another case, and in
July another, which proved fatal. "Up to this period," he remarks, "I am not
informed that a single case had occurred in the practice of any other
physician. Since that period I have had no fatal case in my practice, although
I have had several dangerous cases. I have attended in all twenty cases of
this disease, of which four have been fatal. I am not aware that there has
been any other case in the town of distinct puerperal peritonitis, although, I
am willing to admit my information may be very defective on this point. I have
been told of some `mixed cases,` and `morbid affections after delivery.`"^11
[Footnote 11: Remarks on Puerperal Fever, pp. 12 and 13.]
In the "Quarterly Summary of the Transactions of the College of
Physicians of Philadelphia"^12 may be found some most extraordinary
developments respecting a series of cases occurring in the practice of a
member of that body.
[Footnote 12: For May, June, and July, 1842]
Dr. Condie called the attention of the Society to the prevalence, at the
present time, of puerperal fever of a peculiarly insidious and malignant
character. "In the practice of one gentleman extensively engaged as an
obstetrician nearly every female he has attended in confinement, during
several weeks past, within the above limits" (the southern sections and
neighboring districts), "had been attacked by the fever."
"An important query presents itself, the doctor observed, in reference to
the particular form of fever now prevalent. Is it, namely, capable of being
propagated by contagion, and is a physician who has been in attendance upon a
case of the disease warranted in continuing, without interruption, his
practice as an obstetrician? Dr. C., although not a believer in the contagious
character of many of those affections generally supposed to be propagated in
this manner, has, nevertheless become convinced by the facts that have fallen
under his notice that the puerperal fever now prevailing is capable of being
communicated by contagion. How, otherwise, can be explained the very curious
circumstance of the disease in one district being exclusively confined to the
practice of a single physician, a Fellow of this College, extensively engaged
in obstetrical practice, while no instance of the disease has occurred in the
patients under the care of any other accoucheur practising within the same
district; scarcely a female that has been delivered for weeks past has escaped
an attack?"
Dr. Rutter, the practitioner referred to, "observed that, after the
occurrence of a number of cases of the disease in his practice, he had left
the city and remained absent for a week, but, on returning, no article of
clothing he then wore having been used by him before, one of the very first
cases of parturition he attended was followed by an attack of the fever and
terminated fatally; he cannot readily, therefore, believe in the transmission
of the disease from female to female in the person or clothes of the
physician."
The meeting at which these remarks were made was held on the 3d of May,
1842. In a letter dated December 20, 1842, addressed to Dr. Meigs, and to be
found in the "Medical Examiner,"^13 he speaks of "those horrible cases of
puerperal fever, some of which you did me the favor to see with me during the
past summer," and talks of his experience in the disease, "now numbering
nearly seventy cases, all of which have occurred within less than a twelve
month past."
[Footnote 13: For January 21, 1843.]
And Dr. Meigs asserts, on the same page, "Indeed, I believe that his
practice in that department of the profession was greater than that of any
other gentleman, which was probably the cause of his seeing a greater number
of the cases." This from a professor of midwifery, who some time ago assured a
gentleman whom he met in consultation that the night on which they met was the
eighteenth in succession that he himself had been summoned from his repose,^14
seems hardly satisfactory.
[Footnote 14: Medical Examiner for December 10, 1842.]
|
