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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 siudied 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 practise. 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's 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 Ironsidesbrought 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

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N collecting, enforcing and adding to the evidence ac

cumulated 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.

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 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.

Note:- This essay appeared first in 1843, in The New England Quarterly Journal of Medicine, and was reprinted in the “ Medical Essays " in 1855.

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's 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 what I am now about to communicate to be of some importance, I imagine it cannot be uninteresting to you, especially as it will serve to corroborate your assertion of the susceptibility of the human system of the variolous contagion, although it has previously been made sensible of its action. In November, 1793, I was desired to inoculate a person with the smallpox. I took the variolous matter from a child under the disease in the natural way, who had a large burthen of distinct pustules. The mother of the child being desirous of seeing my method of communicating the disease by inoculation, after having opened a pustule, I introduced the point of my lancet in the usual way on the back part of my own hand, and thought no more of it until I felt a sensation in the part which reminded me of the transaction. This happened upon the third day; on the fourth there were all the appearances common to inoculation, at which I was not at all surprised, nor did I feel myself uneasy upon perceiving the inflammation continue to increase to the sixth and seventh day, accompanied with a very small quantity of fluid, repeated experiments having taught me it might happen so with persons who had undergone the disease, and yet would escape any constitutional affection; but I was not so fortunate; for on the eighth day I was seized with all the symptoms of the eruptive fever, but in a much more violent degree than when I was before inoculated, which was about eighteen years previous to this, when I had a considerable number of pustules. I must confess I was now greatly alarmed, although I had been much engaged in the smallpox, having at different times inoculated not less than two thousand persons. I was convinced my present indisposition proceeded from the insertion of the variolous matter, and, therefore, anxiously looked for an eruption. On the tenth day I felt a very unpleasant sensation of stillness and heat on each side of my face near my ear, and the fever began to decline. The affection in my face soon terminated in three or four pustules attended with inflammation, but which did not maturate, and I was presently well.

“I remain, dear sir, etc.,

“THOMAS MILES.”

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