The Contagiousness of Puerperal Fever

Summary

The Contagiousness of Puerperal Fever is an essay that Oliver Wendell Holmes, then a young Boston physician, read to the Boston Society for Medical Improvement in 1843 and printed in a short-lived medical journal. Puerperal fever, or childbed fever, was an infection of the womb after childbirth that killed many mothers in the first days after delivery, sometimes in clusters around a single doctor or midwife. Holmes collected reports from Britain and America of physicians, nurses and midwives whose patients fell ill one after another while those of their neighbours escaped. One doctor lost several patients in a row after examining a woman who had died of the fever; another case followed a physician who had performed an autopsy and then gone directly to a delivery. Holmes argued that the disease was carried from patient to patient by the attendants themselves, on their hands and clothes. He did not know about bacteria, which were not yet understood as causes of disease, but he reasoned from the pattern of cases. The essay ends with practical rules: a physician who attends births should not take part in post-mortem examinations of fever victims; after a case of puerperal fever he should wash, change his clothes and wait before attending another birth; and a series of cases in one practice should be treated as a warning to stop. Holmes concluded that a 'private pestilence' in a single doctor's practice should be looked upon not as a misfortune but as a crime. Leading obstetricians in Philadelphia, especially Charles Meigs and Hugh Hodge, rejected the idea that gentlemen could carry disease. In 1855 Holmes reprinted the essay as a pamphlet with a sharp new introduction answering them. In Vienna, Ignaz Semmelweis reached a similar conclusion independently in 1847. Their argument was confirmed when Pasteur and others identified streptococcus bacteria in the fever.

Plot or Argument

• The question

  Holmes asks whether puerperal fever is carried from patient to patient by doctors and nurses.

• The evidence

  He gathers series of cases in which one attendant's patients fell ill in succession while neighbouring practices were spared.

• Autopsies and contagion

  He notes cases following post-mortem examinations and links the disease to infections from dissection wounds.

• Answering objections

  He replies to those who say the cases are coincidence or the effect of the season or atmosphere.

• The rules

  He closes with eight practical conclusions for physicians and nurses.

Lessons

• Arguing from patterns

  Holmes had no microscope evidence, yet he built a convincing argument from the pattern of cases. Clusters around one attendant were hard to explain any other way.

  • What pattern did Holmes notice?
  • Why is a pattern of cases strong evidence even without knowing the cause?

• Professional pride

  Some leading doctors were offended by the suggestion that they carried disease. Holmes shows how pride can prevent people from accepting evidence that implicates themselves.

  • Why did some physicians reject Holmes's argument?
  • When is it hardest to accept evidence against ourselves?

• Duty to the vulnerable

  Holmes insists that a doctor's duty to his patients outweighs his convenience or reputation. Women in childbirth had no way to protect themselves.

  • What does Holmes say a doctor must do after a case of the fever?
  • Why does Holmes call a preventable outbreak a crime rather than a misfortune?

• For the Christian reader

  Holmes, a Unitarian, wrote as a moralist as well as a doctor. Scripture calls for care of the vulnerable and repentance when we harm others unknowingly; his essay asks professionals to examine their own hands before blaming fate.

  • How does the essay connect knowledge with responsibility?
  • What might it mean to repent of harm we did not intend?

Context

In the 1840s doctors increasingly attended births that midwives once handled, and many also performed autopsies. Theories of disease emphasized bad air and the constitution of the patient; the germ theory lay twenty years in the future.

Composition

Holmes read the paper to the Boston Society for Medical Improvement in 1843, and it appeared in the New England Quarterly Journal of Medicine and Surgery. After attacks by Philadelphia professors he reissued it in 1855 as Puerperal Fever, as a Private Pestilence, with a new introduction. The Harvard Classics reprinted it in 1910.

Reception

Few physicians accepted the argument at first. Semmelweis's work in Vienna (1847) and later bacteriology confirmed it, and the essay is now regarded as a classic of American medicine and of the history of infection control.

Comparisons

• Germ Theory Papers (Pasteur and Lister)

  Pasteur and Lister supplied the germ theory that explained what Holmes inferred from patterns of cases.

• An Inquiry into the Causes and Effects of the Variolae Vaccinae (with Further Observations and A Continuation of Facts)

  Jenner's case series in the same Harvard Classics volume shows a similar method of argument.

• Hippocratic Writings

  The Hippocratic ideal of first doing no harm stands behind Holmes's demand that doctors examine themselves.

• The Nuremberg Code (Permissible Medical Experiments)

  Later ethics codes formalize the duty Holmes describes: the physician bears personal responsibility for harm to patients.

Quotes

For Students

A reading companion for classical Christian high school students. See the student guide.

Reading Guide

Watch for

• How Holmes groups cases by practitioner.
• The rules at the end of the essay.
• How he treats objections from respected doctors.
• The tone of moral urgency.

Key terms and names

Puerperal fever

An infection of the womb after childbirth, also called childbed fever.

Contagion

The passing of a disease from one person to another, directly or by an object or carrier.

Post-mortem examination

An autopsy, the dissection of a body after death to learn the cause of death.

Accoucheur

A man who attends women in childbirth; an obstetrician.

Seminar Questions

1. Comprehension What kinds of evidence does Holmes collect?
2. Comprehension What must a physician do after attending a case of the fever, according to Holmes?
3. Interpretation Why did Holmes's critics resist his conclusion?
4. Interpretation How does Holmes turn a medical argument into a moral one?
5. Interpretation Why do you think many physicians resisted Holmes's conclusion that they themselves carried the disease?
6. Big Question Who is responsible when harm is caused by ignorance rather than intent?

Faith Connections

• Psalm 139:23–24 (Scripture)

  "Search me, O God": the call to examine oneself honestly, as Holmes asks doctors to do.

• Leviticus 15:13 (Scripture)

  Washing of clothes and body for cleansing; ancient law tied purity to washing, a theme echoed in Holmes's rules.

• Hippocratic Oath (Great Conversation)

  The promise to do no harm underlies Holmes's argument.

Logic and Rhetoric

Central argument: Puerperal fever is carried from patient to patient by doctors and nurses, so attendants have a moral duty to take precautions and to stop practice when cases cluster.

Rhetorical device: moral climax. Holmes builds from clinical cases to the moral verdict that a private pestilence is a crime.

Debate: Resolved: that professionals should be held responsible for harms they cause through ignorance.

Memory Work

the time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon, not as a misfortune, but a crime

Writing Prompts

Essay: Explain how Holmes uses evidence and moral argument together. Which is stronger in the essay?

Comparison with An Inquiry into the Causes and Effects of the Variolae Vaccinae (with Further Observations and A Continuation of Facts): Compare how Holmes and Jenner use series of cases to persuade doctors.

Medical Lens

A founding text of infection control in obstetrics, arguing from case clusters that attendants transmitted childbed fever.

• The essay

  Series of cases clustered around single attendants.

  Childbirth Maternal Fever Infection
• Conclusions 1–8

  Practical rules on autopsies, washing and suspending practice.

  Medical Ethics Public Health Sanitation

Creative Prompts

• Essay

  Compare Holmes's argument with Semmelweis's handwashing evidence. Which is more persuasive, and why?

• Dialogue

  Write an exchange between Holmes and a Philadelphia professor who rejects his claims.

• Classroom

  Chart the case clusters Holmes reports and explain what they suggest.

Further Reading

• The Doctors' Plague, Sherwin B. Nuland

  On Semmelweis and childbed fever.