A System of Midwifery Part 31

It should be very slowly performed, and we should have at each step of the progress a.s.surances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care."

(_Op. cit._ p. 463.)

When once the os uteri is sufficiently dilated to admit the hand, there will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of haemorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circ.u.mstances. The placenta, which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was effected without difficulty. In this instance, haemorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (_Med. Gaz._ Sep. 2, 1837.) The after treatment should be conducted upon the same principles as in other cases of haemorrhage.

_Partial presentation of the placenta._ Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial delivery by turning. The edge of the placenta frequently projects but a very little over that of the os uteri, feeling, as it were, like a second lip; at other times it covers a third or more of the opening, and is usually attached upon the anterior portion of it. Our own observations have rather led to the conclusion, that where the placenta is but partially attached over the os uteri, the first attack of flooding is rarely delayed until the full term of pregnancy, but makes its appearance some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar reason we may understand why the haemorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os uteri being prevented dilating by the close adhesion of the placenta--an opinion which is, moreover, approved of by Dr. Dewees as being "both ingenious and probable." Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall seldom find the haemorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those difficulties connected with a contracted and unyielding state of the os uteri, which we described in cases of central presentation; and if the hand requires to be introduced, which is not often the case, it will seldom experience much opposition.

_Treatment._ In our treatment of partial presentation of the placenta, we must be guided, in a great measure, by the strength of the pains and the degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be sufficient to check the haemorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the membranes will diminish the size of the uterus, and thus excite it to more powerful contraction; if not, a dose of secale cornutum, repeated according to circ.u.mstances, will be of great a.s.sistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quant.i.ties frequently repeated, will rouse the powers; wine or a little brandy, may also be given at intervals; but unless the prostration be very serious, we have not found stimulants so useful as beef-tea, which is usually, also, much more grateful.

CHAPTER XIII.

PUERPERAL FEVERS.

_Nature and varieties of puerperal fever.--Vitiation of the blood.-- Different species of puerperal fever.--Puerperal peritonitis.-- Symptoms.--Appearances after death.--Treatment.--Uterine phlebitis.-- Symptoms.--Appearances after death.--Treatment.--Indications.--False peritonitis.--Treatment.--Gastro-bilious puerperal fevers.-- Symptoms.--Appearances after death.--Treatment.--Contagious, or adynamic, puerperal fevers.--Symptoms.--Appearances after death.-- Treatment._

In enumerating the different species of Dystocia, we have mentioned a long list of causes, by which the process of labour might be rendered one of considerable danger either to the mother or her child; but, for the most part, they are not of very common occurrence, those only which are of trifling import being met with most frequently. Even under the most dangerous forms of dystocia, as for instance, convulsions, and the different forms of haemorrhage, the danger, although great, is capable of being averted, from the mother at least, in the majority of instances by timely and skilful a.s.sistance; the means of treatment which art and experience have supplied us with, being generally capable of affording both certain and effective relief, if used according to the rules which we have given when treating of these subjects; but we now come to a source of danger which follows the most favourable as well as unfavourable labours--which is extremely varied in its nature, fatal in its effects, and (what renders it so peculiarly formidable) by no means uncommon in its occurrence.

Of all the dangers to which a lying-in woman is exposed, puerperal fever is by far the most to be dreaded: there are few or no difficulties during parturition which the pract.i.tioner has to contend with that can be compared to it; there are none in which he is frequently made to feel so helpless, and his various means of treatment so utterly inefficacious; certain it is that puerperal fever in its worst forms has occasionally committed such ravages among patients of this cla.s.s as to rival in destructiveness the most malignant pestilences with which the human race has been afflicted.

One of the greatest improvements in our knowledge of puerperal fever which has taken place in modern times, is the having ascertained that it is not one specific disease, but occurs under different forms, each of which is subject to a good deal of variety, depending upon individual peculiarity, season of the year, and numberless other circ.u.mstances. The chief error into which authors have fallen when treating of this difficult subject, is their having merely described the peculiar form of disease which had come under their own notice, and to which they have exclusively awarded the name of puerperal fever--an error in judgment which has led to still greater errors in practice, and which has certainly tended to prevent the subject being so clearly understood as it might have been. The mode also in which it has been investigated by modern authors has been but of little a.s.sistance in disclosing the true features of the disease; they have indeed rather tended to mislead than to guide us, they have directed our attention to certain effects of it, which they have considered to be the disease itself, and thus rather conceal than disclose the real _natura morbi_.

In our printed lectures on puerperal fever we have taken a similar view.

"I am not sure if the present fas.h.i.+onable morbid anatomy of the day, misnamed pathology, has a.s.sisted so much in developing the real nature of the disease as has been supposed: it appears to me rather to have withdrawn the attention of pract.i.tioners from a close observation of the phenomena presented during life, to the inspection of those changes which are to be found after death. They have rather sought to examine the _effects_ of the disease at a time when it had attained such an extent as to be incompatible with life, than to investigate upon correct and physiological grounds the series of changes which were taking place during the earlier periods." (_London Med. and Surg. Journ._ June 27, 1835.) Dr.

Alison, of Edinburgh, in his dissertation on the state of medical science (_Cyc. Prac. Med._) has taken a similar view of this prevailing mode of investigating the nature of disease; he considers that it is "an important practical error to fix the attention, particularly of students of the profession, too much on those characters of disease which are drawn from changes of structure _already effected_, and to trust too exclusively to these as the diagnostics of different diseases, because in many instances these characters are not clearly perceptible until the latest and least remediable stage of diseases--the very object of the most important practice is to _prevent_ the occurrence of the changes on which they depend. Accordingly, when this department of pathology is too exclusively cultivated, the attention of students is often found to be fixed on the lesions to be expected after death, much more than on the power and application of remedies either to control the diseased actions, or relieve the symptoms during life."

"Pathological anatomy (says Dr. Stevens) is but one of the many 'points of view in which we may consider the science of disease,' and notwithstanding all that has been said about 'la medicine eclariree par les ouvertures des cadavres,' I have a firm belief that morbid anatomy has done little good, particularly in the hands of those who do not understand its real value; for those who are constantly mistaking the effect for the cause, or confounding the immediate cause of death with the cause of the disease, and forming theories on this foundation, not only deceive themselves, but unfortunately, particularly for the inhabitants of hot climates, they have deceived others." (_Obs. on the Healthy and Diseased Properties of the Blood_, p. 182.)

We have made our last quotation from one of the most valuable and original works of the present day upon the subject of fevers, and which has tended in great measure to unveil the mysterious nature of these diseases. Dr.

Steven's researches have been conducted in the truest spirit of pathological inquiry, and form a striking contrast with the modern morbid anatomy of puerperal fevers.

We use the term _puerperal fevers_ precisely with the same meaning as Dr.

Loc.o.c.k has done in his valuable essay on this subject (_Library of Pract.

Med._ vol i.,) requesting our readers to bear in mind his observation, "that they vary in their nature and treatment as much as other kinds of fevers;" that whether occurring sporadically or in epidemics, they rarely, appear twice alike, but vary with the season of the year and the type of the prevailing fevers of the place; they are influenced by the rank, habits, and const.i.tution of the patient, as well as by the nature and locality of her residence.

Although we cannot quite coincide with the views of Dr. Ferguson to their fullest extent, respecting the exclusive cause of the various forms of puerperal fever, viz. the vitiation of the fluids, still, in great measure, we consider them as correct, having not only taught them for many years, but published them in our lectures on this subject in 1835. Much praise is due to the last two mentioned authors for the able manner in which they have handled this difficult subject, they have carefully sifted the ma.s.s of jarring opinions, and tested them by their own great experience; and have not only reduced the subject to a simpler form, but have succeeded, we trust, in removing the very erroneous views of some modern authors respecting the supposed ident.i.ty of certain forms of local inflammation with this disease.

Having drawn our information upon puerperal fevers from the same ample source, we willingly bear testimony to the accuracy with which they have described the different forms; and trust that in giving a detail of our own opinions and observations, it will be found that so far from differing from them, we have tended to confirm, reconcile, and carry out their views.

_Nature and varieties of puerperal fever._ The history of puerperal fevers at the General Lying-in Hospital, would of itself afford an excellent monograph on this cla.s.s of diseases in all their varied forms. When we resided at the hospital in 1826, the cases were all of the inflammatory character; they appeared to occur sporadically, among the out as well as the in-patients; and were successfully relieved by bleeding, hot poultices, and a mercurial purge, and occasionally leeches. During the following years, an epidemic of a highly malignant character spread destruction rapidly among the patients, setting at defiance the treatment previously employed. Still more remarkable was the sudden change in the character of the disease noticed by Dr. Loc.o.c.k in 1822. "In the spring of 1822, puerperal fever existed in the lying-in hospital in two very different and well-marked forms, at an interval of about six weeks between the last case of the first epidemic and first case of the second. The early cases were of an active inflammatory character; the peritoneal covering of the uterus and intestines was chiefly affected; the alb.u.minous and serous effusions in the fatal cases showed a sthenic state of the system, that is, the serum was clear, the coagulable lymph firm and white; the patients bore blood-letting, and other active treatment to a great extent, fairly, and with much advantage; the blood drawn was strongly cupped and highly buffed, and the fatal cases were few. Six weeks afterwards a very different epidemic was found to exist. The same remedies which had been so beneficial a few weeks before, were naturally at first tried, but their bad success confirmed the sagacious remark of Gooch, that 'the effects of remedies form not only an essential but an important part of their history.' (Gooch _on Peritoneal Fevers_, p. 35.) The fever was attended with marked oppression and debility; the local pain was comparatively slight; the pulse was extremely rapid from the first, with no force, and easily compressible. In many of the cases, purulent deposites took place in the joints and in the calves of the legs, and in one case there was destructive inflammation of the eye." (Loc.o.c.k, _op.

cit._ p. 349.)

The various forms and modifications under which puerperal fevers have appeared at different times, have produced an equal variety of arrangement in the cla.s.sifications of authors. Thus, some who have attributed the disease to inflammation, have merely distinguished its varieties according to the different organs which have exhibited after death appearances of congested or injected vessels, or have been covered and imbedded in effusions of coagulable lymph, &c., or have had their structure more or less broken down and disorganized. Thus, for instance, Dr. R. Lee is of opinion, that "inflammation of the uterus and its appendages must be considered as essentially the cause of all the destructive febrile affections which follow parturition; and that the various forms they a.s.sume, inflammatory, congestive, and typhoid, will in great measure be found to depend on whether the serous, the muscular, or the venous, tissue of the organ has become affected." (_Med. Chir. Trans._ vol. xv. part ii.

p. 405, 1829.) He accordingly arranges "the princ.i.p.al varieties of inflammation of the uterus in puerperal women under the following heads, viz. 1. Inflammation of the peritoneal covering of the uterus, and of the peritoneal sac; 2. Inflammation of the uterine appendages, ovaria, fallopian tubes, and broad ligaments; 3. Inflammation of the muscular and mucous tissues of the uterus; 4. Inflammation and suppuration of the absorbent vessels and veins of the uterine organs." (_Cyc. Pract. Med._ art. PUERPERAL FEVER.) This arrangement is manifestly incorrect, and by giving so partial a view of puerperal fevers, must, if adopted, necessarily lead to serious errors in practice. "That these forms of inflammation are the proximate cause of the various febrile affections is most completely refuted by the detail of his own (Dr. Lee's) experience, as relates to the varieties occurring under similar circ.u.mstances."

(Moore, _on Puerp. Fever_.) We may also add, that, according to our own experience, and that of our colleagues at the General Lying-in Hospital, in the worst forms of puerperal fever, the fewest traces of inflammation have been observed; and that in the severest and most rapidly fatal cases it has frequently happened, that not a single vestige of inflammation could be detected. In our review of Mr. Moore's able work in the _Brit.

and For. Med. Rev._ Oct. 1836, p. 483, we have made a similar remark, and quoted a striking pa.s.sage from Dr. Stevens, when speaking of contagious fevers, that "there is not one symptom of inflammation during the fatal progress of the disease, nor one inflammatory spot to be seen after death, to mark its existence, or to induce us to believe that any thing but functional disease had existed in any of the solids; yet these are the very cases of all others which are the most fatal." (_On the blood_, p.

179.)

In many of the worst cases which have come under our notice, there has neither been time nor power sufficient to produce either a symptom or a trace of inflammation; the powers of life have from the very commencement sunk under the deadly influence of the disease, without a single effort to establish even a temporary reaction in the system: hence, in most instances, we are led to the necessary conclusion, that inflammation, when it does appear, is the result of disease, not the disease of inflammation.

"For," as Dr. Ferguson observes, "if any or more of these (phlebitis, peritonitis, &c.) be a.s.sumed as const.i.tuting the essence of puerperal fever, abundant examples may be found of puerperal fever, in which the cause fixed on is absent. Thus to believers in the ident.i.ty of peritonitis and puerperal fever, we can show puerperal fever with a perfect healthy peritoneum. To those who insist on inflammation of the uterine veins, as const.i.tuting puerperal fever, we can show the genuine disease without this condition." (_Essays on the most important Diseases of Women_, part i. PUERPERAL FEVER, p. 81.)

The _vitiation of the blood_ has long been a subject which has excited our deepest interest, and the admirable researches of Dr. Stevens upon the condition of this fluid under the effects of malignant fevers, have tended to disclose the real nature of the diseases under consideration. We have long been convinced that one of the causes of puerperal fever is the absorption of putrid matters furnished by the coagula and discharges which are apt to be retained in the uterus and pa.s.sages after parturition,--a view which has been adopted by Kirkland, C. White, and other older authors. It is with sincere pleasure that we now find ourselves supported by the able author, from whom we have just quoted, in this opinion. Dr.

Ferguson's three positions respecting "the source and nature of puerperal fever" are highly valuable, for they have been deduced from careful physiological experiments, and not less sound physiological reasoning; they are as follows:--

1. The phenomena of puerperal fever originate in a vitiation of the fluids.

2. The causes which are capable of vitiating the fluids are particularly rife after childbirth.

3. The various forms of puerperal fever depend on this one cause, and may readily be deduced from it.

We do not agree with him in supposing that every form of puerperal inflammation is produced by vitiation of the circulating fluids, because in one species of uterine phlebitis, which occurred sporadically, and prevailed a good deal from 1829 to 1832, it was, in our opinion, evidently produced _directly_ by the absorption of putrid matter into the uterine veins and lymphatics, exciting inflammation in these vessels: the same cause, when only carried to a certain extent, produces a local inflammation, which, when affecting the general circulation, is followed by fever. Thus, then, we may have in the same case uterine phlebitis followed by the typhoid malignant puerperal fever--the local and const.i.tutional disturbance arising from the same cause, imbibition or absorption of putrid matter; the one being the local, the other the general effect, but not the one resulting from the other. The doctrine of the vitiation of the blood from its admixture with pus secreted by the lining membrane of an inflamed vein, though very plausible, still requires farther confirmation, for it is doubtful if the introduction of pure healthy pus into the circulation produces any of those dangerous effects which result from the absorption of putrid matters, whether purulent, sanious, mucous, &c. It is the introduction into the circulation of an animal poison generated by putrefaction, which destroys the vitality of the blood, and renders it unfit for maintaining the vital powers.

Few have expressed this opinion more strikingly than Dr. Kirkland, although so long ago as 1774; and it has often created our surprise, that amid all the numerous writings on this subject, which have excited attention during later years, so little notice should have been taken of his observations. We consider that Dr. Kirkland is one of the earliest authors who has shown that puerperal fever is not the result of inflammation, but that it may be produced by the introduction of an animal poison into the circulation. "There are other causes beside inflammation which bring on a puerperal fever; for it sometimes happens that coagulated blood lodges in the uterus after delivery, and putrefying from access of air, forms a most active poison, is in part absorbed, and brings on a putrid fever. In this case the discharge which should immediately follow delivery is not sufficiently large, making allowance for the difference which happens to different women in this respect: small clots of blood make part of the lochia, which are less in quant.i.ty than they ought to be; but the patient has not any other sort of complaint for three or four days till the retained blood begins to putrefy. A fever then first makes its appearance, followed by a quick weak pulse, thirst, pain in the head, want of sleep, sighing, load at the praecordia, restlessness, great weakness, dejection of spirits, either wildness or despair in the countenance, and the white of the eyes is often a little inflamed." (_A Treatise on Childbed Fevers_, by Thos. Kirkland, M. D. p. 70.)

The late Mr. Charles White, of Manchester, adopted a similar opinion, and in our published lectures we have quoted largely from these two authors in support of the opinions which we have there advanced.

Dr. Ferguson's opinion, that the different modes in which the poison infecting the circulation manifests itself, give rise to the different forms of puerperal fever, is highly interesting, and deserves great attention. He conceives that in some instances it spends its virulence upon the peritoneum, producing the inflammatory peritoneal form of puerperal fever. He considers that the gastro-enteric form arises "from the action of the poison being directed to the liver, the organ through which, as the experiments of Gaspard and Fontana, and the admission of all physiologists show, most poisons received into the system endeavour to escape." (_Op. cit._ p. 85.) These views have been proved by injecting putrilage, &c., into the veins of animals, and the effects of which, both as seen in the symptoms during life and the appearances after death, tend strongly to confirm these opinions; still we cannot feel justified in excluding inflammatory forms which have not been indirectly produced by the vitiation of the circulation, but which are the more direct effects of labour itself, or, as we have before observed, from the immediate absorption of putrilage, &c., into the veins and lymphatics, and production of inflammation in them. The production of inflammation in that part of a vein or absorbent, with which putrid matter has come in immediate contact, is an important fact, for it is by this means that nature prevents the poison being carried into the general system, and thus, instead of generating a malignant fever, she limits the injury to a local inflammation, by which farther mischief is confined by the effusion of coaguable lymph, tumefaction, and other means for rendering the vessels impervious. In making these remarks we wish it to be distinctly understood, that we by no means under-value the views brought forward by Dr. Ferguson, that "the introduction of a poison into the circulation is capable of producing local inflammation, varying according to the strength and qualities of the agent," &c.

The results of Professor Tiedemann's experiments, of which we have given an abstract in the _Brit. and For. Med. Rev._ vol. i. p. 241, contain some facts which throw much light as to the modus operandi of certain agents when mingled with the circulation, and tend still farther to prove the correctness of Dr. Ferguson's views. In the experiments where musk was injected into the femoral vein of a small b.i.t.c.h, the effects of the poison upon the abdominal viscera were remarkable; the veins of the abdomen were distended with dark coloured blood, the whole intestinal ca.n.a.l was very red, the mucous membrane of the stomach had a reddish tinge; that of the whole intestinal ca.n.a.l was of a dark red, it was swollen, turgid, and in the highest state of engorgement--the ca.n.a.l also contained a quant.i.ty of effused dark blood in its lower part; the vessels of the liver and spleen were gorged with dark blood.

We are anxious to impress upon the minds of our readers the physiological fact, that most, if not all, vegetable and animal poisons do not act _primarily_ on the nervous system, but indirectly through the medium of the circulation. "The physiological researches (as we have observed elsewhere) especially during the last thirty years, both in this country and the continent, have satisfactorily proved that most, if not all, of the agents which exert such destructive energies on the nervous system, do it through the medium of the circulation: this has been shown by the experiments of Christison and Coindet, of Brodie, Emmert, Viborg, and many others. Those of Sir B. Brodie on the action of the Woorara poison are well known. Emmert showed this to be the case in a still more striking manner, by amputating the leg of an animal, and leaving it connected to the body only by means of the nerves; poisonous substances introduced into the foot produced no effects, not even when applied to the trunk of the nerve; and Viborg even applied one drachm of concentrated prussic acid to the brain of a horse, which had been exposed by trepanning, without producing any effect." (_Brit. and For. Med. Rev._ vol. i. p. 559.)

We cannot agree with the opinion, "that the vitiated state of the blood is the secondary and not the primary link in the chain of phenomena," and "that the nervous system is the main instrument by which this change in the blood takes place." (Loc.o.c.k, _op. cit._ p. 353.) "We believe that is _not_ the deficiency of nervous influence which primarily tends to deteriorate this fluid (although it may possibly react in this way afterwards,) but the deteriorated condition of this fluid, which renders it incapable of supplying the brain and nervous system with their due degree of energy." (_Brit. and For. Med. Rev._ vol. ii. p. 483, 1836.)

In considering the phenomena of fever, Dr. Stevens has well observed, that we must not look upon them "as the result of either a nervous impression, or local inflammation, for even in the beginning of fever its symptoms are universal and peculiar to itself. It is not, therefore, a local affection; and in all the idiopathic fevers, but particularly in those that are produced by the aerial poisons, there is but one thing which is never absent, namely, the diseased condition of the whole circulating current, and, therefore, this alone can be fairly considered as essential to the disease. This morbid condition of the blood is decidedly the first link in the chain of those phenomena which const.i.tute fever, for even before the attack every drop of the vital currant is changed in its properties; and wherever this deranged blood can circulate, there fever extends its empire: for the cause which produces this disease is not confined to a part, but acts on every fibre, and in every tissue of the living system; it disturbs every function in the body, and deranges every faculty of the mind. All the excretions are in a diseased state, and every one of the secreted fluids is changed both in its quant.i.ty and quality. The blood is the medium that conveys the poison, while the impression on the nerves is merely the effect of the diseased condition of its natural stimulus." (_On the Blood_, p. 273.)

These observations just quoted, apply strictly to the causes as well as to the phenomena of puerperal fever, more especially of the adynamic kind; and show that, particularly in this form, we must not merely refer the cause to the absorption of putrid matters by the uterine veins and lymphatics, or to the commixture of the blood with pus secreted from the coats of an inflamed vein, but to the still more pervading and truly epidemic and contagious action of miasmata, with which the air that surrounds the patient is charged. The lungs afford a ready and ample means by which effluvia may be conveyed into the circulating current, and enables us to account for the fact adduced by Dr. Stevens, that in situations favourable to the production of fevers, the blood is frequently found in a very unhealthy state, even before the outbreak of the disease itself. Dr. Kirkland has nearly antic.i.p.ated the discoveries of later years upon this subject; and considering the time at which he wrote, we think that his observations are both interesting as well as valuable.

"Seeing then that an absorption of putrid matter will bring on a _puerperal fever_, with common symptoms, may we not conclude that the putrid miasms of lying-in hospitals will produce the same effect? Is it not reasonable to suppose, that the _puerperal fever_ which has been observed in hospitals, is owing to some cause peculiar to hospitals?

otherwise, would it not be equally frequent in other places? Dr. Pringle informs us that the foul air occasioned by one mortified limb brought on a malignant fever in the military hospital. Peu also seems to have proved, that the putrid _effluvia_ exhaling from wounded men brought on a fever which killed a great many child-bed women who lay in the same hospital; and are not the putrid _effluvia_ arising from the lochial discharge in lying-in hospitals capable of producing the same disease? I have sometimes been called to women in child-bed, where the offensive _effluvia_ arising from this kind of evacuation, pent up in a small close room, at once evinced to what cause their fever was owing; and though I have not any doubt, but in lying-in hospitals every attempt is made to preserve the air pure and the patient in a state of cleanliness, yet where many women lie in the same ward, it is perhaps impossible to obtain these advantages in the perfection to be wished." (_Op. cit._ p. 73.)

Van Swieten compared the state of the inner surface of the uterus with that of a large wound,--"Something of a like nature seems to be affected in the womb, but in a slighter manner, because the injury is here superficial, but on a broad surface." (_Comment. on Boerhaave_, -- 1329.) He quotes also an interesting description from Moschion of the changes which are observed in the evacuations after delivery,--"_Primo sanguis, secundo faeculentus et paucus, ultimo purulentus_." "It hence appears," he observes, "that that fever in lying-in women, which is called the milk fever, does not spring solely from the milk brought into the b.r.e.a.s.t.s, but also from the purifying of the womb by that gentle and superficial suppuration. But, as even the best pus when retained too long becomes acrid and putrefies, the same thing will hold with regard to the purulent evacuations after delivery, if they should be kept back." "But if that purulent matter does not come out, but being sucked back should be mixed with the humours, it may, being brought to the viscera by a bad metastasis of the morbid matter, give occasion to dangerous disorders."

This comparison by Van Swieten and Dr. Kirkland, of the state of the uterus with that of an open wound, has been recently brought into notice by Cruveilhier, and quoted by Dr. Ferguson, in his work. "All the uterine veins and arteries have been torn from the placenta, and they form a part of a large wound, and are, therefore bathed in all the secretions which necessarily take place while this wound is healing. In this respect the uterus presents an exact a.n.a.logy to the surface of an amputated stump; and it is, therefore, not surprising, that the secondary evils of amputation should be so similar to those of the puerperal state." (_Op. cit._ p. 75.) Professor Schonlein also considers that the contagion of puerperal fever has the greatest similarity with hospital gangrene.

The causes of puerperal disease which have been enumerated by Cruveilhier, apply almost solely to those inflammatory affections of the puerperal state which do not depend upon a vitiated state of the circulation, but "are derived from the changes induced by parturition, and are dependent on,

"1. The organic changes induced by pregnancy.

"2. Those induced by the act of labour.

"3. Those consecutive of labour.

"1. Pregnancy:--the hyperthrophy of the uterus; the enlargement of the ligamenta lata; the traction on the peritoneum of the neighbouring organs; the extraordinary development of the arteries, veins, and lymphatics.

"2. Changes induced by labour:--bruising of all the soft parts--they appear raw.