Moreover, he has negative evidence to the contrary, i. e. of having frequently made a careful medical examination of a patient affected with most malignant puerperal fever, and remained by the bedside for several minutes together, and subsequently examined some ordinary case in the ward, and yet the disease was not communicated.

3dly. The Strasburg Hospital seems to disprove the contagious nature of the disease. Here it has generally been observed (and that usually every two years), that the fever becomes so pestilential as to require the closure of the establishment for the purpose of disinfecting the wards. The females who at the time may be affected with puerperal fever are then removed to the division for midwives. Experience has shown that in such instances the disease does not spread. This statement is made upon the authority of Dr Wrieger, of Strasburg.

4thly. Allusion has been already made to the eight midwives and sixteen nurses, in the first division at Vienna. The former must, by law, be married women; and it is believed the same rule applies to the nurses. At any rate, it frequently happens that they become pregnant. Here we have persons in constant attendance upon the puerperal fever cases. Most, if not all, of these are usually confined in the hospital; the only difference in their case being, that they are generally delivered by one of the head-nurses, apart in a private ward, and that the medical men do not assist in the confinement. Now, although we have the means of contagion present here in an eminent degree, the author was, on careful inquiry, unable to hear of a single case where one of the nurses or midwives had puerperal fever.

5thly and lastly. The only facts which appears to give countenance to the view of contagion is the following. It often occurred that the infant of the female affected with puerperal fever died at the outset of the mother's illness; and, in such cases, a post-mortem examimation of the infant proved death invariably to have resulted from peritonitis. The fact is important, when taken in connection with the occurrence of peritonitis in husbands exposed to the contagion of puerperal fever from their wives, as noticed by Mr Storr. But here the evidence is not sufficiently clear to allow us to attribute the result to mere contagion. As there are good grounds for believing that the lochial discharge in ordinary puerperal fever is intensely poisonous in most cases, as also puerperal abscesses, &c., and that there is every reason to believe that the entire mass of the blood is poisoned in such cases; that, on the other hand, the child is very easily affected by any morbid qualities of the mother's milk (which, of all secretions, is, perhaps, that most easily modified by the state of the mother),-it seems more correct to conclude that the milk in this case becomes an animal poison to the child, the peculiar effect of which (in the same manner as cantharides may produce an inflammation of the urinary passages) is to produce peritonitis.

Infection.-Infection, properly so called, that peculiar morbid atmospheric influence which extends beyond the range of personal communication, through the respiratory organs perhaps, and which is distinct from epidemic influences, as well as from true contagion,—this influence could be unequivocally shown to exist in the Vienna Hospital. Many of the facts already adduced in speaking of contagion go far to disprove infection also; such as the non-occurrence of puerperal fever among the nurses. Moreover, the circumstances known to favour infection, i. e. want of cleanliness and ventilation in the wards, are absent. The patients are delivered in a ward especially set aside for that purpose. Moreover, on removal clean sheets are always given. lying-in chamber is partly cleaned every morning, thoroughly every three or four days, and even the very straw mattresses are changed;

The

and so it is with every ward. It may reasonably, therefore, be said that the greatest cleanliness prevails throughout the department; and generally the moment a patient becomes really sick with malignant puerperal fever, she is at once removed into a separate apartment. But, secondly, we have a strong argument against infection exerting so powerful an influence, in this fact, that if these regulations were inefficient, the disease ought to be infinitely more frequent and fatal in the division for midwives, where the wards are altogether less roomy and less airy. These considerations, it is believed, warrant the conclusion, that infection cannot be rightly looked upon as the cause which originates the puerperal fever of Vienna.

Direct application of poisonous matter, or inoculation.-Dr Blackman, of Edinburgh, it is believed, was the first who distinctly stated that it was probable, the medical attendant might communicate the disease, by retaining a portion of poison, subter ungues, which he subsequently directly applied on making an examination per vaginam.* Though this fact may have been suspected by many others, yet, so far as the author is aware, he believes that it was first clearly enunciated by Dr Semelweiss, the assistant-physician of the first obstetric division at Vienna. Reasoning upon some of the facts before noticed, Dr Semelweiss was led to infer, that the real source of the infection was to be found in the hands of the medical men in attendance contaminated with cadaveric poisons; these gentlemen having all more or less diligently attended the numerous autopsies in the dead-house, and frequently handled, as a matter of course, the specimens of disease found. Now, Dr Semelweiss remarks that, after handling dead matter, the hands, however well washed, still retain a peculiarly fetid cadaveric odour, which does not disappear for several hours, and sometimes not till the next day. The presence of this smell implies the retention on the surface, or imbibition by the epidermis, of a quantity, however small, of cadaveric matter. Again, when it is remembered that in many dead houses, from the absence of a nail brush, frequently of scap and warm water, the hands cannot be properly washed, it is exceedingly probable that a portion of this cadaveric matter is retained under the nails; and it is very easy to understand how, on examination made subsequently per vaginam, this poison should be directly and effectively applied. In this manner he supposed the disease was so frequently generated in the wards of the first division, and explained the sanitary condition of the second division, since the midwives made no autopsies, and worked on the phantom, and so did not get their hands infected with cadaveric matter.

Acting upon this belief, Dr Semelweiss recommended all students frequenting the division not to handle dead matter, or if they did, he forbade them to make any examination till the following day. In the second place, he directed all the students who attended the practice of the division to wash their hands in a solution of chlorine prior to and after every examination made on the living subject. The result of these precautionary measures was that the number of deaths at once fell to seven per month, or the usual average of the second division. This fact explains the difference of mortality of the two divisions at Strasburg. Here, likewise, although the medical men in attendance do not dissect, yet they perform operations on the dead body and autopsies, whereas the midwives do not. The difference of the mortality at Prague may also be so accounted for. The apparent exception of the Maternité at Paris is also explained, since the midwives in that institution do dissect and perform the autopsies; and with regard to the * Prov. Med. and Surg. Journal. No. xxv. 1845.

Hôpital Clinique at Paris, the known zeal of the French students for anatomical inquiries, coupled with their general indifference in the selection of bodies for dissection, will also fully account for the frightful frequency of puerperal fever in that hospital.

In Great Britain many of the cases reported and ascribed to contagion from typhus or erysipelas, may in reality have been caused by the direct inoculation of poisonous secretions derived from gangrenous wounds in such cases, with which the hands of the medical attendants, who had previously dressed these wounds, had been accidentally infected.* This view of the case derives some additional confirmation, from the similarity or analogy of the symptoms of puerperal fever with those arising from a poisoned dissection wound.

This poisonous matter may be absorbed in several ways. Through the absorption of the mucous membrane of the vagina, or more directly through trivial wounds about the generative organs, such as the lacerated fourchette in primiparæ, lacerations of the cervix or os uteri, or the extended inner surface of the uterus deprived of its decidua and placenta ; all these parts, both from the general nervous shock and the removal of local congestion, being in a highly favourable condition for absorption.

The feverish symptoms usually occurred on the second or third day after labour; yet cases were noticed where they did not occur before the seventh and even fourteenth days. Generally, the fatal result did not take place before the fourth or fifth day after seizure, but sometimes it occurred as early as twenty-four hours after the first appearance of the fever. Diarrhoea generally preceded the attack, but sometimes, though rarely, the patient was costive. Then followed general langour, and a feeling of weakness, rigors; and the pulse was usually from 120 to 130 in the minute, sometimes, however, as high as 160, very weak. The patient's countenauce assumed a peculiarly anxious expression; there was pain generally about the uterus, either in the organ itself or in the peritoneum about it. As these symptoms increased in intensity, heat set in, with dry tongue, loss of appetite, thirst, &c. The lochia were very seldom affected either in quantity or appearance. The lacteal secretion continued undiminished, and apparently unaltered. Indeed, if at the outset of the disease the skin was observed to be rather drier than usual, this symptom did not last; the perspiration becoming subsequently more copious than otherwise, and continuing so up to the hour of dissolution. Large violet maculæ occurred sometimes in the extremities. In some cases the intellect was affected, but this was of very rare occurrence, as it usually continued clear up to a very few minutes before death. The more marked local symptoms were those of peritonitis, which gradually increased in intensity. The pain generally disappeared an hour before death; the face gradually assuming a more sallowish, yellow, and cadaveric expression.

The appearances presented by the dead body were generally the following.

Arachnitis in a slight degree. Occasionally endocarditis, very generally pericarditis. Almost always some pleuritis or pneumonia. Liver and spleen healthy. Extensive peritonitis, with plastic adhesions, and seropurulent fluid in the abdominal cavity. The uterus was much enlarged, much softened, and tearing very readily, containing pus in the veins, especially in the neighbourhood of the Fallopian tubes. The inner surface was of a yellow-whitish colour, with here and there plastic exuda. tion. Sometimes the lymphatics proceeding along the spine were beaded in appearance, containing pus. Where death occurred early, there was generally only some muddy-looking fluid in the abdominal Dr Peddie's case, Edin. Med. and Surg. Journal, Vol. lxv., p. 78, 1846.; M Storr's case, Prov. Med. and Surg. Journal, No. clxvi, 1843.

VOL. LXXV. No. 186.

U

cavity, with endometritis, and occasionally pus in the uterine veins. Sometimes the case was one of pure peritonitis, the uterus being scarcely affected. The body was very prone to decomposition; its external surface mottled, especially at the extremities; the superficial veins very apparent, of a dull bluish-red colour. The blood generally liquid, and very dark, not coagulating after exposure.

The fever was not equally intense in all cases. This might be due to the idiosyncrasy of the female, or to the variety of the poison. Indeed, Dr Semelweiss thought he had observed that the inoculation of cadaveric matter from cases of typhus, erysipelas, and puerperal fever was most fatal.

The author, therefore, although he is perfectly willing to admit that the fever, like all other fevers, may be very much modified by epidemic influences, thinks himself justified in concluding

In the first place, that-1. The puerperal fever of Vienna may be looked upon as an endemic fever.

2. That it is produced by the direct application of poisonous cadaveric matter, introduced by the hands of the male obstetricians in attendance.

3. That the cadaveric matters derived from the bodies of persons dead of typhus, erysipelas, puerperal or other low fevers, are peculiarly dangerous; but that there is no evidence to show that any ordinary cadaveric matters may not produce it.

4. That it does not appear to be either contagious or infectious. And, in the second place, as the precautionary measures adopted by Dr Semelweiss have produced satisfactorily results, that—

1. Accoucheurs should as much as possible avoid making autopsies, and all contact with cadaveric matter.

2. They should never attend any woman in labour in clothes which may possibly have been infected; but, especially if compelled to handle cadaveric matters, or other poisonous secretions from living persons, they should, prior to any examination made per vaginam, not be satisfied with washing their hands most carefully, and subsequently greasing them, but also make use of a solution of chlorine, to disinfect the hand from any poisonous matters with which it may have become contaminated, before they enter the lying-in bedchamber.

April 29, 1849.-Accounts which reached Dr Routh through Dr Tumanhof, in June 1848, confirmed in every respect the favourable results obtained from the adoption of Dr Semelweiss's precautionary measures. And in a letter since received from Dr Golling, Secundarius to the hospital, bearing date December 24th, 1848, it is stated that the precautionary measures continued to be successful. The origin of the Vienna puerperal fever seems therefore to be fully established.

May 21, 1849.-In a letter received from Dr Semelweiss since, dated March 4th, 1849, the following statistics are given: In one division (the first division)—

Females

In 1846 there were admitted 3354 and there died 459

It was not till the end of May, 1847, however, that the chlorinated lotions were employed. Thus, it appears, that the mortality has diminished in an extraordinary manner.

Professor Michaelis, of Kiel (Schleswig-Holstein), writes that from the time he has employed chlorinated lotions, which extends over a space of several months, he has only lost one female; though, prior to

that period, the mortality was so great, that he was considering whether it would not be right to close the hospital altogether.

III. TOXICOLOGY.

Case of Fatal Poisoning by Sir William Burnett's Fluid (Solution of Chloride of Zinc.) By H. LETHEBY, M.B., &c. (Medico-Chirurgical Transactions, Vol. xxxIII. p. 283. London, 1850.)

In the 70th volume, p. 335, of this Journal, Dr Stratton relates two instances of poisoning from the unguarded use of Sir W. Burnett's disinfecting fluid; but in both cases recovery took place. In the following instance the solution produced fatal effects.

On Thursday the 16th of August 1850, Mr Miller of Eye in Suffolk was hastily requested to visit the child of a poor unmarried woman resident at Reddingfield, a neighbouring village. When Mr Miller arrived, between ten and eleven A.M. of the day mentioned, he found a little girl, aged fifteen months, in a semicomatose state, with the countenance pale and anxious, the breathing thoracic and rapid, the pulse quick and fluttering, and the surface of the body cold and covered with perspiration. The lips were swollen; the mouth was covered with thick transparent mucus; the inner surface of the lips and the lining membrane of the mouth presented an opaque white appearance, as if they had been acted on by some caustic or corrosive substance. The child had been quite well early in the morning; and it had been suddenly attacked about one hour and a half before Mr Miller's visit, with violent sickness. These facts led Mr M. to infer that the child was under the effects of an irritant poison; and the inference was confirmed by one of the attendants producing a bottle of Sir W. Burnett's disinfecting fluid, which had been supplied to the mother about eight or ten days previously, when some persons affected with fever were in the house.

When roused from its lethargy, the child requested cold water, which she held in her mouth with apparent satisfaction; but on attempting to swallow the water, the greater portion was returned by the nostrils. The throat appeared something swelled; and the child frequently raised her hands to the neck.

Mr M. endeavoured to administer a solution of albumen; but the fauces were so swelled and constricted, that little or none passed into the stomach. He observed also that the white of egg employed was coagulated by the fluid matters which still adhered to the mouth. The child occasionally vomited a frothy liquid like curds and whey, and at such times it was roused from the heavy drowsy state; but the coma gradually became more deep, the breathing more slow, the pulse more feeble, the surface of the body colder; and at seven o'clock in the evening the child died, ten hours after the first appearance of the symptoms. The body, inspected twenty-two hours after death, presented the following appearances.

The body was plump and well developed; the face was pale and somewhat swelled. On the lower lip was a dark brown crust, the effect of the action of the liquid. The lining membrane of the lips, mouth, fauces, and œsophagus were of an opaque white colour. The lungs were slightly congested. The auricles of the heart were full of dark semifluid coagula; and the ventricles were empty. The outer surface of the stomach presented a peculiar mottled appearance from ramifications of dark coloured purple vessels. The intestines looked paler than natural. The stomach, which felt hard and leatherlike, contained one ounce and a half of fluid resembling curds and whey. The inner surface of the organ was corrugated, opaque, and tinged of a dull leaden colour. This appearance stopped abruptly at the valve of