during life, and the morbid lesions found on dissection. But when we come to discuss the nature of puerperal, or indeed any fever, we must take a higher flight. "Paulo majora canamus." Our readers will, we think, have guessed by what has already transpired at the theory to which our author is coming.

"The three following propositions embody my views of the source and nature of puerperal fever.

I. The phenomena of puerperal fever originate in a vitiation of the fluids. II. The causes which are capable of vitiating the fluids are particularly rife after child-birth.

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

By the first proposition, I shall endeavour to shew that the cause assigned will account for the phenomena of puerperal fever. By the second, I shall prove that the assigned cause really exists; and by the third, I shall endeavour to trace the various forms of puerperal fever to the one source from whence all of them proceed." 53.

FIRST PROPOSITION.

The blood may be vitiated by the direct artificial introduction of noxious substances into the circulation—or by certain diseases, as scurvy, purpura, jaundice, &c. The results are, a tendency of the blood to escape in a hæmorrhagic form, or mixed with mucus or serum-or in the shape of various local affections of different parts of the body. When vitiating agents are introduced artificially, they generally shew their effects most in the neighbourhood of the point of introduction. Our author then goes on to analyze the experiments of Gaspard, and Cruvelhier, which we need not advert to here, as they are sufficiently known to our readers.

"From these six experiments of Gaspard, we may conclude that the vitiation of the fluids will produce general fever, with local irritation or inflammation of different organs at the same time; that in the first four this fever was accompanied with gastro-enteric disorder; in the other two, by general functional disturbance, resembling the nervous form of puerperal fever." 58.

Various other experiments of Gaspard and Cruvelhier are adduced, and commented on by our author.

"From these and other experiments, Cruvelhier concluded, by believing that in inflammation the veins are chiefly affected; that the redness is venous, that the pus effused is from a simple rupture of veinules; that in inflammations of degenerate tissues, it is the veins which are developed, as in soft cancer and cephaloid tumor. Without entering into this hypothesis, we see that there are two sources from which the blood may be vitiated-either by the primary injection, or absorption of injurious substances; or by direct injury to the solid coats of the veins, which in consequence inflame and secrete a fluid or fluids, which mingling with the torrent of the circulation, act as if they had been primarily injected.' 65.

"Gaspard's and Cruvelhier's experiments prove, that many substances will produce the same fatal effects, and by the same disorganising process; that mercury, thick unctuous substances, acrid fluids, gritty powders, and bits of stick, when placed within the vessels, all produce the same essential train of symptoms; while saliva, milk, urine, bile, cause little disturbance. Many of the deleterious

substances produce no action on the coats of the large vein, and yet the symptoms resulting are precisely those which a wound and inflammation of the vessel will give rise to,

In the first case we are certain the cause of death is to be sought in the action of these substances, not on the injured vein, but on the blood. And in the second, we are equally certain that those very fluids are poured out by the inflammation of the vein, which if injected into an uninflamed vein of a healthy animal, would produce death. We should conclude, therefore, that it is the vitiation of the blood, and not the inflammation of the coats of the vein, which produces the disease.

It may be said, that though it be granted that the phenomena consecutive of artificial vitiation of the blood strongly resemble those of puerperal fever, yet that this identity of cause may after all be only a probable surmise, and that no certain conclusion ought to be drawn, unless it could be proved that putrid substances absorbed by the uterine vessels produce puerperal fever.

Such an experiment has unfortunately too often been made; and Gordon, Campbell, and Kirkland, have most distinctly acknowledged, that retained and putrid placenta or coagula will produce a genuine puerperal fever, not to be distinguished from that they have each described." 67.

Cases are related from Gordon and others in illustration, and then Dr. F. proceeds to

PROPOSITION II.

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The object is to prove that the causes of vitiated blood are peculiarly rife in the puerperal state. Thus are the vessels mechanically injured? they in contact with any noxious matters? The uterus, he avers, after child. birth combines both these conditions. All the uterine veins and arteries have been torn from the placenta, and they form a part of a large wound. They are bathed in all the secretions that take place while this wound is healing. "In this respect the uterus presents an exact analogy to the surface of an amputated stump; and it is not surprising that the secondary evils of amputation should be so similar to those of the puerperal state." Cruvelhier has seized this analogy in its minutest details-and his words are quoted by our author.

"

Whether, then, I turn to the analogies afforded by comparative anatomy; or to the direct evidence afforded by inspecting the human uterus, in a healthy state, soon after delivery; or whether I look to the authorities of competent anatomists, I find, that after child-birth the womb is like an amputated stump, and that it has a reparative process to perform, which, being disturbed, permits the large gaping vessels to spread in the blood noxious secretions which they have imbibed." 80.

PROPOSITION III.

That the various forms of puerperal fever depend on the one cause of vitiated blood, seems to be the most difficult task of all-but it is grappled with manfully by our ingenious author. He sets out, indeed, by assuming that the experiments of Gaspard must have led every one of his readers to this inevitable conclusion, since in those experiments it was seen that the vitiated blood produced in one case one group of lesions, in another case a different group, and so on-the variation being not only of place or organ, but of intensity.

"But how, it will be asked, are we to account for this partitioning off of so diffuse a malady, as that induced by vitiation of the blood? why is it not always spread wherever there is blood? and why are puerperal fevers, now peritonitic alone, now metro-peritonitic, now gastro-enteric, and now falling on the nervous centres ?

We know that the blood-vessels, like every other part of the body, are in their nature capable, of themselves, of repairing injury, and stemming the actions of disease. The experiments of Gaspard and Cruvelhier, permit us to infer that there is always an endeavour to hem in the noxious cause as near to the spot first injured as possible; and Mr. Arnott has remarked,-what Cruvelhier had stated in 1820-that coagula form, to prevent the spread of inflammation of a venous trunk; while the former gentleman, more minute in his investigation, has always found that the injured vessel is obliterated only up to the first branch it gives off as if nature, while endeavouring to pen up the exciting cause of malady in as small a compass as possible, wished to use whatever she could of the other channels of circulation.

:

It is from this law, that we find the injuries of puerperal fever so often confined to the uterus and its appendages, to the lower portion of the peritoneum, and to the adjoining intestinal canal; for we have seen that the point of departure for the noxious matter, is in this disease from the veins of the uterus." 83.

As for the attempt to trace the paths by which distant organs are affected, he thinks this could be done, provided we knew which of the uterine veins became the channel of infection. This being impossible we must be content with the same degree of knowledge which we possess with regard to other poisons affecting the circulation.

"In conclusion, then, I deduce the first, or peritoneal form of puerperal fever, from the action of the poison being more or less confined to this membrane. The second form, or the gastro-enteric; from the action on the liver, the organ through which, as the experiments of Gaspard and Fontana, and the admission of all physiologists shew, most poisons received into the system endeavour to escape. Whether the mucous membranes of the intestines are affected directly by the vitiated fluids, or secondarily through the acrid secretions of the liver, or in both ways as I believe; the group of symptoms constituting my second form of puerperal fever remains the same.

The third, or nervous form, I conceive to result from an impression on the nervous centres, not necessarily inflammatory, though it sometimes leads to in flammation. John Hunter speaks of this condition of the nervous system, under the metaphorical expression of alarm.' The first impressions of the most virulent poisons, are very commonly accompanied with panic and extreme agitations. Fontana found this to be the case with dogs, after inoculation with the viper poison. The symptoms produced by the poison of cholera, of small-pox, and of vegetable miasmata, are in a certain number of cases so characterised. The impression on the nervous system, which is transitory in other cases, and soon veiled by the specific symptoms of some organ or organs labouring under the attack, remains in this as the permanent feature of the disorder; but violent perturbations of the nerves are, under such circumstances, speedily fatal. Where death does not take place from nervous perturbation alone, the membranes of the brain, and the cerebral substance, are found altered by the same process as seen in other parts.

The fourth, or complicated form, is the result of a poison not confined to certain structures, as the peritoneum or uterus, where its violence is pent up and exhausted, but diffused by the circulation over many organs, causing each to react after its own laws, and giving to the disease it produces a character of inextricable confusion, and almost hopeless fatality." 86.

Thus ends this important Section, for which, indeed, the reader was pretty well prepared by all that preceded it. No one can fail to doubt or to admire the ingenuity with which he has worked up all the facts and reasonings that could be made to bear on the question. So systematically has he proceeded that the whole looks more like a sober induction, than a startling hypothesis. The theory, too, is very seductive. We delight to trace numerous, and apparently opposite phenomena to one single cause, and feel a kind of pride in being able to do so. In the present case, however, there is one startling consideration bearing on the theory of our author-namely, that the Almighty must have ordained that half the human race, and the most amiable half, should be not merely once, but many times in their lives, in the same state of danger as a man with an amputated leg! This is a serious drawback on population, and seems to have been overlooked by Malthus and the political economists. Fortunately for the warrior and the puerperal female, the conditions which render amputation and child-birth dangerous, are comparatively rare. The investigation of these conditions is not less important than that of the unique cause of puerperal fever, the result of these conditions. This investigation is rather briefly treated of in a Chapter in which he examines the opinions of various authors respecting the nature of puerperal fever. These opinions we shall pass over, but notice the

PUERPERAL CONSTITUTION.

The Germans attribute the essence of the fever in question to the efforts of Nature to bring back the female constitution to the state in which it was antecedent to pregnancy and parturition. The changes during utero-gestation are slowly made-the return to the ordinary state after child-birth, is rapid -and thus the tendency to disease is increased. The high susceptibility of the nervous system, at such periods, facilitates morbific impressions. The disturbance of lactation plays its part also. Still this theory of the Germans is regarded by our author as very defective.

Dr. Hall has connected this fever with intestinal irritation, and this latter was found in three-fifths of our author's cases. But a careful scrutiny led Dr. F. to infer that the intestinal irritation was secondary to the metro-peritonitic attack-that, in many instances of genuine puerperal fever, no intestinal irritation existed at all—and lastly, that gastro-enteric fever itself does not exhibit the phenomena of puerperal fever. Our author has already shewn that one of the commonest results of vitiated blood is irritation of the hepatic and intestinal functions. This will account for the occasional complication of the intestinal affection with puerperal fever. Dr. F. incidentally alludes here to the danger of exhibiting drastic purgatives in the puerperal state, as they often bring on violent pain and metro-peritonitis.

The Influence of Seasons must be placed in the catalogue of predisposing causes. The coldest and dampest portions of the year are the most fatal, and vice versa. This is very constant. Still these alternations of season cannot be the main cause-they can only be influential, since whole seasons pass without any fever of this kind. It has been observed that when the disease is epidemic here, it is generally so on the Continent.

Hospital Air. On this head there is abundant evidence. The disease is most fatal in such establishments, as they are now managed. "A lyingin-hospital should consist either of a series of cottages, or its spacious wards should contain very few patients." Such a desideratum, however, is almost hopeless, for very obvious reasons.

"With regard to the General Lying-in Hospital,-its locality, rather below the level of the river, and surrounded by a mesh-work of open sewers, fifteen hundred feet in extent, receiving the filth of Lambeth, and some not thirty feet from the wards of the institution, may account for it unhealthiness. It is only after repeated remonstrances that these sources of pollution have, in part, now begun to be obliterated. In the absence of a medical police, nothing but a catastrophe, known under the gloss of a strong case,' has the slightest chance of remedy. Public bodies, like the commissioners of sewers, are hampered by their rigid customs, and by the penalties of the law, from coming forward, while individuals have little inclination, and less influence, in making the appeal." 104.

Uterine Injury. It has already been observed that contaminating matters may be introduced into the blood in two ways; by means of the secretions from the uterine wound, or by means of any injury to one or more of the uterine sinuses. The former source is considered to be analogous to the direct insertion of virus into healthy vessels, as after the viper-bite, dissectionwounds, &c. In the second case," the source of injury is precisely similar to that arising from venesection, where the solid walls of the vein first inflame, and the matter exuded, is afterwards circulated."

"We should expect, à priori, that forcible disruption of the uterine veins by manual separation of the placenta—or that long-continued action of the uterus, compressing and irritating the large uterine wound, as in strong and long-continued after-pains,-that instrumental operations, and all such causes as directly bruise or disturb the wound,-would create diseased secretions from the traumatic surface, or irritate its large pendulous lacerated vessels, and so give rise to the phenomena of puerperal fever. These deductions, à priori, appear confirmed by facts.

It is well known that the first labour is generally much longer than any subsequent one; consequently we may assume that in first labours there is more mechanical injury to the uterus than in any other, and, therefore, a more unfavourable state for the healing of the traumatic uterine surface. Out of two hundred and four cases of our puerperal fever tables, more than eighty were first labours.

Again, of the total number of deaths, (amounting to sixty-eight) one-half were patients confined for the first time. These facts prove that the severity of a first labour, or mechanical injury, is a strong predisponent to puerperal disease. Of four hundred and fifty-six cases, Dugés finds that one-third more first labours than second are attacked; and Campbell, that of eighty-five attacked, twentynine were primiparæ.

After instrumental labours, in which mechanical injury must necessarily be inflicted, thirty-two cases occurred.

Now, as on an average artificial aid is not required more than once in fifty cases, the fact of thirty-two women being seized after instrumental delivery out of four hundred and fifty-six, clearly shews the influence of mechanical injury in producing puerperal fever. In these cases the injury is not the direct effect of the instruments, for that is known to be very slight and mostly none-but of that state of things which necessitates artificial aid." 107.

Dead children-abortions, hæmorrhages-depressing passions of the mind-insufficient food-suppression of the lochia, &c. may all prove exciting or predisposing causes of puerperal fever.