"6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from hæmorrhage.

7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due controul.

"8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance much time is lost that may be very important to the woman." (Op. cit. § 1153.)

We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri : the less we separate the placenta, the less also will be the hæmorrhage; and even this will be in great measure controuled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case itself is sufficiently dangerous without being increased by other unfavourable causes. To hurry the delivery would be only to increase the danger: the operation must be performed slowly and with caution: every rule which we have given (see TURNING) for ensuring its safe and successful termination, must now be adhered to with double vigilance. "Should the woman," says Dr. Dewees, "be very much exhausted before we commence our operations, we should use additional caution in the delivery. It should be very slowly performed, and we should have at each step of the progress assurances, 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 hæmorrhage 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 circumstances. 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, hæmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (Med. Gaz. Sept. 2. 1837.) The after treatment should be conducted upon the same principles as in other cases of hæmorrhage.

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 hæmorrhage 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 hæmorrhage 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 hæmorrhage; 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 circumstances, will be of great assistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quantities 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.-Gastrobilious 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 hæmorrhage, the danger, although great, is capable of being averted, from the mother at least, in the majority of instances by timely and skilful assistance; 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.

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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 practitioner 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 class as to rival in destructiveness the most malignant pestilences with which the human race has been afflicted.

an error

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 circumstances. 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· 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 assistance 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 concealed than disclosed the real natura morbi. In our printed lectures on puerperal fever we have taken a similar view. "I am not sure if the present fashionable morbid anatomy of the day, misnamed pathology, has assisted 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 practitioners 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. Pract. 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 al ready 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 controul the diseased actions, or relieve the symptoms during life."

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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 médicine eclaireé 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. Stevens's

researches have been conducted in the truest spirit of pathological enquiry, 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. Locock 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 constitution 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 two last mentioned authors for the able manner in which they have handled this difficult subject, they have carefully sifted the mass 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 identity 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 class 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. Locock 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 albuminous 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 bloodletting, 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 deposits took place in the joints and in the calves of the legs, and in one case there was destructive inflammation of the eye." (Locock, 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 classifications 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 disorganised. 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 assume, 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 principal 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 circumstances." (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 passage 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 most fatal." (On the Blood, p. 179.)

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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 one or more of these (phlebitis, peritonitis, &c.) be assumed as constituting 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 identity of peritonitis and puerperal fever, we can show puerperal fever with a perfectly healthy peritoneum. To those who insist on inflammation of the uterine veins, as constituting 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 passages 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