form of puerperal fever is caused by the local | ady appearing sporadically, more especially the or endemic infection of the ward-by respiring | first and second forms which I have assigned, an infected atmosphere; the infection origina- when circumstances combine to develop them; ting as stated above. The disease produced nor can I deny that any of these forms, more by it may terminate rapidly in death, without particularly the second and third, may become any tissue or viscus having presented a more so prevalent, owing to a combination of causes, prominent lesion than the rest of the body. as to deserve the epithet epidemic. But most The blood, however, always is more or less al- of the instances in which puerperal fever has tered, and the tissues generally are very defi- become so prevalent as to be so called have cient in vital cohesion immediately after death. occurred in lying-in wards; and the disease When this form of the malady is less rapidly has been limited to them, unless on some ocfatal, one or more of the complications, or rath-casions when the infection has been carried er of the more prominent alterations enumera- abroad from them. The term epidemic is, ted above, are generally observed. therefore, not strictly applicable, the malady being truly endemic as respects such institutions as thus occasion it, the character, the type, intensity, and other features of the malady depending much upon the endemic sources-upon the concentration of the infectious effluvia and other causes generated in these institutions and wards. It is not improbable, however, that certain atmospheric constitutions, depending upon the states of terrestrial and atmospheric electricity, and of humidity and temperature, and other circumstances affecting the prevalence of febrile maladies, may so affect also the form and prevalence of puerperal fever as to render it not only endemic in lying-in hospitals, but also epidemic, or approaching to this state, in various places in which it may break out. For, as I stated above (§ 36, 44, 138), causes similar to, or almost identical with, those which generate it in the lying-in wards, actually exist in various houses and localities, in such forms and degrees of concentration as to give rise to sporadic cases, which, when circumstances combine to favour their spread, may propagate the malady.

125. Between the more primary inflammations, appearing sporadically, and constituting the inflammatory form of puerperal fever, and the malignant form now mentioned, that form which I have named the synochoid holds an intermediate place, passing insensibly into either of the other forms with the intensity of the exciting causes and the amount of predisposition. This synochoid or intermediate form may arise not only from a less concentration of the causes; from a less impure or contaminated air; from a less concentrated or intense effluvium; but also from an impure or infected state of the bed or bed-clothes, or from the infected hands of the accoucheur, causing a local infection during examination; or from other circumstances either already or about to be noticed; but according to the nature of the causes, their concentration, the state of the patient and the predisposition, so will it approach either the inflammatory form on the one hand or the malignant on the other; and so will it occur sporadically, or even extend by infection.

126. Another circumstance deserving a brief notice is the fact, which has been presented to me on several occasions, that, although the cases which occurred when ventilation was most deficient were generally of the third or most malignant form I have mentioned, yet occasionally a less malignant case, or one more properly belonging to the second form, presented itself, and was to be ascribed to the greater constitutional powers of the patient. But during this state of ventilation and infection not one escaped the disease who was confined in the hospital. Subsequently, when ventilation was improved, and when a fever ward was provided outside the institution, the cases presented generally the second form, and very few of the most malignant or third form were then

127. Besides these three forms of puerperal fever, with their complications or more prominent lesions, another may be adduced, namely, infectious, or true typhus fever occurring in the puerperal state; and of which I have seen a few instances. The infection may have been received before or after delivery; but typhus fever appearing in this state should no more be viewed as a form of puerperal fever than smallpox, or any other of the exanthematous fevers ought to be so considered, when attacking a woman in child-bed. I shall, therefore, notice it no further than the diagnosis may require.

128. In the several works which have appeared upon puerperal fever, the epidemic and the sporadic occurrences of its several forms have been mentioned in a very loose manner. I have no doubt of any of the forms of the mal

129. It will be asked, what are these causes which thus exist locally or endemically? 1st. Beds and blankets contaminated by prolonged use, without any attempts at purification (§ 44); 2d. Privies containing immense accumulations of fæcal matters, often rising as high as the boards, emitting contaminating vapours, particularly when frequented or disturbed, and sometimes occasioning, as I have remarked in several instances, asthenic or irritative and spreading inflammation of the vulva, vagina, and cervix uteri of married females, and even also of the rectum. I am convinced that the domestic causes of disease, and even of the most malignant maladies, which I have described in the article PESTILENCES, PROTECTION FROM (§ 10–23), and of which I have even assigned proofs (§ 14) at that place, are mainly concerned in producing the more serious forms of puerperal disease, the malignancy of the attack depending chiefly upon the concentration or intensity of the cause.

130. iii. CAUSES. -The causes of puerperal diseases have been stated above, with reference both to the peculiar condition of the puerperal female, or the predisposition thereby acquired ( 6, et seq.), and to the more efficient and immediate agents and influences (§ 35, et seq., 129). These are disposing and exciting causes, which with their several concomitants, and especially when present in concentrated or intense forms, commonly occasion puerperal fevers-produce it sporadically and favour its spread. From the days of HIPPOCRATES down to the close of the last century, the suppression of the lochia

or of the milk was viewed as the chief cause of puerperal fevers; and certainly there can be no doubt that the suppression of these will often be followed by very serious disease, particularly of a febrile kind. But in most instances the suppression is merely one of the effects of antecedent causes; and it may not-indeed, most frequently it does not-take place in the most malignant states of the disease.

am supported by CHAUSSIER, DUGÉS, CLEIT, and others, while M. DE LA ROCHE considers that a dry state of the air is most favourable to the prevalence of the malady. Humid states of the atmosphere, conjoined with warmth and stillness, are certainly not infrequently productive of sporadic cases arising from the local sources of contamination and infection already pointed out ( 36, et seq.); and from these cases either contagion or infection may extend, when the media are suitable to the transmission, especially by the midwife or nurse.

131. A. The predisposing causes of puerperal diseases have been already enumerated, and the influence of mental emotions has been noticed. The depression caused by fear of the 134. But neither temperature nor grades of disease, especially in lying-in charities, when humidity, nor both conjoined, always account the death of a patient is known, has a remark- for the prevalence or absence of this distemper. able effect in favouring the extension of the There seems to be a disposition to the prevadisaster, and the depressing feelings entertained lence of it at some periods and not at others, by unmarried puerperal females exert a simi-independently of the conditions now remarked lar influence. Large losses of blood, by uterine upon. The states of the electricities, in as far hemorrhage or otherwise, have a manifest in- as they affect the human body, may be the fluence, not only in predisposing to, but also in cause of this predisposition, or emanations from aggravating the danger of this disease, more the soil, of a nature quite incognizable to our especially in lying-in hospitals and wards. Sev- senses and means of detection, may favour its eral instances demonstrating the truth of this development and diffusion. But the epidemic statement have been observed in the course of occurrence of the malady seems allied to the my experience. Hemorrhage appears to in-prevalence of low, or adynamic, or eruptive fecrease the predisposition, both by augmenting vital depression and shock, and by favouring the absorption of morbid secretions and excretions, and the passage of contaminating effluvia into the circulation.

vers, more especially of typhus and erysipelas; and when puerperal fever is found to prevail in lying-in hospitals, independently of crowding or want of due ventilation, it generally partakes of the nature of the prevailing epidemic, or of the general epidemic constitution.

132. Hydrometric and thermometric states of the atmosphere also favour the occurrence of 135. Neglected states of the bowels, constipuerperal fever, both by depressing nervous pation, or diarrhea; improper or insufficient power and by concentrating animal exhalations. food; addiction to the use of spirituous liquors Cold and humid states of the air frequently pre- or cordials, and living in low, ill-drained, and vent due ventilation of wards and apartments, ill-ventilated houses, also predispose to puerpeand the requisite dilution of the contaminated ral fevers. It is difficult to determine the inatmosphere; and all methods of warming ly-fluence of first or subsequent labours, or of the ing-in apartments which do not promote due ventilation, or currents of fresh air, tend remarkably to generate a pestilential effluvia in lying-in wards or hospitals. Humidity at all seasons, but more especially during winter and spring, favours the generation and propagation of this and its allied diseases, as remarked by writers of all ages, more especially of erysipelas, fever, dysentery, and rheumatism.

winter of 1827 and 1828.

kind of labour. But very quick labours have been viewed as favouring the occurrence of puerperal disease in those confined for the first time; and prolonged or difficult labours in subsequent confinements. Premature labour seems to dispose to puerperal fever; but it may be mentioned that, when the patient is infected by the disease previously to delivery, or to the full period of gestation, premature labour will 133. Some difference of opinion has existed be thereby induced. Of this I saw two instanrespecting the seasons and states of the weath-ces in consultation with medical friends in the er favouring the development of puerperal fever, especially in lying-in wards. My experi- 136. Other circumstances often concur with ence convinces me that cold is influential chief- the foregoing in predisposing to puerperal fevers, ly by preventing that amount of ventilation more especially an age approaching to or above which is requisite when several women are in forty years; females who have suffered previous child-bed in the same apartment. According abortions, and who are vitally or mentally deto my own observations, during a period of thir-pressed or exhausted; severe, prolonged, or inty years, the disease has been most prevalent strumental labours; those who have been subduring the last three months and the first four ject to diarrhoea, hemorrhoids, or leucorrhoea; of the year. M. DUGES's observations, which and those who are cachectic, or have been illare limited to 1819 and 1820 merely, show an fed, or kept too low during their confinement. order of frequency as follows: November, Feb- Indeed, insufficient nourishment, or inanition, ruary, January, October, December, September, in the puerperal state, is a more frequent preMay, March, April, August, July, June M. DE disposing cause than usually believed. These LA ROCHE, of Geneva, exhibits the following require no remark, especially when they are order of prevalence: January, March, Novem-concomitants of the foregoing causes, and with ber, December, April, October, September, Feb- other states of predisposition noticed above. ruary, July, August, May, June. As respects (See § 6, 10, et seq.) the influence of humidity there is greater uncertainty. But I believe that a moist state of the air, especially when conjoined with a low temperature, is most injurious, especially as respects lying-in wards; and in this opinion I

137. B. The exciting causes are chiefly those which tend to contaminate the atmosphere of the lying-in apartment, or which may occasion a local infection.-(a) The sources of contamination have been described above (§ 35, et seq.,

128, 129); and although their nature and effects | retained in the vagina; portions of the placenta must have been long ago recognised, their re- left adhering to the uterus, and death of the moval and prevention have hitherto received foetus in utero, may severally cause uterine very slight attention. But these are not the phlebitis, or other forms of this disease, espeonly sources. Many houses retain within their cially if the labour has been tedious, or has reown walls sufficient causes of contamination quired the use of instruments. and of local infection, as just stated, and as fully demonstrated under the head PESTILENCES, protection from (§ 10-23). These causes are often productive of dysentery and of asthenic inflammation of the vagina and uterus, and they may be inferred not to be less innocuous to females on the eve of delivery, the foul air evolved from these sources infecting the female organs, and thus producing sporadically either some one of the forms of puerperal fever, or uterine diseases incidental to the puerperal state. That these maladies have been thus produced in several instances I have had sufficient evidence to prove; and that the more febrile or severe may be propagated to other females in this state, when circumstances combine to favour the propagation, I firmly believe. Besides these sources of extrinsic contamination, and the effluvia disengaged from foul beds (see 44), there are other influential causes which should not be overlooked, namely, direct and mediate contagion or infection, and the intrinsic contamination caused by morbid matters imbibed, and carried into the circulation from the uterus and vagina.

[The epidemic puerperal fever which proved so fatal among the lying-in patients of the New York Alms-house at Bellevue in 1840, could be distinctly traced to a vitiated state of the atmosphere, both general and local. For twelve or fifteen months preceding, there had been an unusual tendency to epidemic disease, generally of a typhoid character. An incurable diarrhoea, followed by mortification of either extremity of the alimentary, often with the loss of eyes, defied the efforts of medicine. Mortification often succeeded blood-letting. Ophthalmia, when treated in the usual antiphlogistic manner, was followed by rapid ulceration of the cornea. Scarlatina was very malignant and fatal. In short, there was a universal typhoid tendency in all diseases, requiring a tonic and supporting course of treatment.]

138. Not the least important of the exciting causes of sporadic cases, which, however, in circumstances favouring infection, may become more or less prevalent, is confinement in a low, close apartment, near where the exhalations from privies, cess-pools, or drains find an outlet and contaminate the air. Apartments near the ground floors of houses which are provided with privies and cess-pools that have no communication with drains and sewers-and most houses are thus most injuriously constructedare liable to have the air in them contaminated at all seasons from these sources; but more especially in winter, when they are kept more closely shut, and when the exhalations arise not much less abundantly, and penetrate wherever hydrogenous exhalations may possibly pass.

139. The unguarded use of improper beverages, as beer, ale, wine, spirits, &c.; all sudden mental emotions, or shocks, frights, chagrin, anxieties, &c., and premature excesses of any kind, may concur to induce an attack of certain forms of the disease, especially of the more inflammatory. Coagula in the womb, or

140. (b) The infectious nature of puerperal fever has been denied by some, proved and believed in by many, and imperfectly elucidated, or stated without precision or due limitation by most recent writers on the disease. Infection, or even contagion, is undoubted-unless by the inexperienced and the skeptical-in certain circumstances and forms of the malady. MM. TONNELLE and DUGÉs, however, do not believe in the contagious nature of puerperal fever, and adduce their experience at the Maternité in Paris in support of their opinion. During the latter part of 1818 and spring of 1819, the disease was extremely prevalent in Paris, where I was then residing, and had an opportunity of seeing some of the cases which were so numerous in that institution, where alone about three hundred women died of it in these two years. It was prevalent at that time not only in lying-in wards, but also throughout Paris and its environs. These physicians state that it did not extend itself to the bed nearest that in which a patient was affected by it; and they assert that women newly delivered there had each a separate apartment, and yet were attacked. These are the chief facts in proof of their opinion, but they prove nothing beyond what has often been demonstrated (see ◊ 143, et seq.), viz., that the malady is often propagated by the mediate contact of the hands of the midwife, and by the effluvium imbibed and conveyed by the clothes. They, however, admit, what was generally observed, both there and in other institutions, that when the fever was prevalent it generally attacked several in the same ward, and was sometimes confined entirely to one ward, a fact sufficiently demonstrative of at least an infectious or contaminated state of the air or of the bedding in that ward.*

[* Dr. VACHE, of New York, has given a very interesting

account of the prevalence of epidemic puerperal fever at the New York Alms-house in 1840. The disease made its appearance in the Alms-house on the 12th of June, 1840, and lignant that it was immediately determined to vacate the was quickly followed by two more cases, apparently so maroom, with a view to its purification. The inmates were accordingly removed, and the apartment was whitewashed, beds and bedding introduced, and at the expiration of about ventilated, and scrubbed; the bedsteads were cleansed, new a week it was considered sufficiently disinfected to return to it in safety. But the disease immediately reappeared, equally as violent and irremediable as before, and it was con cluded most judicious to abandon the building. Another was therefore prepared at some distance from the Alms-house, and appropriated as a nursery, after being put in the most perfect order; the bedsteads were cleansed and painted; new beds and bedding were furnished; the physician and nurse were changed; the pregnant women were directed to cleanse their persons by bathing; new clothes and shoes were given to them immediately previous to transferring them to their new habitation, and all intercourse arrested with the ins mates of the surrounding premises. Notwithstanding these precautions, the first woman confined, and subsequently four others in succession, out of five labours, were attacked with the disease, and in every case it was fatal. The lying-in apartments at Bellevue were then abandoned, and others procured at Blackwell's Island. The same precautions were observed, and for a time the change of air, free ventilation, and a more generous diet seemed to have accomplished the object; several were delivered, convalesced, recovered, and were discharged without an untoward symptom; but the disease soon broke out with redoubled fury, attacking almos every woman confined, and setting at defiance every effort for their recovery. The disease in each locality was almost uni formly fatal. The treatment was diversified, consisting a

a case, where, from want of accommodation, he was unable to wash his hands with due care. He was soon after called to two patients requiring assistance, and went without farther ablution, and without changing his clothes, and both these were seized with the disease and died.

141. A circumstance worth noticing is mentioned by M. DUGES, which is no mean proof of the influence of the infected air of the hospital upon the lower animals. During 1819 several cats, frequenting the wards of the Maternité during the prevalence of fever, were attacked by painful distention of the abdomen, and tumefaction of the parts of generation. The most of them died in four or five days; and the dissection of them was made, in the presence of Pro-tended those affected with it. He remarks, that fessor CHAUSSIER, by M. DUGÉS, who found in the peritoneal and pleural cavities a large quantity of a whitish serum mixed with albuminous flocculi, and a thin whitish coating covering the abdominal and thoracic viscera. A similar instance of the cat of the hospital becoming infected occurred in the hospital to which I was consulting physician during the prevalence of the fever in it.

142. In 1824, I was requested by a practitioner in the Edgeware Road to see a patient with him in this disease. She was the sixth case which he had had in the course of a few days. She was moribund when I saw her. I learned from him that each case of midwifery which he had attended from the first of these six cases was attacked in succession and had died; that he had called the most eminent accoucheurs to see these cases; that they had prescribed large bleedings; and that the present case had been also largely blooded, as was then the general practice, the injurious effects of which were making themselves apparent. I insisted that contagion had caused these cases, advised measures to be taken against his being the medium of its transmission, and no other cases occurred to him for a considerable time.

144. Dr. GORDON states, that the malady attacked only those women who were attended by a physician or nurse who had previously athe had abundant proofs that any person who had been with a patient in puerperal fever became charged with an atmosphere of contagion which infected every pregnant or puerperal woman who came within its sphere. Dr. HAMILTON affirms that this fever is produced by an infection sui generis, and that he is quite positive that this infection is of so virulent a nature that it may be conveyed by a third person. Dr. Gooch records that a surgeon, after opening the body of a woman who died of this disease, continued to wear the same clothes, and delivered a lady a few days afterward, who was attacked by a similar malady and died. Two more of his patients were seized in rapid succession, and also died. He then suspected the transmission of the infection by his clothes, changed them, and met with no more cases of the distemper. A washerwoman and nurse washed the linen of a female who had died of puerperal fever. The next lying-in patient she nursed died of this disease, and so did a third; when the circumstance having become known, she was no longer employed. At Sunderland, forty out of fifty of these cases occurred in the practice. of one surgeon and his assistant. Many other proofs of infection have been adduced by Drs. LEE, MOORE, WALLER, ROBERTSON, and by many recent writers. The last-named writer, in a most instructive communication (Lond. Med. Gaz., vol. ix., p. 503), states, that a midwife in extensive practice among the out-patients of a lying-in charity, within one month delivered thirty cases living in an extensive suburb of Manchester, and of this number sixteen were attacked with puerperal fever, and they all died; and that, of about three hundred and eighty delivered at this time by the midwives of this charity, none had the disease except the patients delivered by this midwife. Other conclusive

143. Dr. CAMPBELL wrote on this disease in 1822, from a short experience; and, because he saw no reason to satisfy himself of the. propagation of it by contagion, contended, in opposition to the no mean authority and more extensive experience of HAMILTON and GORDON, that the disease was neither infectious nor contagious, although he has adduced no conclusive evidence that some, at least, of the numerous cases which occurred in 1822 did not arise from contagion. It must be admitted that the sources of sporadic contamination which I have described above (§ 137, 138), are so abundant in Edinburgh, where Dr. CAMPBELL prac-facts are adduced of contagion by this writer. ticed, that the difficulty of discriminating between the influence of these and of contagion is thereby much increased. With a candour which always characterizes the truly scientific inquirer, this physician states that subsequent experience has shown him his error (Lond. Med. Gaz., Dec., 1831), and, much to his credit, he adduces the following facts: After examining the body of a female who died of the disease after an abortion, and carrying some of the diseased parts to the class-room, he attended the delivery of a woman the same evening without having changed his clothes: she died. Next morning he went in the same clothes to assist a difficult case, the subject of which also died of the disease; and of others who were seized, within a few days, three shared the same fate. In June, 1823, he assisted at the dissection of

general bleeding, cups, leeches, blisters, and fomentations to the abdomen, Dover's powder, camphor, turpentine, calomel, and opium, mercurial purgatives, Peruvian bark, stimulants, &c.]

[Numerous facts of a similar kind have fallen under our observation during a practice of twenty-two years, mostly in this city; but we conceive it unnecessary to go into detail to prove the contagious nature of this disease, as there are few, if any, American practitioners who do not fully believe in this doctrine. In three instances we have known the disease to follow up the accoucheur so closely that he has found it necessary to relinquish practice for a season, notwithstanding all the precautions he could use to avoid extending the disease through the medium of his clothes, &c. There is something truly remarkable in the extreme tenacity of this animal poison, and the minuteness of dose necessary to infect the lying-in female, as well as the certainty of infection upon exposure to the smallest particle of the infectious matter.]

145. These facts sufficiently show the contagious nature of this disease; that this fever may be propagated both by the hands, and by

the clothes, or by either, of a third person, that | 24th March, 9th, 10th, 11th, 27th, 28th April, third person being generally the midwife or and 8th May, seven in all, of which five died. nurse. But not only is it thus contagious-the He then left town. Another physician writes tangible communication often taking place du-to Dr. HOLMES as follows: "The first case was ring an examination per vaginam--but it is also in February (1830), during a very cold time. infectious through the medium of the bedclothes She was confined the 4th and died the 12th. or bedding, or the body-clothes of a patient, or Between the 10th and 28th of this month I at of a midwife or nurse, or the contaminated air tended six women in labour, all of whom did of a lying-in ward. I have had several occa- well except the last, as also two who were consions of observing that a lying-in hospital, or fined March 1st and 5th. Mrs. E., confined ward, for some time after having been opened February 28th, sickened and died March 8th. or purified, will remain free from puerperal dis- The next day, the 9tb, I inspected the body, ease; but that, if too many patients be admit- and the night after attended a lady, Mrs. G., ted, or if, owing to the season, weather, temper- who sickened and died the 16th. The 10th I ature, and humidity, the wards are too closely attended another, Mrs. B., who sickened, but shut, the emanations from the discharges, &c., recovered. March 16th, I went from Mrs. B.'s will soon contaminate the air, and infect the room to attend a Mrs. H., who sickened and more recently-delivered women, the effluvium died 21st. The 17th I inspected Mrs. G. On from those first attacked increasing the infec- the 19th I went directly from Mrs. H.'s room to tious state of the air, which is confined for a attend another lady, Mrs. G., who also sickened time to the wards where the emanations were and died 22d. While Mrs. B. was sick on the first accumulated, but which soon becomes dif- 15th, I went directly from her room, a few rods, fused through all the wards and apartments. and attended another woman who was not sick. Up to the 20th of the month I wore the same clothes. I now refused to attend any labour; and did not till April 21st, when, having thoroughly cleansed myself, I resumed my prac tice, and had no more puerperal fever. The cases were not confined to a narrow space. The two nearest were half a mile from each other, and half that distance from my residence. The others were from two to three miles apart. There were no other cases in their immediate vicinity." (P. 517.) In another communication, the writer considered that he carried the contagion to five cases; and both he and the preceding correspondent state that the disease infected the young and the more aged-the strong and the weak; and without being influenced by the labour or other circumstance.

146. It has been very justly remarked by Dr. HOLMES, of Boston, United States, that, "suppose a few writers of authority can be found to profess a disbelief in contagion-and they are very few compared with those who think differently is it quite clear that they formed their opinions on a view of all the facts; or is it apparent that they relied mostly on their own solitary experience?" Dr. DEWEES, in the last edition of his treatise on the diseases of females, has expressly said, "In this country, under no circumstance in which puerperal fever has hitherto appeared, does it afford the slightest ground for the belief that it is conLagious." The evidence already furnished may be viewed as quite decisive of the infectious and contagious nature of the disease in Europe; but Dr. DEWEES is incorrect as to his statement of the matter as respects the United States; for, as Dr. HOLMES has remarked, Dr. FRANCIS states that the disease was, in some instances, supposed to be conveyed by the accoucheurs themselves; and Dr. PIERSON, of Salem, United States, admits this to have occurred to himself in several consecutive cases. Dr. CONDIE, although not previously a believer in the contagious nature of the malady, "has, nevertheless, become convinced by the facts that have fallen under his notice, that the puerperal fever now prevailing is capable of being conveyed by contagion." (Trans. of Coll. of Phys. of Philadelphia, July, 1842.) Dr. WARRINGTON stated at the same meeting of the college, that, after assisting at an autopsy of puerperal peritonitis, he was called upon to deliver three women in rapid succession. "All these women were attacked with different forms of what is commonly called puerperal fever." At this meeting, also, Dr. WEST stated that seven females delivered by Dr. JACKSON in rapid succession were all attacked with puerperal fever, and five of them died. These were the only cases which occurred in that district; for the women became alarmed at the existence of what Dr. DEWEES and a few with him have denied, and sent for other assistance. "And here I may mention that this very Dr. S. JACKSON is one of Dr. DEWEE's authorities against contagion !"

147. A physician in Boston, United States, had the following consecutive cases: on the

148. Dr. RAMSBOTHAM remarks, that he has known the disease to spread through a particular district, or to be confined to the practice of a particular person, almost every patient being attacked by it, while other practitioners had not a single case; and he views the distemper as being capable of conveyance in not only common modes, but through the dress of the attendants on the patient. (Lond. Medical Gaz., 2d May, 1835.) Dr. BLUNDELL says, that some practitioners have lost ten, twelve, or a greater number of patients in scarcely broken succession;" that this fever may occur spontaneously, he admits; that its infectious nature may be plausibly disputed, he does not deny; but he would considerately add, that he had rather "that those he esteemed the most should be delivered, unaided, in a stable, by the manger-side, than that they should receive the best help in the fairest apartment, but exposed to the vapours of this pitiless disease. Gossiping friends, wet-nurses, monthly nurses, the practitioner himself, are the channels by which the infection is chiefly conveyed." (Lect. on Midwifery, p. 395.) My friend, Dr. KING, of Eltham, men. tioned at a meeting of the Medical and Chirurgical Society (Lancet, 2d May, 1840), that some years since a surgeon at Woolwich lost sixteen. patients from puerperal fever in the same year. He was compelled to give up practice for one or two years, his business being divided among the neighbouring practitioners. No case of the disease had occurred in the practice of these: