LETTER XLI.

GENTLEMEN:-There is a "word of fear" that I shall pronounce when I utter the name of Puerperal fever; for there is almost no acute disease that is more terrible than this-even small-pox, which reduces the fairest form of humanity to a mass of breathing corruption, cannot be looked upon with greater awe, since, like an inexorable Atropos, it cuts off the thread of life for those to whom Clotho and Lachesis would give the longest span. There is something so touching in the death of a woman who has recently given birth to her child; something so mournful in the disappointment of cherished hopes; something so pitiful in the deserted condition of the new-born helpless creature, forever deprived of those tender cares and caresses so necessary for it—that the hardest heart is sensible to the catastrophe. It is a sort of desecration for an accouchée to die.

The disease in question, from its liability to assume the character of a devastating epidemic, acquires an importance far greater than would appertain to it, were it limited to the occasional fatalities of its sporadic or accidental formulas-for when it does prevail as an epidemic, it sometimes rages over a great extent of country, or districts, and lays not aside its destroying wrath, not for weeks only, or months, but even for a term of years; carrying in its train fear, expectation of death, and the overthrow and desolation of the domestic altar.

The maladies comprised under the denomination of puerperal fever, for there are several of them, are so insidious in their approach, so sudden and violent in the attack, and so rapid in their progress, that the fatal boundaries are not unfrequently passed before assistance is sought for from the hands of the physician. It is, therefore, clearly your duty to make yourselves accurately acquainted with its nature, signs and treatment. I shall accordingly, in the present letter, endeavor to lay before you such views upon the subject as I have been able to obtain from no little clinical observation of cases, from reflection upon what I have myself seen, and from conversation and reading.

Puerperal fever, denominated, by the public, child-bed-fever, is also called peritoneal fever, puerperal peritonitis, metritis, metro-peritonitis, uterine phlebitis, and lastly, pyogenic fever: it is a disease consisting of inflammation of the serous coat of the abdomen, or of some portion of it-inflammation of the ovaries—one or both of them; of the womb, with, or without coincident inflammation of the peritoneum; of the veins of the womb; or of the absorbent vessels of that organ.

It is probable, that a major part of the cases consist of serous inflammation only,-cases in which the sub-serous textures have little participation in the pathological modifications of the peritoneum proper.

Many of these samples of peritonitis, however, coincide with violent inflammation of one or both of the ovaria-of the ligamenta lata, and of the external superficial tissues of the uterus.

In pure samples of metritis—or of uterine phlebitis, the inflammatory modification of the tissues may not, on the one hand, or on the other may, extend to, and involve the serous lining of the womb, and spread far and wide throughout the various folds and reflections of the whole peritoneum.

Leaving out of consideration the nature of the recondite causes that operate upon the economy to develop the various puerperal inflammations; such as an epidemic or an endemial influence; or a poison conveyed in the clothing or persons of physicians and nurses, one would seem to perceive sufficient provocatives to the attack of inflammation, in the state of the parturient woman's constitution, and in the events of the labor by which she may have been brought to bed. Indeed, there is room for surprise, that the examples of violent inflammation of the tissues concerned in parturition, are not far more numerous than they are really found to be.

In the first place, it is extremely rare to let blood for a patient pregnant and nigh to her term, without discovering the proofs of an inflammatory tendency, in the sizy and cupped appearance of the blood, when allowed to lie in a state of rest. I beg you to take notice, in your subsequent practice, of this point.—But if the blood be sizy in nearly all pregnant women, then all such women are, to say the least, in a state of proneness to inflammatory attacks-since that siziness of the blood indicates an excessive predominance of the fibrinous element. I beg you to allow me

to repeat, that in 1,000 grains of healthy blood, there should be found not more than 3.5 of fibrine-but, if you bleed a pregnant female far advanced in the gestation, you will discover size enough in the coagulum to lead to the supposition that instead of 3.5 there must be not less than 10, or perhaps 15, of the plastic material.

Pregnancy, for most women, is carried on at the expense of an exalted general vital force,—for many of them, the latter weeks of gestation are weeks of feverishness; and when, upon such a basis of dyscrasy of the blood, we come to superadd all the sanguine and nervous exaltations of the conflict of labor, which is attended with greatly increased action of the heart and arteries, we may well believe that the blood is invariably left in a pathological condition at the delivery.

The nervous system, too, in most cases of hard labor, becomes exhausted, and is rendered thereby extremely impressionable by all morbific causes: all the causes of inflammation must act with redoubled intensity upon it, and inflammation once begun, may, with difficulty, be prevented from extending far and wide beyond its radiating point.

As to the serous lining of the abdomen, there is scarcely any portion of it that is not affected, in pregnancy, by the vast extension of the peritoneal superficies of the womb and the abdominal integuments, or by the pressure effected upon them.

The birth of the child takes off this pressure-leaves much of the peritoneum in a state of relaxative flaccidity-and thus brings it into an ataxic condition, inviting the approach and onset of disease.

The repeated, protracted, and vehement contractions of the abdominal muscles, cannot but have a tendency to effect contusions in the opposite surfaces that are so violently jammed or ground together during the labor throes; while the lower portions. of the membrane or the cervical portion of the uterus, containing within it the foetal presentation, are thrust with an incalculable force down below the plane of the superior strait, and oftentimes held for hours against some part of the osseous structure of the pelvis; so that one is amazed to find the tissues escaping wholly from disease, when it was probable they could not escape absolute destruction.

Consider also the state of the textures composing the womb

itself; and reflecting that the power of the womb is resident only in its muscular fibres: see what and how great must be the mechanical violence done to the remaining elementary structures of the organ during the protracted and agonizing contractions of those muscles, contractions that seem, in some instances, to make every sensitive cord feel the violence that is directed and occasioned by the motor cords.

The labor, too, is not the end of the scene, for the womb and the vagina, with their whole cortege of arteries, veins, capillaries, nerves, and absorbents, as well as the muscles and cellular tela, are passing, during forty days after the birth, back again into the non-gravid state; a transition-period, full of hazard, and open to the attack of inflammation.

There are new determinations of blood to be established. The torrents that have poured for months, and in increasing volumes, along the uterine and spermatic branches, are suddenly cut off in a measure by the closure or quasi obliteration of their accustomed channels; and great veins and sinuses, as big as a little finger, must allow their walls to collapse, compelling their endangium to re-enter the state of non-gravid abeyance from which the pregnancy had forced them to issue.

Upon the interior surface of the uterus is left the cotyledynous superficies, with the patulous orifices of the lochial vessels, that were uncovered by the detachment of the placenta. Those mouths are often bathed with fluids of the most putrid and offensive and even acrid character, provoking inflammatory exaltation of the capillary and nervous textures, and the endangial tissue of the veins.

Finally, the new life-force in the breasts must begin; and the firm tension of the mammary glands and galactophorous tubes developes fever, which is akin to inflammation.

In addition to all the causes above enumerated, it is proper to take into consideration the state of the skin. There are few women who go through with the labor without violent perspiration, which issues from the head and thorax, and flows in copious streams. Such a condition of the cutaneous exhalants leaves the delicate vascular and nervous apparatus of the skin in a highly susceptible or impressionable attitude, so that cold and damp operate with peculiar intensity in causing disease.

There are, besides, many labors that are interfered with by the

officious intermeddling practitioner, whether male or female, who happens not to have been well instructed in the duties of the obstetrician. Instruments are the not unfrequent causes of contusion, as well as of laceration of greater or less moment; so that multitudinous provocatives and causes of disease are to be discovered, even in the most simple healthful case of parturition.

There are, moreover, epidemic causes of puerperal fever. I cannot tell you what is an epidemic cause, since it is uncognoscible, recondite, and beyond the ken of the human understanding. We can know that it exists, and we can witness the efficacy of its awful causation, in the frightful devastation of hospitals, towns, villages, and even large and extensive districts of country.

Dr. Sydenham showed long ago, that a constitution of the atmosphere may exert modifying influences upon the nature of diseases, and, that as the constitution changes from time to time, so will the characteristic qualities of any disease undergo conformable modifications from year to year. He showed that there may reign influences to render prevailing maladies either synochous, or typhous, so that the fiercest attack of pleuritis shall participate in the nature of the most ataxic forms of the typhus fever, or upon some unknown non-meteorological mutation of the qualities of the ambient air, the serous inflammations shall recover all their activity and red-hot intenseness.

No eudiometrical researches have hitherto succeeded in wresting from Nature her direful secret as to the essence of epidemic causation. The poisonous exhalations from the bogs of the Valteline, or the marshes of the Campagna, in the eudiometer betray no combinations of the air different from those that rest on the pinnacle of the Shreckhorn, or the Faulhorn; no additional infusion of carbonic acid, no supersaturation of oxygen, nor excessive nitrogenous dilution. Hypotheses and conjectures, however specious and plausible, are all that we have to rest upon in the arduous and anxious explanation.

In the case of the confessedly contagious disorders, we seem to come at something like approximation to the truth. We can, in the case of small-pox, visibly and palpably demonstrate, if not the essence of the contagion, at least the contagious virus, a material in which it exists. We can take it from one, and transfer it a thousand leagues to another, and plant, as it were, its seeds