Class JtLCa^SJl 
 Book M£l 
 
 GopiglitN?- 
 
 COBJUGHT DEPOSIT. 
 
ON THE 
 
 
 •6 
 
 NATURE, SIGNS, AND TREATMENT 
 
 CHILDBED FEYEES; 
 
 IN A SERIES OF LETTERS 
 
 ADDRESSED TO THE STUDENTS OF HIS CLASS. 
 
 BY 
 
 CHARLES D. MEIGS, M.D., 
 
 PROFESSOR OF MIDWIFERY, AND THE DISEASES OF WOMEN AND CHILDREN, 
 IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC. ETC. 
 
 PHILADELPHIA: 
 
 BLANCHARD AND LEA 
 
 1854. 
 
.V\s\ 
 
 Entered according to the Act of Congress, in the year 1854, by 
 
 BLANCHARD AND LEA, 
 
 in the Office of the Clerk of the District Court of the United States, in and for the 
 Eastern District of the State of Pennsylvania. 
 
 PHILADELPHIA : 
 T. K. AND P. G. COLLINS, PRINTERS. 
 
TO 
 
 R. LA ROCHE, M.D. 
 
 My dear La Eoche : — 
 
 The constant and loving friendship, that for more than 
 twenty-five years, in uniting me with you in many interesting 
 affairs — literary, professional, and others — has largely contributed 
 to my happiness, makes me desirous of some suitable occasion to 
 offer you a memorial of my grateful regard, and at the same time 
 pay a tribute in acknowledgment of the eminent station you have 
 acquired as one of the most learned and accomplished of American 
 Physicians. 
 
 I should take far greater satisfaction in dedicating this volume 
 to your name, if I could believe it quite worthy of your accept- 
 ance and approval ; but, as it is probably the last formal contri- 
 bution I shall have it in my power to make to our American 
 Medical Literature, I will not allow the occasion to pass without 
 offering it, and bespeaking for it, at the same time, your favor- 
 able consideration. I owe you so much, that I would to God I 
 could bring you a better gift, for I consider that whatever of 
 success I have had as a physician is, in a measure, due to your 
 good and loving counsel, without which I should perhaps have 
 never become a public teacher and a writer on Medicine, nor 
 have been much employed as a practitioner. It was you who, 
 many years ago, drove me from idleness to industry, and from 
 presumptuous reliance on my own power of observation in Clini- 
 cal Medicine to an acknowledgment of the advantages and neces- 
 sity of studying the writings of other physicians. I am, therefore, 
 deeply your debtor for many things in addition to that kindly 
 regard that has been the pure source of many pleasures for me. 
 
 Perhaps you may even yet remember the occasion when, so 
 many years since, as we were strolling of a summer day, under 
 
IV 
 
 the elms on the west side of Independence Square, I was boasting 
 of the superior advantages of clinical observation as a means of 
 learning to be a physician, and expressing my distrust of, as well 
 as my disgust for medical books, which, of all things, I found the 
 most wearying and unsatisfying; you came to a full stop, and, 
 turning towards me, said : " Now, Meigs, you may depend upon 
 it you are wrong in that, and I advise you to give up such 
 opinions altogether, because you will never succeed as a physi- 
 cian unless you do read, and read a great deal on Medicine. No 
 man ought to be so self-conceited as to suppose that, out of his 
 own mere observations and reflections, he can, during a short term 
 of existence, acquire what it has taken mankind twenty-five cen- 
 turies to learn concerning the nature of diseases and their cure. 
 Such a thing is impossible ; and you will make an egregious mis- 
 take if you suffer yourself to believe that you can ever become a 
 learned, useful, and successful physician, unless you should give 
 yourself up to the reading of works on Medicine ; which if you 
 will do, you may succeed and do well, but cannot on any other 
 terms." I well remember that you looked at me and spoke to 
 me with the air of a young Gamaliel, and I, knowing that you 
 but advised me to follow in your own good and true lead, listened 
 attentively, and heard and was convinced. 
 
 I cannot pretend to say that, after so many years, I am now able 
 to repeat exactly the words you addressed to me on the occasion, 
 but I believe they were nearly those above written ; certainly, I 
 have recorded the very spirit of them, and even now remember 
 how much I was shocked and humbled, though convicted, by 
 your timely and friendly rebuke. Though it would not be pro- 
 per for me to say more than that from that time I became a 
 reader in Medicine, I consider it would be neither immodest in 
 me to acknowledge that it is to you I am indebted for what 
 habits of medical reading I have since practised, nor vainglorious 
 to add that I have, in consequence, met with a fair degree of 
 success as a professional man; because, I wish here to repeat 
 that I am, in this measure, indebted to you for my present easy 
 circumstances, for the privilege of being an American medical 
 writer, and for an enviable station as Professor in a flourishing 
 College of Medicine. Assuredly, but for your kind rebuke, I 
 might have gone on to the present hour without learning any- 
 
TO R. LA ROCHE, M. D. V 
 
 tiling more than they taught me at college, and that routineer 
 Physic that even quacks and Thompsonians seem at last to 
 acquire. Never did words spoken by one friend sink more 
 deeply into the heart of his friend than yours into mine ; and I 
 can now do no more than thank you with all my heart while I 
 dedicate this little fruit of your then goodness and sincerity to 
 your honored name. 
 
 After this explanation, I must beg you to allow me to seize 
 the occasion to say something about the book that I have laid 
 before you, and call your attention to the Letter form in which I 
 have written it ; a form I was led to prefer by several motives. 
 Among these motives was a sudden, off-hand promise I had made 
 to the Students of my Class at the college. Having been much 
 pressed for time, in the great number and variety of topics the 
 discussion of which had led me to near the close of my curriculum 
 of winter lectures, I had only two days left to devote to the con- 
 sideration of childbed fevers, the history of which had conducted 
 me to the last hour of the Term. Feeling how inadequate was 
 that short time to the fulfilment of the important duty before me, 
 I then engaged to finish my instructions as to childbed fevers, 
 by writing and printing my thoughts concerning them in a series 
 of Letters to those worthy gentlemen, and I have thus but exe- 
 cuted a task undertaken out of a right motive. These Letters 
 are, therefore, to be considered as addressed to my own pupils of 
 that year ; and, notwithstanding many of them are already become 
 successfully established as professional men, I feel that I still 
 have a right to speak to them as I used to do when we met in 
 our lecture-room. It being to those gentlemen that I have writ- 
 ten, it is for them to judge whether I have not used a language 
 and manner very similar to that I employed in my public min- 
 istry, as their Professor of Midwifery, and the Diseases of Women 
 and Children. 
 
 This book was never written for you, nor for men of your age 
 and experience in Medicine : still, I trust there may be some things 
 set forth in it, neither unpleasant to read, nor uninstructive in the 
 details for many a medical brother who has not seen the topic 
 treated so fully and methodically as I have here attempted to do. 
 
 I am well aware that some of our people do object to see 
 medical subjects treated in this way, supposing that the Letter 
 
VI TO E. LA EOCHE, M. D. 
 
 form is not suited to the dignity of such topics ; but as I could 
 never, for the life of me, discern why a writer should not make 
 use of the method of communicating his opinions that suits him 
 best, I resolved to adopt this one because it gives me less trouble, 
 and, because I believe that the more direct, plain, and simple 
 one's discourse is, the easier is it to be understood. In adopting 
 this Letter form of speaking to the young gentlemen whom I have 
 addressed, I seem to be still surrounded by them in my lecture- 
 room or my library, and conversing with them viva voce. More- 
 over, we have so many medical writings, under the form of letters, 
 that I am, in this, only following the example of my predecessors 
 and betters, and so, take a warrant from them. 
 
 A strong motive to make this book was also found in the fact 
 that we have, in our American bookstores, only one really useful 
 work on the special subject which is universally admitted to be 
 of the very highest importance. I allude to the thin octavo 
 volume published by Messrs. Haswell & Barrington, one of the 
 series of our friend Dr. Bell's Medical Library, and which was a 
 reprint of Gordon's work, with Hey's, and Armstrong and Lee's 
 on puerperal fever, with an introduction furnished by myself, 
 and containing my then views on the disease. That volume is 
 certainly a very rich one, and would be so did it contain only 
 Alexander Gordon's treatise on the epidemic at Aberdeen ; for I 
 conceive that no man can have any just notions of the treatment 
 of childbed fever until he has read Gordon's book. But, since his 
 day, so much light has been cast on the subject, that the time has 
 arrived to present that subject to our American physicians as it is 
 now ; and this is what I have endeavored to do. It is for others 
 to say whether I have done it in a useful manner. 
 
 The object of every publication ought to be to do some good, and 
 I cannot but indulge the hope that the pains I have herein taken 
 may have some useful results for physicians as well as the public ; 
 for I believe I have put down, in my Letters to my Students, the 
 very best and most reliable opinions that I could collect out of 
 all the many writers on childbed fevers that have come into my 
 possession ; a thing which, so far as I know, has not yet been done 
 by any other author. 
 
 Having been exclusively concerned in medical affairs since 1809, 
 and engaged in the Practice of Physic since 1813, I ought to be 
 
TO E. LA EOCHE, M. D. Vll 
 
 in a way to be able to judge that there is no subject in the wide 
 comprehension of medical clinics that requires a man to know 
 more accurately what he is about than that of the diagnostication 
 and conduct of childbed-fever cases ; and if I should be found to 
 have given, even some very small helps in so great a matter as 
 that, it shall assuredly be admitted that I have done some good 
 by this publication, and, if so, I may hope to avoid Fichte's con- 
 demnation. 
 
 , Should you then approve of this labor of mine as to the proba- 
 ble tendency of it in helping the practitioner, I trust you will not 
 object to the manner of it, solely because of its Letter form, but 
 accept it for the good it may do, notwithstanding you might prefer 
 to see me write in some other way. Indeed, I cannot imagine, 
 nor ever could, that Medicine is a thing of that dignity and 
 authority that it should suffer disparagement and loss because it 
 is not treated of in a particular formal style of composition; 
 because, the dignity of Medicine depends less on its rhubarb and 
 its jalap, on its viscera and its vessels, its bones and their mar- 
 row, than on the moral conduct and intellectual attainments of 
 those who study it as a science and practise it as an art before 
 the people of the land: Medicine is Doctors, not physic. If I 
 were about to write a deed of trust, or an indenture to convey an 
 estate in land, I should endeavor to conform to the forms of such 
 writings ; but desiring to say to those young gentlemen what I 
 know or believe on the subject of one of the most insidious, dan- 
 gerous, and often intractable of disorders ; one, the outbreak of 
 which always carries terror with its invasion, pain with its pro- 
 gress, and often, unspeakable distress and woe as its consequence, 
 I wished to speak to them just as I would do were I walking 
 with them in the street, or conversing with them in a parlor, on 
 a subject of the most urgent vital interest both to them and to 
 society. 
 
 As to the style of these Letters, I am not a fitting judge, nor 
 should I be allowed to judge were I the most fitting person in 
 the world to do so; because they are no longer mine, but are 
 become the property of whosoever may choose to possess them. 
 There is, so far as has come to my knowledge, no style particu- 
 larly appropriate to the discussion of questions in Physic ; all that 
 is wanted in it being, to tell the truth, as plainly and honestly as 
 
Vlll 
 
 possible. To do this, every man ought to follow his own bent, 
 and write like himself, and not like everybody else; and if the 
 public don't like it, the public will find the remedy is easy : they 
 have only to laugh at it and let it alone, for a book will soon 
 die that is neither amusing nor useful. Assuredly, as I thought, 
 on that occasion, twenty-five years ago, our medical literature has 
 little in it amusing; and yet, I see not why we physicians should 
 ever wear sour faces merely because we are doctors, and ever fear 
 to smile lest we should not seem sad enough for our melancholy 
 vocations among the sick and the dying. If our writers would 
 but mix a little more sugar with their physic, the young men 
 would take it better; for it would then be like milk for babes, 
 and they would find themselves seduced, instead of being com- 
 pelled, as now, to read our tiresome tractates on subjects that 
 have little in them of a nature to win by pleasing. Young men 
 are not old enough to be as grave as the seven wise men of 
 Greece, nor will they become so until they become oldish. 
 
 But, my dear friend, as to the style of this book, I may remind 
 you that I never had, these forty years past, any time to study 
 that part of writing; and I never shall make, as indeed I never did 
 make any pretensions to the possession of writing-skill. I never 
 sought for a word in my life; they jump into my mouth when I 
 want to speak them, or they drop from my pen when I would 
 indite them. But I don't think that any person can write well, 
 except he write deliberately and with constant attention to the 
 manner of his writing. If, therefore, I must either endeavor to 
 write elegantly, or not at all, I must hold my peace and go down 
 to my grave, after a long practical career, with the fruits of so 
 much labor and anxiety of no value, except it might be deemed so 
 in the limited circle of my patients, and by my personal friends 
 and acquaintances. But, I do not think that a physician who has 
 enjoyed a very large clinical practice for many years, ought to be 
 content to die without, in some way, showing his sense of obliga- 
 tion to those who have sustained him all his life long, as well as 
 to the profession that has admitted him in its ranks. Is it not 
 true that both you and I have often mingled our regrets on seeing 
 certain gentlemen depart from the scenes of their ministry, leaving 
 no memorial of their experience or their thoughts for those they 
 left behind to pursue a similar toilsome path, one in which acqui- 
 
TO R. LA ROCHE, M. D. IX 
 
 sitions are made with pain and difficulty, and amidst doubts and 
 misapprehensions ? I could not feel content to do so, and there- 
 fore, notwithstanding the perpetual interruptions and the fatigues 
 to which I am still subject, I have written these Letters, with 
 less regard, I confess it, to the manner than the matter of them. 
 You are aware that I have already appeared before our brethren 
 as a writer on different occasions. 
 
 I believe that the only American work on the subject of Ob- 
 stetrics that was in existence, when I began to study Medicine, 
 was the small duodecimo Compendium of Midwifery by the venera- 
 ble Dr. Samuel Bard, of New York. We had, at that day, re- 
 prints of Denman's Midwifery, and the two volumes of Burns, 
 edited by Dr. James, the London Practice, pirated from Dr. Clark, 
 and a very much razeed copy of Baudelocque's two fine volumes. 
 I apprehend that, at that period, few of our American practitioners 
 possessed more obstetric works than those I have above named, 
 and not many, all, even of these. Since that time, we have had 
 the benefit of Dr. Dewees's contributions, and some few others of 
 less note than his, among them my own. There is a ground, 
 then, in this little progress, to hope that we shall gradually obtain 
 an American medical literature on this branch, as well as in other 
 branches of our science. 
 
 At the present time, we are abundantly supplied from abroad. 
 I recently took the trouble to prepare a translation of M. Colom- 
 bat's Treatise, and also one of the able writings on Midwifery, of 
 the celebrated M. Velpeau. Besides these, I have printed my 
 own work on Midwifery, and one on the Diseases of Women, which 
 appear to have been well received, if I may judge from the demand 
 for copies and new editions of them. My Essay on the Acute and 
 Chronic Diseases of the Cervix Uteri, and a small Tract On Certain 
 of the Disorders of Young Children, with the present Letters on Child- 
 bed Fevers, comprise all that I have done in the way of medical 
 writing, if I except many articles in the shape of journalistic 
 Medicine. I presume that I shall stop with the present volume; 
 and, indeed, I may say that I must soon stop altogether, for I am 
 heartily tired of the life of a Physician, and earnestly desire before 
 I die to have, if it might please God, some small time of prepara- 
 tion for the change that must soon come to both you and me. 
 But you have much the advantage of me, because you are 
 
X TO E. LA ROCHE, M. D. 
 
 younger, and have leisure to study, and had, indeed, a strong 
 taste for hard study, when you showed me, what I wish you 
 could show to every American medical student and physician, 
 that to study is a duty imposed by conscience as well as self- 
 interest. The work on Pneumonia you lately gave us, as evi- 
 dence of this, is destined to be among the classics of Medicine; 
 and if you will but carry out your long-cherished design of be- 
 queathing to us the fruits of your thirty years of study and ob- 
 servation of yellow fever, you will have still a greater advantage 
 over me, for it will place you among the first writers on Medi- 
 cine of the present c*entury ; while my productions, alas ! will be 
 forgotten or neglected, except by some curious collector, desirous, 
 perhaps, to see what were the thoughts of Obstetricians in the 
 United States in the middle of the nineteenth century. How 
 few of all the authors whom I have cited, in my examination of 
 the doctrine of milk metastasis, are of any interest at the present 
 day, beyond that of revealing to us the phases through which 
 we have passed from their day to our own ! Yet, among them, 
 who doubts that La Motte and Mauriceau shall last as long as 
 Horace or Cicero! I for one, cannot conceive that such litera- 
 ture as theirs is a perishable thing, but look on it as destined 
 to accompany mankind down the long future lapses of time. 
 Make haste, then, slowly, to lay your treatise on yellow fever 
 before the world — for, as I sincerely love you, in the same sin- 
 cerity, I rejoice in the prospect of your lasting fame. You have 
 time to write useful things, and elegant; while I shall be but 
 too happy if my American brethren, overlooking the want of 
 elegance, should bestow on me the praise of making contributions 
 useful to our art, promotive of our common progress, and so, be- 
 neficial to the public at large. It is only by repeated trials that 
 the medical men on this side of the Atlantic, may hope to rival 
 their brethren of the Old World. I admit that care should be 
 taken to write as well as possible, by all those who sincerely wish 
 to see established a respectable American medical literature; but 
 a long time must probably elapse before we shall find writers like 
 Coste, or Forbes, or Yirey; because we are a working people, and 
 cannot yet afford to sustain a purely literary class, like that of 
 which those gentlemen • are such pure specimens: we have not 
 leisure, therefore, to consider so much the manner as the matter 
 
M. D. XI 
 
 of our communications. But the day of American literature will 
 come, as M. De Tocqueville prophesies; and when it does arrive, 
 the manner as well as the matter will, as he foreshows, be purely 
 American. You have spoken very freely of our shortcomings, as 
 medical litterateurs, on the eighth page of your introductory letter 
 to the work on Pneumonia, but I think you ought to take encou- 
 ragement to believe that your exhortations to improvement will be 
 answered by a visible augmentation of the literary and scientific 
 force of the American medical mind. For the present, I joyfully 
 admit that our medical people are daily rising in intellectual 
 vigor, and that the knowledge of the theory and practice of our 
 art is not only quite equal to any just expectations to be enter- 
 tained as to its usefulness, but that a love of study is far more 
 wide-spread among us than it was forty years ago. Of a truth, 
 we American physicians buy and read more medical books than 
 any like number of our class beneath the moon. Hoping that 
 these good prospects may soon become realities, I now bid you 
 farewell, assuring you again of the affectionate attachment of 
 Your servant and friend, 
 
 C. D. MEIGS. 
 
 Philadelphia, October, 1854, 
 324 Walnut Street. 
 
CORRECTIONS. 
 
 At page 58, line 13 from bottom, for attaches, read affiches. 
 " 58, " 12 " for Richet, read Bichet. 
 
 " 290, " 6 " for anaplastic, read aplastic. 
 
CONTENTS. 
 
 LETTER I. 
 
 PAGE 
 
 Motives for writing these Letters — Great diversity of opinions on the disease, 
 and want of a better understanding of its nature and cure . . .38 
 
 LETTER II. 
 
 Reference to the ancients 39 
 
 LETTER III. 
 
 Inquiry into the origin, progress, and extent of the medical doctrines on milk- 
 metastasis, or what the French writers called errements du lait . . .52 
 
 LETTER IY. 
 
 Inquiry into the real state of the blood in childbed fevers . . . .72 
 
 LETTER Y. 
 
 Is there a poisoned state of the blood? — Of conjectural putridity — Vitiated 
 blood regarded by some as the cause of childbed fevers — In what way the 
 blood can become changed — It is a dependent of the blood-membrane in 
 disease, and not vice versa 79 
 
 LETTER VI. 
 
 Contagion in childbed fever — Definitions — Contagions are both specific and in- 
 cubative — Conditions of the problem — Common tendency to believe in con- 
 tagion — Dr. Holmes's pamphlet — Tonnelle's, Baudelocque's, Jacquemier's, 
 and Kiwisch's views — Von Busch and his hospital-epidemic — Collins's, Du- 
 bois's, and Scanzoni's opinions — Dr. Campbell's experience — Author's expe- 
 rience, with a table — Emitter's cases — Gooch a contagionist, and Armstrong 
 — Roberton's account of the Manchester Epidemic — Churchill . . .85 
 
XIV CONTENTS. 
 
 LETTER .VII. 
 
 PAGE 
 
 Childbed fever sporadic and accidental, or epidemic and unavoidable — Table 
 of epidemics from 1652 to 1853 — It is not a fever, but a phlegmasia — Fever, 
 what is it? — A group of various inflammations differing in character — 
 Opinions of various authors as to the cause — Dr. Ferguson, Churchill, Dance, 
 Tonnelle", Ch. White — Tonnelte's dissections — Case by Author — Gordon's 
 work — Case by Author — Remarks on the so-called vitiation of the blood . 114 
 
 LETTER VIII. 
 
 Opinions of Gooch faulty from his having preceded Dance and Tonnelle — Gasc 
 — Raciborski on the veins — Uterine phlebitis — Putrescentia uteri — Serous or 
 exo-metritis — Mucous or endo-metritis — Metritis parenchymatosa — Affection 
 of the subjacent organs in peritonitis . . 142 
 
 LETTER IX. 
 
 Description of a case of peritonitis in a woman recently confined . . . 149 
 
 LETTER X. 
 Metro-phlebitis 159 
 
 LETTER XI. 
 
 Etiology — German notion of acute blood-dissolution ; Kiwisch's case — Sizy blood 
 
 of pregnancy — Febricula of gravid women — Case of Mrs — State of 
 
 the utero-placental disk — Undischarged lobuli of the placenta — Pressure — 
 Contusion — State of cervix in labors — Over-distension of womb — Relaxation 
 of abdominal walls and sudden withdrawal of textural tension — Torpor of 
 bowels in the gravid — Exalted vital state in labors, analogous to intense 
 hysteria — iEsthesis — Debility from labor — Cold — Unrest — Indigestions — 
 Seasons ; Tenon's table of them 174 
 
 LETTER XII. 
 
 Humboldt on climate — Epidemy — La Roche on miasm — Cosmic agents — Filth 
 — Tenon's state of the air and the sick at Hotel Dieu — Influence of these on 
 the nervous mass — Views of Oken, Cuvier, and Flourens on the nervous 
 mass — The animal naught but nerve — Modifications of nerve crasis caused 
 by epidemy — M. Cerise — Weakness of a cause that affects only one class out 
 of many — Accidents 190. 
 
 LETTER XIII. 
 
 Collins cited to show that typhus fever is confounded with childbed fever — Preg- 
 nant women in cholera; Kiwisch's testimony — Typhoid fever not connected 
 with childbed states — Smallpox and childbed fever — The womb compared to 
 a stump in amputations — Remarks on the contagion of typhus and other 
 zymotic diseases 201 
 
CONTENTS. XV 
 
 LETTER XIV. 
 
 PAGE 
 
 Erysipelas and peritonitis compared — Error to consider childbed fever an ery- 
 sipelas, since it is a group of both phlegmonous and membranous inflamma- 
 tions — Dr. Philip Pitt Walsh's views on puerperal fever — Dr. J. Y. Simpson, 
 of Edinburgh, on identity of erysipelas and phlebitis — Ontologists . . 206 
 
 LETTER XV. 
 
 Description of a childbed-fever case 212 
 
 LETTER XYI. 
 
 Diagnosis of childbed fevers by inquiries as to pain, rigors, the breathing, 
 soreness or tenderness of the belly ; the mammary glands and milk ; inter- 
 mittence of the pain ; the bladder of urine ; is it a urinary or a uterine 
 pain? — The early phlebitis not painful — Date of the attack, and the time 
 already elapsed — Milk fever; M. Chevillard's case — Eemissions in the cases 
 — One described by Tonnelle — Milk fever with after-pains, or incipient child- 
 bed fever? — 'Touching, as a diagnostic proceeding in childbed fever — The 
 tympanitis — Compare pains of phlebitis and peritonitis — The mind — Pus- 
 intoxication 217 
 
 LETTER XVII. 
 
 Preparation for labor . 227 
 
 LETTER XVIII. 
 Means of cure 230 
 
 LETTER XIX. 
 
 On the treatment by means of bloodletting as the remedy-in-chief for childbed 
 fevers — Estimate of the quantity of blood moved by the heart in given times, 
 in health and in disease — The power of bloodletting as a controller of the 
 circulation, and, consequently, of the innervations — Anodyne power of vene- 
 section — Instances in point from Armstrong, from Gordon, from Legouais, 
 from Author — Puzos — Dr. Lee's tables of cases treated with and without 
 venesection — Gordon — Rule as to time- — How to bleed — Gordon's pupils — 
 Late venesections — A fatal case — Two cases suddenly cured — A sudorific 
 mixture — Case of venesection after violent hemorrhage .... 237 
 
 LETTER XX. 
 
 On leeching as a remedy for childbed fevers, with a comparison of its advan- 
 tages with those of venesection » , . 276 
 
xvi ' CONTENTS. 
 
 LETTER XXI. 
 
 PAGE 
 
 Emetics in childbed fevers — Report of the commission on Doulcet's specific — Dr. 
 Jno. Clarke's views of the Doulcet treatment — Dr. White and Denman favor 
 a moderate use of them — Ferguson's opinions — De La Roche's guarded re- 
 commendation — Tonnelle's experience, with cases ..... 282 
 
 LETTER XXII. 
 
 Mercurials in childbed fevers, whether used in the form of calomel or by in- 
 unction ........ 289 
 
 LETTER XXIII. 
 
 Purgatives in the treatment of childbed fevers . . . . . . 299 
 
 LETTER XXIV. 
 
 Opium and turpentine-oil in childbed fevers . . . . . . . 307 
 
 LETTER XXY. 
 Sudorifics .322 
 
 LETTER XXYI. 
 
 Blisters — Sinapisms — Stupes — Cataplasms — Turpentine, used as topical reme- 
 dies in childbed fevers 329 
 
 LETTER XXVII. 
 
 Typhus, with childbed fever — Diet — Horizontal rest 334 
 
 LETTER XXYIII. 
 
 Febris gravidarum et parturientium 346 
 
 LETTER XXIX. 
 
 Crural phlebitis, commonly called milk-leg 351 
 
PUERPERAL FEVER 
 
 LETTER I 
 
 motives for writing these letters — great diversity of 
 opinions on the disease, and want of a better under- 
 standing of its nature and cure. 
 
 to the members of my class of 1850-51 :— 
 
 Gentlemen : — 
 
 1. It is a very remarkable tiling that, in the present age of the 
 world, there should, among medical men, exist such great differ- 
 ences of opinion concerning the nature, causes, and treatment of 
 one of the most familiar, and at the same time, most terrible and 
 fatal of disorders; I mean the disease or diseases grouped toge- 
 ther under the denomination of childbed fevers — puerperal fever, 
 puerperal peritonitis, peritoneal fever, metro-peritonitis, fever of 
 lying-in women, &c. &c. 
 
 2. One might suppose that time enough has elapsed, even 
 since the revival of medical learning in the fifteenth century, and 
 more especially since the surer establishment of our medical phi- 
 losophy after Harvey's discovery of the circulation, and the 
 great enlargement of the circle of science by Pecquet, Kudbeck, 
 and Aselli's invention of the absorbents at a later period of the 
 seventeenth century, to have enabled our people to come to some 
 certain conclusions on these questions. Many thousands of cases 
 of childbed fever have been observed — many hundreds of dissec- 
 tions have been made to investigate its post-mortem appearances — 
 yet all these, with books, essays, pamphlets, and conversations 
 without number, have failed to harmonize the opinions of our 
 
 3 
 
36 PUERPERAL FEVER. 
 
 and skill to defend the woman from threatened destruction, he 
 knows not where to strike, or how to interpose his shield ; he 
 gropes in thick darkness among his hypotheses, and what he does, 
 being done without a clear understanding of what he should do, 
 the victim is often lost through the physician's inefficiency. 
 
 6. Shall I then, while I complain that the books are already 
 too many for us, shall I add to their number by contributing 
 one more volume to the catalogue? Shall I add to the con- 
 fusion I am so truly and so heartily ashamed of? No man 
 ought to write a book unless he can set forth in it a new and 
 useful thought, or place in a clearer view the thoughts of ante- 
 cedent writers. This just sentiment I have derived from a writer 
 who speaks upon the subject as follows : — 
 
 7. "Whatever may be the subject of a scientific work, the 
 author of such a work must not conceive of knowledge in a mere 
 historical fashion, and only as received from others ; but he must 
 for himself, have spiritually penetrated to the i d e a of knowledge 
 on some one of its sides, and produce it in a self- creative, new, 
 and hitherto unknown form. If he be but a link in the chain of 
 historical tradition, and can do no more than hand down to 
 others the knowledge which he himself has received, and only in 
 the form in which it already exists in some work whence he has 
 obtained it, then let him leave others in peace to draw from this 
 fountain whence he also has drawn. What need is there of his 
 officious intermeddling? To do over again that which has 
 already been done, is to do nothing ; and no man, who possesses 
 common honesty and conscientiousness, will allow himself to in- 
 dulge in such idleness. Can the age, then, furnish him with no 
 occupation which is suited to his powers, that he must thus 
 employ himself in doing what he ought not to do ? It is not 
 necessary that he should write an entirely new work on any part 
 of knowledge, but only a better work than any hitherto existing. 
 He who cannot do this, should absolutely not write. It is a 
 crime, a want of honesty to do so, which, at the most, can only 
 be excused by his thoughtlessness and utter want of any true 
 understanding of the vocation he assumes." 
 
 8. These are the words of Prof. Fichte, which you may find at 
 p. 126 of his Lectures on the Yocation of the Scholar ; and they 
 
MY ENGAGEMENT TO WRITE. 37 
 
 are well worthy to be considered by every person who has the 
 intention of writing a new book. I fully admit the justice of 
 Prof. Fichte's condemnation of all those who, without due con- 
 sideration, would add to the already heavy burden of our own 
 peculiar literature, which, so abundant is it, has already become 
 too vast for use, except by such as can give themselves up to a 
 merely literary life. Yet, notwithstanding the philosopher's pro- 
 test, which I have cited above, I feel impelled to write these Letters 
 to you, partly in fulfilment of the promise I made at the close of 
 my Course of Lectures — partly because I have felt obliged in this 
 way to make up to you for the short-comings of my Public-in- 
 struction at the College, and, in a still stronger degree, because I 
 think it would be a useful thing to set forth certain points that, 
 though of the highest importance in our art, have not been ade- 
 quately explained and enforced by those to whose labors we are 
 indebted for the first suggestion and advancement of them. For 
 example, in the use of venesection, as proposed by Dr. Gordon, 
 while I look up to him as my real guide and teacher in this mat- 
 ter, I conceive that even he has in some respects failed to make his 
 own wishes and sentiments clearly known. I should, I think, do 
 a real service to my American medical brethren if I should be 
 enabled to be a useful commentator on, and successful advocate 
 of Dr. Alex. Gordon's great point of treatment. 
 
 9. Further, I am now sixty-two years of age, and first began 
 to be conversant with medical affairs in the year 1809. I have 
 had a very large and long experience in practice. I have written 
 and published various essays, chapters, and lectures on this very 
 subject. During many years I was connected with an establish- 
 ment here for giving private lectures on Medicine, and it is now 
 near fourteen years that I have had the honor to be one of the 
 Professors in the Jefferson Medical College at Philadelphia. All 
 these circumstances give me a warrant to speak, by this volume, 
 on the subject of childbed fever; and as I conscientiously believe 
 that another treatise is demanded, in the present state of our 
 knowledge on this subject, I shall, therefore, keeping in view the 
 warning and protest of the good German professor and philoso- 
 pher, address myself to this task. If I have, indeed, attained to 
 the full possession of the idea of childbed fever, both 
 as to form and substance, my labor shall not prove to be vain; 
 
38 PUERPERAL FEVER. 
 
 not that I suppose myself to be in possession of knowledge in 
 this matter that other men have not dreamed of — for I have no 
 such vanity — I only hope, and humbly trust, that my laborious 
 life has not been in vain devoted to studies connected with this 
 department of Science, and earnestly desire, before I depart hence, 
 to make one further acknowledgment of that debt I owe to those 
 American brethren who have sustained me by their good opinions 
 during so many years — all that I am, and have, being due to 
 them; since I conceive that an American physician who is cast 
 off and rejected by them is lost already. 
 
 10. In studying the subject of childbed fever, it will behove 
 you to inquire what is its nature, its causes, tendencies, signs, and 
 liability to modification and control by means of the medical art ; 
 to know whether it will be always one and the same — or whether 
 it is not rather a group of affections, classed together under this 
 one appellation. You should strive to attain to the possession of 
 the idea, or spiritual image and form of the disease, as it is, not 
 in nature, but in the intelligence ; so as to create, as it were, a 
 spiritual model, or eidolon, which you can denominate by this 
 title — and which, once formed and perfected in your own under- 
 standing, might enable you to compare all the future possible 
 events of your practice in this particular, with the true, absolute 
 spiritual, intellectual standard, or idea of it. To attain to the 
 possession of this idea, you should not rest content with learning 
 what men of your own epoch have said on it — you must also have 
 some clear notions of what was deemed and said in other times, 
 and so, coming downwards from the beginning, make yourselves 
 masters of its absolute identity, which consists not only in what 
 is, but also in what was, and, to a certain extent, what shall be 
 hereafter, as to childbed fever. I pray you not to make the mis- 
 take of regarding the Art and Science as already perfect — for, of 
 a truth, Medicine is a thing always becoming, it has never 
 yet become, and long ages must elapse ere it can reach such a 
 stage of perfection. Hence, I propose in my next letter, to invite 
 you to go back with me to an ancient date, that we may together 
 for a moment contemplate this subject, as it was manifest, more 
 than two thousand four hundred years ago. 
 
LETTER II 
 
 REFERENCE TO THE ANCIENTS. 
 
 11. I AM in the present communication to invite your attention 
 to certain very ancient views of childbed fever, and I heartily wish 
 it were in my power to set before you, in these communications, 
 such a full and comprehensive prospect of the disorder, as might 
 make you acquainted with it as it was in all past time, as well as 
 show you clearly what it is to-day, and under all possible circum- 
 stances and forms of it. The former, however, I could not do, 
 even if I possessed learning sufficient, without violating the plan 
 of this work. I must, nevertheless, beg you to take notice, that 
 as childbed fever consists of certain affections to which only 
 lying-in women are liable, you are to conclude that it must have 
 been familiarly known to the most ancient nations, and cannot but 
 still occasionally break out in all lands; so that it is by no means 
 a new form of disease discovered in modern times, but one coeval 
 with the pains and risks of the puerperal state, in all ages of the 
 world. We have no right to doubt that the women of ancient 
 Thebes, Babylon, Athens, Eome, Byzantium, Alexandria, Venice, 
 and Grenoa, were as subject to its seizure as those of London or 
 New York, and that many tens of thousands of them, managed by 
 their Shiphrahs and Puahs, must have perished under its sporadic 
 or epidemic forms. Hence the reflection arises that the Medical 
 Sciences are of very slow growth, since in some thousands of 
 years they have not grown up to maturity, even on this most 
 trite and startling subject; it being certainly true, that we are still 
 left to grope our way amidst the treasured stores of human ex- 
 perience, and are still seeking in vain for that full and positive 
 knowledge that we so much need and so earnestly desire. 
 
 12. It is not necessary in citing the writings of Hippocrates, 
 or other ancient authors, to settle, even were this possible, ques- 
 
40 PUEEPEEAL FEVEE. 
 
 tions as to their personal identity. Such ancient productions, as 
 Hippocrates's writings, are precious to us, rather because they 
 come to us as reflections of thought from ages long past, than 
 because they represent the ideas of any particular individual ; for 
 posterity always takes less interest in individuals, than in opin- 
 ions, thought, rationales, dogmas, characteristic of times elapsed. 
 It is sufficient for us to know that the books attributed to Hippo- 
 crates II. are among our most venerable records, and that they 
 have for many centuries been the admiration of our class. Hippo- 
 crates II., the supposed author of the Books of Epidemics, lived at 
 the same time with Socrates and Plato, and was therefore con- 
 temporary with many most illustrious and elegant scholars, in a 
 day when admirable arts and important sciences sprung, as it 
 were, perfect, upon the stage of the world, like Minerva fully 
 armed. 
 
 13. Daniel Le Clerc, in JOHistoire de lalfedecine, page 113, informs 
 us that this prince of physicians was born in the island of Cos, in 
 the first year of the eightieth Olympiad, about thirty years before 
 the breaking out of the Peloponnesian war, A. M. 3005. The 
 Peloponnesian war, according to Sir Isaac Newton's Chronology, 
 p. 40, began 431 B. C, so that Hippocrates was born about 451 
 before the advent of our Saviour. 
 
 14. Those among you who should feel any desire to peruse a 
 very severe and very learned history and criticism of the man and 
 his writings, will be both instructed . and amused by the curious 
 volume of Etudes Historiques et critiques, sur la Vie et la Doctrine 
 cV Hippocrate, &c. &c, par M. S. Houdart, M. D. &c. ; 2d edition, 
 1840. 
 
 15. Among the many exemplifications of diseases on which he 
 treated in his writings, Hippocrates has left us accounts of several 
 persons who were under his care in childbed fever, and they are 
 so clearly stated that readers at all familiar with the disorder at 
 the present day, readily recognize the pictographic excellence of 
 his representations. In Book I. Sect. V., Be Morb. Mul., he 
 already gives us a pretty clear account of childbed fever ; but 
 it is in the Books of Epidemics that we must look for his cases. 
 Among others, here is one which gives you an account of the 
 illness of Dromeades's wife, which is numbered Case XI. in the I. 
 
CASE OF DKOMEADES'S WIFE. 41 
 
 Book of the Epidemics. Bead it, and you shall not fail hereafter 
 to meet with instances to convince you, not only of the fidelity 
 of his relation, but show you that the disorder is one which was 
 familiar in the most remote nations of antiquity : — 
 
 16. "The wife of Dromeades, recently delivered of a daughter, 
 was doing as well as usual, when, on the second day after her de- 
 livery, she had a severe chill and a high fever. From the very 
 first of this attack she complained of pain in the hypochondria, 
 accompanied with nausea, rigors, anxiety, and sleeplessness, which 
 continued for some days. The respiration was slow and sighing. 
 On the day succeeding the chill, she had free healthy evacuations 
 by stool ; the urine was heavy, white, and troubled, like urine 
 disturbed after long resting, but without sediment. The night 
 was sleepless. On the third day, about noon, a violent chill, high 
 fever, and urine as before; pain in the hypochondria; qualmish- 
 ness ; a bad night, without sleep : general sweat ; coldness, 
 promptly succeeded by a return of the heat. On the fourth day 
 the hypochondriac pain was less : she had gravative pain in the 
 head ; lethargy ; a few drops of blood from the nostrils ; the tongue 
 dry ; thirst ; urine thin and oily : a little sleep. Fifth day, thirst, 
 nausea; same state of urine, no stool. About noon violent de- 
 lirium, soon after which she became calm, and fell into a lethargic 
 state. A slight coolness in the course of the night ; sleep ; de- 
 lirium. Sixth day — in the morning a chill, followed by a prompt 
 return of the heat. General sweat, cold extremities, delirium: 
 slow, suspirious respiration ; soon after which, spasms, beginning 
 at the head, and which speedily terminated in death." 
 
 17. Hippocrates, you see, speaks of pain in the hypochondria, 
 by which you are not, I think, to understand literally the region 
 of the body now so called, but the under parts of the abdomen, 
 which is the usual seat of the pain in such cases as that he de- 
 scribes. Admitting this interpretation of his word hypochondria 
 to be correct, then any person familiar with the incidents of a 
 childbed fever will plainly perceive that the wife of Dromeades 
 fell a victim to inflammation originating in the parts contained 
 within the pelvis, and extension of that inflammation to parts 
 above the plane of the superior strait, as well as into some of the 
 larger veins or sinuses of the womb, for she manifestly exhibited 
 
42 PUERPERAL FEVER. 
 
 during her illness, the proofs that she had infected the mass of the 
 blood with corpuscles of pus, that could only have been produced 
 by the inflamed tissue-surface of a vein or veins. I take this to 
 be evident by the hysteroidal state, or pysemic-intoxication con- 
 dition of the woman on and after the fourth day. No such de- 
 lirium is to be looked for in the pure peritonitic forms of the 
 malady. 
 
 18. Case X. of Book III. contains an account of one of the 
 servants of Pantimedes. This woman being prematurely confined, 
 was, on the first day seized with intense fever, and other symp- 
 toms of disease, of which she died on the seventh day ; and doubt- 
 less with the same childbed fever we so often witness in the United 
 States. As the details of the observation are quite meagre, I shall 
 not quote them here. 
 
 19. The Xllth Case, Book III. contains the relation of another 
 instance of the disorder. A woman, who in a laborious labor 
 gave birth to a male child, was attacked with fever, thirst, nausea, 
 and cardialgia, dry tongue, disorder of the bowels, marked by 
 thin, small, liquid dejections, and insomnia. On the second day 
 she had a slight chill, followed with smart fever. There was a 
 moderate cool sweat about the head. On the third day, griping 
 stools, that were copious, crude, and thin. The fourth day another 
 chill, with general reaction and insomnia. The fifth day was bad; 
 and the sixth was similar to the fifth : she had copious, liquid stools. 
 On the seventh day the chill returned, with smart fever, consider- 
 able thirst, and violent agitation : towards evening there came on 
 a universal cold perspiration, followed by cooling of the whole 
 body, particularly the limbs, which could not be kept warm. At 
 night another chill; and the extremities continued to be cold. She 
 got no sleep, and was slightly delirious, with frequent lucid inter- 
 vals. At noon, on the eighth day, she had febrile heat, thirst, 
 great heaviness, and vomiting of small quantities of yellow bile. 
 The night was bad, with insomnia. She passed the urine in great 
 abundance, but involuntarily. On the ninth day, there was re- 
 mission of the symptoms ; heaviness in the evening, with vomit- 
 ing of small portions of bile. On the tenth day, a violent chill in 
 the exacerbation of the fever ; obstinate insomnia. In the morn- 
 ing, urine very copious, without sediment ; the extremities reco- 
 
43 
 
 vered their warmth. On the eleventh day, vomiting of greenish 
 bile, soon succeeded by severe rigor and a return of the coldness 
 of the extremities. Towards evening, sweat, chills, and frequent 
 vomiting. The night was bad. On the twelfth day, the vomiting 
 increased, and she brought up a great quantity of dark fetid 
 matter, which was followed by frequent hiccough and excessive 
 thirst. On the thirteenth day, bleeding at the nose, which was 
 succeeded by her dissolution. The stools were always frequent, 
 and were accompanied with continual rigors. The patient was 
 about 17 years of age. 
 
 20. Few medical men, upon examining the foregoing relation, 
 I suppose, would fail to discover in it the proofs that this woman 
 died with a childbed fever, and that the fever was nothing more 
 nor less than an open manifestation of such constitutional irrita- 
 tion and nervous perversion as might naturally be expected to 
 arise from an inflamed state of parts shortly before concerned in 
 the acts of gestation and parturition. I conceive it is not required, 
 in order to satisfy our curiosity in regard to the causes and course 
 of the phenomena, to suppose that the woman was first affected by 
 the causes of a fever — properly so called — and that the local inflam- 
 mations and degradations were accidents supervening during the 
 fever. It is far more consonant with a spirit of right reason, to con- 
 strue the circumstances in an opposite way, and consider that a 
 certain area or areas of phlogosis being first established within the 
 pelvis, the febrile phenomena were awakened by that cause. Galen, 
 in his second commentary on the third book of Hippocrates, cites 
 this very case, and says that Hippocrates would have mentioned 
 the fact, had any external cause led to the premature delivery of 
 the servant of Pantimedes. The illustrious commentator remarks : 
 "Itaque ex morbo constat vitiosis collectis humoribus abortisse;" 
 that is — " It is, therefore, clear that she miscarried on account of 
 a disorder arising from a collection of vitiated humors." Galen, 
 in a long comment, argues to show that the woman's delivery 
 prematurely, was due to the bad state of her health, which he 
 deduces from Hippocrates's description of the fever — thirst, dry 
 tongue, disordered bowels, &c. &o. — but he also expresses a sus- 
 picion that these affections might be the ready results of an active 
 and distinctive phlegmasia ; yet I conclude from his words that he 
 knew as little what was going on in the case as his great prede- 
 
44 PUERPERAL FEVER. 
 
 cessor himself. In none of the cases is any memorandum to be 
 found of the treatment, except, indeed, where the author says 
 that the extremities could not be kept warm; whence I conclude 
 that attempts must have been made, though vainly, to restore the 
 temperature. Galen's comment on the case before given, that of 
 Dromeades's wife, is too short to be of any interest. 
 
 21. Celsus, who speaks of the uterus and some of its morbid 
 states, has left us nothing at all, worthy of citation, upon our par- 
 ticular topic. 
 
 Aretseus was a Greek physician who flourished about Anno 
 Domini 150, which is some ten years later than Galen, which 
 leaves us to suppose he may have been a contemporary prac- 
 titioner. In the whole of his eight very dull books, there does 
 not appear the least notice of the disorders we are studying, 
 so that, as far as concerns that particular interest, he might as 
 well have never been born. The epoch of Aretasus is a disputed 
 point, however, for some persons would make him a physician 
 during the reign of Augustus, while others carry him down to 
 Adrian and Severus. 
 
 Oribasius was a voluminous writer who lived in Julian's age, 
 and who accompanied that emperor in his expeditions, and is said 
 to have assisted in establishing him on the throne. The 112th 
 chapter of the 4th book might, d priori, be supposed likely to 
 contain his views on those disorders that attack women in their 
 confinement, for it is headed : "Ad vulvae inflammationem, dolores, 
 ulcerationes, mordicationes, pruritus sinus muliebris, ad eandem 
 procidentem, et item ad ea omnia quae ad conceptiones et foetus 
 pertinent." This entire chapter, however, consists in only thirty- 
 seven lines of a double-column page. It has not even a reference 
 to the disorders that follow childbirth. The 50th chapter, 9th 
 book of the Synopses, "De uteri inflammatione," is utterly jejune, 
 and even childish, except that he advises the woman to be bled 
 at the arm on the third day, provided certain puerile methods 
 indicated by him should fail of a cure. 
 
 Aetius, author of the Tetrabiblon, was of the fifth century. 
 When these works of Aetius came out translated by Janus Cor- 
 narus, in 1541, they were highly applauded and eagerly sought 
 after, but I presume few persons now look into them, except with 
 the hope of catching a reflection of the medical opinions of that 
 
THE GREEK PHYSICIANS. 45 
 
 remote age. Aetius wrote a great many chapters, and among them 
 he treats, in cap. 38, tetrab. iv., sermo iv., de uteri inflammatione. 
 In all this chapter on uterine inflammations, the only allusion to 
 our topic consists in his mentioning abortions as sometimes being 
 the cause of inflammation of the womb. It is a singular thing that 
 Aetius, who, in tetrab. iv. sermo iv., devotes twenty -five chapters 
 to midwifery, and another series of thirty-five chapters to diseases 
 of women, should have said not a word on that great and import- 
 ant group of disorders that are treated of in these Letters, though, 
 as compiler rather than author, he had ransacked all the works of 
 his predecessors to make up his commonplace-book of a Tetra- 
 biblon. It is probable, indeed, that what he did know was tradi- 
 tionally rather than empirically acquired. He confesses as much 
 in his 14th chapter, when he says on Parientibus facienda: 
 "Qaa3 praeparare oportet, et quomodo secundum naturam parien- 
 tibus consulendum sit, supervacuum fuerit scripto prodere, quam 
 ex Ion go usu, non modo obstetrices, sed reliquas quoque mulieres 
 ista sciunt." 
 
 Alexander Trallianus, a Lydian Greek, came later than Oriba- 
 sius and Aetius, but earlier than Paul of Aegina. The author of 
 his article in Biog. Med. of Diet, des Sc. Med. assigns his epoch 
 with that of the Emperor Justinian, and says that one of his four 
 celebrated brothers, Anthemius the architect, w T as employed by 
 Justinian in the construction of Sancta Sophia at Constantinople. 
 Alexander of Tralles is looked upon by some writers as second 
 only to Hippocrates. Still, whatever may be his merit as a writer 
 on physic, he has none as a writer on our subject, for it was in 
 vain that I searched his pages for a dot of light upon the opinions 
 of his time concerning childbed fevers. 
 
 Paul Aeginetta, though in his treatise on inflammation of the 
 womb whether connected with pregnancy and labor or in the 
 non-gravid state, he shows that he had a very plain view of the 
 fact that the constitutional accompaniments are due to it and to it 
 alone, yet I shall not trouble you with a citation from his article, 
 which you may consult at page 620 of the Sydenham Society's 
 edition, Yol. I. Paul flourished during the seventh century, and, 
 as he was a voluminous writer, and one supposed to be well ac- 
 quainted with our Aiedical literature down to his own epoch, we 
 may regard his silence as to any decided progress, as a sure sign 
 
46 PUERPERAL FEVER. 
 
 that nothing considerable had been effected during the eleven 
 hundred years from Hippocrates to Paul. 
 
 22. Upon the decline of science accompanying the ruin of the 
 Eoman Empire, philosophy took up a temporary abode under the 
 protection of the Caliphs, and it is certain that many able medical 
 men issued from the schools and colleges established by those 
 magnificent yet semi-barbarous sovereigns. Among those phy- 
 sicians, Johanna Ben Massoviah, a Syrian Christian, known in 
 Europe as John Messue, was physician at the court of Haroun al 
 Easchid, who died A. D. 801, and was a very learned man of that 
 School; where also flourished at about the same date in the ninth 
 century, the Bachtishuas, Gabriel and John. Messue has ab- 
 solutely nothing worth quoting for you in his works, and I shall 
 therefore content me with referring you to his " Particula tertia 
 sectionis primse, continens summas quatuor — Summa prima, que 
 est de cognitionibus meri" — a chapter too stupid, I should think, 
 to invite your attention. Nevertheless, it shows that nothing was 
 yet done, though the doctors lived in clover, as we may judge 
 from their great intimacy and familiarity with those dangerous 
 and uncertain people, the Caliphs, whose whims and caprices 
 sometimes rewarded us with purses stuffed with sequins, and 
 sometimes, on the slightest occasion, amputated our heads with 
 the cimeter, or choked us with the bowstring, or drove us into 
 the outer darkness of disgrace and poverty. One of the most dili- 
 gent and learned men of his day, was the great Arabian philoso- 
 pher and physician, Abou Ali Houssain Ben Abdallah Ben-Sina 
 Al scheikh Al Keis, commonly known as Avicenna, who was born 
 at Bokhara in the 370th of the Hegira, and died at Hamadan in 
 428. 370 of the Hegira corresponds to 980 A. D. The canon of 
 Avicenna was, for our class, previous to the revival of learning 
 in Europe, like a volume of the Scriptures for authoritativeness, 
 until the writings of Hippocrates and Galen — of which they are, 
 after all, but miserable compilations — allowed them to fall into 
 merited contempt. Yet it is well to search the canons of Avi- 
 cenna, to find what he knew about childbed fever. I have vainly 
 examined the whole of the 21st Fen. of the III. Book, for an item 
 of really useful thought, or the smallest mark of progress, and am 
 left with the certainty that women at the court of Kouahrezm, 
 where he was in high honor as a practitioner, either never applied 
 
THE ARABIANS — GUAYNERU8. 47 
 
 to him in their lying-in troubles, or, that if they did, he knew as 
 little concerning the childbed fevers which must have prevailed, as 
 the most ignorant and brutal Arab midwife. Yet, after all, it is easy 
 to conclude that an Arabian physician could have little occasion 
 for the study or practice of the Obstetric arts, since the Hareem is 
 a sacred place among the Orientals, and it is far more likely that 
 a Sultanna should be left to die in the hands of a wise woman, 
 the traditional representatives of the midwives of the Scriptures, 
 than expose herself to the manipulations of a male surgeon. I 
 do not suppose then that medical men were called on to assist in 
 labor, though the curious case of one of Haroun al Easchid's 
 ladies, cured so singularly by Gabriel Bachtishua, shows that the 
 doctors may have sometimes given advice outside of the Hareem. 
 The story is told in the Historia Dynastiarum- of Gregory Abul- 
 pharajius, translated by our colleague, Dr. Pockoke. 
 
 Averrhoes, who died in A. D. 1206, and Avenzoar, who lived to 
 A.D. 1262, both Moorish physicians of Spain, have nothing upon 
 our subject. Their works, like those just mentioned, show that, 
 from Hippocrates to near the end of the thirteenth century, the 
 illness of Dromeades's wife would be construed pretty much in 
 the same way by all our brethren from Thasos down to Bagdat, 
 Kouarezhm, and Seville. 
 
 23. Antonius Guaynerius, whose black letter quarto was 
 printed at Lyons by Constantin Fradin in 1525, was an Italian 
 physician, native of Liano, near Milan, who lived until 14-10. He 
 was much celebrated as a practitioner and writer, and was public 
 professor, and, to judge from his Opus Preclarum, as it is entitled, 
 was about as knowing a person in these matters as any man of 
 his time. The 37th chapter on folio 165, "de regimine enixe," 
 contains the sum of all he had to say concerning the diseases and 
 accidents of lying-in women ; and if you should adopt the opinion 
 that childbed fever is, and always has been, the most considerable 
 cause of the mortality of childbed, you will admit that, Guayneri, 
 being a very fair representative of the learning of his time, there 
 must have been very little of it, as far as regards Obstetricy, its 
 diseases and accidents. 
 
 24. The same may be said with propriety of nearly the whole 
 of the writers in Spach's collection, which, under the title of 
 
48 PUERPERAL FEVER. 
 
 Gynceciorum, sive de mulierum, turn communibus, turn gravida- 
 rum, parientium et puerperarum affectibus, et morbis, folio 1567, 
 contains a considerable number of authors, who wrote on the 
 diseases of women, and the disorders and circumstances of preg- 
 nancy and labor. The collection of Spach is valuable chiefly as 
 a work in which a man can see how stupid the profession of 
 Physic was up to a late period in the history of Letters. Spach's 
 volume has transmitted to us the works on female complaints, of 
 Felix Plater, Moschion, Cleopatra, Priscian, an anonymous writer, 
 Trotula or Eros, Nicholas Eoch, Bonacioli, Silvius, Kuff, Mercu- 
 riali, Montana, Trincavelli, Bottom, Le Bon, Pare*, Albucasis, 
 Eousset, Caspar Bauhin, Cordseus, Martin Akakia, and Mercado. 
 Among the best is the treatise of Mercatus. ' Louis de Mercado, 
 known in our libraries as Ludovicus Mercatus, was a native of 
 Yallaclolid, and was of fame so great as to be chosen Physician 
 to Philip II., as well as to Philip III. He attained to the great 
 age of 88, and died in 1599, about the time when "William. Har- 
 vey was a Student of medicine. As he died so old a man at the 
 end of the century, you may set him down as eminent and active 
 35 years earlier, which will place you about 1564, when Spain 
 was receiving the golden harvests of Mexico and Peru, just 
 conquered, as we are now waiting our arrivals of two and a half 
 millions a month from California. Mercado's work, De commu- 
 nibus mulierum afrectibus, is printed in the closing part of 
 Spach's Gymeciorum, and occupies its folio pages from 803 to 
 the end of the volume at p. 1080. 
 
 At the 1070th p. he says : There is also a kind or condition of 
 fevers that are peculiar to lying-in women, and proper to them 
 only, and which is not even by chance to be ever observed in 
 others, or at least very rarely; it depends upon suppression of the 
 discharges, or on a diminished flow of the courses, and their be- 
 coming putrefied within the womb, or converted into a sort of 
 suppuration. In such cases, fever cannot be avoided, as Hippo- 
 crates has taught us — "when pus is formed," &c. This is clearly 
 shown by the uterine discharges, which, under such circum- 
 stances, issue forth with a strong fetid odor, and of a watery, 
 sanious, or other unnatural character. Such fevers are similar 
 to all other kinds arising from sources of putrefaction; from bubo 
 or other unnatural tumor; from substances putrefying within 
 
HIPPOCRATES — RAYNALDE. 49 
 
 the womb, that the heart becomes heated, and that fever arises, 
 is certain. That Hippocrates was well informed on these sub- 
 jects, is evident from what he says in his first book, de morbis 
 mnliebribns, referring to the causes of fever in the lying-in 
 woman by the words " when the discharges in a newly delivered 
 woman do not go on well, as if the mouth of the womb were 
 closed and its substance inflamed, the cavity of the organ is 
 contracted with spasms after the escape of the foetus. If this 
 should be the case the discharges cannot proceed." He adds 
 the following as the prime causes, saying that if the effusion is 
 suspended, fever is lighted up, with tympanitic distension of the 
 belly. The woman cannot be touched even, without giving rise 
 to pain all over the body, particularly if the abdomen be touched. 
 The belly is much vexed with pains ; there is also backache, loss 
 of appetite, wakefulness, punctura, (sic), and after the 5th or 7th day 
 the bowels are liable to become disordered with dark and offensive 
 stools, and urine, velut asinina. 
 
 In England, so late as the reign of Henry YIIL, there lived 
 Dr. Thomas Kaynalde, author of " The Birth of Manhynde other- 
 wyse named the womaviS booJce" &c. This is a translation with 
 modifications of Eucharius Ehodion's work de Partu Hominis, 
 printed in 1535. My copy of Eaynalde, 2d edition, is 1565. Now 
 I would have you know, that women in King Henry's time had 
 puerperal fever, as well as their predecessors and successors ; 
 and when attacked this is the way they were managed. 
 
 11 Likewise do yf the woman have the ague after her labour, for 
 that cometh of like cause, by retention of the floweres ; and in 
 the fever let her use to drinke water in the whiche is decocte 
 barley beaten, or cider and barley together, or water in which is 
 sodden Tamarinds, or whay of mylke, and let her eate a cullis 
 made of a cocke and sweete pomegranates, for these things do 
 provoke the flowres, and mittigateth the immoderate heate,. re- 
 freshing greatly the body, loossyng and opening suche thinges 
 the whiche before were constricte and cluddered together. If the 
 body after labour do swell and inflate, then let her drinke water 
 in which is sodden cicer and cummin, beaten together." — Fol. 
 lxxiii. 
 
 What do you think, young gentlemen, of our professional 
 dignity and usefulness as conductors of childbed fevers in England 
 4 
 
50 PUERPERAL FEVER. 
 
 so short a time ago that four or five men's lives might possibly 
 reach from Henry's age to our own ? Certainly that was not an 
 age remarkable for our progress. 
 
 25. Yet you see that even so lately as in the very close of the 
 16th century, this learned man had not gone one step beyond the 
 date of Hippocrates, who flourished about B. C. 420 ; so that, since 
 even Mercado and Eaynalde himself had not advanced one step, 
 we may say we all stood stock still on this matter for 2000 years. 
 But as I am not proposing here to write a whole history of Medi- 
 cine for you, I shall now cease to call your attention to the older 
 volumes of our library. But it will be, I hope, for you, a pleasing 
 reflection, that in our recent age we have made a most wonderful 
 and gratifying progress in knowledge, though, as I have said 
 before, we have not, even yet, found a common stand-point, 
 whence we may all take the same view, and behold the circum- 
 stances as they really are, and all agree that we see them well 
 and truly ; for ours is a science that is in process of becoming and 
 one that will yet become. We are still the victims of many a de- 
 lusion in what is called the philosophy of Medicine, as well as in 
 practice ; we have still many barbarisms to be given up, for we 
 doctors are a very traditional class of people. To learn that the 
 barbarous customs of antiquity, in relation to many points in our 
 art, were not laid aside even in the splendid age and court of 
 Louis XIV., of which a singular proof is to be found in old 
 Dionis's delightful little duodecimo, Traite general des Accouche- 
 mens, &c, Paris, 1724, open the book at page 327, and you shall 
 read the following startling story : — 
 
 " There are certain teachers who insist that as soon as a woman 
 is delivered, the skin of a black sheep, just torn from the body of 
 the animal, must be laid over the patient's abdomen, under the 
 idea that the warmth of such a skin restores and comforts the 
 parts that have suffered. M. Clement applied one of them to 
 Madame la Dauphine at her first confinement, but it was not 
 repeated in her others on account of the inconveniences attending 
 it. In fact, the precautions required are very troublesome, for a 
 butcher must be had in readiness to skin the animal in an adjoin- 
 ing chamber, so that the skin can be had quite warm. The 
 butcher who skinned the sheep for Madame la Dauphine's case, 
 having taken it off and wrapped it in his apron, and having 
 
BICHET. 51 
 
 brought it close to the bedside, the sheep, all bloody and naked, 
 followed him to the bedside, which frightened all the ladies who 
 were present at this spectacle." 
 
 26. Is not this a strange story, and could you believe that, 
 though this bloody skin torn from a living animal that afterwards 
 walked up to the bedside of Mary-Anne of Bavaria, at the birth 
 of Louis, Duke of Burgundy, could not, under any circumstances, 
 be of any aid to a sick person, it is still held by some in our 
 most polished society as a most excellent cure; and that I, even 
 I, have witnessed nearly such an application some fifty years ago, 
 and have recently declined the proposal to apply one — a proposal 
 that came from a high social quarter. It shows us how slowly 
 we advance. But yet we have made, and are now making pro- 
 gress with great strides. I shall here close my communication, 
 with assurances of that faithful gratitude with which I shall ever 
 be your friend and servant, 
 
 C. D. M. 
 
LETTER III. 
 
 INQUIRY INTO THE ORIGIN, PROGRESS, AND EXTENT OF THE MEDI- 
 CAL DOCTRINES ON MILK-METASTASIS, OR WHAT THE FRENCH 
 WRITERS CALLED ERREMENTS DU LAIT. 
 
 27. In this letter I propose to call your attention further to 
 certain ancient opinions or notions, concerning childbed fever, 
 whose former existence in our Class or Scholarship, though they 
 be now supposed no longer to prevail, do, to a certain extent, 
 still mould our views of diseases, and bias our methods of cure. 
 I heartily wish I were capable of setting before you in these com- 
 munications so complete a representation of the most ancient as 
 well as modern notions, that my pages, like a bright Daguerreo- 
 type plate, might reflect the whole of the truth in even its most 
 trivial and minute parts, and finally fix them there, so that, but 
 to look upon them would be to have a conspectus of one entire 
 medical cosmos — if I may be allowed to compare the small with 
 the great. In educating yourselves as physicians, you ought to 
 aim at the possession of a vast amount of knowledge of Medicine ; 
 for Medicine is an individuality or identity, which, to be 
 thoroughly known, must be known not only as it is, but as it 
 was; our successors in future ages, are they to whom is vouch- 
 safed the knowledge of what it is destined to be. Oar own mis- 
 sion is to know its past and its present states only ; and we should 
 be but imperfectly taught, if we stop short of the possible in these 
 regards. 
 
 28. I have said, in another place, that words, written or spoken, 
 are not always lost in silence as soon as the ordinary reverbera- 
 tions of them cease ; but, on the contrary, they become a sort of 
 material things, durable and indestructible in the minds of men ; 
 lingering among them for ages, and passing downwards with the 
 
THOMAS WILLIS. 53 
 
 lapse of time to continually exert their mischievous or beneficial 
 agency in human thought and action. How much more, when a 
 generally received doctrine has become deeply impressed in the 
 mind and heart of society, sealing itself, as it were, in the very 
 constitution of the public intelligence and morals ; marking a 
 public opinion, and attending it even in its changes, yet modify- 
 ing and biasing it even where its presence is no longer acknow- 
 ledged, or even suspected! 
 
 29. Many such things have, through a traditional acceptance, 
 become parts of the public faith, in both theory and practice ; per- 
 verting facts, converting words into meanings foreign to their 
 real functions, thus masking truth under a false disguise, hiding 
 it with the mists of prejudice, and changing it into a lie. 
 
 30. In regard to childbed fever, which, as I have already shown 
 you, was a disease frequently met with, though misinterpreted by 
 the ancient, the mediaeval, and early modern physicians, a par- 
 ticular interpretation of it grew up in Europe about the middle 
 of the seventeenth century, and acquired so great a vogue, that 
 one might venture to say it had an almost universal adoption, not 
 only by our brethren, but by the common people ; and being once 
 established, it continued rigorously to control our medical opinions 
 in this particular relation, until near the close of the eighteenth 
 century. 
 
 31. Many of my readers will perhaps be disposed to contend, 
 as certain writers have, that it died out then, and has been now 
 for some seventy years completely expunged from the doctrines of 
 the schools. But this is a point on which I shall feel constrained 
 to differ with the majority, and believing that the long-cherished 
 interpretation is, under a certain disguise, existing among us, 
 lying concealed among the cloudy theories of many of us, I am 
 about to develop for you the origin, nature, and extent of that 
 curious and mischievous dogma of the metastases of the milk. 
 
 32. Thomas Willis, vide Biog. Britan.; sub voce, was born 
 January 27, 1621-2, in Wiltshire, England ; and after an illustri- 
 ous medical career, leaving writings which have been handed 
 down with veneration to our own class, died, Nov. 16, 1675. In 
 1655, Willis published his Diatribce Duo Medico- Philosophical ^ 
 quarum prior agit de Fermented lone, sive de motu intestino particula- 
 
54: PUERPERAL FEVER. 
 
 rum in quovis cor pore; altera de Febribus, sive de motu earundem in 
 sanguine animantium. His accessit Disputatio Epistolica de urinis. 
 My copy is one of the 4th edition, 12mo. London, 1677. 
 
 33. Willis's chemical opinions respecting fermentation, led him 
 to believe that not only life itself, but growth and nutrition, and 
 death at last, are results of forces and actions of fermentable mate- 
 rials, whether they be blood, bile, chyle, or other substances, whose 
 changes lay in us the foundations of fevers, dropsies, and other 
 dangerous and mortal distempers. Hence you may perceive how 
 he should conclude that the humors of the body, by their per- 
 versions and degradations, may come to play the most important 
 part in the animal economy, whether in its healthy or its diseased 
 states. There has never existed any class or sect of physicians to 
 repudiate the opinion that the humors of the body, its fluids, are 
 liable to become diseased, and so affect the health; but while 
 certain sects have attributed greater, others have conceded less 
 pathogenic power to the fluids. You would be in error then, to 
 think that the humoral pathology as to childbed fevers, took its 
 rise in the writings of Dr. Willis, although it is agreed, that to 
 him, most particularly, attaches the repute of the promulgation 
 of a dogma, which it is the main object of this letter to explain. 
 
 34. The sixteenth chapter, page 269, de puerperarum febribus, 
 contains Willis's development of an idea concerning extraordinary 
 particles contained in the blood. According to him, women, dur- 
 ing their menstruating age, are subject to the periodical produc- 
 tion, within the mass of their blood, of certain highly fermentable 
 particles, which, if, contrary to the nature of the body, they 
 happen to be retained within it, except the woman be pregnant, 
 they give rise to a variety of disorders. In pregnancy, the men- 
 strual material is not required to be cast out by the emunctories, 
 for while ever the child remains in the womb, an alible substance 
 or milk is continually being deposited in abundance about the 
 uterine placenta, for the nourishment of the foetus. When the 
 child has been expelled, the menstrual wants come to be sup- 
 plied by the outflowing lochia at first, and subsequently, by the 
 secretion of milk in the mammary glands. But if the secern- 
 i n g operations of the breasts should be lessened, or suspended, 
 or wholly wanting, the material of the milk is then determined 
 
THOMAS WILLIS. 55 
 
 towards and accumulated about the uterus, from whence it is 
 discharged under the appearance of a whitish humor ; and this 
 is what is called pale or white lochia. 
 
 35. The author next proceeds to set forth his opinions in regard 
 to the generation of the milk, whether that substance be gene- 
 rated in the breasts or in the womb ; and also the metastasis of 
 it from the one to the other ; on the lochial discharges after the 
 long suppression of the menstrua ; on the state of the post-partum 
 womb, and the influence of such state upon the other parts ; and, 
 finally, on the fevers of lying-in women, whether milk-fever or 
 putrid fevers as they are called. 
 
 36. I should be well pleased to translate here, and so reproduce 
 for our American medical literature, the whole of this celebrated 
 physician's sixteenth chapter, but I do not feel assured that the 
 taste of the majority of my readers would approve of so many 
 citations in this book ; and besides, the space allowed me does not 
 admit of it. Indeed, I do not think you can read what I have 
 already said of Willis's views, without becoming at once acquainted 
 with the length and breadth of them. You have seen that, ac- 
 cording to him, women are peculiar creatures in this, to wit, that 
 they, at stated periods, separate in the mass of the blood certain 
 fermenting particles, whose presence in excessive quantity does 
 not fail to develop disease under forms diverse according to cir- 
 cumstances — disasters from which they are in general conserved 
 by their menstrual evacuations, which statedly carry away these 
 products forth of the body; by pregnancy, which consumes or 
 appropriates them as the nutritive elements of the foetus; by milk 
 or lacteous juices thrown off under the form of the lochia ; and 
 lastly, by the milk of the mammary glands, on which the new- 
 born child depends for subsistence. 
 
 37. Such is Willis's hypothesis, which became, and still is, in 
 many parts of Christendom, a dogma. In this sketch of it, 
 you may readily enter into his views of the pathogeny of milk 
 fever, retained or suppressed lochia, childbed fever, and all its 
 diverse influences and consequences, in the human body. Nay, 
 agreeing with him in his postulate as to the retained ferments of 
 the menstrua, we may easily proceed with him to his final con- 
 clusions, and come to adopt in its fullest measures the milk 
 
56 PUEEPEEAL FEVEE. 
 
 dogma, which, as I have said, acquired an immense influence upon 
 the medical mind, and which still dominates over many a profes- 
 sional judgment, even in some who never heard of it before, nor 
 even suspected its tyranny over their opinions. 
 
 38. I desire you should remember that Willis printed his little 
 duodecimo in 1655, which was six years after the beheading of 
 Charles I., and during the most brilliant period of the Protectorate, 
 and during the administration of Cardinal Mazarin in France. It 
 did not at once meet with the brilliant success as an especial hypo- 
 thesis it afterwards found, particularly upon the continent. Indeed, 
 it may be said to have never acquired the same authority in En- 
 gland as among other nations, though it was felt there, and still 
 does influence British practitioners. If you wilFcross the Channel, 
 you shall find that at Paris, there had flourished, some time earlier, 
 an eminent medical person, Jacques Guillemeau, who was born in 
 1550, and died in the year 1613, leaving a reputation of the first 
 mark, as an able practitioner and accomplished scholar, which he 
 undeniably was. His is that ponderous folio, entitled Les CEuvres 
 de Ghirurgie de Jacq. Guillemeau, &c, &c, Pouen, 1619. He 
 was a pupil of Ambrose Pare, and was a copious and pleasing 
 writer, and an earnest student. Occupying as he did an eminent 
 public station, you would naturally look among his pages for any 
 clear traces of this milk dogma, or lait repandu hypothesis, if it 
 was already in existence, and you would confidently expect to 
 find them there, if anywhere in the medical literature of his era. 
 Well, then, you shall in vain turn all the pages of Guillemeau, for 
 any signs of the appearance of the dogma, whence you may safely 
 conclude its dawn had not yet appeared to the principal medical 
 men, about the close of Louis XIII.'s reign, and the days of 
 Cardinal Kichelieu. 
 
 39. You may now turn to a volume entitled, Trots Livres 
 appartenans aux Infirmitez et Maladies des femmes. Priz du Latin 
 de M. Jean Liebaut, Docieur Medecin, a Paris, et faits Francois. 
 Pouen, 1609, 8vo. pp. 923. The original Latin edition appeared, 
 I believe, as De Sanitate Foeeunditate et Morbis mulierum, Paris, 
 1582, 8vo., and was translated into French in 1582. My copy 
 is 1609, 8vo. Liebaut, according to the authors of the Diet, de 
 Biog. Med., appears to have practised with much success at Paris, 
 
LIEBAUT — LOUISE — RIVIERE. 57 
 
 where lie died in 1596. This writer, in his 33d chapter, says : 
 "The milk, therefore, is the benign excrement of the breasts, 
 ordained by nature for the nourishment of the child, whether 
 within or without the mother's womb;" and at p. 777: "The 
 menstrual blood, therefore, is not made aliment in the breasts, 
 but altogether (tout entier). just as it is, and in just such quantity 
 as it is when received by the breasts, it is converted and trans- 
 muted by the breasts in nature of milk, without any portion of it, 
 no matter how small, being attracted by the breasts for their own 
 nourishment, and from which the milk acquires its form, its nature, 
 and its whiteness." At p. 325-7, he argues in favor of the idea 
 that the menstrual blood is not an impure substance, but only the 
 excess provided by nature above the ordinary sanguine mass; 
 and hence, you perceive that in the time of Liebaut the notion of 
 a hit repandu, or the milk dogma was unknown, for certainly as 
 he was in much esteem at Paris, where he had a large business 
 and numerous professional connections, he could not but have 
 become acquainted with the idea, had it as yet arisen. Now this 
 writer died in 1596. 
 
 40. I may be excused from citing the opinions of a woman, 
 Louise Bourgeois, on the grounds that she was a very learned per- 
 son, much acquainted with, and greatly esteemed by the principal 
 medical men about the court of Henry IV., of France. We have 
 the spirited and naive memoirs of her own life and proceedings 
 as a Paris sage-femme, and particularly her relation of the several 
 confinements of the Queen, Mary de Medicis, whom she attended 
 in labor on the 7th September, 1601, 22d November, 1602, Feb- 
 ruary 10th, 1606, April 16th, 1607, April 7th, 1608, and November 
 26th, 1609. To take her own account of these matters, she was in 
 great estimation by La Riviere, who was Henry's physician, with 
 Du Laurens and others, which afforded good opportunities for her 
 to know of this great doctrine, if it had then already been bruited 
 abroad. Louise gives us all her opinions in chap. 23, whence it is 
 clear she never had the least idea of the so-called milk-infarctus, 
 though, from a passage in Mauriceau, Du Laurens seems to have 
 been somewhat infected with it. 
 
 41. As I have mentioned the name of La Riviere, I beg you to 
 take up Lazari Riveni, opera omnia, &c, Fol. Frankfort, 1669. 
 
58 PUERPERAL FEVER. 
 
 At Book 15, chap. 24 of the Pract. of Physic, you will find 
 whether he had heard of the milk dogma, or no. It is proper to 
 say he was born 1589, and departed this life in 1655 — the year 
 when Willis's book de febribus came forth from the press. 
 Eiverius contains not a word in that way ; and, of course, as he 
 was a most eminent physician, he had not heard it broached. 
 
 42. Among the medical classics of France, and, indeed, of the 
 end of the 17th and beginning of the 18th century, there is no 
 higher name than that of Francois Mauriceau. It is said of him 
 by Dr. Begin, in his notice Diet, de Biog. Med., that he may be 
 regarded as " the first French surgeon whose writings bear the 
 impress of a true accoucheur ;" that he marked out the path that 
 was afterwards followed with such brilliant renown by Yiardel, 
 Peu, Portal, Deventer, Lamotte, and latterly by Smellie, Lauver- 
 geat, Levret, and Baudelocque. This admirable colleague of ours 
 was born about the middle of the 17th century, and lived until the 
 year 1709, when he died on the 17th day of October. He died six 
 years earlier than his master, Louis XIV. Mauriceau was engaged 
 in practice until the close of his life, and among the most elevated 
 classes of society. 
 
 43. There is a delectable story told by Bichet, author of Obs. 
 sur VArt. des Ace, &c, 12 mo. 1758, who describes at p. 85, the 
 labor of Madame la Marquise de Clermont, daughter of Mons. le 
 Marquis d'O, Lieutenant-General of the marine, who laid eight 
 days in labor at Versailles. It would seem that the whole court 
 was thrown into what the modern theatrical attache's call a won- 
 derful excitement about it. Dionis was called in, and Richet says 
 that " le celebre Monsieur Mauriceau" was also present, and gave 
 what appears to me to be a very shrewd opinion on the case of 
 the sick Marchioness. This was in 1708, only a year before the 
 decease of the good man. 
 
 44. Mauriceau was an elegant scholar, and being a leading man 
 in the highest literary circles, he would not have escaped the 
 infection of the milk, had it already risen to the height of his own 
 level. At p. 412, torn. i. he says : " Those who, when they dis- 
 cover a sort of whitish lochial discharge, believe that the color 
 is due to the milk of the mammary glands, flowing out from the 
 womb, found their opinion upon the circumstance that, generally 
 
MAURICEAU — LAMOTTE. 59 
 
 speaking, the milk ceases to be formed by the breasts in propor- 
 tion as these whitish lochia continue to flow ; and they say further, 
 that it is evidently milk, as every one may conclude from its 
 consistency and color ; but if they understood anatomy well, they 
 would know that there is no vessel of communication between 
 the mamma and the womb ; unless, indeed, they should imagine 
 the transfer to be made by a supposititious anastomosis of the 
 mammary with the epigastric vein, a thing that cannot be, since 
 neither the one nor the other of those veins goes either to the 
 mamma or to the uterus." 
 
 45. He proceeds afterwards to show that milk cannot by any 
 process be carried into the uterine vessels, and so escape from 
 their orifices as white lochia. On this subject he reasons as well 
 as any modern, in his luminous 413th page, closing his argument 
 with a citation of Aristotle, B. 7, C. 2d, Hist. Animal. " Natura 
 enim ita fert, ne humor locis pluribus, simul erumpere soleat." 
 
 46. Even in his chapter on phlegmasia dolens or crural phle- 
 bitis, one which of all others he might be expected to devote to 
 what was, shortly after his time, denominated " Depot laiteux," 
 milk deposit, lait repandu, and milk-leg, as it is vulgarly named 
 to the present day, he does not even hint at the dogma we are in- 
 vestigating. Now you may consider that Mauriceau must have 
 been near the head of his profession at Paris, from 1670 to the 
 first years of the 18th century, and as he barely sneers as you 
 see at the doctrine, which had not yet got up to his level, you 
 may conclude that Willis's hypothesis had not fairly got across the 
 Channel, and become established on the Continent in fifty years 
 after its promulgation at Oxford in England. 
 
 47. We have the privilege to claim another most worthy col- 
 league in our profession, that good honest man, Sieur de la Motte, 
 sworn surgeon and accoucheur at Yallognes in Normandy, author 
 of that famous Traite Complet des Accouchements naturels, non 
 naturels, et contre nature, &c. &c, Paris, 4to. 1721. An honester 
 or more sagacious practitioner has not lived since his day. He 
 had an excellent bringing up, in the wards of the Hotel Dieu, at 
 Paris, and practised with much success and fame during many 
 years; his volume is aere perennior. 
 
 48. Neither in his Chapter 6, Book 5, devoted to the history of 
 
60 PUERPEKAL FEVER. 
 
 the lochia, nor in Chapter 7, Book 5, on inflammation of the womb, 
 does he allude to lait repandu. But, you should note that la 
 Motte was born in 1655, the year of Willis's publication, and lived 
 until June 1737, and moreover, that he was a diligent student, 
 and ripe scholar, whom nothing escaped. Then you must infer 
 that the dogma had not reached him when he wrote, which may 
 have been about the year 1708 to 1710, since the printed approba- 
 tion of the surgeons of Yallognes, MM. Fromont, des Kosiers, and 
 Hanouel, bears date April 16, 1712. 
 
 49. One of the most illustrious men of modern times was 
 Frederick Hoffman, professor of the Frederick's Academy at 
 Halle. His birth took place on the 19th of February, 1660, at 
 Halle, and he died in the same city, October 4, 1742, being 
 eighty-six years old. Hoffman's distinguished position as teacher, 
 as writer, and as correspondent, would have made him familiar 
 with the doctrine we are examining, and doubtless we should have 
 had some marks of his opinion concerning it had it reached him, 
 and been deemed worthy of his respect. The second volume, 
 opera omnia, contains, beginning at p. 156, his 10th chapter, sect. 
 ii. de inflammatione et febre uterina, both the 4th and 5 th sec- 
 tions of which contain his views as to the causes of childbed 
 fever under the aforenamed title, but there is nowhere to be found 
 any elucidation or acknowledgment of this doctrine, even when 
 he speaks of milk fever, which, occurring generally about the 
 third day, he supposes may, when coinciding with a suppression 
 of the lochia, give rise to those states of obstruction in the circu- 
 lation that should result in his uterine inflammatory fever. 
 Volume I. contains, at p. 80, his 14th chapter, sect. ii. book i. De 
 Secretione Lactis. The whole article is free from any trace of the 
 doctrine of lait repandu. 
 
 50. Nicholas Puzos was born at Paris, 1686, and died in 1753. 
 I do not know a better, braver, or more skilful physician than 
 Puzos. A learned and judicious man, he enjoyed an immense 
 public confidence. It were indeed to be wished that our profes- 
 sion might be graced, by now owning many such persons as M. 
 Puzos. I cannot peruse his pages but I am prompted to regard 
 him as one of our most accurate and solid observers, and his 
 Traite des Ace. &c. &c, Paris, 1759, 4to. as one of the most pleas- 
 
HOFFMAN — PUZOS. 61 
 
 ing, instructive volumes in the medical library. It appears to 
 me that he may have been in his most flourishing state about 
 1730-40. He is certainly to be regarded as one of the chiefest 
 advocates and propagators of the doctrine concerning lait repandu, 
 Depot laiteux, milk infarctus, and all the hypothetical conse- 
 quences of Willis's notion. 
 
 51. I might select Puzos therefore as the expounder of the 
 dogma, and confine myself to citations from his writings ; but I 
 shall prefer to go further, and to another and later fountain. 
 
 52. Puzos, however, opens at p. 218, Chapter 21, with these 
 words, that serve to set forth a principle which, were it true 
 in fact, might serve as its sufficient explanation: "Milk is un- 
 deniably the first, and the only nutriment the child makes 
 use of in the first stages of its formation ; and as soon as a 
 woman becomes pregnant, she acquires the faculty of producing 
 milk." After some remarks upon the failure, before his time, to 
 present or explain a rationale of this operation, he proceeds to 
 say that, "what the physiologists have most clearly taught upon 
 this subject is, that milk is nothing but a species of chyle, which, 
 in confusedly circulating along with the blood in the vessels, be- 
 comes charged with certain properties of the blood, and so ceases 
 to be pure chyle." He explains that there are no separate chan- 
 nels, for the circulation of this milky humor, which, whenever the 
 uterus is cut open, always appears as blood, as it does also when 
 the placenta becomes detached. He insists that it accumulates in 
 the bloodvessels of the womb for the nutrition of the foetus, and 
 he uses these words : " It is also known that at the commence- 
 ment as well as during the whole progress of pregnancy, the milk 
 is determined in abundance towards the womb; penetrates into its 
 interior to escape thence, subsequently, always mixed with the 
 blood, in order to insinuate itself into the venous roots of the 
 placenta, from whence it passes along the umbilical vein, which 
 distributes it in the whole body of the child." 
 
 " When a pregnant woman is bled, the blood always assumes a 
 whitish appearance on the surface, and there is no doubt that this 
 whitish matter is milk, which, being the lighter portion, rises 
 above the fibrous portion." 219. 
 
 53. Puzos assures us that its appearance is not evidence of bad 
 
62 PUEEPERAL FEVER. 
 
 blood, and he asks whether the urine of pregnant women is not 
 usually thick and whitish. Evidence of the same force he thinks 
 is to be found in the milky effusions that we occasionally observe 
 in the cavities and in the cellular tela, commonly called Depot 
 laiteux, or milk deposits, &c. 
 
 54. " As soon as a woman is confined," says he, " the milk 
 which had previously been regularly determined to the parts 
 where it was continually being absorbed, of necessity changes its 
 course to flow towards those parts from which it might most 
 readily escape. Finding almost no further issue at the womb, it 
 was proper there should be provided a sort of reservoirs, in which 
 it might be detained for a certain space, and then eliminated." 
 
 55. These reservoirs are in the breasts, and Puzos remarks that, 
 "but for this wise provision, the milk must be tumultuously 
 thrown upon the different parts, and give rise to the same dis- 
 orders that are often caused, when, through imprudence or any 
 unfavorable disposition, it takes false routes and deposits itself 
 among the tissues, which cannot free themselves from it." 220. 
 
 56. The above may serve well enough to show you how good 
 old Puzos was accustomed to reason upon these- questions, and 
 indeed the general character of medical thinking upon them. It 
 is not therefore required that I should accompany him in a further 
 progress through all the possible consequences of a deviation or 
 misplacement of this milk in the pregnant woman's blood. My 
 design in quoting him at all, was, mainly, to show how far the 
 doctrine had extended at the most flourishing period of his fame 
 and usefulness. You will promptly conceive that a woman, 
 attacked either in her pregnancy or lying in, with any violent 
 disease, must be accused of some fault in regard to the milky 
 element in her blood, and that, if she should die with apoplexy, 
 or metritis, or peritonitis, or phlebitis, or no matter what, it is 
 always, and under all circumstances, to some milk infarctus, or 
 deviation and dissipation of it into unfit parts and channels, that 
 the result is to be charged. Antoine Petit, a celebrated man of 
 his epoch, Trade des Mai. des Femmes accouches, &c. &c, p. 182, 
 tells us that, " nothing is so common at Paris as milk-disease, 
 that is to say, diseases arising from some vitiation, arrest, de- 
 posit, or depravation of the milk, from a suppression of the second- 
 
DOUBLET — VIGAROUS. 63 
 
 ary and tertiary lochia. These disorders vary infinitely, accord- 
 ing as the deposit takes place in the head, the chest, the belly, the 
 extremities, or the skin." 
 
 57. Notwithstanding the surprise with which I find so powerful 
 an understanding in this manner misled upon plain questions in 
 physiology and pathogeny, I am still ready to confess my ad- 
 miration for the man, and to warmly urge you in particular to 
 study his great paper on Depots laiteux, which contains examples 
 of practice altogether as admirable as the great practice of Alex. 
 Gordon himself. I shall not follow Puzos any further, considering 
 myself acquitted of obligations to you as to him, at least for the 
 present. 
 
 58. The Nouvelles Recherclies sar la Fievre Puerperale, par M. 
 Doublet, Medecin de la Faculte de Paris, et de la Societe Koyale 
 de Medecine, was published 12mo. at Paris, 1793. 
 
 59. I might perhaps select this volume, as containing a most 
 vehement defence and exposition of the milk dogma, a defence 
 and exposition carried on with elaborate research and argument, 
 as well as illustration — for the author appears to have examined 
 almost everything ancient or modern, that might enforce or con- 
 firm his notions as to the universal derangements proceeding from 
 error loci of the lacteal secretion. But, as I cannot without 
 impatience, notice the violent twisting of the truth, and the violent 
 perversions of his judgment, everywhere displayed, I shall pass 
 by it with this slight notice, yet feeling that I shall not have fully 
 answered the demand of this inquiry, unless I could persuade 
 you to look with me into the " (fours Elementaires des Maladies 
 des Femmes, ou une nouvelle meihode pour etudier et pour classer les 
 maladies de ce sexe. Par Marie Joachim Vigarous, Prof, a l'ecole 
 de Medecine de Montpellier — Paris, 1801," 2 vols. 8vo., for Yiga- 
 rous is the best defender and illustrator of the doctrine. 
 
 60. Any person who should desire to learn, in their fullest 
 extent, the doctrines of the Milk school in Obstetricy, may be 
 assured he shall find them set forth and vindicated in this work. 
 Yigarous gives one hundred and eleven pages to the discussion, 
 from 376 to 487, vol. ii., and they contain all one could desire of 
 explanation. But let us hasten to see what Yigarous has left us, 
 and respectfully hearken to the voice of the dead author, who 
 
64 PUERPERAL FEVER. 
 
 speaks to us in his pages, though his frame is now dust on the 
 shores of the Mediterranean. An illustrious dead physician is 
 still far worthier than many an incompetent living doctor. I 
 would liefer live after I am dead than die daily all my life long. 
 
 61. At p. 376 he observes: "I have already said, that towards 
 the close of gestation there is formed a great quantity of lym- 
 phatic juices, that are habitually determined towards the womb 
 for the nutrition of the foetus ; that subsequently to the birth, they 
 continue to be evolved in abundance, and then change their direc- 
 tion, and convey to the breasts the materials those glands are 
 destined to eliminate for the nutriment of the child." 
 
 62. The change of determination is not, in general, effected 
 without a degree of fever, of little moment, and which is vulgarly 
 known as milk fever. This, then, is the gist of the dogma ; and, 
 provided your studies have been of a kind to allow you to believe 
 on the one hand, that blood is blood and something else besides 
 — a mixture of blood and milk, you may set yourself up as a 
 sufficiently good humoralist ; but if, on the other hand, you are 
 really to regard the sanguine mass as a specific thing, as much 
 so as any particular bird, plant, fish, or worm ; that it consists 
 of fibrin 3, albumen 80, corpuscles 127, and water 790, I do 
 not discern how you can be in danger of falling into the deep 
 slough of the humoral pathology. On the contrary, I indulge 
 the hope that a clear understanding of the blood's crasis, or con- 
 stitution, may keep you harmless as to other poisonings of that 
 vital fluid, whose least qualitative and quantitative modifications 
 are found to exert so great an influence on man's vital state. 
 How, indeed, should it be possible for you to fall into the errors of 
 the humoral pathology, after you have once become satisfied that 
 the blood is a mixture of certain solid constituents, 210, with pure 
 water its diluent, 790 ; that the water of the blood is not evolved 
 by the vital forces, but only absorbed ; whereas the solid constitu- 
 ent, 210, is created, or at least transformed and evolved, by the 
 powers of the solid living parts? 
 
 63. There are many various states of the bodily health that 
 
 coincide necessarily with any alteration in the ratio of all these 
 
 constituents, but there is not one of them that can convert the 
 
 - blood into milk as it flows in the bloodvessels, milk being a 
 
YIGAROUS — GOUBELLY. 65 
 
 production of the mammary gland, and not a direct result of the 
 Hasmatosis. 
 
 64. Nevertheless, it is well for the Student to hear M. Yigarous, 
 and I now beg you to observe that he quotes, approvingly, Bat- 
 tisti's thesis on the diseases of women, to convince that milk fever 
 is of two kinds, one epJieniera lactea and the other febris lactea, 
 which arises "when a woman's breast, being already over full of 
 milk, continues to receive an additional quantity, whereupon a 
 portion of the excess is drawn into the torrent of the humors, 
 causing symptoms of a continued remitting fever with quotidian 
 type, ushered in by chills, and followed by a hot stage, and after- 
 wards by a sweat of an acrid and peculiar odor, which resolves 
 the paroxysm ." 377. 
 
 65. Though this fever generally ends in a sweat, as above, " it 
 may end by a spontaneous or artificial evacuation of milk from 
 the breasts ; by lochia, in greater or less abundance; by urinary 
 discharges ; by critical evacuations by stool ; by a miliary erup- 
 tion ; by a metastasis to different parts, frequently attended with 
 serious, and sometimes mortal consequences." 277. A milk fever 
 is a thing of a purely nervous nature, and when all goes on well 
 and properly, the case is one of ephemera lactea. It is a natural 
 incident in what the French Doctors call la revolution du lait. 
 But when it does not proceed in order then it becomes febris 
 lactea. 378. 
 
 66. Yigarous might have stated an infinite number of divisions 
 and classifications of the accidents and deviations of the milk, from 
 Mons. Goubelly 's two volumes of Connoissances necessaires sur la 
 Grossesse, sur les Maladies laiteuses, et sur la. cessation des Regies, &c, 
 par M. CI. And. Goubelly, &c, &c., &c, Paris, 1785, for Goubelly 
 practised and taught in his professorship, and wrote when the 
 dogma was at its culmination. You would be amused to see to 
 what a variety of applications it served in Goubelly 's hands, as 
 well indeed as in everybody else's. But Yigarous disapproved 
 both of making three distinct species of milk fever, and also of 
 absolutely confounding them together as one, though he admits 
 their " successive affiliation." He considers it probable that the 
 fever that follows upon a lying-in, has its source in milk fever, 
 which affords occasion why differeut morbific causes should make 
 
 5 
 
6Q PUERPERAL FEVER. 
 
 their power be felt ; and he also supposes that the puerperal fever 
 which attacks nurses, and women not suckling, and those fevers 
 that arise after the termination of a milk fever, are due to a nerv- 
 ous spasmodic affection, analogous to that which precedes the 
 milk fever. 380. " But it is certain that the puerperal fever is 
 not a special fever, or sui generis, since it varies in different indi- 
 viduals; with the constitution of the year; and under divers causes, 
 that may complicate it or originate it." 380. 
 
 67. From page 388, I select for you the following curious 
 thoughts of Yigarous, and first ask you to conceive, if you can, 
 the process by which an intelligent reason can be so hoodwinked 
 and betrayed, unless it be by the force of educational and scholastic 
 prejudice, which, it appears, can compel men to go traditionally 
 wrong. This physician had witnessed the dissections of many 
 bodies of persons, dead with childbed fevers, and must have seen 
 with his own natural eyes, the pus, the serum, the coagula of 
 albumen, the adhesions and bridles that are left there by the inflam- 
 mation, yet the scholastic eye of Vigarous interpreted all those 
 products as milk, for he was the slave of the milk dogma, as were 
 all the disciples of that whole school ; and what is still more sur- 
 prising, the ghostly form of this imaginary evil ens, still walks 
 among the modern schools, mysteriously influencing the teachings 
 and practice which, by this time, one would think, should have 
 come to be based, not on belief, but on knowledge, not on mot t 5 , 
 but on yvwotj. These are the words : — 
 
 68. "The metastatic congestion of the lymphatic and milky 
 juices, constitutes the natural cause of the malady (childbed fever) ; 
 this is proved, not only by the effects of the puerperal fever in 
 women dying with the disease, but also by the critical phenomena 
 presented by those who recover from it." 388. 
 
 69. " We find in the abdomen a collection of purulent matter, 
 which cannot be alone the product of an inflammation of the 
 bowels and epiploon, because, as Selle* remarks, that inflammation 
 is never in a direct ratio to the mass of purulent matter discovered. 
 Ofttimes, the inflammation noticed is of small moment, but the 
 quantity of pus great ; at other times the amount of inflammation 
 is considerable, that of the pus small." He ends the paragraph 
 by informing us that, while inflammation does form one of the 
 
YIGAROUS — JOERG. 67 
 
 complications, it also becomes one of the causes of milk-metastasis 
 by exciting spasm, &c. 388. 
 
 70. Page 400 opens with observations on "Bilious gastric puer- 
 peral fever," which attacks in the summer and during the reign of 
 a bilious constitution of the season. At 413 we have the "Putrid 
 bilious puerperal fever;" at 438 the "Puerperal fever complicated 
 with phlogistic affection ;" at 450 " Sporadic puerperal fever from 
 a nervous cause; taking cold, &c.;" and lastly, at 467, he treats of 
 the different terminations of puerperal fever, where I shall cite him 
 as follows : — 
 
 71. " We have now reviewed most of the forms of the puerperal 
 fever, and have seen that the milky matter which plays the prin- 
 cipal part in it, was set in motion by different causes, whether 
 humoral or nervous. We have learned to combat these causes 
 by all the means belonging to the art of curing, but vainly should 
 we have labored to destroy the disease while the milky matter 
 was left fixed upon the lower belly, and particularly on the bowels 
 and chyle-ducts. It becomes certainly mortal, when nothing can 
 change its determination and open for it a new route towards the 
 skin, for then it corrupts and gangrenes the vessels and all the 
 viscera of the abdomen. We have seen that the whole science of 
 the treatment consists in deviating the milky humor, while it is 
 still movable, and in preventing it from fixing in the abdomen." 
 
 72. Pew modern physicians have any idea of the extent to 
 which this milk dogma prevailed over us from its uprising, about 
 the beginning of the century, until near its close, say nearly one 
 hundred years ; nor do they know or admit, that to the present 
 day it biases many opinions, and modifies, to a great extent, the 
 practice of our art, under a changed form, it is true, yet still itself; 
 so that one might say of it, mutato nomine de te fabula narratur. 
 See what I have said, in sec. 186, on vitiated blood. 
 
 Professor Jorg, of Leipsig, was born in the year 1780, and of 
 course could not rise into eminence earlier than the close of the 
 first ten years of the present century. He seems to have acquired 
 a great reputation as a practitioner, as well as a Medical writer; 
 yet I am much surprised to observe how deeply his mind was 
 imbued with this doctrine of milk metastasis, in his treatise on 
 diseases of women, or Handbuch der Krankheiten der Weiber, &c- 
 
b» PUERPERAL FEVER. 
 
 My copy is the 3d edition, 1832. His preface to the 1st and 2d 
 editions bears date, March 15, 1821. I know not the date of the 
 first impression. This writer, it is true, does not adopt the milk 
 dogma in its plenary acceptation, but it is evident that in reason- 
 ing on the subject of puerperal fever, and on the suppurations that 
 follow it, he is not delivered from the tyranny of that school. In 
 a note on p. 714, he sets forth his views ; and after saying that the 
 depots do not consist in real milk, he adds, " Betrachtet man die 
 Sache mit ganz vorurtheilsfreien Augen, so gelangt man zu der 
 ueberzeugung, dass Keine Yersetzung von wirklichen milch, 
 sondern eine ausscheidung von dem Milchstoffe aus dem blute 
 Statt habe." In this sentence I conceive is contained the admis- 
 sion that among the causes of puerperal fever we are to count 
 certain changes in the blood, the basis of which always is to be 
 discovered in the female power of milk production. In his learned 
 book Trattato generate di Ostetricia, Teoretica et Prattica, Professor 
 Asdrubali shows that in 1812, the date of his edition, he was 
 himself one of the last lingering defenders and expositors of the 
 milk dogma; see torn. ii. § 322. 
 
 73. Even here, where a sound physiology is inculcated, and 
 educated men ought to be free from the thraldom of sectarian and 
 scholastic tyranny, it still, though buried and forgotten for more 
 than half a century, stalks among us, and sheds a sort of corpse 
 light upon the living body of our Medicine. I myself scarcely find 
 an occasion to converse with my brethren on these topics, without 
 recognizing its presence in the idea that the " blood is poisoned," 
 that it is a disease of the blood, or that the state of the blood, in the 
 case, demands or admits of this or of that treatment. What dif- 
 ference, pray, does it make, whether the said poison is "Willis's, or 
 Puzos's, or Doublett's, or Yigarous's aberrant and infarcted milk- 
 particles, or Dr. White's absorptions, which bring about the putrid- 
 ity of childbed fever, or Dr. Eobert Ferguson's " vitiated blood," 
 as he calls it? See White of Manchester, 205, and passim ; and 
 Butter, 342 ; and Ferguson's whole volume ; principles, practice, 
 and philosophy. 
 
 74. You shall find that even Eokitansky himself uses such 
 language as this: speaking of puerperal peritonitis, he says., "This 
 disease is often, and even generally, the result of a primary con- 
 
JOERG — BICHET — ASDRUBALI. 69 
 
 dition of the blood of the female, which predisposes to an exuda- 
 tive process, and is totally distinct from the physiological tenden- 
 cies of the blood during pregnancy," &c. &c. (vol. ii. 313, Syden. 
 edition). Here is the doctrine, as clear as in any passage of Selle, 
 or Bichet, or Groubelly ; and it now exists in England, where I 
 have been rallied because I was a man who ought to have known 
 that a certain state of the blood, consisting in an excessive pro- 
 duct of the fibrinous, or plastic element, or exudative matter, is 
 the real cause of eclampsia puerperalis. 
 
 75. There is a funny old author, already mentioned in sec. 35, 
 whose name was Bichet. His book, Observations sur VArt des Ace, 
 &c, 12mo. Paris, 1758, is an amusing exemplification of curious 
 toadyism ; for, being a doctor about the court, he seems ever to 
 stand, as it were, cap in hand, ready to prostrate both himself and 
 his scholarship at the foot of whatever royal or even noble dignity 
 might graciously deign to tread upon his academic neck. He 
 must have had a good business, if we may judge from his accounts 
 of cases. 
 
 76. " I was called in," says he, " in 1712, to see a saddler's wife, 
 in the King's petite Ecurie. At that time I was practising surgery, 
 though I was also an obstetrician at Versailles. At the house of 
 the sick woman I met Madame de l'Epee, who was then a midwife 
 there, and who told me that, six weeks before, she had delivered 
 the patient, soon after which there came on a very violent fever. 
 The woman was twice bled, and was also purged ; but it all did 
 not prevent the patient's leg from falling into the condition in 
 which I found it. I knew at once that it was a depot, and said to 
 Madame de l'Epee that the cataplasms were of no use, and that 
 the leg must be incised to let out the contained matter. The 
 husband went to beg M. Marechal, first surgeon to the king, to 
 come and see his wife, and I myself called on M. Marechal to 
 bring him to the sick woman, having first made him the disserta- 
 tion of the disorder. When he had examined the leg, he said it 
 was very hard, and ©edematous, with phlyctenae; and that the leg 
 must be opened in order to try and save the patient's life. When 
 the operation was done in presence of our first surgeon, there 
 escaped about one pint of milk, in a very corrupted state. .His 
 incision extended from the knee to the external malleolus. The 
 
70 PUERPERAL FEVER. 
 
 woman recovered in about six weeks, as there was no further 
 cause of milk." p. 226. 
 
 77. I wish you would look over Bichet's accounts of his cases, 
 were it but to laugh at the solemn reverence with which he speaks 
 of his little majestuous nobility -babies, and of his great patroness, 
 Madame la Duchesse de Yentadour, a lady who was his favorer on 
 all occasions, and most faithfully endeavored to keep her protege 
 clear of all the bad cases in which, haply, his succes might be 
 compromised by a failure to cure the disease. 
 
 78. I have a great number of those authors who advocated the 
 doctrine of the milk school ; and to me it would be a most pleas- 
 ing task to cite them for you, in their chronological order, with 
 extracts from their pages ; but in this work-day country of ours, 
 where every man seems to be spurred forwards by a national 
 rage for business and money-making, I fear I should go too far 
 were I to indulge my taste for citations. Besides, I remember 
 that Mons. Sue, in his Essais Histor. Litter, et Critiques sur VArt. des 
 Accouchements, Preface, xxviii., tells us how Mignard, the painter, 
 complaining one day to Ninon de l'Enclos of his daughter's bad 
 memory, " Yous etes tres heureux," said the lady, "elle ne citera 
 point;" and Sue himself asks : "A quoi done servent les citations? 
 Le plus souvent pour satisfaire la vanite d'un pedant, et la soufii- 
 sance d'un auteur." Lest, therefore, I should be accused of such 
 a pedantry or self-su Siciency as Mons. Sue condemns, I shall, 
 for the present, let those old authors sleep in their quiet and 
 almost forgotten graves. 
 
 79. In fine, it remains for the Student, after what I have now 
 said, to ponder the question as to what the blood really is ; and 
 determine for himself, whether it indeed can become so changed as 
 to take on itself a function as common-carrier for all sorts of things, 
 conveying, like an Adams & Co.'s express wagon, all possible 
 packets and packages to the proper places of a general parcels- 
 delivery, no matter how they get inside of such a convenient 
 omnibus ! 
 
 80. Our late distinguished and lamented townsman, Dr. S. 
 George Morton, defined "Species, a primordial form;" but no 
 physiologist would dare deny that the specific characteristics of 
 creatures consist in the representation of their combined parts, or 
 
BLOOD, A SPECIES. 71 
 
 that the parts are as essentially specific, as the whole. If an ani- 
 mal differs from another in its dental formula, or in any other 
 peculiar thing, to that degree as to give it a specific character, it 
 does not derive that specific nature from the place or number of 
 the teeth, or horns, or from its external form alone ; but from 
 every item within its whole constitution, which makes its form 
 and substance to be repeated in generation from age to age, end- 
 lessly; and there is nothing within it more absolutely specific 
 than its blood — even spermzoons are specific in form; and so 
 are granules of starch, and pollen-grains of flowers; and so are 
 stamens and pistils. Yet, you shall hear scientific people talk of 
 the blood circulating within the living body, and permitting the 
 manifestation of the most perfect health and power, though, all 
 the while, loaded with foreign materials, and modified to that 
 degree as to cause the most extraordinary suddenness, the greatest 
 violence, and an irremissible tendency of disease to destruction of 
 the life! 
 
 81. Think, think for yourself, Student of Medicine! Make 
 yourself a free citizen of the Medical "Republic of Letters, that 
 you may know of yourself, and not of another, what is the truth. 
 Make yourself no man's servant or valet, to do his bidding and 
 believe what he believes. The ipse dixit, and the magister sensit, 
 was for the slaves of Pythagoras, not for American Students. 
 The reproach of our calling is, that we tend to believe every- 
 thing that is told us, and do not take a stand-point of our own, 
 where we can be fixed immovably. I would rather be a dog, 
 and come to a master's whistle, than be a Scholar with a soul so 
 pliable, that ipse dixit or magister ita sensit should be the rule of 
 my medical opinions. Truth is everlasting, since it is but the 
 expression in nature and morals of God Almighty's will and 
 power. Truth may be searched into, in many things that respect 
 our calling and mission in the world; and they are but unworthy 
 members of the Scholar-class, who content themselves short of its 
 possession. But I moralize in vain, and shall, therefore, bring 
 to a close this letter, already mayhap too long. 
 
 a d. m. 
 
LETTER IV. 
 
 INQUIRY INTO THE REAL STATE OF THE BLOOD IN CHILDBED 
 
 FEVERS. 
 
 82. It is not enough for yon to nave inquired concerning the 
 opinions of that large section of our class who, in former times, 
 took those strange views as to milk-metastasis, milk-engorgement, 
 milk-infarctus, &c, about which I spoke in my last letter to the 
 Class. You cannot avoid being, to a considerable extent, biased 
 in your practice, by the notions you shall imbibe concerning the 
 state of the blood in pregnant and lying-in women, since much of 
 your etiology, as to childbed fever in particular, will be con- 
 nected with your views as above stated. I feel impelled, there- 
 fore, in discharging the duty I assumed, when I promised to write 
 to you on this subject, to speak still further on the nature of the 
 blood, in this relation ; and to that end I now invite you to con- 
 sider the nature of the Hsematosis in the foetus in utero. If our 
 sentiments on that question should coincide, I see not how we 
 shall disagree as to the hsematosis of the adult ; and this I regard 
 as a question of the utmost importance, in whatever scheme of 
 philosophical practice. 
 
 83. The physiologists have fancifully compared the absorbents 
 of the body to a sort of uteri, in which the germs of the blood 
 may undergo a quasi incubation, before the product is thrown 
 into the general torrent of the circulation at the debouches of the 
 thoracic duct into the vein. It is, without doubt, correct to say, 
 that the elements of our nourishment, whether they consist of 
 absorbed or resorbed molecules, do undergo a process of animali- 
 zation in their transit along the absorbent vessels — for they there 
 do acquire form, or sphericity, and even a certain reddish or 
 rosaceous tinge> especially in the upper portion of the thoracic 
 duct. 
 
EVOLUTION OF THE BLOOD. 73 
 
 84. I say it is a fanciful thought to compare the absorbents to 
 ntriculi, and regard the young chyle-corpuscles as embryo disks 
 of blood, which are soon to be born into the venous system, 
 and then transported with the circulation in various directions 
 throughout the living economy; their development, or educa- 
 tion, becoming thereby complete. In this view of it, we might 
 regard each absorbing tube as a little womb, and every corpuscle 
 of chyle as an embryo-globule of blood, to be matured after its 
 birth into the world of the sanguine circulation. Such an hypo- 
 thesis leads naturally to the admission that the organized blood, 
 or the corpuscular or discoidal blood, consists of both younger 
 and older, or immature and mature globules ; but, in either case, 
 we must, for the early incubation of the blood of the adult, look 
 to these supposed vehicles or absorbents. 
 
 85. Admitting that this is a just representation, we have still 
 to look elsewhere than in the absorbent system for the power by 
 which the young and new-born disks or globules may be trained, 
 and brought to their most perfect state of development. If the 
 absorbents and their glands do really possess the power of im- 
 parting life and organization to the material but not yet living 
 elements found in the chyme, it is not asking too much to invite 
 you to consider that the bloodvessels, also, are possessed of an 
 hsematosic power, and a power, too, still greater than that of the 
 absorbents, which are only their ancillary portions, or parts pro- 
 vided with a force sufficient to engender only, but not to com- 
 plete the evolution of the solid constituents of the blood. 
 
 86. But I have now to ask you, how is it with the foetus in 
 utero ? How is the blood of the foetus prepared and amplified ? 
 
 87. The embryo, or foetus, as you know, has no point of con- 
 tact with its mother, save by the placental tufts, which, in a word, 
 are but the capillary terminations of the umbilical arteries, them- 
 selves branches of the aorta. In fact, the young embryo commences 
 its existence by extending an aortic trunk downwards, until it 
 divides into two arteries, which are, at that period, its umbilical 
 arteries. 
 
 88. Such an embryo has no occasion for primitive iliacs or 
 femoral arteries, for it has no members as yet. The first two 
 branches of the aorta, therefore, are, in fact, the two umbilicals^ 
 
74 PUERPERAL FEVER. 
 
 which at a later date, are denominated primitive iliacs, and so on, 
 as the arteries come into existence. Now, the distal branches of 
 the two primitive umbilical arteries collected together in the 
 numerous lobuli of the placenta, apply themselves so closely to 
 the living walls of the mother's womb, that exosmose from her 
 vessels, and endosmose into the foetal capillaries, can very readily 
 take place, and a transfer be effected of the mother's plasma, into 
 the venous system of the embryo she is carrying in the womb. 
 And these placental or umbilical tufts are the only points of 
 contact betwixt the mother and foetus. Everywhere else she is 
 defended from such contact by the membranes of the ovum ; so 
 that, when the child puts forth its hand, or thrusts out its foot, or 
 rolls in the womb, it cannot touch her, but only its own envelops. 
 
 89. I say truly, therefore, that the only thing of the child that 
 touches the mother, is the transitory and deciduous apparatus, 
 called a placenta. 
 
 90. All the oxygen the child can acquire, can reach it only by 
 the placenta, and all its nutriment must come into it by the same 
 opening, for the placenta is its only aerating and its only absorptive 
 surface as to the world without. 
 
 91. As nothing solid, nothing that has form, can be the subject 
 of endosmose, it is clear that the child can get from its parent 
 nothing but plasma, which is water, containing in solution the 
 proteine and salts, &c, &c. required for its development. It 
 cannot take any blood, but must make every corpuscle for itself, 
 out of the plasma it has absorbed. 
 
 92. But, as you have seen, all that enters into it gains access only 
 by the radicles of the umbilical vein, and the whole supply is first 
 cast into its venous system; its absorbing apparatus can- 
 not be said to have anything to do with the function of haematosis, 
 as far, at least, as relates to its absorptive force. The resorptive 
 system may, I deny not, have some part to play in the evolution 
 of certain principles of the blood, after the life of the embryo has 
 begun to acquire somewhat of the force of the foetal life — not 
 earlier. 
 
 93. But, if the whole product on which it is dependent, is first 
 poured into its veins, and thence into its heart, arteries, capillaries 
 and so on, in the circulation-round, you cannot escape, nor even 
 
THE ENDANGIUM. 70 
 
 evade tlie conviction, that the power of Hsematosis is a power 
 attached to the bloodvessel tissue ; and, if it be so as to the foetus 
 or embryo, it must be so as to the child, the youth, and the man. 
 I am not going to discuss the question whether blood is made in 
 the lungs, as some aver, or in the liver, as others say, or in the 
 spleen, &c, &c. It is a sufficient answer to all such propositions, 
 that the blood resides within the bloodvessels, and that, whether 
 they be pulmonary splenic or hepatic bloodvessels. To deny that 
 the Haematosis is a bloodvessel force, and say that it is a 
 pulmonic force, &c, is but to elude, and not to meet and answer 
 the question. Neither ought any man to say that the blood is 
 developed or evolved from the primary but dead elements of it, 
 by oxygen; for all the oxygen in the universe of God could not 
 compound one small corpuscle of blood, except its material elements 
 were first brought together within reach of the inductive power 
 of a nervous mass, in an endangium, by whose force to be 
 evolved. 
 
 94-. I do not say a nervous mass, consisting of a cerebro -spinal 
 axis and its dependencies, but a nervous mass, even if considered 
 in the state of what Mr. Oken called point-substance. Are not 
 even the living elements of the egg capable, under incubative heat, 
 of inducting into the elements of the blood of the chick in ovo, 
 neurosity of a force sufficient to cause them to assume the form 
 and qualities of blood, such as we observe in the punctum saliensf 
 It is therefore in the highest degree unphilosophical to reason as to 
 the power of oxygen, or to the liver or spleen, or to glands alone, 
 as the cause of Hasmatosis, since oxygen is only one of the con- 
 ditions necessary to the act, while nervous induction from the 
 nervous mass, is a condition equally important and indispensable. 
 
 95. But what do you mean, Gentlemen, when you pronounce 
 the word bloodvessel? Do you mean to express the idea of the 
 elastic wall of arteries, or the muscular fibres with which certain 
 parts of vessels are provided? In my opinion, the concise idea 
 of a bloodvessel is that which we have when we speak or think 
 of the membrana vasorum communis (Endangium) ; for that is 
 the tissue to which appertains the vital property of the vessel, as 
 relative to the mutual action and reaction between the living 
 solids and the fluid blood. Muscular and areolar and elastic walls 
 
76 PUERPERAL FEVER. 
 
 of bloodvessels do not contain or transmit that nerve-power by 
 induction, which is essential to the formation and preservation of 
 the blood in a living state ; they are not the indispensable parts 
 of the bloodvessel, for every sophomore knows that when a blood- 
 vessel penetrates within an organ, to do its physiological work 
 there, only the Endangial membrane goes in, leaving all its ac- 
 companiments outside. 
 
 96. Burdach, Phys. vol. vii., p. 88, says: "The blood is the 
 totality of the substance of an organism under a liquid form ;" and 
 Prof. Oken, Phys. Philosophy, p. 354, says, sect. 1994: "The blood 
 is the fluid body ;" and in sect. 1995, " The body is the fixed or 
 rigid blood." The antagonism orpolarity of these 
 two is a vital force — either dies but for the 
 continued activity of the other, and this relation of 
 each to the other takes place through, and only through the 
 solids of the bloodvessel (Endangium). 
 
 97. Allow me to cite for you another passage from Burdach, 
 vol. vi., p. 194: "A vessel is the special delimitation of the vital 
 juice constituting a liquid apart and distinct from all other 
 humors ; that is to say, the blood : it traces out the path it is to 
 pursue, and marks the direction it takes. It may be regarded as 
 the expression of the blood in space, for it was formed by its 
 current, and is one with it. Hence, it follows that the most 
 essential part of the vessel must be in immediate contact with the 
 blood, and constitute the main layer of its walls. This internal 
 membrane (jnembrana vasorum communis, Endangiura) extends 
 uninterruptedly throughout the heart, the arteries, the capillary 
 vessels, and the veins," &c, &c. 
 
 98. This is the true bloodvessel — it is the solid 
 through and by which all the induction of life, or nerve-force, into 
 the elements of the young blood is effected, in order to raise them 
 to strength and perfection, and it alone sustains the life of the older 
 or maturer globules. Hence, a condition of that induction is, that 
 the blood should move from space to space within the inducting 
 or Hasmatosic surface. To rest is to die ; to cease to be endowed 
 with oxygen is to die ; and to be removed from the presence and 
 influence of the Endangium, is equally sure to bring about the 
 death of the blood, which lives in and by it, as its perpetual, 
 
ENDANGITIS. 77 
 
 watchful, particular providence and protection, its life-giver and 
 sustainer. 
 
 99. The blood-globules being of various ages, and various 
 degrees of perfection, their material elements are first passed, by 
 the power of nerve-induction, from death to life, and, when that 
 power is withheld, from life to death. The vital state of the blood 
 is, therefore, in constant dependency on the vital state of the En- 
 dangium. Is that tissue healthy, the blood is so likewise ; is it 
 sickly, exhausted, dying — the blood changes its phases along with 
 those of the power it depends upon. Is the Endangium struck 
 with palsy in a limb, or in a larger part of the body, as in para- 
 plegia — it is dangerous and noxious to the blood, to be driven 
 within the vessels of such a deranged and diseased structure. 
 
 100. Many of our most fatal childbed fevers are nothing more 
 nor less than instances of endangitis ; cases, in which the mem- 
 brana vasorum of the uterine and crural, and even the cava 
 veins, are the seats of an inflammation called childbed fever, 
 milk-leg, depot laiteux, &c. &c. 
 
 101. A woman pregnant, is often observed to labor as to her 
 circulation ; she becomes sometimes plethoric and hyperinotic ; 
 at other times she is to the last degree hydraemical. The force of 
 her hasmatosis is exaggerated or exhausted, as the case may be, 
 and the direct fault, the pathological fault, is to be traced to a 
 state of the Endangium, which is her blood-making tissue, 
 her blood-membrane, and which has the same relation to 
 the function of haematosis, as the gas tro- enteric mucous membrane 
 has to the process of her digestions. If the digestive organs be- 
 come diseased, the power of digestion falls proportionally; if the 
 hasmatosic tissue becomes diseased, the haematosis fails in like 
 manner. 
 
 102. We habitually speak of the digestive mucous membrane, 
 and of the respiratory mucous membrane — bio od- membrane 
 is equally a true and honest word, one that conveys an accurate 
 and concise meaning or idea. Well, then, when I speak to you of 
 blood in diseases, as depraved, as vitiated or dissolved; as ruined 
 and incompetent to carry on the functions appurtenant to it; 
 as the antagonism of the solids; I desire you to understand me as 
 speaking of diseases of the membrana communis (Endangium). I 
 
78 PUERPERAL FEVER. 
 
 do not more conclusively refer the dysenteric diarrhoeas, croups, 
 &c. to a state of the gastro -intestinal, or pulmonary or laryngeal 
 mucous membrane, than affections of the blood to affections of 
 the blood-membrane, Endangium. All scarlatinas, measles, 
 variolas, varicellas, erysipelas, gout, rheumatism, and many forms 
 of childbed and other fevers, have their prime seat in the blood- 
 membrane (Endangium), and are but so many varied expres- 
 sions of its diseased conditions. 
 
 103. This proposition I offer to you, knowing that it will ex- 
 cite a smile of contempt for me in many a self-sufficient physiolo- 
 gist. Still, it is one so true, so useful, so enlightening to the path 
 of the practitioner and the researches of the pathologist, that I am 
 ready to meet with the scorn, which from many a professional 
 martinet it cannot avoid and draw down upon me, as a medical 
 dreamer full of wild theories and unsustained assumptions. 
 Time will show whether our class have not, for more than twenty 
 centuries of studies and observations, neglected to look into the 
 pathology of the membrana vasorum communis, a tissue that 
 has perhaps more extensive and important relations to etiology 
 in our cardinal fevers, than even the digestive or the pulmonary 
 mucous membrane, or both of them together. 
 
LETTER Y. 
 
 IS THERE A POISONED STATE OF THE BLOOD? — OF CONJECTURAL 
 PUTRIDITY — VITIATED BLOOD THE CAUSE OF CHILDBED FEVERS 
 — IN WHAT WAY THE BLOOD CAN BECOME CHANGED — IT IS A 
 DEPENDENT OF THE BLOOD-MEMBRANE IN DISEASE, AND NOT 
 VICE VERSA. 
 
 104. What difference does it make to you, whether our Class 
 shall receive and adopt the milk-dogma of Thomas Willis and 
 the Frenchmen, from Goubelly to Puzos, and from Doublet to 
 Vigarous ; or whether they shall prefer to fill the blood with va- 
 rious products of absorptions and resorptions, and then attribute 
 to the noxious presence of those putative foreign matters, a host 
 of diseases, whose evolution is made by them to depend upon 
 them either alone or in chief? I repeat that you are doomed on 
 many future occasions to fight with the shadow of the milk-dogma 
 of the eighteenth century. If you will take up Alexander Gor- 
 don's Treatise on Puerperal Fever, you may even there see that, 
 although he says nothing about milk-metastasis, his mind was 
 clouded from first to last with dreams of putridity, of which he 
 saw the pretended signs in the appalling weakness of his patients. 
 
 It was not until he had dissected the body of Mrs. , No. 38 
 
 of his dark early list, that he became aware it was an inflamma- 
 tion he had been treating — I say, " aware ;" and, perhaps, I ought 
 scarcely to say so, since, in a subsequent page, he observes that 
 "the disease, which was inflammatory in its beginning, becomes 
 putrid with progress. The source of the poison is in the cavity 
 of the abdomen, for which there is no antidote in the Materia 
 Medica. . . . This deep-seated poison cannot be corrected 
 in any other way, than by being carried out of the body,' 7 
 etc. etc. 
 
SO PUERPERAL FEVER. 
 
 105. Poison ! Antidote I 
 
 106. What poison? Do you hear Gordon speak of a deep- 
 seated poison in the belly which has no antidote in the Materia 
 Medica ? Do you know this poison ? I am sure, for one, that I 
 am wholly ignorant of its nature, and that no person has ever 
 analyzed it, or even seen it, though Dr. Thos. Douglass {Dub. 
 Hosp. Reports) says, he could smell the efnuvia of puerperal fever ! 
 It has never appeared, and we say de non apparentibus et de non 
 existentibus eadem est ratio. The poison was in the mind of the 
 observer. But Gordon is not alone in his views. 
 
 107. Dr. Charles White, of Manchester, p. 213, says: "It does 
 not appear that this disorder can be ascribed to simple inflamma- 
 tion. The patients complain chiefly of tension, soreness, and 
 tenderness of the belly, and are seldom affected with that excru- 
 ciating pain which usually attends common inflammation of the 
 bowels ; but it evidently manifests itself to be of the putrid kind, 
 occasioned by human effluvia; by the accumulation of acrid putrid 
 bile, and a putrid colluvies through the whole intestinal canal 
 and organs of generation, and is a malignant fever of the same 
 genus as the jail or hospital fever." 
 
 108. Dr. Rigby, of London, in an article beginning p. 482 of 
 vol. vii. of Brit, and Foreign Med. Review, notices Dr. Robert Fer- 
 guson's Essay on the Most Important Diseases of Women. Hear 
 Dr. Rigby : "In a notice of Mr. Moore's work in our second 
 volume, we ventured to express our own belief that the affections 
 which we ourselves considered as especially entitled to the name 
 of puerperal fever, belonged to that class of diseases, the funda- 
 mental character of which is a morbid condition of the 
 blood, produced by the introduction of some deleterious 
 agent into the circulation." There you have it ! This 
 is in Dr. Rigby 's own words. The blood is poisoned by "some 
 deleterious agent!" Suppose it had been Puzos's or 
 Doublet's milk, or Thomas Willis's ferment! what is the difference 
 to the poor woman ? In his Midwifery, Philadelphia edit., p. 417, 
 the same gentleman observes that, " 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 a great mea- 
 
RIGBY — FERGUSON — DENMA2T. 81 
 
 sure, we consider them as correct, having not only taught them 
 for many years, but published them in our lectures on this sub- 
 ject in 1885." . . . "We cannot agree with the opinion that the 
 vitiated state of the blood is the secondary and not the primary link 
 in the chain of phenomena (p. 423)." What a strange opinion! 
 A man holding such a tenet as that, must surely be one who re- 
 gards the blood as a self-producing substantiality, and wholly 
 independent afterwards of the solids. Yet the same person, if 
 interrogated concerning his philosophical opinions as to the has- 
 matosis, could readily be cross-questioned into an admission that 
 the blood-making power is one of the principal attributes of the 
 special vital solid charged with that high and indispensable 
 function. 
 
 109. Dr. Ferguson, in his work, p. 53, has this formula: — 
 
 "1. The phenomena of puerperal fever originate in a vitiation of 
 the fluids. 
 
 "2. The causes which are capable of vitiating the fluids are par- 
 ticularly rife after childbirth. 
 
 " 3. The various forms of puerperal fever depend on this one 
 cause, and may readily be deduced from it." 
 
 110. Denman, in his doubting recommendation of venesection 
 in the treatment, urges the necessity of great promptness in the 
 use of the method, as signs of putridity early appear ; and Dr. 
 Hulme, p. 112, says: "As the puerperal fever hath a strong 
 tendency to run quickly into a state of putrefaction, all causes 
 during pregnancy," &c. 
 
 111. It is an easy thing to multiply the citations concerning 
 putridity, as to childbed fever, but I shall not overload 
 these pages with them. It is enough, one would think, to quote 
 those above, to set you to pondering upon the possibility of 
 putridity in any living body. A man may have a foul and 
 even putrid sore on his surface, or, in confluent smallpox, the 
 ooze from innumerable pustules may make the man resemble a 
 living mass of corruption ; but putrid blood in the vessels, and 
 heart, and brain ! Surely, the word putrid does not, nor cannot 
 express the meaning of the speaker! Such a word is a traitor 
 to the speaker of it ; in plain English, it is a false word. Does 
 
 6 
 
82 PUEEPEEAL FEVEE. 
 
 it not mean the same thing, under a different name, as milk in 
 the blood, errement de hit, &c? 
 
 112. The notion of putridity in the blood, is surely not very 
 different from that of milk fermented in the same fluid. But of 
 these ferments we know nothing. It is only words we use, and 
 the meaning of them is vague and imprecise. Some persons 
 suppose that substances may find admission into the recesses of 
 the body, that are neither spores nor ova; but. like spores and 
 ova, capable of evolution within, to the destruction of the vital 
 powers, and even of the organization. Others insist that spores 
 of vegetables, which are cells, obtaining admission, produce cells 
 within cells, to the utter subversion of the texture and the life. 
 We know nothing of them ; we do not see them, and cannot prove 
 their existence — nor, indeed, if we could do so, would they be 
 thereby proved to be the causes of Zymotic disorders. 
 
 113. After a careful examination of the opinions and sugges- 
 tions of many of the most distinguished and acknowledged good 
 authors on the subject, I cannot bring myself to believe that 
 because a woman is pregnant, or lying-in, her blood may lose its 
 specific character and become something else — which is not 
 blood, but which still carries on the functions of the blood, and 
 either destroys her life through childbed fever, or, after bringing 
 her down to the gates of death, instantly, in the twinkling of an 
 eye, ceases to trouble her, and allows the recovery of the most 
 perfect health, even in a very short time. It is not to be doubted, 
 that multitudes of women laboring under childbed fevers, even of 
 the worst character, have been cured by a simple venesection, a 
 jugulare febrim bleeding, that, at a single blow, has struck down 
 the power of the inflammation to advance one line beyond its 
 actual area, and at the same moment impressed upon it a sure 
 tendency to disappear rapidly by resolution. I have seen and 
 treated many such a case. Where was the poison, where the 
 putridity, that were thus cured or removed by our good bleed- 
 ing at the arm! 
 
 114. I am anxious that you, as Students of my Class, should, if 
 possible, be educated in absolute freedom from all shackles of 
 dogmatism. It is a dogma to say that the blood is poisoned, and 
 that an entity foreign to the body is within it, exercising on the 
 
VITIATED BLOOD — PUTEIDITY. 83 
 
 organism its pathogenic force. I say it is a dogma, and a dogma 
 is only an "I think." To think is not to know, but only to 
 believe : a dogma is a settled opinion ; but a settled opinion is 
 not a knowledge, but only a belief. Now, as to foreign matters 
 in the blood, you can only think them to be there, you cannot 
 know it. 
 
 115. If there is a foreign entity in the blood capable of self- 
 multiplication, as by fermentation or the evolution of cells, why 
 then, it might follow, that the diseases so developed by them 
 should be contagious; but if the childbed fever is not a fever, 
 but only an inflammation, then it cannot be transported or 
 communicated by contact or combination, or ad distans. 
 
 116. Many men say, and even insist, that childbed fever is con- 
 tagious ; and I consider it quite probable, that if you could pass 
 the question to a vote in this country, much the larger portion of 
 the forty-two thousand American physicians would vote in the 
 affirmative ; and that they would be sustained by a similar senti- 
 ment of the public at large. I have been dismissed or released 
 from my engagements to superintend the confinement of certain 
 of my patients, because either they or their friends became ap- 
 prehensive of the contagion I might carry from puerperal-fever 
 patients that I had not under care ; for the rumor of epidemic 
 childbed fever was so terrifying, as to absolve those families from 
 the obligation of treating their physician with respect, or even 
 politeness. My conversations and my intercourse with the bre- 
 thren, convince me, too, that even where the individuals have 
 been highly educated, there is a natural disposition among the 
 medical men to adopt the convenient hypothesis of contagion; for 
 the far greater majority of my personal acquaintances think that 
 an accoucheur, who has the misfortune to take care of a case of 
 puerperal peritonitis, is scarce fit to be trusted near a pregnant, 
 parturient, or lying-in woman. 
 
 117. We ought to reason together upon this subject, as one 
 that deeply concerns our feelings and our interests as well as 'our 
 duty ; for if there is a shadow of reason why we should adopt the 
 belief in contagion, we should make haste to discover the truth, 
 and be guided by it in our conduct. I do not wish to say any- 
 thing in this letter to excite anger, or lead my reader to think me 
 
81 PUERPERAL FEVER. 
 
 deficient in respect for other men's opinions. Yet I cannot 
 refrain from expressing the surprise with which I behold the 
 indifference with which the most important opinions are taken 
 up or laid down, and particularly, on this subject of contagion, 
 which as to childbed fever appears to me to have no shadow of 
 reason in its behalf. 
 
 118. But while the opinion of childbed fever contagion ought, 
 in my view of it, to find no supporters among truly educated 
 medical men, I am well aware that you are to be left to the ope- 
 rations of your own judgment in adopting or rejecting it; nor 
 have I the least desire to persuade you to think, because I think ; 
 I only wish you to think because you have inquired into and 
 discovered the truth of the matter. 
 
 119. To me personally, it is nothing, that you should believe 
 this or that. The direction of your opinions interests you, and 
 that portion of the people who are to confide, in their distresses, 
 in your sagacity and knowledge, and in an important degree 
 also, the profession of which you are members ; for what you do 
 or say in this matter cannot but have influence, greater or less, 
 on some parties, who will be misled by your erroneous opinions, 
 or correctly informed by your truly enlightened and just views 
 of the subject. I hold it to be the duty of every man of us to 
 endeavor, at least, to do something towards spreading abroad the 
 truth; and so adding, even if it be but one poor mite to the 
 Treasury of Science. Your opinions, therefore, do not interest 
 me personally. 
 
 120. If what I think is truth on this subject, it is no truth of 
 mine ; it is nature's own truth ; and I have, therefore, not the 
 least inclination to find that any Student of mine shall believe, 
 because I believe, this or that. Far from it — I heartily despise, 
 and deny his claim to the Scholarship, any man who makes him- 
 self the slave of other men's opinions; for a Scholar can only be 
 truly a Scholar by becoming a freeman in the Eepublic of Letters, 
 holding all his rights in knowledge and science in absolute fee 
 simple, so that what he has is his, and not another's. 
 
 C. D. M. 
 
LETTER VI. 
 
 CONTAGION IN CHILDBED FEVER — DEFINITIONS — CONTAGIONS ARE 
 BOTH SPECIFIC AND INCUBATIVE — CONDITIONS OF THE PROBLEM 
 — COMMON TENDENCY TO BELIEVE IN CONTAGION — DR. HOLMES'S 
 PAMPHLET — TONELLe's, BAUDELOCQUE'S, JACQUEMIER'S, AND 
 KIWISCH'S VIEWS — VON BUSCH AND HIS HOSPITAL-EPIDEMIC — 
 COLLINS's, DUBOIS'S, AND SCANZONl'S OPINIONS — DR. CAMPBELL'S 
 EXPERIENCE — AUTHOR'S EXPERIENCE, WITH A TABLE — BUTTER'S 
 CASES — GOOCH A CONTAGIONIST, AND ARMSTRONG, ROBERTON, 
 AND CHURCHILL. 
 
 121. I JUST now opened Stephens's Thesaurus Linguce Latince, to 
 learn what is his interpretation of the word Contagion, which he 
 derives from Contingo, tigi, tactum, egere, which he says is, idem 
 quod continuatio ; and after giving as usual an infinite number of 
 derivations from the verb, he remarks of Contagium, that it is pro 
 contactu, and means genus morbi qui ex contactu contrahitur, a spe- 
 cies of disease contracted or taken by means of touching. Ste- 
 phens cites many instances of its use by authors. 
 
 122. Dr. Thomas Willis, deFehribus, p. 224, says that by the word 
 contagion we mean that force, or those acts, by means of which an 
 affection existing in one individual, may excite a like affection in 
 another individual ; and that this effect may be produced either 
 immediately by contact, or mediately, and ad distans ; as if, the 
 disease being in a house, the poison should be transported thence 
 into another house ; or, as if, a person, by touching any clothing, 
 &c, that had been left in an infected place for many weeks, months, 
 or even years before, should contract the plague by such touch. 
 
 123. In explanation of this faculty of contagion, Willis sug- 
 gests that from all bodies whatsoever, there continually escape 
 
86 PUERPERAL FEVER. 
 
 effluvia which envelop or surround them with a nebula or haze, 
 and clothe them as down of a peach invests the fruit ; an idea, 
 which, according to him, is received by philosophers as one of 
 the truest propositions. In this manner, he thinks, pestilential 
 poisons may be supposed to arise, and escape as effluvia, or vapors; 
 and being specific in character, are capable of reproducing the 
 same specific diseases, whose existence, in a body, caused that 
 body to create and eliminate them. 
 
 124. Consider now these views of the celebrated English phy- 
 sician, and inquire into their reasonableness ; and, further, de- 
 termine, for your own satisfaction, whether a woman, who labors 
 under a childbed fever which is either a metritis or a phlebitis, 
 can develop a metritis or phlebitis in another pregnant or lying- 
 in woman, and in no other human being besides; and more than 
 that, whether a physician, or a nurse, can carry Willis's nebula 
 or halo in his hair, his dress, or his hands ? Such are the inquiries 
 you are to make and to answer: You must answer them. 
 
 125. As the word contagion is in constant use in our calling, 
 one ought to know what he means to say when he employs it, and 
 should, therefore, know its value as the sign of his idea. What 
 is the value of material idea excited in you, when you used the 
 word contagion ? 
 
 126. Krauss, whose learned lexicon is, I presume, much to be 
 depended on, says of the word contagion, that it is poisoning or in- 
 fecting by a touch; and Dr. Dunglison, in his Medical Dictionary, uses 
 these words: "Contagion is the transmission of a disease from one 
 person to another by direct or individual contact. The term has 
 also been applied, by some, to the miasmata arising from dead 
 animal or vegetable matter, bogs, fens, &c; but in this sense it is 
 now abandoned." 
 
 127. Webster's Dictionary tells us that, "contagion is literally 
 a touch, or touching. Hence, the communication of a disease by 
 contact; or the matter communicated; more generally, that subtil 
 matter which proceeds from a diseased person or body, and com- 
 municates the disease to another person, as in cases of smallpox, 
 measles, anginas and malignant fevers, diseases which are com- 
 municated without contact. Also, pestilence, a pestilential dis- 
 ease, venomous exhalations." 
 
KRATJSS — WEBSTER — NACQUART. 87 
 
 128. Nacquart, in the Diet des Sci Med., says, under the word 
 contagion * * * it is proper to call by the name of contagion, the 
 mode by which diseases are transmitted from one person to an- 
 other, by mediate or immediate contact. Contagious, contagiosus, 
 susceptible of transmission by touch. 
 
 129. I think the above citations may suffice to show that when- 
 ever you use the word contagion as of contagious diseases, you 
 imply disorders, produced, whether by means of actual contact of 
 persons or by means of effluvia, nebula, or halos, which, evolved 
 by an individual, and enveloping him like an invisible mist, may 
 be carried by him from place to place ; or surrounding, or adher- 
 ing to clothing, &c, may poison other people, and so reproduce, 
 not all sorts of diseases, but the Yery same sort of disease which 
 gave rise to it in its specific nature and attributes. If you will 
 use the word contagion, I think you are bound to restrict it to its 
 real sense and meaning. 
 
 130. If, as some pretend, childbed fever is a fever indeed, and 
 not a mere topical inflammation that gives rise to febrile pheno- 
 mena by means of the irritating power of the local disease, there 
 might remain some chance of a probability that such an affection 
 should be a contagious one. I know not what ideas you may have 
 imbibed upon these points, but it is the object of this work to 
 prove that childbed fever is a simple state of inflammation in 
 certain tissues of pregnant women, and of women lately confined, 
 and that the fever that attends it is a natural effect of intense con- 
 stitutional irritation from the local disorders. So far as I have 
 been able to investigate the subject by reading and by clinical 
 observation, as well as by necroscopic researches, I rest deeply 
 convinced that the fever does not take the initiative, except in 
 very rare instances ; but on the contrary, that an area of inflam- 
 mation being first established, the reactions ensue thereupon ; and 
 I beg you here to observe that, in all the truly contagious dis- 
 orders, the constitutional affection leads the train, and brings on 
 the topical lesions after an indispensable preliminary incubation. 
 
 131. Do not suppose that I am ignorant of the opinions of 
 eminent persons, who do not view the matter in this light, but 
 conceive of the disease as a real fever, and that some most 
 celebrated writers, even among those who were never slaves of 
 
88 PUEEPERAL FEVEE. 
 
 the milk dogma, have insisted that there is no inflammation in the 
 case, in most epidemics. Maximilian Stoll asserts these opinions 
 in his articles on puerperal fever in the Ratio Medendi, 211. I 
 do not wonder at this circumstance, when I reflect that childbed 
 fever is often an epidemic disease that spreads over whole dis- 
 tricts and even great countries, for it is a very difficult thing to 
 conceive of a purely topical affection as governed by the force and 
 laws of epidemics. 
 
 132. Contagious diseases, it is worthy to be observed, are always 
 specific in character. Thus smallpox-poison or contagion, de- 
 velops only smallpox, and never measles, or scarlet fever, or jail 
 or yellow fever, or inter mittents, or spasmodic cholera. Whenever 
 the virus acts at all, it can only act in one line, in one specific 
 way. The same is true of syphilis and all other truly contagious 
 diseases. As to contagious diseases, further, they affect the race 
 of mankind without respect to age or sex of those who become 
 exposed. There is no presumable exemption among men. Of 
 smallpox, Willis says; we are all predisposed to it: quae nimirum 
 prcedispositio naturalis, homines quidem solos omnes, idque semel huic 
 morbo ohnoxios reddit." 254. 
 
 183. In a case so specific as this of smallpox, there can be little 
 hope to deny, on philosophical grounds, the absolute contagious- 
 ness, which is also clearly discoverable by our empirical know- 
 ledge of the facts, as in contagion by contact, ad distans, and by 
 inoculation. 
 
 134. If one of the conditions of contagion is that it is no 
 respecter of persons, but attacks all individuals alike, you should 
 consider whether one of the indispensable conditions of the pro- 
 position, that childbed fever is contagious, is not wholly wanting; 
 childbed fever, attacking not women only, but only puerperal and 
 parturient women. How comes it then to pass, that a mortal 
 virus or contagion should have power over a woman who is preg- 
 nant, or recently delivered, while it is innoxious for all others in 
 the world ? Do you say that there is, in nature, a contagion of 
 intense virulency as to the human body, only, when in the exer- 
 cise of the highest, the most culminating forces bestowed upon it 
 by the Creator ? You know already that in some hospitals where 
 every parturient dies with the epidemic, no harm falls on the 
 
CONTAGION — SPECIFIC — INCUBATIVE. 89 
 
 nurses or the physicians, and this too in a house filled with a con- 
 tagion, terrible as plague, and more mortal than variola ! Come 
 now, think of this ! ask, how can these things be ? why should it 
 attack the pregnant or in-lying woman alone ? Is such a creature 
 not a woman still; still a member of the race; still under the law 
 of species ? Hath not a woman eyes ? hath not a woman "hands, 
 organs, dimensions, appetite, affections, passions ; fed with the 
 same food, hurt with the same weapons, subject to the same dis- 
 eases, healed by the same means, warmed and cooled by the same 
 winter and summer" as a man is? "If you prick her will she 
 not bleed ? If you tickle her, doth she not laugh ? If you poison 
 her doth she not die ?" Why, theu, do you say that, being, in 
 all her physical attributes, and in all of her sensibilities, one of 
 the race, yet she is in this unlike to her kind ; that a contagion, 
 mortal as nicotine, and speedy as prussic acid in its processes, is 
 absolutely innocuous for all her race, except for her alone, and 
 for her also, except she be pregnant or recently delivered ? Not 
 only must she be pregnaDt, to subject her to such influence, she 
 must be well advanced towards her term; for my own experience 
 herein coincides with that of Kiwisch, to show that early preg- 
 nancy and abortion rarely afford subjects for childbed fever; 
 though it is true that some of the cases related by Hippocrates, as 
 well as by more modern writers, are of a very early date of the 
 gestation. 
 
 135. If you could make out the case that pregnant women are, 
 without exception sick women, which you cannot do, then you 
 might, with some semblance of reasonableness, come and declare 
 to all the world that pregnancy, being a pathological state, it 
 contains in its very fact the rationale of this susceptibility to a 
 poison fatal as arsenic. But, I repeat, you cannot say so; and 
 further, in an epidemical season, it matters not who is the woman 
 or what the state of her health that goes to the pest-house called 
 a lying-in hospital, to be confined, she meets the cause there, and 
 there it seizes upon and destroys her. 
 
 136. It is an absolute condition of contagion, that it must under- 
 go some certain incubation. If it is a ferment, it must have time 
 to ferment ; if a spore, it must have time to develop spores ; if 
 infusorials or infusorial ova, there must be time for incubation. 
 
90 PUERPERAL FEVER. 
 
 Such is the law of variola, vaccinia, measles, varicella, &c. &c. 
 Is this so ? Yes ? Then read this case from Tonnelle, Archives 
 Generates, 22, 360. "Obs. II. Puerperal fever, with Uterine Phlebitis; 
 
 rapid progress. Marie Cons , 28 93t.; of an excellent constitution; 
 
 happily delivered at the Maternite*, Dec. 26th, in the evening; was 
 well the next morning, the 27th; but had some vague pain in the 
 belly in the evening of the day. On the 28th, in the morning, 
 the pains became more violent. The lochia, at first abundant, 
 were now suppressed; the face pale, with changed expression; 
 tongue dry; pulse small, contracted, and frequent. She had a hip 
 bath, and fifty leeches on the hypogaster. The leeching, though 
 plentiful, did not lessen the pains. During the day she was very 
 anxious and agitated. In the evening she was delirious, and fell 
 into a deep stupor. The skin soon became covered with a viscid 
 sweat ; the extremities grew cold, and she died in twenty hours 
 after the commencement of the disorder." The dissection disclosed 
 the most extensive suppuration of the parts within the pelvis. 
 
 137. Now tell me whether this was a contagion, and whether, 
 if you had given her a dose of arsenic, you would have killed her 
 quicker! Contagion, indeed! A man must be very badly in- 
 formed to say so. Kiwisch, Klinische vortrage 1, Abth. 529, sa}^s : 
 " The course of a case of childbed fever is so rapid, that there are 
 few cases of epidemic disorders that hasten with such speed to 
 their termination ; and we have observed one instance, in which it 
 completed its course by destroying the life of a woman, confined 
 after a natural labor, in the short space of eight hours." Is 
 Kiwisch a man of truth? Then what have you to say to such a 
 contagion as this? 
 
 138. Many a woman has entered upon her labor in apparent 
 health, and has scarcely given birth to her offspring before she 
 was attacked by metro-phlebitis, and then been deprived of ex- 
 istence within less than twenty-four hours. Forty-eight hours is 
 frequently time enough to effect the dissolution. Are these 
 innoculations ? Are these contagions ? Are these infections ad 
 distans f It is nonsense to say so. 
 
 139. I hope you will not answer me saying that facts are 
 stubborn things, and facts show it to be contagious, for women 
 do fall sick with childbed fever, provided they be attended by a 
 
COXTAGIOX OF CHILDBED FEVEE. 91 
 
 certain physician, or a certain monthly nurse; whereas other 
 women, waited on by any other physician or nurse in the same 
 town, street, or district, shall not be attacked at all ; nor would 
 these poor women suffer, had they the good fortune to fall into 
 the hands of people who should not carry contagion with them 
 wherever they might go ! 
 
 1-10. ISTow here is a caret in the series of your conclusions. You 
 are not believing, but you are going further : you know that 
 childbed fever is contagious, because Dr. A meets in his practice 
 with seventy cases of the disease, while Dr. B, an equally busy man, 
 does not encounter a single one, though they cross each other's 
 path every day. Dr. A's track is marked out by victims, while 
 there are no traces of Dr. B's path, except it be in recovered wo- 
 men. And you reiterate that facts are stubborn things. Yet you 
 do not know, you only infer and suspect, or surmise that, if Dr. 
 B had taken charge of A's cases, and vice versa, the result would 
 have been the same on the whole, only the dead women would 
 have lived and the others would have perished. Who told you 
 so ? You believe so. Well, I have some small respect for your 
 belief, while I should bow reverently to your knowledge— you 
 believe so — I don't believe so at all. 
 
 141. You have reasoned badly; and it is true, as Cuvier has 
 spoken the words, that "it is only when the laws of General 
 Physics and those that result from conditions of existence are 
 exhausted, that we are reduced to the simple laws of observation." 
 Cuvier: Regne animal, Introduction, p. 6. In saying "facts are 
 stubborn things," you rely on simple observation, and through it 
 have reached the conclusion that Dr. A's patients were poisoned 
 by him, and Dr. B's not poisoned at all ; in doing so you have 
 laid aside a method of reaching the truth, far more sure and 
 certain than your empirical one, I mean that of- comparing the 
 conditions of existence of the problem. 
 
 142. What are those conditions ? 
 
 1. The patient, a woman, is a human being. 
 
 2. She is assailed by the most malignant of contagions, and which 
 . can destroy within twenty, or even within eight hours — as 
 
 precipitately as cholera, yellow fever, or Syrian plague. 
 
 3. She is pregnant, or recently delivered. 
 
92 PUERPERAL FEVER. 
 
 4. No human being save a pregnant or parturient woman is sus- 
 
 ceptible to the poison. 
 
 5. The poison is developed bj the body of the living but sick 
 
 woman. 
 
 6. It is developed with almost instant activity. 
 
 143. Now, out of these six conditions of the existence of your 
 proposition, every one of which is indispensable, you must give 
 up No. 5 and No. 6. You cannot maintain an hypothesis of this 
 kind, especially as relative to the 5th and 6th propositions, for 
 you are compelled, in your contagious maladies, to allow of an 
 incubative stage, but here is none. Old John Eernel knew better 
 than this, for in his Universa Medicina, 8 vo., printed at Utrecht in 
 1656, he says, at p. 508 of the Libri Quatuor Posteriores: "Id 
 intro subiens, spiritus, sanguinem, humores, partisque substantiam 
 contagione labefactat; hinc sensim serpit longius in partes prin- 
 cipes, sed tarn segniter, ut raro ante diem vigessimum, interdum 
 non nisi anno symptomatis se prodat." He is speaking of the 
 contagion of rabies. If you will be contagionists, I wish you 
 would join in Fernel's wish, where he says : " Velim tamen insuper 
 mihi aculeos ex animo evellas, quos non nulli infixerunt" You must 
 give up No. 5. and No. 6 as to all first cases, because the woman 
 could not take it from the physician or nurse, when neither the 
 one nor the other had approached a case. 
 
 144. Further, childbed fever, say you, is a specific contagion. 
 It cannot therefore have multifarious sources; it is developed by 
 a living being, and transferred as a nebula, or a substance, from 
 place to place. Do you mean to say that a healthy woman, who, 
 falling into labor, gives birth to her child in a natural way, 
 afterwards creates and dispenses a miasm or ferment, a germ, a 
 spore, a cytoblast, an ovulum, that, reproducing themselves, can 
 poison and destroy other women? If you say so, then what 
 other sources are there that produce these entities in any first 
 case of the disease ? You are inconsistent with yourself, for you 
 say that the specific poison of childbed fever is a something 
 evolved by the vital force of a sick woman; not a woman in 
 health : where, then, I repeat, shall we go to seek for the source 
 of that specific thing that made this well woman sick first in 
 the series of cases ? She could not evolve the poison or miasm 
 
CONTAGION — DR. HOLMES. 93 
 
 when she was in health ; but according to you, this disorder of 
 hers is specific; that is to say, it is produced by a certain, always 
 identical cause. 
 
 145. You argue that the disorder is contagious because many 
 women are observed to fall victims in the same hospital, or the 
 same ward, or under the care of the same practitioner or nurse ; 
 and you say with an air of authority, that "facts are stubborn 
 things." Yery well, let it be admitted that facts are stubborn 
 things, but let us interpret them aright and not falsely. Let us 
 not fall under a delusion to believe, as St. Paul says, a lie. But, 
 above all, let us not, in advocating a particular interpretation, 
 become factious, and fall foul of all others except those who 
 swallow our orthodoxy as to science and conduct. Let us not 
 " assume the God, affect to nod," and shake the spheres with our 
 voice potential. 
 
 146. An American writer, in a small pamphlet essay on the 
 contagion of puerperal fever, assures the Kepublic of Medical let- 
 ters that he would not be " understood to imply that there exists 
 a doubt in the mind of any well-informed member of 
 the medical profession, as to the fact that puerperal 
 fever is sometimes communicated from one person to another, 
 both directly and indirectly." Such is the text of Dr. Holmes's 
 paper on the subject; yet our celebrated townsman, the late Prof. 
 Dewees, whose writings in obstetricy gave him a world-wide fame 
 as a well-informed member of the medical profession, at p. 420, 
 Treat, on Dis. of Females, uses the following language : " In this 
 country, under no circumstance that puerperal fever has appeared 
 hitherto, does it afford the slightest ground for the belief that it 
 is contagious." 
 
 147. Dr. Holmes does not agree as to doubts with Dr. Eobert 
 Lee. " The facts I have observed," says that distinguished writer, 
 " though they have led me to adopt the opinion that the disease 
 is sometimes communicable by contagion, and sometimes has a 
 connection with erysipelas, have not, perhaps, been sufficiently 
 numerous, and of so decisive a character, as to dispel every doubt 
 on the subject of its contagious or non-contagious nature, and 
 prove that it is a specific inflammation." — Lect. on Mid. p. 489. 
 You see that Dr. Lee almost doubts and almost does not doubt. 
 
94 PUERPERAL FEVER. 
 
 148. That M. Tonnelle* was a "well-informed member of the 
 medical profession" is proved by his celebrated paper on puerperal 
 fevers in the Archives Generates, Nos. 22 and 23, and by universal 
 consent. Now he asks, at p. 349, of torn. 22 : " Shall we have re- 
 course to contagion to explain the development of these affections ? 
 Not more than to the foregoing; for, with but a little knowledge 
 of the arrangements of the hospital wards, it is out of the question 
 to admit this (contagion) cause. A single infirmary collects to- 
 gether all sorts of cases of disease following lying-in ; along with 
 the gravest puerperal fevers are found the lightest disorders. 
 Such a state of things is certainly fit to favor contagion, yet we 
 have never seen anything that should lead us to believe in it. 
 Moreover, women recently delivered, notwithstanding they were 
 placed in separate wards, took the disease; indeed, here it is the 
 ordinary rule for them to take it, being often attacked immediately 
 after labor and before they have had any communication with the 
 other women." 
 
 149. Dr. A. C. Baudelocque, a well-informed member of the 
 medical profession, and whose admirable work on puerperal fever 
 was crowned by the Medical Society of Bordeaux, says that although, 
 in the actual state of our knowledge, it is not possible to dissipate 
 the prevailing uncertainty on the subject, "I nevertheless, in 
 spite of the assertions of several respectable English physicians, 
 for example, Joseph and John Clark, am in favor of the non-con- 
 tagionists." — Traite de la Peritonite Puerp. 127. 
 
 150. Dr. Jacquemier, one of the latest as well as most intelligent 
 authors on midwifery, says : " I do not invoke," as rationale of the 
 invasion, ' ' contagion, because it seems absolutely foreign to the 
 development of puerperal fever, as well when it prevails epidemi- 
 cally as sporadically." — Manual des Ace. 2 vols., Paris, 1846, p. 
 660, vol. 2. 
 
 151. Kiwisch von Eotterau, whose early and most lamented 
 death has robbed Grerman obstetricy of the second Wigand, and 
 whose brilliant intelligence allows him a place in the highest ranks 
 of our Scholar class, was a man so extraordinary that I will not 
 forego the pleasure of presenting to you some extracts from the 
 biographical notice of him by his friend, Dr. Halla, which is 
 printed in the Vierteljahrschrift fur die Heilkunde, ix. Jahrgang, 
 1852. 
 
TONNELLE — BAIT D EL OC QUE — KIWIS CH. 95 
 
 152. Franz Kiwisch, Eitter von Kotterau, was a native of 
 Klattau, in Bohemia, where he was born April 30, 1814. At the 
 age of twenty -three, after five and a half years of earnest Student 
 life, he was admitted, in 1837, to the degree of doctor of medicine, 
 and a few months later to that of doctor in surgery. He then 
 entered the Prague Lying-in Hospital, as clinical adjunct, where 
 he remained two years, gathering an immense amount of experience 
 and learning in all matters pertaining to his professional pursuits. 
 He subsequently travelled in Denmark and Sweden, and then 
 spent some time at Paris and London. After returning from 
 these travels, he gave lectures, at Prague, on diseases of women, 
 ■which added greatly to his reputation, and contributed mainly to 
 the spreading abroad of knowledge on those subjects throughout 
 all Europe. Those who read his admirable Klinische Vortrage, 
 know how well this fame was truly earned and highly deserved. 
 In all this career he was connected with the best of that bright 
 galaxy of learned medical Scholars, whose names are now con- 
 stantly repeated in the progress and prospects of our literature. 
 In 1845, K. removed to Wurtemberg, where his great reputation 
 attracted crowds of visitors who came to seek his health-giving 
 counsel, and it was here he received pressing invitations to St. 
 Petersburg, from individuals of the Imperial family. The death 
 of Prof. Jungmann, of Prague, opened a higher career for Ki- 
 wisch, who returned to the Bohemian capital, to the great joy of 
 the profession there. His excessive labors, and all-sacrificing in- 
 attention to his own health, led to a series of maladies, which re- 
 moved him from the world, of which he was an ornament, on the 
 29th October, 1851. 
 
 Let me now proceed to show you what were the sentiments of 
 this extraordinary man on the question before us. After arguing 
 the subject at length, he adds: "Let us assume a readily communi- 
 cable contagion as the sole, or even as the chief cause of the sick- 
 ness, yet I cannot comprehend how it shall happen in most of the 
 lying-in institutions, where a free communication goes on among 
 the inhabitants, that the attacks will suddenly cease to take place, 
 and again break out as suddenly, so that the most decided conta- 
 gionist ought to be driven to the conviction that such disorders 
 do depend upon some local origin, or atmospherical influence." — 
 Klin. Vortrage, ii. 583. 
 
yb PUERPERAL FEVER. 
 
 153. Such, are the words of the illustrious Franz Kiwisch; and 
 though they alone, ought to suffice to show that some well-educated 
 physicians do entertain doubts on the question of contagion in 
 childbed fever, I cannot help calling your attention to the follow- 
 ing striking relation, which, it seems to me, might be enough to 
 end the controversy, if anything can end it in the present age of 
 the world. 
 
 154. The Neue Zeitschrift fur GeburtsJcunde, edited by von 
 Busch, Kitgen, and Siebold, Berlin, 1852, Art. II. p. 313, has a 
 paper by Dr. Yon Busch. relative to an epidemic of childbed fever 
 in the lying-in hospital of the University at Berlin. 
 
 In February and March, 1851, after an antecedent epidemic 
 grippe, childbed fever became more extensively epidemic than it 
 had been for many preceding years. It broke out among the 
 women in the hospital in the month of February, the cases being 
 of a mild type, amenable to treatment ; but in March, it prevailed 
 with great violence, so that soon, almost all the women were seized, 
 and many of them died with the disease. In consequence, the 
 hospital was closed in order to spare the mortality, and it was 
 shut up during six entire weeks, and was, during the time, care- 
 fully cleansed and ventilated. Dr. Yon Busch supposed that such 
 a perfect cleansing and ventilation might relieve him from the 
 pain of seeing so many women's lives exposed to danger by being 
 confined in a house whose atmosphere had proved highly delete- 
 rious, yet he was sorely disappointed when, upon opening it again 
 for admissions after the six weeks had elapsed, he observed that 
 all the women who now came in were seized with the childbed 
 fever with greater or less violence, on the day following their 
 delivery. A similar incident is related as to the Dublin Hospital, 
 for we find that Dr. Robert Collins, in his great work, at p. 387, 
 says, that during the epidemic of 1819-20 in the Dublin Hospital, 
 Dr. Labat, the master, used the greatest care in ventilating and 
 cleansing the house, but could not check the progress of the cases. 
 " In one instance, a ward, in which there had not been any patients 
 for several months, and which in the mean time had been kept 
 strictly clean and well aired, was opened, and five patients ad- 
 mitted, three of whom were seized with puerperal fever and died." 
 This does not look like effects of contagion. It is a malaria rather ; 
 there was poison in the house. 
 
von busch's hospital. 97 
 
 155. Under the alarming circumstances existing within the 
 lying-in institution at Berlin, Dr. von Busch was inspired with 
 the happy idea of clearing the house of its pestilential atmosphere 
 by means of an elevated temperature, and accordingly, he directed 
 one or more stoves to be placed in each of the wards. The doors 
 and windows being then all closed, fires were made of stone-coal 
 in all the stoves, and the apartments were heated to 52° — 60° E., 
 the heat being steadily maintained during two consecutive days. 
 
 156. The result was surprising, inasmuch as from that day forth, 
 during the whole semester, not one single woman was attacked in 
 that hospital, although childbed fever cases still continued to 
 occur in the city. If, now, the disease was contagious in von 
 Busch's hospital, could there be a more virulent one than' that he 
 described ; or, if it could become contagious, was not this the 
 most likely place in the world for it to acquire that character ? 
 
 157. In the month of December, four persons in von Busch's 
 hospital were attacked, of whom one died. Hereupon the ward 
 was immediately vacated, and then heated as before, and with 
 complete success, for from that time until now (June, 1852), not 
 another case has occurred. 
 
 158. Do you say again, facts are stubborn things ? I grant you. 
 Well, then, here are very stubborn facts. Yet I know not what 
 you may say or think about this most interesting relation by Dr. 
 von Busch. 
 
 159. The celebrated Parisian Professor, Paul Dubois, who is, I 
 believe, looked upon as the person now at the head of the list of 
 individuals illustrious in this art in his native country, says, at p. 
 342, Diet, de Med., tome 26 : "When, in an establishment (for lying- 
 in women), several women are successively attacked, it is impos- 
 sible to say whether there was infection or contagion in the case" 
 * * * at p. 343, he proceeds : " Kelatively to contagion there is a 
 point still more controvertible. It is not repugnant, perhaps, to 
 many physicians, to admit there may be contagion from one sick 
 woman to another woman in good health. But what shall we say 
 of an indirect contagion, of which a healthy person, in some way, 
 serves as the vehicle, and which could not pass from one woman 
 to another except in this way ? The possibility of such transmis- 
 sions has been suspected, inferring from facts worthy of attention, 
 
 7 
 
yo PUEEPERAL FEVEE. 
 
 doubtless, but the significance and importance of which have been 
 singularly exaggerated, through ignorance, malice, or the spirit 
 of system, the histories of them not being sufficiently circumstan- 
 tial or precise to carry away the conviction of sober men ; and 
 which, besides the way in which they have been stated, admits of 
 a much more natural interpretation." 
 
 160. Such are Prof. Dubois's words. You can judge of their 
 meaning and value. Yet I should be unjust here, were I to fail 
 in citing the next following sentence, as follows: " In a question 
 so little understood, to doubt is at least a duty : nothing but numer- 
 ous and impregnable proofs can establish in science, a fact relative 
 to a mode of transmission, which is rejected, for the present, by 
 the generally received opinions of pathological physiology and 
 pathology." If you claim Paul Dubois as a contagionist, you 
 may examine your title to do so in the foregoing. Yet Paul 
 Dubois is one of the men most likely to be a contagionist, for he 
 firmly asserts there i s a puerperal fever. 
 
 161. If you must persist in asserting that the disease is a con- 
 tagious one, you must admit that it should be most so in crowded 
 wards, and you ought to infer, nay, know that von B.'s patients 
 must have been poisoned, partly by the women sick there, and 
 partly, at least, by the professor and his assistants, who killed 
 these poor women by contact or ad distans ; for, according to you, 
 the nebulae or halones must have been partly wafted from bed to 
 bed, and partly inoculated by the physician's hands. Even the 
 beds and other furniture must have been full of contagion ; as full, 
 at least, as the persons and clothing of the physicians and nurses. 
 Yet as soon as von Busch had baked the house in a heat of 52° 
 — 60° Keaumur, for two whole days, your contagious matter, as 
 you call it, was utterly destroyed, eradicated, or driven away, and 
 the poor women who next came in found themselves perfectly safe. 
 The professor did not remove the contagious beds or any portion 
 of the contagious furniture. On the contrary, he left the wards 
 in the very condition they were in when the last patient was dis- 
 missed; and he did so, doubtless, with a view to subject, not the 
 wards only, but all their furniture to the disinfecting power of heat 
 at 52° — 60° E. I may venture to say he baked the cause, and 
 thereby deprived it of its noxious quality, just as we bake or cook 
 certain articles of food, which, in their raw state, might poison us. 
 
99 
 
 162. Those of you who are contagionists ought to contend that 
 Prof, von Busch, and all his aids, nurses, and servants, should 
 have been baked, for forty-eight hours, along with the walls and 
 ceilings and furniture of the hospital; because, say you, the con- 
 tagion, halo, or nebula would come back with the re-entering 
 patients and doctors, after the three days should elapse. Do you 
 not, you who are contagionists, believe ; nay rather, do you not 
 know, that this nebula must invest them like the invisible cloud 
 about the form of Cytherea, when she walked along with the pious 
 iEneas? 
 
 "At Venus obscuro gradientes aere ssepsit, 
 Et multo nebulae circum Dea fudit amictu, 
 Cernere ne quis eos, neu quis contingere posset, 
 Molirive moram, aut veniendi poscere causas." 
 
 JEneid, Lib. i. 411. 
 
 163. If Professor von Busch, and his aids and servants, could 
 not, according to your hypothesis, but represent what Dr. Oliver 
 Wendell Holmes, in his Contagion of Puerperal Fever, calls a "pri- 
 vate pestilence," it is certainly a staggering answer that all these 
 private pestilences should have been so completely disinfected by 
 von Busch's stoves ; and I take it for granted that a mattress or 
 a pillow, on which a woman has exhaled the contagion of child- 
 bed fever along with her last dying sigh, ought to be as valid a 
 "private pestilence" as a professor, student, nurse, or any ward- 
 maid. The latter were not there. 
 
 164. I with great satisfaction here refer you to Dr. Eobert Col- 
 lins's work, before cited, wherein, at p. 387, he recounts the triumph 
 he obtained over the cause of childbed fever by purifying the whole 
 hospital. In February, 1829, it was scourged with the epidemic. 
 He turned out all but the most destitute of the women, filled the 
 wards, in rotation, with chlorine gas, closing the windows for forty- 
 eight hours during the disinfecting process. He painted the floor 
 and all the woodwork, with chloride of lime mixed with water, to 
 the consistence of cream, and left it on for forty-eight hours more. 
 After this, the woodwork was painted, and the walls and ceilings 
 whitewashed. The blankets, &c. were scoured and then stoved 
 at a temperature of 120° to 130°. From this time, February, 
 1829, until the close of his mastership, in November, 1833, Dr. 
 Collins lost not a single patient with the disease in Dublin Hos- 
 
100 PUEEPERAL FEVER. 
 
 pital, a result highly honorable to the distinguished physician and 
 philanthropist. Where was the contagion fled ? Dr. Collins and 
 his assistants, matrons, and ward-maids were not chlorinized ; were 
 they ever, indeed, private pestilences? 
 
 165. Dr. Holmes would not be understood to imply that there 
 exists a doubt in the mind of any "well-informed member of the 
 Medical profession" as to the fact that puerperal fever is " some- 
 times" communicated from one person to another, " both directly 
 and indirectly." Yet Prof. Scanzoni, who is a well-informed man, 
 perhaps even as well-informed as those I have already cited for 
 you, in his Lehrhuch der Geburtshulfe, Band III., ii. Abtheil.p. 468, 
 says : " With these views is connected the question whether 
 puerperal fever is contagious or no. There are still to be found 
 some physicians who suppose that this question must be answered 
 affirmatively. We, for our part, are of the opposite opinion, 
 because, out of our own considerable experience, there has not 
 appeared a single case in which we could or ought to make out a 
 contagious origin. All the grounds presented by the contagionists 
 in support of their hypothesis are either without proof, or refer 
 only to the existence of a miasmatic or epidemic causation of the 
 disorder; or finally, lead to the inference of some deleterious 
 substance, matter, poison, &c, &c, brought from a sick lying-in 
 woman within the economy of a sound, healthy woman, and that 
 gives rise to a blood disease, while certainly no man can speak 
 here as to any specific contagion." 
 
 166. It is true that Scanzoni afterwards refers to Skoda and 
 Semmelweiss's opinion, that some of the cases in the Vienna Hos- 
 pital were communicated by the hands of persons who had recently 
 assisted in dissections ; and he adds, relative to the sentiments of 
 Kiwisch, Seyfert, Lumpe, and Zipfl, that it would occupy him 
 too long to trace out their views against contagion in the cases, 
 and refers to their admirable writings only for the purpose of 
 remarking " that he will not deny the possibility of an infection in 
 certain cases, but considers it is going too far, to attribute the puer- 
 peral attacks in hospitals to this principle of contagion alone." 
 
 167. In this last passage, while Scanzoni admits, or rather will 
 not deny, that the disease is, in certain cases, communicable,'! do 
 not conceive he allows of its contagiousness ; but only, that disease, 
 
SCANZONI — KIWISCH — CAMPBELL. 101 
 
 being developed in a lying-in woman, that disease is apt to assume 
 the, nature of childbed fever. As far as that I am willing to go 
 myself; for I am aware that anything that could set on foot a 
 diseased train in such a person, could scarcely fail to develop 
 childbed fever. This, however, is far from the idea of a contagion 
 d contactu, or ad distant 
 
 168. It may be presumed that no person now denies that 
 dissection wounds are very dangerous ; and every well-informed 
 anatomist, about to make a post-mortem examination of the putre- 
 fying viscera, after a fatal peritonitis, or any other disease, would 
 be extremely careful not to interfere with such a subject should 
 he have, at the time, any abrasions of the fingers or hands. See 
 the cases of Mr. Win. Hutchinson, and Mr. Dease, as they are 
 stated by Mr. Colles, in Dublin Hospital Reports, vol. iii., p. 204 to 
 216. I should think that no experienced accoucheur could read 
 these two cases of dissection wounds, without finding in them 
 evidences to show that the constitutional disorders, growing out 
 of the accidents, were due to a phlebitic disorder, or, to employ a 
 better word, to an extensive inflammation of the Endangium. 
 To wound the fingers in the delivery by embryotomy, of a long 
 decomposing and offensive foetus, by spiculae from the cranium, 
 or by the point of a sharp crotchet, is a very dangerous accident, 
 and is followed by great distress, as I have more than once ex- 
 perienced in my own person. But to carry the putrid material 
 substances of a dead body, and to inoculate with them the organs 
 of a woman in labor, even though fatal, ought not to induce you 
 to consider such a childbed fever as contagious. I beg you to 
 read the shocking histoirette, at p. 356 of An Introduction to the 
 Study and Practice of Midwifery, and the Diseases of Women and 
 Children, by Dr. fm. Campbell; London, 1833; 8vo. The 
 author's words are: "In the autumn of 1821, he attended the 
 dissection of a married woman, who died of the disease, after an 
 abortion of the early months; removed the pelvic viscera and 
 external parts, and carried the whole, in his coat pocket, to the 
 class-room. The next morning, dressed in the same clothes, he 
 assisted, with some of his pupils, in an instrumental delivery at 
 Bridewell. This woman was seized with the same affection, and 
 died. The same night, he accompanied Dr. Orr to the delivery of 
 a woman residing in the North-Back of the Cannongate; she was 
 
102 PUERPERAL FEVER. 
 
 equally unfortunate, and three other poor women shared the same 
 fate in quick succession." In a subsequent year, 1823, he assisted 
 at the dissection of a childbed fever case, but "did not wash his 
 hands with the care he desired." Thence he went immediately 
 to attend two other women in labor, both of whom died. Do you 
 remember that Bichat died for looking into a jar in which he had 
 an anatomical specimen macerating, and that Prof. J. S. Dorsey, 
 of the University of Pennsylvania, lost his life from a like cause ? 
 Ko man ought to carry home viscera in his pocket, and wait on 
 sick women in the same clothes. This I admit most cheerfully. 
 Dr. C, however, did not long continue to be a "private pestilence." 
 I repeat, that in epidemic seasons the cause of childbed fever 
 exercises a sort of dictatorship over women ; and whether you 
 bring on fever by fatigue, by burns, by cold, exposure, improper 
 diet, or by whatever cause, including this inoculation, it becomes 
 this very childbed fever — it could become nothing else. If the 
 disorder arises from a laceration of the uterus, it is no more true 
 to say of it, it is contagious, than when it arises from a dissection 
 virus. Such dissection virus may kill a man or a virgin, as well as 
 a lying-in woman, but it could not give either of them a childbed 
 fever. Is not this a reasonable and just discrimination? Does 
 it leave any ground on which to found the belief that a man may 
 carry a nebula for weeks about his person, or radiate, ad distans, 
 so virulent a poison ? 
 
 169. I have practised midwifery for many long years ; I have 
 attended some thousands of women in labor, and passed through 
 repeated epidemics of childbed fever, both in town and in hospital. 
 After all this experience, however, I do not, upon careful reflec- 
 tion and self-examination, find the least reason to suppose I have 
 ever conveyed the disease from place to place, in any single 
 instance. Yet for many years I carefully considered whether 
 such transfer, by a third person, might be possible, and carefully 
 read the statements of various authors to that effect. In the 
 course of my professional life I have made many necroscopic re- 
 searches of childbed fever, but did never suspend my ministry as 
 accoucheur on that account. Still, I certainly was never the 
 medium of its transmission. 
 
 170. I have, in numerous instances, gone from the bedside of 
 
TABLE OF CASES. 103 
 
 women dying with childbed fever, whether sporadic, or to the most 
 malignant degree epidemic, withont making my patients sick. I 
 have also endeavored to assist my brethren, when they had snch 
 cases and I had none. 
 
 171. I did not then, nor should I now, fear to be the medium 
 of transmission. But I have been unceremoniously set aside, after 
 having been for months engaged, even for some who owed me 
 impayable gratitude for the services I had for years rendered 
 them. And this treatment I got, not because I merited it, for I 
 did not merit to be regarded as a private pestilence, nor was I 
 found to be so, in fact, by those who had more good sense, or 
 who could appreciate the feelings with which a physician finds 
 himself to be looked upon as a peripatetic pestilence, or poisoner 
 of women for love of gain, or what is worse, stupidity. 
 
 172. In a series of labors, 468 in number, and beginning with 
 No. 1, I find that Nos. 18 and 19 were affected, and that No. 18 
 died with childbed fever ; No. 31 was sick, but recovered; Nos. 
 195 and 259 were sick and recovered; but No. 291 died, as did 
 also 293. Nos. 332, 339, 435, 444, 445, and 455 were attacked 
 and recovered. The above cases, viz: 18, 19, 31, 195, 259, 291, 
 293,332, 339, 435, 444, 445, 455, are in all 13 cases in 468 labors, 
 of which three died and nine recovered. Now if I was the medi- 
 um of contagion for any one of that series of 468 confinements, 
 why did I poison them in the ratio and order above set forth ; 
 and why did I not communicate the disease in more than 13 out 
 of 468 cases? What became of my nebula from 31 to 195 ; to 259, 
 and between 291 and 445, and so to the end, or 468? Such a 
 table is far more easily explained by regarding the falling out of 
 the cases as coincidences and accidents, than as material causations 
 through a " private pestilence." 
 
 173. At page 631 of my work on Obstetrics, 2d edition, I have 
 related the circumstances attending the practice of a physician of 
 Philadelphia, who, in one of our epidemic seasons, lost a consider- 
 able number of women in childbed. I beg to refer you to that 
 page, where you will see how he lost one of the number, whom 
 he did not visit until she was advanced so far in the disorder, that 
 upon the first inspection he pronounced her case hopeless. This 
 case swelled his list equally with the first one he saw, to which 
 it is not possible that h e should have communicated the poison. 
 
104 PUERPERAL FEVER. 
 
 His patients were scattered over a great superficies of the city 
 and districts, some of them being more than two miles from 
 others. At that time, many women were attacked, in various parts 
 of Philadelphia, as well as in the State of Pennsylvania ; yet, so 
 far as has come to my knowledge, no other medical gentleman 
 happened to encounter such a great number of childbed fever 
 cases as he did. I visited in consultation with him some of the 
 very worst of the cases, and touched the patients, and was as liable 
 to imbibe, or to be clothed with the effluvia from their bodies as 
 he was; nevertheless, I did not carry any poison, or other cause of 
 disease, to any patient of mine ; and if not I, then' how should he 
 become capable of doing so ? He is a gentleman who is scrupu- 
 lously careful of his personal appearance, of great experience as 
 a practitioner, and well informed as to modern opinions on the 
 contagion of childbed fever. Still, those of you who are contagion- 
 ists will say that he carried the poison from house to house ; and 
 if so, then you ought to give some rationale of the fact. Did he 
 carry it on his hands ? But a gentleman's hands- are clean. Did 
 he carry a nebula or halo about him ? Then why not I also ? 
 If the nebula adhered to his clothing, it might as well have ad- 
 hered to mine. 
 
 174. What will you say, young gentlemen, of the experience 
 of my friend, Dr. D. Butter, formerly of Philadelphia, but now of 
 the city of Chicago, who passed through terrible scenes here in 
 an epidemic of childbed fever some years ago, when he had a most 
 extensive midwifery practice in town and country — I pray you, 
 refer to my Letters to the Class, 3d edit. p. 591, for what I have 
 there related on this subject. During that sad time, I saw several 
 fatal cases with him, in consultation ; and, though he seemed to 
 be tracked by the cause of the disease, to judge by the numerous 
 attacks of it in his lying-in patients, I was not tracked by it ; I 
 took no precaution, except such as every decent man should be 
 supposed always to take; yet I never did carry the disease from 
 his cases to any house where I visited lying-in women. But he 
 was charged with being a carrier of contagion. How could he 
 carry the cause ? What was the cause — was it some oozone that 
 stuck to his hands or coat ? Was it a nebula, a halo, or an efflu- 
 vium, or a miasm that mixed with the hairs of his head, or the 
 woollen or cotton fibres of his dress ; or an exhalation from his 
 
105 
 
 skin, or a halitus from his lungs, like the fiery breath of Cacus ? 
 and can you say of him, as Virgil sings ? — 
 
 " Faucibus ingentein fumum, mirabile dictu, 
 Eyoniit?"' 
 
 iExEiD, Lib. viii. p. 252. 
 
 175. Come, now ; was not such a poison more sticky than bird- 
 lime, seeing that Dr. Eutter, worn out with fatigue, and wounded 
 in spirit by his cares for the unfortunate victims of an epidemic 
 disease, left the city for the purpose of regaining some strength, 
 and to escape from the repetition of such disheartening labors, and 
 that even a quarantine could not liberate him from this poisoned 
 cloud ! One might hope it would have been blown away by the 
 wind, or that it would have evaporated, or become too dilute to 
 kill, after a ride of seventy miles, and an absence of ten days ! 
 But it happened, after this rustication of ten days, at a distance 
 of thirty-five miles from the city, that your birdlime, or cloud, 
 still adhered to him, as you contagionists would say. And more 
 than that, he could not even wash it away, or shave it off; for, 
 upon coming back to the city and to his professional toil, before 
 he engaged in practice again, he caused his head to be close 
 shaved ; he entered a warm bath, and washed himself clean ; he pro- 
 cured a new wig, new clothes, new hat, new gloves, 
 and new boots. He did not touch anything he had worn, 
 and took the precaution even to leave his pencil at home, and 
 his watch. "Well, what do you think happened next ? He went 
 out to attend a lady in labor, who had a favorable parturition ; 
 yet was next day assailed by a horrible childbed fever, of which 
 she died, in spite of all his efforts, and mine, to help him ; for he 
 called me in consultation immediately after being himself sum- 
 moned to her chamber. I know that that lady died with perito- 
 nitis. I was a great deal with her in the illness ; but she did 
 not poison me, nor my clothes ; for, though I went on with my 
 practice, I poisoned nobody, and made nobody have even so much 
 as a finger ache ! 
 
 176. Dr. Butter repeated this attempt at personal disinfection at 
 a subsequent period, which was two years later, and with the same 
 ill success. The gentleman was much and disparagingly spoken 
 of on account of the above-mentioned events in his practice, which 
 I cannot but regard as both cruel and unjust, particularly as his 
 
106 PUERPERAL FEVER. 
 
 success in the treatment was most brilliant ; for during the epi- 
 demic he had charge of seventy cases, of which he lost only 
 eighteen, and I know not the man who can boast of a higher 
 triumph of his art of healing in this malady. 
 
 One of the most decided of contagionists was Dr. Douglas, of 
 Dublin. He carried his doctrine very far, for he supposes that 
 the contagion is so virulent that it may at times affect even 
 virgins. His paper was published in Dublin Hosp. Reports, vol. 
 iii. p. 144, and you may read in his "Report" that, "when puer- 
 peral fever is epidemic, I consider it really contagious, but, for the 
 most part, only to lying-in women ;" yet he thinks that women 
 pregnant or nursing, and even some who have been several 
 months confined, and even unmarried women, "at particular 
 periods," might be liable. 
 
 177. That estimable physician, the late Dr. Gooch, of London, 
 whose character and talents I shall never cease to admire, was 
 a most firm believer in the contagion of puerperal fever, as you 
 shall find by reading his Account of some of the most important Dis- 
 eases of Women. Though an admirable writer, a most learned man, 
 and judicious practitioner, he appears to me to have looked into 
 this subject with a mind so prejudiced, that anything and every- 
 thing coming in his way to illustrate or enforce it was seized upon 
 with an avidity more suitable to a g6be~mouche than to a person 
 of his intellectual rank. At p. 75, speaking of the frequent oc- 
 currence of cases in the practice of particular individuals, he says : 
 " One instance of this kind was very remarkable ; a general prac- 
 titioner, in large midwifery practice, lost so many patients from 
 puerperal fever, that he determined to deliver no more for some 
 time, but that his partner should attend in his place. This plan 
 was pursued for one month, during which not a case of the dis- 
 ease occurred in their practice. The elder practitioner being then 
 sufficiently recovered, returned to his practice ; but the first pa- 
 tient he attended was attacked by the disease and died. A 
 physician who met him in consultation soon afterwards, about a 
 case of a different kind, and who knew nothing of his misfortune, 
 asked him if puerperal fever was at all prevalent in his neighbor- 
 hood; on which he burst into tears, and related the above circum- 
 stances." Now it is evident that good Dr. Gooch states this inci- 
 dent as confirmatory of his views concerning contagion ; and to 
 
GOOCH — ARMSTRONG — JOERG. 107 
 
 render the inference the stronger, gives the touching picture of the 
 physician's grief; but surely the poor man's tears do not 
 prove the contagion to have been carried by him, after a quarantine 
 of thirty days. Or does Dr. Grooch hint that the "general practi- 
 tioner" was himself a generator of the poison ? If he was not a 
 diseased man, and capable of generating the miasm in his own 
 economy, what was it that he had " sufficiently recovered" from ? 
 Had he recovered of his nebula, his halo, his ingentem fumum ? 
 Men are said sometimes to be under a cloud; but I know not 
 how a man is to recover from his childbed fever cloud or nimbus. 
 
 178. Facts and Observations relative to the fever called Puer- 
 peral, by John Armstrong, M. D., is a work of great merit and 
 name. This gentleman saw the epidemic cases at Sunderland, in 
 the year 1818. At p. 171 (Barrington and Haswell's edition), 
 he refers to Gordon's sentiments, and proceeds : " And I am now 
 well convinced that when puerperal fever is once generated, there 
 is almost always cause to apprehend its being communicated to 
 other puerperal women, especially by accoucheurs and nurses who 
 have previously waited on affected persons." Dr. Armstrong 
 does not argue the question, but gives us purely and simply his 
 own belief. I request for Dr. Armstrong's opinion your most re- 
 spectful deference ; but I at the same time beg you to remember, 
 that there is a wide difference between belief and knowledge. 
 There is great risk, in studying any book written by such a man 
 as Dr. Armstrong, that you should take his opinions for facts, and 
 believe merely because he believed thus or so. 
 
 Professor Jorg (sec. 747, p. 702 of his Treatise on Diseases of 
 Women) says of epidemic childbed fever, that it prevails with 
 greatest virulency in crowded hospitals, breaking out without any 
 of the causes he had before been explaining. Contagion, accord- 
 ing to him, occurs only under such circumstances as these, to 
 maintain the disorder, and the best and strongest health affords 
 no security against its attacks. 
 
 I advise you to read A Treatise on Puerperal Fever, &c, by Wm. 
 Hey, Esq. This gentleman saw the epidemic cases at Leeds from 
 1809 to 1812. He was a very careful and conscientious writer, 
 and judicious practitioner, who, being fully aware of prevailing 
 opinions on its contagiousness, gave his attention to the evidences 
 arising in his own practice. Dr. Hey is certainly to be classed 
 among those who reject the doctrine. 
 
108 
 
 PUERPERAL FEVER. 
 
 179. Having not the least wish to persuade you to be of my 
 opinion, by any other means than those connected with expositions 
 of truth on the subject, I ought, while defending my own senti- 
 ments, to show you the opinions of others of an opposite kind. 
 Among the most considerable advocates of contagion was Dr. 
 John Eoberton, of Manchester, England, author of Essays and 
 Notes on the Physiology and Diseases of Women, and on Practical 
 Midwifery, Lond. 1851. This writer, at page 439, tells us that 
 the Medical officers of the Lying-in charity of Manchester met, 
 January 4, 1851, in consequence of a great mortality in the pre- 
 ceding four weeks, in the practice of a certain woman, who was 
 one of the twenty-five midwives belonging to the establishment. 
 That Charity usually had in charge about three hundred and 
 eighty labors per month, or four thousand five hundred and 
 ninety per annum. 
 
 180. On the 4th of December, 1850, the said midwife, Mrs. x, 
 delivered a woman, who soon afterwards died ; and this is the 
 first fact in the statement of the history of the epidemic; and it 
 should be observed that nothing is said in relation to the cause 
 of the first woman's attack. Mrs. cc's books, upon examination, 
 showed that she had delivered in 
 
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eobekton's epidemic. 109 
 
 181. All these cases of childbed fever, sixteen in number, more 
 than half of all the women delivered by Mrs. x, proved fatal ; 
 which excited the feeling of alarm, and led to the meeting of the 
 officers. The other twenty-four mid wives of the Charity, who 
 were continually crossing Mrs. x in their routes of practice, met 
 not with a single case, though about ninety women per week 
 were brought to bed by them. Dr. Eoberton says : "The fact that 
 sixteen fatal cases of puerperal fever occurred in one month, in the 
 practice of a single midwife, while the patients of the other mid- 
 wives were exempt from attacks of the disease, leads to the con- 
 clusion that the midwife was the means of communication (I take 
 not upon myself to say in what manner) from one woman to 
 another, from one affected with the fever to another in health." 
 
 The author proceeds to say " That, besides being infectious, 
 that is, capable of being conveyed in some tangible medium from 
 one woman to another, this disease is propagated by a cause of a 
 more general kind, probably existing in the atmosphere after fever 
 has prevailed for some time in a locality, cannot be doubted." 
 
 Hear him again: "A short time after the meeting (January 4), 
 the puerperal fever, among the patients of the other midwives a s 
 well as in private practice, began to appear in various 
 parts of the town. It never prevailed more generally, nor per- 
 haps more fatally i n Manchester. But about the beginning of June 
 it had disappeared." 
 
 182. These accounts, contained in Dr. Eoberton's book, have 
 been greatly relied upon as not evidence merely, but as proof, 
 that the disease was transmitted by the unhappy midwife, Mrs. x; 
 and one ought to infer that if the accusation against her as a peri- 
 patetic pestilence, or "private pestilence," could be made good, 
 the whole epidemic, with all its terrors and fatalities, might be 
 charged upon that miserable woman, as fruits of her power to 
 poison through her Cacus-breath, her steeped hands, or her halo 
 of miasm. 
 
 183. Dr. Eoberton enjoys an enviable reputation as physician 
 and writer, and I hope that there are few persons more ready than 
 I to acknowledge his great merits as a member of our Class. Yet 
 I cannot escape the conviction that all this relation concerning the 
 Charity midwife is an unintentional wresting or distortion of the 
 
110 PUERPERAL FEVER. 
 
 pathogenic truth, of the matter. Is it improbable, to say the least, 
 that he had no better reason to accuse Mrs. x of poisoning the 
 third than the first patient, of December 4, 1850? She could not 
 have poisoned No. 1, because she was not yet herself poisoned. 
 She did not poison No. 2, nor No. 7, nor No. 12, nor No. 13, nor 
 No. 15. If it was the fault of Mrs. x to establish the infection 
 "in a locality," so as to give it power to be contagious when "the 
 fever had prevailed for some time in a locality," then Mrs. x 
 was the real dispenser of the cause of the Manchester epidemic; for 
 if that poor woman had not been in practice, the first sixteen cases 
 would not have appeared. She spread abroad the contagion 
 until it became contagious. Mrs. x was deemed so dangerous 
 that she was suspended of her functions and sent out of town. Yet 
 about the first week in January (there had been sixteen 
 cases) it had got among all the people, even in private practice. 
 What a very concentrated nebula (multo amictu) must it have been, 
 that clung around the poor woman's farthingale ! 
 
 184. It is much to be regretted that Dr. Eoberton did not give 
 us some clear notions relative to the amount of the fatalities of this 
 bad epidemic, instead of merely saying it "never prevailed" more 
 extensively or fatally in Manchester ; for we should be better able 
 to come to a conclusion as to contagion, or no contagion, if we 
 could know the number of the victims and the time required to 
 destroy them. 
 
 185. The Ninth Annual Report of the Registrar- General of Births, 
 Deaths, and Marriages in England, shows, p. 74, that in 1846 there 
 were born in Manchester 8,279 children, which may be assumed 
 as near the number for 1851. Now, as the twenty-five midwives 
 of the Charity had about 380 labors per month, they would have 
 4,560 labors in a whole year. Mrs. x lost sixteen women in 
 one month. The epidemic lasted for six months, and was never 
 more extensive and " fatal in Manchester." It had got, by the 
 first days of January, among the other twenty -four midwives, and 
 even into the walks of private practice. ■ There must have been 
 born 2,280 children in the six months of its reign, whose mothers 
 should have been exposed to the virulent poison ! How many of 
 these did it really affect? This question cannot be answered. 
 Yet if we take Mrs. x*s results as . the basis, we may conclude 
 
EOBERTON" — CHURCHILL. Ill 
 
 *that many hundreds of women were seized and destroyed ; for, as 
 she lost sixteen out of thirty cases, the other twenty-four women 
 may have had an equal number, which would give us 384 deaths 
 in that epidemic. I trust, however, that not above one hundred 
 lying-in women died. 
 
 186. If the whole number of births at Manchester was 8,279 
 per annum, there were born in the epidemic reign 4,189 children ; 
 and if, of all those mothers, only one hundred died with childbed 
 fever, or even if 384 of them perished with it in a vast and crowded 
 population, many of them miserably poor and ill fed, how hard 
 must it be to prove that contagion had anything to do with the 
 matter ? How hard a thing it is to come to such a result, after a 
 dispassionate inquiry, I now leave you to judge. 
 
 187. The vol. of the Syd. Soc, 1849, contains Dr. Fleetwood 
 Churchill's Historical Sketch, at p. 41 of which, that gentleman 
 writes, that "The evidence and proofs thus adduced, are of ex- 
 treme importance ; and I fear we must conclude, however reluct- 
 antly, in favor, not merely of the contagiousness of puerperal fever, 
 but of the possibility of its contagion being carried by an inter- 
 mediate party. This makes the practice of midwifery doubly 
 distressing during the prevalence of an epidemic, and ought 
 deeply to impress us with the necessity of the utmost care and 
 caution." 
 
 188. Dr. Fleetwood Churchill has referred to Alex. Gordon's 
 cases ; to Gooch's instances ; to the cases at Sunderland, where 40 
 out of 53 persons came into the care of one single surgeon ; to 
 Mr. Roberton's examples, as above ; Dr. Pierson of Salem ; to Dr. 
 Condie's belief; and to Peddie, Beecroft, Copland, and Campbell. 
 As all these instances put together do not confirm, or even 
 strengthen the instance given of Dr. Roberton's nurse, Mrs. x, 
 I shall not load my book with them. You can, if you please, 
 explore these evidences, called by Dr. Churchill proofs, at your 
 leisure, and found your matured opinions upon the fullest and 
 most searching inquiry. I will make, however, one remark in 
 connection with what Dr. Churchill, and others, have said about 
 the "utmost care and caution," and it is this: If obstetricians do, 
 in fact, carry the poison of childbed fever with them, there is 
 really, it appears to me, only one step for them to take, and that 
 
112 PUERPEKAL FEVER. 
 
 is, to abandon the study and practice of Midwifery altogether. It 
 is idle to make a rule, as some scribblers propose, of desisting 
 from practice for a week, or a month. There can be no use in a 
 quarantine, when the law of the contagion is wholly unknown ; 
 and if a physician is to have 12 cases per annum, one breaking 
 out on the first day of each month, to quarantine him for 30 days 
 each, he will be a person of but little use to the community as a 
 practising accoucheur. It would be better to quit at once and 
 forever, and leave the women to take care of themselves, or refer 
 their wants to the Shiphrahs and Puahs, who, after all, might 
 haply turn out to be veritable Mrs. cc's, or gentlemen-pestilences, 
 and so develop an epidemic as fatal and general as that of Man- 
 chester in 1851. 
 
 189. Most assuredly, could I bat once bring myself to believe 
 in the contagion of childbed fever, I could never afterwards be 
 induced to practise my Art. All the malignant assaults on us in 
 the volume of Elizabeth Mhell, and all the objurgations uttered 
 against us by the good old priest, spoken of by Dionis, Traite ge- 
 nerate des Ace, Paris, 1724, p. 427, could not so much influence 
 my conduct, in this regard, as a momentary doubt of the trans- 
 ferability of this mortal disease. I utterly reject and deny it ; and, 
 of course, I shall not be distressed because two very young gen- 
 tlemen say, "We think the contagiousness," or, to use the more 
 explicit term used by Dr. Christison, the " communicability" " of 
 childbed fever, in all its forms, is a fact established on the most 
 irrefragable evidence ; so much so, that it would now be almost 
 criminal for any practitioner to act on the opposite assumption." 
 Vide McClintock and Hardy, Pract. Observations, p. 29. To all 
 which I have only to add, Voild comme Von ecrit Vhistoire ! What 
 is the precise difference between being "almost criminal" and very 
 criminal indeed ? 
 
 190. But alas ! gentlemen, nurses are as fell in their poisoning 
 qualifications and nature, and are as prone to become "private 
 pestilences" as we abused physicians ; and as the women will 
 require some aids, some skill, some science in their many troubles, 
 what are they to do ? Twenty -five centuries have hardly served 
 to lift our Obstetricy from the depths of barbarism and ignorance, 
 into that somewhat dawning light it now enjoys, as I have 
 
IS CONTAGION" A TRUTH? 113 
 
 already shown in these Letters. And shall we now go back 
 again to the capabilities of a Celsus, or an Avicenna, or an Aven- 
 zoar? Or shall we rather disregard the jejune and fizenless 
 dreamings of sophomore writers, who thunder forth denuncia- 
 tions, and would mark, if they might, with a black and inefface- 
 able spot, the hard-won reputation of every physician, who, in 
 the Providence of God, is called upon to contend with the rage of 
 one of the most destructive of epidemics, and pay an ungrateful 
 service; indispensable to the victims it is allowed to attack, and 
 in the propagation of which they have no more to do, than with 
 the propagation of cholera from Jessore to San Francisco, and from 
 Mauritius to St. Petersburg. 
 
 191. Let us then decide — I have long ago decided for myself to go 
 on. "Will you go on, or will you stop here ? Is contagion a truth ? 
 Then, for heaven's sweet sake, I implore you not to lay your 
 impoisoned hands upon her who is committed to your science 
 and skill and charitable goodness, only for her safety and comfort, 
 and not that you should, after collecting fees, soon return her to 
 her friends a putrid corpse. What a horrid idea ! 
 
 C. D. M. 
 
LETTER VII 
 
 UNAVOIDABLE — TABLE OF EPIDEMICS FROM 1652 TO 1853 — IT 
 IS NOT A FEVER, BUT A PHLEGMASIA— FEVER, WHAT IS IT? — 
 A GROUP OF VARIOUS INFLAMMATIONS, DIFFERING IN CHA- 
 RACTER — OPINIONS OF VARIOUS AUTHORS AS TO THE CAUSE — 
 DR. FERGUSON, CHURCHILL, DANCE, TONNELLE, CH. WHITE, TON- 
 NELLE'S DISSECTIONS — CASE BY AUTHOR — GORDON'S WORK — 
 CASE BY AUTHOR— REMARKS ON THE SO-CALLED VITIATION OF 
 THE BLOOD. 
 
 192. Childbed fever, which is always one and the same, to wit, 
 a phlegmasia, may occur either as a sporadic or as an epidemic dis- 
 ease. For example, a woman in labor may suffer some contusion 
 or laceration of important parts ; or she may have suffered, to a 
 great degree, from fatigue, or terror ; or she may be affected by 
 cold damp, or by improper diet or drinks ; or she may have been 
 previously sick in such a way as, after labor, to develop within 
 her frame that train of morbid conditions which constitutes a 
 childbed fever. Such an event occurring now and then, but 
 rarely, would be denominated a sporadic childbed fever, or puer- 
 peral fever. There is an almost infinite number of contingencies 
 in the state of a woman's general health, that might, after the 
 completion of her labor, cause the rise, and insure the rapid 
 destructive progress of inflammation, either in the organs of 
 generation, or, in the serous lining of them, within the pelvis. 
 Any of them, thus acting, might develop a childbed fever, which 
 you would characterize as a sporadic case of the disorder. It is 
 admitted that many towns, cities, districts, and even whole coun- 
 tries are observed to present, for a series of years, only rarely, 
 
SPOEADIC — EPIDEMIC. 115 
 
 cases of such sporadic childbed fever; and the causes of the 
 attacks, in such instances, being for the most part easily to be 
 ascertained, the cases may be considered as accidental cases. 
 
 193. On the other hand, it shall happen that women, confined 
 in any. town, city, district, or country, shall be observed to be, 
 very generally, assailed by a disease, whose physical charac- 
 teristics do not materially differ from those of the sporadic or 
 accidental cases, just mentioned; and when we come to inquire 
 into the causes of these numerous, or almost universal attacks, 
 we can find none palpable, and so are obliged to fall back on 
 what we think or know of contagion, infection, malaria, or epi- 
 demy, in order to satisfy our cravings after knowledge or expla- 
 nation. Suck cases are cases of epidemic childbed fever, and, as 
 such, ought not to be looked on as accidental, like the first-named 
 class, but rather as unavoidable cases. 
 
 194. It is a very easy thing for a man to understand how it 
 may happen, that puerperal women should be attacked with 
 destructive inflammation in the pelvic and abdominal viscera, in 
 consequence of the different lesions I just now mentioned ; and one 
 would naturally expect that a violent endo-metritis, or a rapid 
 uterine phlebitis, or an extensive peritoneal inflammation, should 
 soon place the woman's life in peril, or even hurry her, after a 
 very short course of such inflammation, to the grave ; because the 
 lying-in state is one that readily exposes to the assault of inflam- 
 mation. You would not, therefore, feel greatly surprised to find, 
 now and then, that a person, whom you had attended in labor, 
 should be seized with and die from the effects of such an inflam- 
 mation ; and such instances must be met with by every person 
 considerably employed in the practice of Midwifery; being 
 accidents that must, and will attend the trials of parturition. 
 They have been observed in all ages and nations, and must be 
 met with hereafter, as long as the nature of woman and the phy- 
 siological laws of parturition remain unchanged. 
 
 195. But, when the disorder becomes epidemical, seizing upon 
 a considerable part, or all the women who happen to be brought 
 to bed within its reign in a certain village, or hospital, or country, 
 then the mind becomes astonished and bewildered, and hastens to 
 lay hold upon any probable or possible rationale of events so 
 
116 PUERPERAL FEVER. 
 
 distressing that they not only render the practitioner himself 
 unhappy, but excite a great inquietude throughout the largest 
 communities. 
 
 196. Childbed fever becoming epidemical may prevail so exten- 
 sively as to implicate almost all the women who are brought to 
 bed under its reign; or the force of the cause may be so slight 
 as to produce illness in only here and there an unfrequent exam- 
 ple, so that the epidemic cases may be very rife or not. Hence 
 it will occasionally be a difficult thing for you to say whether the 
 cases you meet with should be called sporadic or epidemic ones ; 
 and the means by which you will at length determine the point, 
 will have relation to the frequency rather than to the phenomena 
 of the attacks. For, unless I greatly misinterpret both history and 
 my own experience, there is little difference in the manifestations 
 in the sporadic and epidemic forms. Under certain circumstances, 
 however, you will find the epidemic cases more difficult to cure 
 than the accidental ones. Dr. J. C. Douglass, in Dublin Hospital 
 Reports, vol. iii. p. 142, thinks that not more than one in six of 
 sporadic cases will be found to prove fatal, " whereas, in the truly 
 epidemic fever, hardly one-half of those absolutely attacked 
 recover." But I must defer my remarks, on this point, to a later 
 page. 
 
 197. Ozanam, in his history of epidemics, gives us an account 
 of different dates and places where this malady has been observed; 
 so likewise does Dr. Meissner ; and F. Churchill, in his Midwifery, 
 has made out a table of the instances. From these different sources 
 I have arranged the subjoined table: — 
 
 What T have derived from Ozanam is marked with the letter 
 ; from Meissner, with the letter M ; from Churchill, with the 
 letters Ch. 
 
 TABLE OF EPIDEMIC OCCURRENCE OF 
 CHILDBED FEYER. 
 
 A. D. PLACE OF PUBLICATION. AUTHOR. INITIAL. 
 
 1652. Leipsic. 
 
 Welch. 
 
 0. 
 
 1664. Paris. 
 
 Peu. 
 
 Ch, 
 
 16*72. Copenhagen. 
 
 T. Bartholin. 
 
 0. 
 
 1*723. Frankfort and Leipsic. 
 
 F. Hoffman. 
 
 0. 
 
 1U6. Paris. 
 
 De Jussieu, &c. 
 
 0. 
 
TABLE OF EPIDEMICS. 
 
 117 
 
 A. "D. PLACE OF PUBLICATION. 
 
 AUTHOR. 
 
 INITIAL. 
 
 1746. London. 
 
 J. Clark. 
 
 M. 
 
 1750. Lyons, Paris. 
 
 Doublet, Pouteau. 
 
 Ch. 
 
 1760. Aberdeen. 
 
 Gordon. 
 
 Ch. 
 
 1760. London. 
 
 White. 
 
 Ch. 
 
 1764. Dublin. 
 
 J. Clarke. 
 
 M. 
 
 1765. London, Derbyshire. 
 
 Moore, Butter. 
 
 M. 
 
 1767. Xormandy and Dublin. 
 
 J. Clarke. 
 
 M. Ch. 
 
 1769. London. 
 
 Leake. 
 
 O. 
 
 1770. London. 
 
 Leake. 
 
 Ch. 
 
 1770. Yienna. 
 
 Fauken. 
 
 0. 
 
 1771. London. 
 
 White. 
 
 Ch. 
 
 1773. Edinburgh. 
 
 Young. 
 
 Ch. 
 
 1774. Paris. 
 
 Doulcet. 
 
 0. 
 
 1774—1781. Paris. 
 
 Doulcet, Fenon. 
 
 Ch. 0. 
 
 1774. London, Dublin. 
 
 Moore, Collins. 
 
 M. Ch. 
 
 1776. Yienna, 
 
 Stoll and Finke. 
 
 0. 
 
 1782. Paris. 
 
 Doulcet. 
 
 Ch. 
 
 1783. London. 
 
 Osborn. 
 
 Ch. 
 
 1786. Lombardy. 
 
 Cerri, Tenon. 
 
 0. Ch. 
 
 1787. Gottingen, Dublin. 
 
 Osiander, Collins. 
 
 M. Ch. 
 
 1788. London, Dublin. 
 
 J. Clarke, Collins. 
 
 Ch. M. 
 
 1789—91. Aberdeen. 
 
 Gordon. 
 
 Ch. 
 
 1792. Copenhagen. 
 
 Rink. 
 
 M. 
 
 1795. Yienna, 
 
 Jseger. 
 
 Ch. 
 
 1803—13. Dublin. 
 
 Collins, Douglass. 
 
 Ch. 
 
 1808. Barnsley. 
 
 Hey, Naegelle. 
 
 Ch. M. 
 
 1812—13. Leeds, Sunderland. 
 
 Hey, Armstrong. 
 
 Ch. 
 
 1814—15. Edinburgh. 
 
 Hamilton. 
 
 Ch. 
 
 1814 — 15. Northumberland, Pa. 
 
 S. Jackson. 
 
 M. 
 
 1815. Munich. 
 
 F. Boyer. 
 
 M. 
 
 1817 — 18. Pennsylvania. 
 
 Dewees. 
 
 Ch. 
 
 1818. Wurtsburg. 
 
 Schloss. 
 
 M. 
 
 1818 — 19. Bamburg, Dresden, Munich, 
 
 
 
 Prague, Yienna. 
 
 Eisenmann. 
 
 
 1818—23. Dublin. 
 
 Collins. 
 
 Ch. 
 
 1821—22. Glasgow, Sterling. 
 
 Campbell. 
 
 Ch. 
 
 1823. Yienna. 
 
 Leppich. 
 
 M. 
 
 1825. Hanover. 
 
 Dommes. 
 
 M. 
 
 1826. Dublin, Berlin. 
 
 Collins, Neumann. 
 
 M. 
 
 1827. Barmen, Neuenhaus, Sunderland. 
 
 
 M. 
 
 1828—29. London. 
 
 Gooch, Ferguson. 
 
 Ch. 
 
118 PUERPERAL FEVER. 
 
 A. D. 
 
 PLACE OF PUBLICATION. 
 
 AUTHOR. 
 
 INITIAL. 
 
 1829. 
 
 Paris Maternite. 
 
 Tonnelle. 
 
 Ch. 
 
 1830. 
 
 Giessen. 
 
 Bitgen. 
 
 M. 
 
 1833. 
 
 Yienna. 
 
 Bartsch. 
 
 Ch. 
 
 1833. 
 
 Prague. 
 
 Quadrat. 
 
 M. 
 
 1834. 
 
 Paris. 
 
 Bouchut. 
 
 M. 
 
 1835. 
 
 Yienna, Dublin. 
 
 Klein, Beatty. 
 
 M. Ch. 
 
 1838. 
 
 Stockholm, Paris. 
 
 Elliot, Willmer. 
 
 M. 
 
 1839. 
 
 Wangen. 
 
 Zeugerle. 
 
 M. 
 
 1843. 
 
 Paris. 
 
 Bidault, Arnaut. 
 
 M. 
 
 1845. 
 
 Dublin. 
 
 McClintock. 
 
 M. 
 
 1853. 
 
 Philadelphia. 
 
 
 C. D. M. 
 
 198. Looking at this table, the question will properly present 
 itself as to whether the examples set forth in it should be re- 
 garded as instances of epidemic prevalence of childbed fever, or 
 whether you should consider the occurrences as examples of 
 endemic disease; for you may prefer to discriminate between epi- 
 demic and endemic disorders. 
 
 199. It does not appear to me to be of any great importance 
 which of the conclusions you should, under the circumstances 
 adopt, for it is quite clear that the malady may break out, and 
 rage with violence in certain circumscribed spaces ; and on the 
 other hand, that it may prevail, at one and the same time, over 
 extensive districts, and even whole nations and countries, and yet 
 be ever one and the same disorder. 
 
 200. The disease, wherever it is met with, can be only one, and 
 the causes, whether endemic or epidemic, are, in all probability, 
 the same ; since, even in the accidental or truly sporadic cases, 
 the phenomena are often not different, even in violence, from those 
 of the most violent epidemic kind ; and I consider that a woman 
 dying of childbed fever from some accidental cause, as a contu- 
 sion, laceration, or chronic disease of an ovary or a Fallopian tube, 
 or the bladder of urine, passes through the same phases of morbid 
 action, as she who dies in an empested hospital ; since she gives out, 
 during the progress of the malady, the very same manifestations, 
 both as to the parts directly affected, and the affections of the 
 whole constitution. 
 
 20 1. The object of making such a table as the above, being 
 
THE DISORDER ALWAYS ONE. 119 
 
 merely to show, at one glance, that our disorder may prevail as 
 an epidemic in different years, and at different and distinct places 
 at the same time, there is no motive, perhaps, to enlarge it, which 
 it would be very easy to do, especially from the records in the 
 United States, where it has, for a considerable number of years 
 past, committed ravages in Vermont, New York, Pennsylvania, 
 Illinois, and Virginia. 
 
 202. I have heard of one small town in a northwestern State, 
 where, out of some 600 inhabitants, about 60 parturient women 
 died with it in a single epidemic. Dr. Ozanam, in his Malad. 
 Epidemiqries Contogieuses et Epizo., torn. ii. p. 280, quotes Dr. 
 Cerri, of Milan, to show that about the date of 1786, and the be- 
 ginning of 1787, an epidemic broke out in Arzaga, in Lombardy, 
 among lying-in women, in which none were spared. Dr. Wm. 
 Hunter, of London, had charge of a hospital in which, out of 32 
 women attacked, 31 died; so that you are to understand that the 
 epidemic cause, whatever it may be, is sometimes feeble, and at 
 others most comprehensive as well as most devastating; and, yet 
 that cause, strange to say, acts only on pregnant and confined 
 women ; doing no harm to all other women, or to children or 
 men ! 
 
 203. But it is time now for us to begin to inquire more soli- 
 citously into the nature of the disorder; what it is, what are its 
 seats, causes, signs, tendencies, treatment, differences; and what the 
 prophylactic measures best adapted to the management of it. 
 
 204. In a former letter (V.), I at great length exposed for you 
 the opinions of writers on the nature of the disease, and I now 
 refer you to those sections, for what I have there said. 
 
 It was not until near the close of the last century, that our peo- 
 ple began to open their eyes to the stark-staring truths revealed 
 by numerous post-mortem examinations of victims to the disorder ; 
 for, as I showed you in sections 54, 59, 71, 75, in the last century 
 they could not, or-would not see the proofs of an inflammation, 
 but only the signs of lait repandu, in the effusions and adhesions 
 left in the belly by a destructive case ; and the fact is, that, when- 
 ever they did so, they were obliged to come back again to the 
 ancient admission of Mercado, and others before him, that childbed 
 fever is an inflammation of parts contained within the abdomen 
 
120 PUERPERAL FEVER. 
 
 and pelvis, for that was the view taken of it by the old writers 
 whom I cited for you in my second letter, sections 21, 24. 
 
 205. De la Roche, who wrote an esteemed book on the subject, 
 printed in 1783, entitled it Recherches sur la Nature et le Traite- 
 ment de la Filvre Puerperale, ou Inflammation oVFntrailles des 
 Femmes Enceintes; and he says, in his second page, "Cette maladie, 
 a laquelle j'ai donne* le nom d'inflammation d'entrailles, par des 
 raisons qui seront developpe'es ci-apres, a ete nommee par les 
 Auteurs Anglais, Fievre puerperale, et regarded, par la plus 
 part d'entr'eux, comme une espece parti culiere de Fievre pu- 
 tride." But you see here that De la Roche took a better view of 
 the disorder, and, though he did not go directly to the point of 
 believing it, with Paul of iEgina, to be inflammation of the womb, 
 but inflammation of the bowels, he was much nearer the truth than 
 Doublet, Puzos, Yigarous, Selle, and the whole host of the milk- 
 men. 
 
 206. Though the discoveries made by means of those post-mor- 
 tem examinations were so clear, and so undeniable, yet all the 
 doctors have not, even to this very hour, absolutely given in, and 
 perceived and acknowledged the truth of the matter; for there are 
 still great multitudes of them, in every quarter of Christendom, 
 who persist to consider the disease as a fever, and to treat it so in 
 their therapeutical ministrations. 
 
 207. You know, however, that in all my public lectures on this 
 subject, at the College, I have ever striven to persuade you that 
 this is a grave error, which it is urgent to dissipate, if possible, 
 because of its clinical mischiefs. But what hope is there that a 
 public opinion, which has ruled and reigned over the Medical 
 mind for centuries, should be abated or changed by an argument, 
 or any number and power of them ? In my opinion, one chief 
 cause why our brethren do persist to regard this dreadful malady 
 as a fever, consists in its name; and I, myself, though most anxious 
 to see the error subverted and completely overthrown and de- 
 stroyed, am, perhaps, aiding in these letters to uphold it, in that 
 I have entitled this book Letters on Childbed Fever. 
 
 208. Mankind make use of language in order to communicate 
 their ideas, wishes, or commands. Without language the race 
 would ever remain ignorant, powerless, and barbarous. It is to 
 
WRONGLY NAMED. 121 
 
 language that they owe civilization and all its attendant blessings. 
 Without language men could not combine in society, nor effect, 
 through the power of co-operation, any of those conquests over 
 both brute and animated nature, which, whenever they are effected, 
 do result in the establishment of both the public and the private 
 weal. Words, then, are the signs of men's ideas ; and if when we 
 utter a word it excites in another's mind ideas corresponding to 
 those we would by those words express and impart, then our 
 words are the representations of our thoughts. But if words are 
 used that excite ideas different from those material ones that exist 
 in the mind of the speaker, then the words are traitors and de- 
 ceivers ; and they who hear them are misled, while those who use 
 them are equally betrayed by them. 
 
 209. The word Fever, excites a certain material idea of Zy- 
 mosis in the mind of the hearer of it. Typhus and typhoid fever, 
 yellow fever, intermittent fever, bilious remittent fever — all these 
 words excite ideas that are similar, in all who hear them, in that 
 they all comprise an idea of Zymotic affections that are always 
 signified by the word Fever. So also the word childbed 
 fever, excites a material idea in the mind. But the impression 
 varies according to the opinion taken by the hearer, of the 
 Zymotic or other nature of the disorder intended to be expressed 
 by the compound word. If one should say the word childbed 
 fever, it would be difficult for the hearer to disembarrass himself 
 of the notion of a relation of some Zymotic cause to the affection, 
 as leading to the whole train of pathologic consequences. 
 
 210. At present the question is, Is there such a thing 
 as a childbed fever? To this question I am compelled 
 to answer in the negative ; wherefore, I must consider the word 
 a false and misleading one, since it implies that the disorder is a 
 fever, when, in fact, it is not a fever, .but a phlegmasia, or pure 
 inflammation. Hence, I say, the word childbed fever is a false 
 and deceiving word, which ought to be banished from our medi- 
 cal vocabulary. But how can this be done? Who hath authority 
 to do this great thing! Assuredly not I; and I know full well, 
 there is not a man in the whole world, of influence and power 
 so great as to change the habits and convictions of society, on 
 any one subject, even the uses of a word; and of all things, none 
 
122 PUERPEKAL FEVER. 
 
 is more difficult to change than language, which goes on to be re- 
 peated from age to age, by habit, even against conviction. 
 
 211. The English language already possesses the word child- 
 bed fever, and that is the reason why I use it ; but I protest 
 against its falseness; and I now put you, who are my pupils, on 
 your guard against its deceptions, for there is no such thing as a 
 childbed fever. 
 
 212. The disease called childbed fever is: — 
 
 1. Inflammation of the Womb — Metritis. 
 
 2. " of the Uterine veins — Metro -phlebitis. 
 
 3. " of the Peritoneum — Peritonitis. 
 
 4. " of the Ovaria — Ovaritis. 
 
 5. It is all the foregoing disorders united in one case, or any 
 
 two or more of them combined together. 
 
 In a woman affected with childbed fever, the disorder may 
 consist in Endo-metritis; that is to say, in inflammation of the 
 inner wall of the womb, or its inner layer, if one might so con- 
 sider it; or in an Exo-metritis, wherein the outer stratum is 
 affected ; or, the whole mass of the uterus may be the seat of an 
 inflammation that shall soften it in such a way as to allow you, 
 in examining the organ after death, to push your finger through 
 the texture of it in any direction, the substance of the tissues 
 being, by the power of the inflammation, reduced to a state of 
 pulp-like ramollescence that, so to speak, rots it, or destroys the 
 cohesion of its tissues. 
 
 213. In some of the instances of childbed fever, the womb 
 itself seems wholly to escape, while its larger veins are observed 
 to be the sole seats of the inflammatory action, whose post-mortem 
 results are detected as purulent deposit within the tubes of those 
 veins, whose canals are thus converted into abscesses filled with 
 pus: an abscess is a circumscribed cavity containing pus, and 
 these vein-inflammations are among the most fatal of the childbed 
 fever forms, principally because of the insidious nature of the 
 attacks. In these examples of metro-phlebitis, the inflammation 
 often proceeds very far, even to an incurable stage, before the 
 woman feels any pain or becomes the subject of the least consti- 
 tutional disturbance; so that, when the constitutional irritation 
 has begun to manifest itself, or the pain to be felt, it is already 
 
WHAT IT IS. , 123 
 
 too late to interpose with any good effect, and the patient must 
 be lost. But, of this hereafter. 
 
 214. Childbed fever often occurs, and passes through all its 
 stages as a simple peritonitis; that is to say, the inflammation is 
 limited to the serous lining of the pelvis and abdomen, the womb 
 and ovaria wholly escaping from any serious lesion, so that, 
 when the remains of the patient are examined after death, no traces 
 of disease are to be found, except those referable to the peritoneum 
 itself; but this is not always the case. 
 
 215. Many of the very rapid and uncontrollable instances ex- 
 hibit, after death, the evidences of an antecedent inflammation of 
 the womb, the uterine veins, and the peritoneum also ; so that, as 
 I before said, childbed fever may be metritis, or metro-phlebitis, 
 or metro-peritonitis, or a peritonitis pure and simple, or all of 
 these" inflammations combined together in one and the same 
 individual. 
 
 216. Whenever these inflammations occur in pregnant or 
 lying-in women, then the disease is childbed fever, and it is 
 nothing else; nor are childbed fevers ever anything else, except 
 when they occur as accidents in typhus, smallpox, plague, and 
 other typhous diseases, of which they are in some instances mere 
 complications. 
 
 217. Hence, I say, a woman may be attacked with smallpox, 
 and during the existence of that disease may or may not be seized 
 with one or all of the above inflammations. In case of her Sing 
 attacked, and dying so, she would die of a complication of small- 
 pox and childbed fever. 
 
 218. The same is true of yellow fever, of bilious, typhoid, or 
 jail or ship fever. Whatsoever disturbs the nervous and circula- 
 tory systems in a woman during the lying-in state, may or may 
 not develop the abdominal inflammations that constitute our 
 disorder. 
 
 219. Childbed fever, being inflammation of parts within the 
 abdomen or pelvis, that inflammation must begin at or within 
 some certain area. It is not known how great this incipient area 
 is, or whether, indeed, there may not be several such areas serving 
 as starting-points or radiant points, whence the phlegmasia spreads 
 i n various directions. Yet, it is most proper for you to consider 
 
124 PUERPERAL FEVER. 
 
 it as a highly probable thing, that the area of phlogosis always 
 does begin somewhere below the plane of the superior strait, or, 
 at least, upon some superficies of the genitalia interna. 
 
 220. I should be sorry that you, who are Students of my Class, 
 and whom I hold it a sacred duty to instruct according to my 
 conscientious conviction of what is both true and reasonable, as 
 well as practically useful, should here take up the idea that I am 
 speaking without due consideration, when I say that all the affec- 
 tions and accidents that can develop acute inflammation of the 
 reproductive organs in lying-in women, do, at the same time, and 
 by that very fact, tend to develop in them a childbed fever, which 
 will be simple or complicated, as the case may be. Many writers 
 j udge that we ought to exclude some of the inflammations arising 
 from accidents, as wounds, &c. &c. M. Gase is one of these, but 
 I do not coincide with his opinion. 
 
 221. Instead of rashly, and without due consideration, making 
 these asseverations, I have given much time to the examination 
 of them in many of oar best authorities, and among them, 
 Dr. Robert Ferguson's Essays on the most important Diseases of 
 Women, Part Z, Puerperal Fever. London, 1839. I may take 
 advantage of this epistolary method to say that this is perhaps 
 the " crack" English book on the subject, and that our English 
 brethren take it very much as a sort of medical Gospel in the 
 disorder, praising it in their Reviews, and referring on all occa- 
 sions to its authoritative opinions. 
 
 222. I sincerely hope and confidently trust I have in my bosom 
 no cis- Atlantic prejudices against English writers on Medicine, 
 which is a Republic, wherein all the people are equal. Yet I must 
 say I consider it the most misleading and weakest book on child- 
 bed fever that has appeared since 1795. Its whole basis lies upon 
 an hypothetical dogma, closely allied to the milk-dogma, that child- 
 bed fever depends upon avitiated state of the blood; 
 which is the reason why I look upon it as being tainted with the 
 ghostly odor of lait repandu, erremn,ent de lait, or milk metastasis, of 
 the old French milk-dogma. The three following propositions 
 from his p. 83, embody Dr. Ferguson's views of the source and 
 nature of puerperal fever : — 
 
 " I. The phenomena of puerperal fever originate in a vitia- 
 tion of the fluids. 
 
VARIOUS OPINIONS OF IT. 125 
 
 " II. The causes which are capable of vitiating the fluids are 
 
 particularly rife after childbirth. 
 " III. The various forms of puerperal fever depend on this 
 one cause, and may readily be deduced from it." At p. 81, 
 he goes on to say : — 
 "The cause, therefore, of puerperal fever is, I think, simply a 
 vitiation of the blood, which cause is demonstrably sufficient to 
 produce all the phenomena ; that phlebitis, or peritonitis, or metro- 
 peritonitis, are only secondary effects of this one cause." 
 
 223. This is Dr. Ferguson's doctrine, in his own words, in a 
 nutshell ; and we will now let it stand so until a better occasion 
 to discuss it shall arise, for Dr. Ferguson is not the only writer 
 to attribute our malady to primary alterations of the fluids. 
 
 224. Dr. Fleetwood Churchill, in his proem to the Sydenham So- 
 ciety's vol., p. 34, says : "I must honestly avow that, while I admit 
 the existence of local disease, I do think that epidemic 
 puerperal fever is something more than that, al- 
 though I may not be able to define exactly what it is." What do 
 you think is this "something more?" 
 
 225. Dr. Ch. White, of Manchester, Syd. vol., p. 203, says: "It 
 does not appear that this disorder can be ascribed 
 to simple inflammation. The patients complain chiefly 
 of a tension, soreness, and tenderness of the belly, and are seldom 
 affected with those excruciating pains, which generally attend 
 common inflammation of the bowels; but it evidently manifests 
 itself to be of the putrid kind occasioned by human effluvia, 
 by accumulations of acrid putrid bile, and ofaputrid col- 
 luvies through the whole intestinal canal, and organs of 
 generation, and is a malignant fever of the same genus 
 as the jail or hospital feve r." But why multiply citations ? 
 These are enough to show that the good authors disagree with 
 the proposition I have laid before you, as to childbed fever, viz : 
 that it is a phlegmasia and not a fever : still, the admirable paper 
 of Mr. Dance, on Phlebitis, which you can see in the eighteenth 
 and nineteenth volumes of the Archives Generates de Medecine, 
 having thrown more light on the phlebi tic form of childbed fevers 
 than anything before or since his time, I intend to cite for you so 
 freely from him as to show you very fully what were the views 
 he took of the cases. 
 
126 PUERPERAL FEVER. 
 
 The valuable papers of Mr. Dance, are in the Archives Gene- 
 rales, vols, xviii. and xix. for 1828 and 1829, and bear the follow- 
 ing title : u De la phlebite uterine et de la phlebite en general, considerees 
 principalement sous le rapport de leurs causes et de leurs complications. 
 Par M. Dance, agrege a la Facultd de Medecine de Paris." The 
 results obtained and clearly explained by M. Dance, are so in- 
 structive, as well as so important in their applications to clinical 
 practice, that I should be most happy to transfer every one of his " 
 remarks to these pages, were it consistent with the design of these 
 Letters to do so; but, under the circumstances, I am compelled 
 to restrain this desire, and only to say that M. Dance considered 
 uterine phlebitis to be one of the most dangerous, and at the 
 same time, least understood of the diseases of lying-in women. 
 Nevertheless, it had, previously to him, engaged the attention of 
 several intelligent physicians, who appear to have recognized it, 
 at about the same time, in France and in England. Among the 
 former, he particularizes M. Chaussier, Schwilgne', Eibes, and 
 Husson; and Clarke and "Wilson among the latter. Following 
 soon upon some preliminary remarks, M. D. relates, at p. 476, 
 vol. xviii., the history of a " Case, in which inflammation of the 
 veins of the womb had extended to the ovaric veins, and their 
 ramifications within the ovaries and broad ligaments, attended 
 with intense cerebral symptoms. The woman, 22 years of age, and 
 of a good constitution, entered the Hotel Dieu, May 30, 1826, so 
 delirious as to be unable to give any account of herself. It was 
 found that she had left the Maternity two days after a natural 
 labor, that occurred on the 18th of the month, and went to her 
 usual occupations. She was attacked with violent fever, and 
 afterwards with delirium; and on her being brought into hospital, 
 was found greatly disordered ; vociferations, cries, incoherent talk- 
 ing, obscenity, wild looks, brilliant conjunctivas, extreme variable- 
 ness of the features, wild laughter ; then taciturnity and apparent 
 calm; succeeded, in a moment, by renewed cries that filled the 
 entire ward. The breasts were flaccid; the lochia consisted in a 
 slight whitish and offensive oozing. The womb was felt above 
 the plane, where strong pressure gave no pain. Pulse quick 
 and frequent ; skin moist ; tongue natural. Such was the state of 
 the patient, who, without any considerable change in these ap- 
 pearances, sank and died on the nineteenth day after her delivery. 
 
DANCE. 127 
 
 At the jiost-morteyn examination, marks were observed, of pre- 
 ceding irritation of the brain, with vasc^ar engorgement ; mucous 
 membrane of the stomach of a blackish color, thickened, and a 
 little softened ; bowels natural ; womb from five to six inches in 
 length, and with walls from six to eight lines thick. The cavity 
 of the womb was furrowed or puckered with the inequalities of 
 a grayish false membrane, that lined its surface. Beneath this 
 membrane, the substance was blackish, friable, and softened to 
 the depth of several lines. The surfaces exposed by incisions, 
 exhibited many gaping orifices of vessels, from which escaped a 
 purulent matter, upon pressure. The cavity of these vessels, any 
 of them, was lined with a thick layer of pus, almost as consistent 
 as false membrane. The substance surrounding the cut-off vessel, 
 appeared as a yellowish-brown aureole : wherever the substance 
 of the womb was incised, vessels in this condition were disco- 
 vered. The ovaries were two-thirds larger than natural, and their 
 tissue riddled with little abscesses ; but pus came, also, from their 
 veins, when incised. The Fallopian tubes and their ligaments 
 were sown with numerous small abscesses, chains of which were 
 seen. The Fimbriae were red, and composed, each, a thick mass, 
 infiltrated with pus. The two ovaric veins were transformed for 
 full half their length, into long and solid cords, within which 
 thick false membranes were observed adhering to their inner 
 walls. These appearances were not discovered in any of the 
 other veins of the subject. At p. 480, M. Dance describes the 
 orifices seen at the utero-placental disk, on the inner surface of a 
 new-delivered womb, and from which the fluid of an injection, 
 made downwards from the vena cava, readily escapes into the 
 womb's hollow. He gives an account of the appearance of them 
 presented after the detachment of the placenta, some of the 
 vessels being so open as to admit the point of the little finger ; 
 and these openings lead into the veins and sinuses of the uterus. 
 These vessels do not convey their outer coats within the sub- 
 stance or texture of the womb, but only their inner or lining 
 membrane (membrana vasorum communis — Endangium), or true 
 bloodvessel. This womb- vessel rests upon the womb-tissue, 
 which serves as its basement tissue ; thus taking the place of the 
 other coats, or ordinary basement, which, as I remarked, is left 
 outside. These sinuses and large veins, therefore, remain very 
 
128 PUERPERAL FEVER. 
 
 large after parturition, as they cannot contract, except as the in- 
 volution of the womb, ^ich constantly reduces their caliber, 
 enables them to grow gradually smaller, or more delicate. The 
 relation of Dance's 1st Case, appears to me quite suited to give 
 you very plain views of the disease, its seats, and tendencies. 
 The delirium, one of the most obvious of its symptoms, is highly 
 characteristic of phlebitis, with pyaemia. 
 
 Case 2, is at page 485. The patient died a few hours after her 
 delivery; had had fever, pain, and delirium. The alimentary 
 organs were found to be natural ; but the uterus was greatly dis- 
 ordered, and so soft as to break by bending, or by being folded. 
 The ringer could be pushed through its tissue as readily as into 
 a hepatized lung, so great was the ramollescence. The right 
 ovaric vein was inflamed, and contained pus, with coagula and 
 false membrane. The vena cava was also inflamed, and had 
 pseudo-membranous deposits on its walls, but no coagula, or fluid 
 pus. 
 
 Case 3 was that of a patient attacked, four days subsequent 
 to delivery, with rigor, headache, palpitations, fever, great de- 
 pression, hot and dry skin, and pale but moist tongue. The 
 belly was soft, and not painful. The hypogastrium, raised by 
 the underlying uterus, was salient above the pubis; epigastric 
 distress ; small and very offensive lochia. The pulse was frequent. 
 Upon the twelfth day after delivery, she was delirious, and had 
 subsultus of the mouth and tongue. Pressure on the hypogas- 
 trium gave no pain. She was sometimes delirious, and at others, 
 had wanderings. At night, a chill ; and she died in fifteen days 
 after her delivery. There was no sign of peritonitis. Outer 
 aspect of the womb, which was large, quite natural ; but the 
 inner wall exhibited a violaceous hue, and was full of holes, the 
 size of a writing-quill, containing a whitish viscid pus. 
 
 The 4th Case was one of inflamed womb-veins, and ovaric vein ; 
 the latter, throughout its entire length. There was pus in the 
 articulations of the wrists, and in the second metacarpal series. 
 There was pus in the symphisis of the pubis ; but there was no 
 peritonitis. 
 
 The 5th Case, by M. Dance, was one in which the inflammation 
 was limited to the region of the womb covered by the placenta. 
 It was attended with the usual sign — delirium. In Case 6, 
 
DANCE. 129 
 
 inflammation of the uterine veins passed onwards into the 
 ovaric and hypogastric veins. There was brown ramollescence 
 of the uterus ; numerous pus-cavities, of a peculiar appearance, 
 were seen in the lungs ; a double pleurisy ; pus in the symphysis 
 pubis ; delirium ; and death on the eighteenth day from delivery. 
 M. Dance supposes the pneumonia to have been derived from the 
 pus, transported along with the blood, into the lungs. 
 
 The 7th Case was inflammation of veins, lying within the sub- 
 stance of the uterine walls, the round ligament and right ovary, 
 and the right ovaric and hypogastric veins. There was brownish 
 ramollescence of the womb, and traces of peritonitis; pleurisy, 
 and numerous small purulent foci in the lungs. She died twenty- 
 five days after her delivery. Case 7. Uterine phlebitis, chiefly of 
 vessels in the left half of the womb, extending into the ovaric 
 vein ; slight traces of intro-pelvic peritonitis ; double pleurisy, 
 with pus in small cavities in the lungs. There had been some 
 hypogastric pain, upon pressure. Delirium. Died twenty days 
 post partum. Case 9. Subacute metritis, with uterine phlebitis. 
 Died twenty-ninth day after childbirth ; had had very little pain ; 
 great weakness; dry, hard tongue; intense thirst, small lochia, 
 and a pulse at 120. The skin was yellow; lethargy ; involuntary 
 stools ; speech not to be understood. Complaining of no pain ; 
 she sank on the twenty-ninth day after the birth of the child. 
 There were two small abscesses in the lung, and some traces of 
 peritonitis. A large purulent collection was found in the veins 
 of the womb, which veins proceeded towards a double tumor 
 upon the outer surface of the organ, that was composed of an 
 assemblage of vessels, all filled with pus, and which, after uniting 
 into one single vein proceeded to open, at the distance of nine 
 inches, into the vena cava. This vessel was the right ovaric 
 vein, filled throughout its entire length with pus." In Case 10, 
 there was blackish ramollescence of the womb ; inflammation of 
 its veins, of both the ovaries, and of the right hypogastric ; ab- 
 scess in the cava ; gangrenous softening of the spleen ; peri- 
 carditis ; pus in the left pleura ; numerous abscesses in the lungs, 
 chiefly the left. Eamollescence of the Trigone cerebral. New ab- 
 scesses under the skin of both forearms, and also between the 
 intercostal muscles and the pleura. These lesions resulted in 
 death, about four months subsequent to the parturition. In Case 
 9 
 
130 PUERPERAL FEVER. 
 
 11, softening of the womb; peritonitis; pus in veins in the pelvis ; 
 abscesses in right lung, liver, and brain. The labor had been a 
 very laborious one. At first, the woman complained of dull 
 pain in the hypogastrium, and had a continued fever, attended 
 with profuse sweats at night. The emaciation was rapid ; then 
 came on a gradual prostration, with altered physiognomical ex- 
 pression, a low delirium, abundant diarrhoea, and death soon after 
 her delivery. Cases 12 to 21, all exhibited the familiar signs of 
 this cruel disorder, all of them being accompanied with the usual 
 symptoms during life, particularly the delirium, and exhibiting 
 the post-mortem evidences, except Case 21, which was cured at the 
 close of about two months. This woman was much bled, during 
 her illness, both with venesection and leeches. M. Dance's third 
 and last article, vol. xix. 1829, contains his excellent reflections 
 upon the foregoing histories. As to the treatment, he thinks 
 that venesection is much to be preferred to leeching, because it 
 disen gorges the womb much the most rapidly, and so, favors its 
 involution. By means of venesection the caliber of the 
 veins is lessened ; and hence, the propagation of the inflamma- 
 tion along the tract is prevented, and the transport of the pus 
 less to be dreaded. He also approves of baths, fomentations, 
 emollient eataplasms, cooling drinks, and scrupulous attention to 
 the diet and regimen of the woman. I trust, my dear young 
 gentlemen, that the perusal of even this rapid and very meagre 
 sketch of M. Dance's opinions and experiences may convince you 
 of this one thing at least, viz : that you will, in practice, meet 
 with cases of uterine phlebitis, and that you must cure them or 
 lose your patients, and that you will not cure any of them unless 
 you first learn that all these phlebitic affections are not fit to be 
 called membranous inflammations, but only and truly phlegmon- 
 ous inflammations; and as they are often connected with peritoni- 
 tis, a purely membranous or superficial phlegmasia, you will be 
 able to cure the latter, and yet leave the former to destroy your 
 friends, if you do not act wisely and well. 
 
 I have not been able to obtain the original authority for a strange 
 passage in Dr. Grardien's Traite Complet oV Accouchemens et Maladies 
 des Filles, des Femmes, et des Enfans, who, in vol. iii. p. 382, has 
 the following words: "Walter, who opened more than five thou- 
 sand five hundred (cinq mille cinq cents) bodies of persons who died 
 
TONNELLE. 131 
 
 with, peritonitis, always found the greatest resemblance between 
 the fluid effused into the abdomen, and that noticed in women 
 who have perished with puerperal fever." I said this is a strange 
 passage, since it is difficult to imagine how one individual could 
 possibly have opportunity to make such an immense number of 
 dissections in a single disease. If there is no mistake in the state- 
 ment, it may serve to show how slow is the progress of knowledge, 
 for we are not yet agreed after the cinq mille cinq cents. 
 
 226. Another great flood of light was likewise thrown on the 
 subject of childbed fevers twenty-five years ago, by M. Tonnelle\ 
 Indeed, one might safely conclude, that from the era of Hippoc- 
 rates, down to the date of this publication, no such considerable 
 stride in advance, as these, was made by any physicians of any age 
 or country. I mean to speak of a step forwards in the knowledge 
 of the real seat and nature of the disease. As to progress in prac- 
 tice, I always believe we are indebted more to Alexander Gordon, 
 than to any other person whatever. In every point of view, how- 
 ever, a famous and certainly a most fair and conscientious book 
 is that of M. Tonnelle, who served at the Maternite, at Paris, 
 with M. Desormeaux, in a horrible epidemic of childbed fever 
 there, and who acknowledges that eminent person to have been 
 his guide, his teacher, and friend in the affair. Dr. Desormeaux 
 was, at the time, at the head of the establishment la Maternity. 
 Tonnelle's paper bears the stamp of truth and accuracy, and I 
 advise every one of you to read it as soon as possible, in the 
 twenty-second and twenty -third volumes of Archives Generates. The 
 epidemic raged in the Maternite Lying-in Hospital in 1829, where 
 Tonnelle' was so diligent in learning, that he dissected the bodies 
 of 222 women, who perished there during the prevalence of the 
 malady. These dissections were most carefully made, and by the 
 most able hands. The examinations disclosed the fact that — 
 
 In 193 cases there was peritonitis. 
 
 In 197 " there was alteration of the womb and its append- 
 
 In 79 " there was simple metritis. 
 
 In 29 " superficial softening. 
 
 In 20 " deep-seated softening. 
 
 In 58 " inflammation of the ovaria. 
 
132 PUERPERAL FEVER. 
 
 In 90 cases pus in the veins. 
 
 In 32 " pus in the lymphatic vessels, and at the same time, 
 
 In 3 " pus in the thoracic duct. 
 
 In 9 " inflammation and suppuration of glands, as the 
 
 lumbar, inguinal, &c. &c. 
 In 32 " where the veins were inflamed, the womb was also 
 
 inflamed. 
 In 11 " where the veins were inflamed, the womb was in 
 
 a state of ramollescence or putrescency. 
 In 5 " where the veins were inflamed, there was also me- 
 tritis and ramollescence of thewomb. 
 In 34 " where the veins were inflamed, there was perito- 
 nitis only. 
 In 8 " the veins alone were inflamed. 
 In 20 " the lymphatics were in suppuration concurrently 
 
 with suppuration of veins. 
 In 13 " lymphatics in suppuration, together with suppura- 
 tion of the womb. 
 In 6 " lymphatics in suppuration ; there was also ramol- 
 lescence of the womb without suppuration. 
 { lymphatics in suppuration with simple peritonitis. 
 ' lymphatics in suppuration without other compli- 
 cation. 
 ' Ovaritis with simple peritonitis. 
 ' Ovaritis with divers alterations in the womb. 
 ' Ovaritis with simple metritis. 
 1 Ovaritis with ramollescence. 
 ' Ovaritis with suppuration of vessels. 
 ' Ovaritis with all the preceding forms combined. 
 
 227. M. Tonnell^ remarks, that the above results show, that 
 affections of the womb, in childbed fever, exceed in number the 
 cases of peritonitis ; that they are most generally combined in 
 the cases, and that each of them may be wanting in childbed fevers. 
 He also considers it to show, what is very remarkable, that in 134 
 of the cases, the veins or lymphatics contained pus. 
 
 228. I should never finish were I to go on with quotations to 
 prove that individuals who die with childbed fever, show the 
 manifest and undeniable marks of inflammation within the belly ; 
 
 In 3 
 
 In 2 
 
 In 29 
 
 In 27 
 
 In 8 
 
 In 7 
 
 In 12 
 
 In 16 
 
TONNELLE — A CASE. 133 
 
 and I shall not take the trouble to dhdeavor to convince you that 
 these phlegmasias do take their rise in parts contained within the 
 pelvis, or that the primary areas of the inflammation are i n t r o - 
 pelvic areas, which spread, on the one hand, far and wide 
 within the abdomen when they are peritonitic, or, on the other, 
 effect their deadly purpose without rising above the plane of the 
 superior strait, in all those cases that consist in pure metritis or 
 metro phlebitis or ovaritis, under the various forms of putrescency 
 of the womb, phlebitis uterina, &c. &c. 
 
 229. M. Tonnelle's reports of his post-mortem examinations 
 appear to me to be perfectly clear and truthful. I say so, not 
 only because his representations agree with those of other writers, 
 but because they tally with the repeated observations I have my- 
 self made during a great number of years that I have practised 
 Midwifery. I have met with multiplied instances of putrescency ; 
 of softening, whether of the whole texture, or the inner or outer 
 stratum only, of the uterus ; of pus in the veins, and pus in the 
 lymphatics ; destructive and softening inflammation of the ovaries ; 
 broad ligaments full of pus, and inflamed peritoneum, with and 
 without affection of the womb or its bloodvessels. 
 
 230. I shall here relate, for you, a case of my own, with an 
 account of the dissection. The woman perished with precisely 
 the same constitutional disorders as I have so many times ob- 
 served in cases of sporadic, and likewise epidemic, and even 
 hospital childbed fever. 
 
 Mrs. Gr. S. B., set. 28, had, at various times, in the latter weeks 
 of her second pregnancy, complained of severe pain in the left 
 iliac region, in textures somewhere near the upper strait of the 
 pelvis. In complaining of the attacks of pain, she also frequently 
 had fainting fits; but recovered from them without very alarming 
 accidents. On Tuesday (8th of June, 1841) she gave birth to a 
 healthy boy, after a short but natural labor. Nothing unusual 
 attracted my attention in the course of the labor, and I had no 
 suspicion that those pains and the faintings were connected with 
 some very serious mischief, particularly as they gave out no signs 
 during the efforts of parturition. Thursday, 10th, abundant 
 secretion of milk, with a slight milk fever. Monday, June 14, 
 a flatulent belly, and considerable fever, but not so much as to 
 
134 PUERPERAL FEVER. 
 
 excite in me any alarm: examined the hypogastric m, and also 
 the vagina, and found pain when I pressed upwards the left cul- 
 de-sac of vagina, or thrust moderately against the left side of the 
 pelvis, towards the ischial plane. 
 
 231. Tuesday, 15th of June. This morning, no dysury, no 
 pain ; pulse nearly natural : the same at 4 P. M., at which time 
 she was in excellent spirits, the belly being soft, and not painful 
 to the touch ; pulse moderate. She said she was so much better, 
 that I need not visit her again until to-morrow: the bowels free. 
 In the afternoon, she ate a saucer-full of strawberries ; was com- 
 fortable, and slept soundly until 4 A.M., Wednesday, 16th of 
 June, when she awoke, saying she was perfectly comfortable, and 
 " never felt happier in her life." She asked for the child, nursed 
 it, and then said : " Nurse, take the boy ; and I shall turn over, 
 and have a delightful morning nap." At the moment the nurse 
 took the child from her, she was seized with the same excruciat- 
 ing pain in the left iliac region, as before her confinement. I 
 arrived soon after 6 A. M., and found her bathed in colliquative 
 sweat ; pulse feeble, and exhausted ; pains intolerable ; belly 
 greatly distended. Pulse, which was quick, grew rapidly weaker 
 and weaker, and the body and limbs cold. An enormous ephi- 
 drosis now came on, and lasted until 1 A. M., of Thursday, June 
 17, when she expired. 
 
 232. I repeat that this woman died with all the constitutional, 
 as well as local symptoms of a true childbed fever. She survived 
 the attack only twenty -one hours — say from 4 A. M., Wednesday, 
 16th, to 1 A.M., Thursday, 17th of June. 
 
 233. Prof. Pancoast made the examination; both the ovaries 
 enlarged and red ; peritoneum slightly glued by means of exuda- 
 tive matter. The involution of the womb had gone on na- 
 turally. The left Fallopian tube was as big as my thumb, and the 
 cavity of it would admit a finger, instead of a bristle or small 
 probe, as usual. It was full of pus, and the outer extremity was 
 open, so as to discharge the pus into the belly. The tube had 
 probably already collapsed, and was of a liver hue. This enlarged 
 left Fallopian tube, and the corresponding broad ligament, were 
 the seats of the most intense inflammation. 
 
 234. This Fallopian tube had, doubtless, been long inflamed, 
 
CASE — GORDON. 135 
 
 and that had given rise to the pains she had complained of some 
 weeks before her delivery ; it was converted into an abscess, the 
 canal of the tube serving as the walls of the abscess. It had opened, 
 and discharged its purulent contents, as she turned at 4, A. M. ? 
 in giving the child to the nurse. A phlegmasia was the result, 
 which killed my patient in twenty-one hours with a childbed fever, 
 or puerperal peritonitis. This is a pure sample of what I called, 
 at sec. 200, accidental, or sporadic childbed fever. 
 I have seen, in forty-odd years, many cases and dissections of child- 
 bed fever, and I never saw a more exquisitely marked case than 
 this. Let no man, who denies my position that childbed fever is 
 phlegmasia, say that Mrs. G. S. B.'s disease could not be like the 
 bad cases that occur in hospitals. I aver, that the worst hospital 
 cases cannot present symptoms more strikingly characteristic than 
 those I saw here ; I mean the altered physiognomical expression, 
 the utter exhaustion, the eructations, passing into black vomit ; 
 the pallor, and the failing pulses, and the clammy sweats, and 
 rapid extinction, which, by many, would have been regarded as 
 evidences, or, rather, proofs of putridity, or vitiated blood. 
 
 235. I have lying before me "A Treatise on the Epidemic Puer- 
 peral Fever of Aberdeen. By Alex. Gordon, M. D., Physician to 
 the Dispensary, London, 8vo. 1795." Such is the title to Gor- 
 don's famous work, that I have so often urged you to study, as a 
 sort of Gospel book for this particular line of clinical informa- 
 tion. You have many times heard me say that, to Gordon we 
 are really indebted for the greatest and most useful reforms in 
 our practice in the disease ; and I shall have much still, to say 
 about his great services to us, in a future page. For the present, 
 I have brought him before you that you may see what his 
 opinions are concerning Isabel Allan's case, a woman, aet. 38, who 
 was confined on the 22d Sept. 1790. Twenty-four hours after 
 delivery, she had a violent rigor, succeeded by acute pain in the 
 hypogaster, especially on the right, with great fever. She had 
 been sick 30 hours when Gordon was called, on the 24th. He 
 found the belly considerably tumefied; pulse 140, and hard; 
 sick, and vomited green bile ; lochia suppressed, and urine high 
 colored. She had all the symptoms of puerperal fever. He 
 ordered her to be freely bled: abdominal fomentations, and a 
 diaphoretic draught at night. In the morning, 25th, happy to 
 
136 PUERPERAL FEVER. 
 
 find her apparently much better; Pulse 124, pain of belly much 
 abated ; sweating profusely. This he endeavored to promote by 
 emetic tartar, in small doses. In the evening, there had been a 
 rigor of long duration, followed by considerable increase of fever 
 and pungent pain, with tension of the belly. A large blister to 
 the abdomen. Next morning, 29th, all the symptoms worse; 
 swelling increased, and pulse 160. In 24 hours she died. 
 
 " I found the peritoneum and its productions, the omentum, me- 
 sentery, and meso-colon in a state of inflammation. The omentum 
 had lost about half its substance by suppuration ; the mesentery 
 and mesocolon, and that part of the intestinal canal with which 
 they were connected, were very much inflamed. But the disease 
 appeared more especially to occupy the right side; the right 
 ovarium had come to a suppuration ; the colon, from its caput, 
 along the course of its ascending arch, was much inflamed, and 
 beginning to ran into gangrene. A large quantity of pus and 
 extravasated serum appeared in the cavity of the abdomen, which, 
 when taken out and measured, amounted to two English pints. 
 The peritoneal coat of the uterus was inflamed, and the organ 
 itself not so compact and contracted as it ought to have been. 
 Upon opening it, its cavity was found covered with a black 
 colored substance, which, at first sight, had the appearance of 
 mortification, but when wiped off was found to be nothing but 
 the membrana decidua, in the state in which it naturally is about 
 this time." p. 28. 
 
 236. Here you see the undeniable proofs of an inflammation 
 so great in violence, and of so vast a superficial extent, that you 
 cannot but very readily attribute to it all the signs of constitu- 
 tional disturbance that Gordon describes ; disturbance that must 
 certainly lead to the dissolution of the patient, if unchecked and 
 uncured by remedies. It is true you can find in many more 
 recent authors, accounts of dissections more elaborately told 
 than this one, yet this is a very clear one, and, it seems to me, a 
 very convincing one. You are to remember that this was one of 
 the epidemic forms, and you should know that Gordon lost 27 
 out of 77 women that were sick with the disease. 
 
 237. What was the cause of the chill she had on the 23d? and 
 why had she that pain in the lower belly ? Was not the chill 
 
CASE. 137 
 
 the evidence of that concurntur of the powers that we notice in a 
 forming inflammation ? Are you surprised that there should be 
 so much pain — so rapid a pulse (140) — so sick a stomach — such 
 tension of the belly, sweats — and at last, exhaustion of the nervous 
 forces, and then death to end all ? Every case you are doomed 
 to meet with hereafter, will be, in many respects, just like this, 
 though modified by the particular seat, as metritic, phlebitic, 
 ovaritic, peritonitic, &c. 
 
 ._ 238. Some years ago, Messrs. Barrington & Haswell published 
 a volume here, containing the works of Gordon, Hey, Armstrong, 
 and Lee, on puerperal fever, and I made for it an introduction, 
 which contained some of my views on it at the time, 1842, which 
 is now 12 years ago. At p. 25, there is an account of a case from 
 my note-book, and as that case made, at the time of its occurrence, 
 a strong impression upon my mind, and as I have a still lively 
 impression of the person and the incidents, I am about to tran- 
 scribe it here ; for I think it will do you good to read so true an 
 account of a case. It will do you good, I say ; for it will show 
 you how this disease acts when it has taken strong hold of a 
 strong woman. 
 
 239. Mrs. W. Gr. aet. about 20 years, healthy and strong, was 
 delivered, Thursday, Nov. 4th, 1830, of a girl; in a labor of four 
 hours. Friday, 5th, and Saturday, 6th, quite comfortable ; breasts 
 contained a little milk, but they were not swollen or painful. 
 On Saturday a dose of castor-oil was taken, which operated ten or 
 twelve times that day. Diet, tea and bread, and oatmeal gruel. 
 No fever. Sunday, 7th, 10 A. M. Had a chill in the night; had 
 rested badly, and now has pain and soreness in the right iliac 
 region : the part very tender, resonant, and distended. The 
 fundus uteri sore to the touch. Lochia bright and free ; urine 
 plentiful ; tongue whitish, moist, soft, and supple; headache, thirst; 
 dorsal decubitus ; motion of thighs gives pain in the belly ; to 
 turn or to rise also gives pain ; pulse 148, with a vigorous stroke. 
 I bled 18 ounces from a large orifice, whereon she became faint, 
 and I bound the arm. In a few minutes after the bleeding, pulse 
 112, but it soon rose again, and beat 152. To relieve the tym- 
 panitis, an enema, which produced two dejections with relief. 
 A flannel bag filled with wheat bran, and soaked in boiling vinegar 
 
138 PUERPERAL FEVER. 
 
 and water, being first well pressed, was laid on the abdomen, and 
 changed occasionally for a fresh one. At 20 minutes past 3 
 P. M., pulse 145, with a smart stroke ; tenderness of the belly 
 neither less nor greater. I now took 12 ounces of blood from the 
 arm, plena rivo ; but was obliged to stop for the faintness, though 
 I had drawn the pillows from under her head, in hopes of getting 
 a better bleeding. In 15 minutes after the v. s. pulse 144. At 
 6 P.M., ordered 8 grs. calomel with opium jss. grs. for a dose. To 
 drink gum water. At 6J P. M., has slept, and feels decidedly 
 less pain and soreness ; but as the pulse was full and strong, I 
 drew away 22 fluidounces of blood, which was carefully measured. 
 It made a firm clot, and had a thick coat of size. She now took 
 of manna 3ss, sem. anisi 3j> magnesia carb. iss, aq. bullient. lyj. 
 An infusion being made of the manna and anise, the magnesia 
 was added to the strained liquor. The dose was one fluidounce 
 of the mixture every hour, until the bowels should be moved. 
 At 10J P. M., pulse 136, full and strong; the right mamma filling 
 and hardening ; the left, soft and flaccid, yet the gland developing 
 itself favorably; no headache ; thirsty ; soreness and pain, carefully 
 examined, much lessened; lochia free; decubitus still dorsal. 
 Monday 8th, at 8 A. M., pulse 130, and softer ; has slept a good 
 deal ; no pain except from firm pressure on belly ; thirst lessened; 
 both mammae full and hard. 3 P. M., pulse 120, full and strong ; 
 no pain, not even from pressure ; tongue clean ; several dejections; 
 not thirsty. Tuesday, 8th, 9 A. M., pulse 124 and strong ; tongue 
 a little furred ; plenty of milk ; breasts soft ; no pain ; several de- 
 jections. 9 P. M., pulse 111 ; nipples sore. Wednesday 9th, 10 
 A. M., sitting up; no pain; pulse 126. In a few days after this 
 memorandum she was quite well. Between 11 and 6 o'clock on 
 the first day of the disease, I drew away 52 ounces of blood from 
 this woman's arm, without which I think she must have died. 
 
 240. If you will examine this case, I believe you cannot doubt 
 it was a case of childbed fever, nor that it consisted in intense 
 inflammation that had laid its incipient areas upon the intro- 
 pelvic peritoneum, and was rapidly spreading out those areas 
 above the brim of the pelvis. My venesections and other reme- 
 dies checked its progress, and, at last, impressed upon it a dispo- 
 sition to recede by resolution ; so that, by 3 P. M. on Monday, 
 the resolution of the inflammation was completed, and the consti- 
 
CASE. 139 
 
 tutional irritations had fallen with it. If I had not bled the 
 woman so well, would she not, by 3 P. M. of Monday, have been 
 affected with all those metro-abdominal inflammations, that Gor- 
 don found in his dissection of Isabel Allan's body ? I have no 
 doubt it would have been so ; nor have I any doubt that my art 
 rescued the woman from imminent destruction. I have rescued 
 many such, and so will you, if you but make yourself acquainted 
 with the truth of the matter. What truth ? Why this truth — 
 childbed fever is a phlegmasia, and is not a childbed fever. If 
 you can cure the inflammation, all the rest will be cured, " ipso 
 factoP 
 
 241. I do not pretend to know what made this woman sick ; 
 all I do know about it is, that she was a very rosy, beautiful, and 
 most healthy creature, when in labor, and for some time after the 
 child was born. Her mother, who nursed her, gave her too large 
 a dose of castor-oil. I presume, that if she had not taken the 
 dose she would not have been ill, and that the disturbance both 
 nervous and sanguine, produced by the violent purgings, laid the 
 areas of the phlogosis, somewhere within the pelvis, and so she 
 got an accidental, generally called, sporadic childbed fever, or 
 puerperal peritonitis. No vitiated state of the blood, as Fergu- 
 son supposes, vide sec. 222, had anything to do with the matter ; 
 nor any miasm, contagion, halitus, nebula, or halo. It was a 
 pure accident that gave rise to an inflammation ; but, if I had not 
 cured her, she would, by Monday afternoon, have been in a 
 deeply typhous state, and then, indeed, her blood would have 
 been vitiated and even ruined. Grooch tells us, p. 7, that, " Dr. 
 Clark suspected that the disease (epidemic in 1787) might be 
 occasioned by the purge that is always given to lying-in women 
 on the second day after delivery, but glysters were not more suc- 
 cessful." I have seen several persons attacked in consequence of 
 the inopportune, or excessive use of purgatives. 
 
 242. Let me say further, that I cured this inflammation because 
 I got to the house not later than 10 A. M., when the disorder 
 was only a few hours old ; and also, probably, because it had not 
 yet become a phlegmon of the substance of the womb, or of any 
 of its large venous sinuses. I mean by this to sa} 7 , that, had 
 some of the veins begun to inflame, I should, in all probability 
 
140 PUERPERAL FEVER. 
 
 have failed, as I have on several occasions. One of those occa- 
 sions made a profound impression upon me, and I will now tell 
 you about it. Two years and a half ago, I attended, in her con- 
 finement, a tall, slender, weakly woman, in her third pregnancy. 
 She had a good labor, but shortly afterwards was seized with 
 childbed fever ; that is to say, she had intense rigor, with most 
 rapid pulse, hypogastric pain, dorsal decubitus, altered physiog- 
 nomy, and, indeed, the alarming symptoms of a direful attack. 
 The chill was not yet ended when I arrived at her house, and I 
 immediately bled her, though she was yet shivering occasionally. 
 But, as I could not, on account of her fainting, get more than 16 
 or 18 ounces, I felt heartsick for fear, as to her safety. I should 
 have had no such fear, could I have abstracted 25 ounces, and I 
 never have any when I can do so early ; but, if I find myself 
 compelled to desist far too soon, that is, before I can get some 
 24 or 26 ounces, I always consider myself a baffled man, and 
 retire with inexpressible anxiety as to my patient's security. 
 Not so, never so, when I can say as I bind up the vein, " I have 
 succeeded in my venesection to my heart's content ;" for then I 
 always go away confident in the result for my patient. Never- 
 theless, the venesection, with other remedies, did afterwards 
 appear to me to have cured her ; for her pain, and soreness, and 
 fever went away, and her milk and lochia came back again. Yet 
 in a few days she became hysteroid (they always become hyste- 
 roidal when pus is mixing with the blood) ; and so, in some days 
 afterwards, she died, as I have seen many die, from pysemic 
 fever. Upon dissection, no traces of peritonitis were discover- 
 able, but everything in the belly was fair and normal. Even the 
 womb, whose involution had gone on well, seemed so natural 
 that one would suppose it a healthy specimen. Even when 
 incised, it looked well. The inner wall was as it should be. 
 Many incisions disclosed nothing, to our great surprise, until, at 
 last, the bistoury laid open a congeries of veins, on the right side 
 of the womb and in the broad ligament, which were full of per- 
 fectly laudable pus, and then the truth was known. She had perished 
 with pyaemia. I did treat and did cure a violent and extensive 
 peritonitis, but there was also an incipient metro-phlebitis that I 
 failed to cure. That phlebitis went to the pyogenic stage, and 
 so, furnishing pus-corpuscles, which were washed away into the 
 
GORDONIAN VENESECTION. 141 
 
 torrent of the circulation, infected the whole mass of the blood, 
 and destroyed my patient. I shall ever believe that if I could 
 have taken 25 ounces at that first bleeding, I should have eradi- 
 cated, not only the peritonitic, but also the phlebitic affection. 
 It is true that a well-designed and well-executed venesection is 
 often able jugular e febrim. 
 
 243. 1 find I have already written a very long letter, without 
 exhausting the subject concerning which I desired to communi- 
 cate my sentiments. I shall, for fear of fatiguing your attention, 
 release it now, and proceed in my next letter with further ob- 
 servations on the question : What is childbed fever ? 
 
 C. D. M. 
 
LETTER VIII. 
 
 OPINIONS OF GOOCH FAULTY FROM HAVING PRECEDED DANCE 
 AND TONNELLE — GASO, RACIBORSKI, ON THE VEINS — UTERINE 
 PHLEBITIS — PUTRESCENTS UTERI — SEROUS OR EXO-METRITIS — 
 MUCOUS OR ENDO-METRITIS — METRITIS PARENCHYMATOSA — 
 AFFECTION OF THE SUBJACENT ORGANS IN PERITONITIS. 
 
 244. Dr. Kobert G-ooch, of London, appears to have been a 
 physician who attracted to himself everybody's love and con- 
 fidence; and, I think, that the present century has not produced 
 a medical man, in all England, who had so general an esteem as 
 he. His writings are charming by the simplicity and beauty of 
 their style, and by an air of truth and sincerity that is seen in 
 every page. His Account of the Diseases peculiar to Women is an 
 octavo-volume of 432 pages, printed at London, 1829. 
 
 245. I am going to cite for you one of Dr. Gooch's paragraphs ; 
 not because it represents what I consider to be a truth in regard 
 to childbed fever, but because I have so great a respect for the 
 memory of this good physician, that I wish you to know what 
 his sentiment was, though my own differs widely from his. But 
 here is the excerpt from his page 96 : — 
 
 11 The most remarkable circumstance that the experience of the 
 last few years has taught us about peritoneal fevers is, that they 
 may occur in their most malignant and fatal form, and yet leave 
 few or no vestiges in the peritoneum after death. The state of 
 this membrane, indicated by pain and tenderness of the abdomen, 
 with rapid pulse, appears to be, not one uniform state, but one 
 which varies so much in different cases, that a scale might be 
 formed of its different varieties ; this scale would begin with a 
 little more than a nervous affection, often removable by soothing 
 remedies, and when terminating fatally, leaving no morbid appear- 
 
gooch's views. 143 
 
 ances discoverable after death. Next above this, a state, in which 
 this nervous affection is combined, with some degree of conges- 
 tion ; indicated, in the cases that recover, by the relief afforded by 
 leeches, and in the cases which die, by slight redness in parts of 
 the peritoneum, and a slight effusion of serum, sometimes color- 
 less, sometimes stained with blood. Above this might be placed 
 those cases in which there are, in the peritoneum, the effusions of 
 inflammation, without its redness; namely, a pale peritoneum, 
 and no adhesions ; lymph, like a thin layer of soft custard, and a 
 copious effusion of serum, rendered turbid by soft lymph. Lastly, 
 the vestiges of acute inflammation of the peritoneum, namely, 
 redness of this membrane, adhesion of its contiguous surfaces, a 
 copious effusion of serum, and large masses of lymph." 
 
 246. There, gentlemen, is Dr. Gooch's opinion expressed in his 
 own words, and if he is right in it, you are to come to the con- 
 clusion that a woman may have a childbed fever, according to 
 the first degree of his proposed scale, which is only a nervous 
 affection, removable by soothing remedies (I know not what he 
 means by soothing remedies), or, if not so cured, ending in death 
 without traces of lesions in the peritoneum. Will you agree 
 with him to call this a puerperal fever ? 
 
 247. Now, I wish you to observe, that Dr. Gooch's book was 
 published in 1829, and that as M. Tonnelle's articles in the Ar- 
 chives Generates , did not appear until 1830, a year after Gooch's 
 book was published, he could not have been so well informed on 
 the subject of childbed fever, as he must have become after read- 
 ing Tonnelle's disclosures. 
 
 248. I wholly deny that a woman can have a childbed fever, 
 according to Dr. Gooch's first scale, and should deeply lament to 
 find a Student of mine taking up such an idea ; since I cannot 
 conceive of his entertaining it, without at the same time admit- 
 ting childbed fever to be a fever, which is a doctrine both false 
 and dangerous ; false as to the pathology, and dangerous as to the 
 practice ; that is, false both exegetically and practically. 
 
 249. There is a writer on puerperal fever, who is often referred 
 to as authority; but, though in general a sensible author, his 
 pathological views here are no better than Gooch's. However, 
 in his " Dissertation sur les maladies des femmes a la suite des Gou< 
 
144 PUERPERAL FEVER. 
 
 cites, connues sous le nom de Filvre puerperale" J. Charles Gasc very 
 sensibly says: "Observez que cette inflammation locale est un phe'- 
 nomene tellement constant dans la maladie qui nous occupe, que, 
 si elle n'existoit point, on ne pourroit point dire qu'il y eut fievre 
 puerperale." The inexcusable fault of Gasc's treatise is, that it 
 formally pleads that childbed fever is inflammation of the perito- 
 neum only, and that the womb and the bowels have no concern 
 in it. He says, 279: "Nous avons demontre que cette maladie 
 n'etoit qu'une phlegmasie du peritoine." 
 
 250. The cause of Dr. Gooch's mistake, and Gasc's also, was 
 that they knew less of phlebitis, than has been known since their 
 day ; and I have only, perhaps, to turn your thoughts to the case 
 which I related in sections 225 and 242, in order to let you at 
 once know, that a woman may die of childbed fever, and leave no 
 morbid signs, for those, at least, who do not search for them in 
 the right place. In that case, I was near giving up the search, 
 after the womb had been repeatedly incised, and laid open 
 through and through, when, at length, a stroke of the bistoury 
 showed me veins filled with pus. In fact, those veins had 
 secreted it from their inflamed membrana communis. And here 
 let me put you in mind that the great venous vessels, that ramify 
 within the tissue of the uterus, consist of the endangium alone ; 
 for it is quite true, that a bloodvessel penetrating into the sub- 
 stance of an organ, or viscus, does leave all its adventitious coats 
 outside ; carrying in, only the true, real bloodvessel, which is the 
 endangium. Now, some of the uterine vessels are so large, that, 
 in a recent womb at term, and not contracted, one can, when it is 
 cut open, readily thrust a finger into the cavities of the sinuses. 
 This, I know to be true, having done it myself. In looking at 
 these vessels, it is evident that they consist merely of the endan- 
 gium, or membrana communis, which, requiring no other base to 
 rest on, does use the substance of the womb as its basement 
 tissue. 
 
 251. If you will study M. Raciborsky's paper on the veins, in the 
 Mem. de 11 Acad. Boy. de Med. vol. ix., you will learn that he fully 
 establishes this doctrine, in regard to the vessels ; and I wish very 
 much that you should satisfy yourselves with regard to it, for it 
 throws much light on the subject of metro-phlebitis, by showing 
 
PHLEBITIS. 145 
 
 that where the veins of the womb become affected with phlebitis 
 in the deep-seated structure of the organ, the basement tissue 
 or organ itself must also soon become affected, and that violent 
 and universal phlebitic inflammation of the viscus may hasten the 
 whole uterus into that state of ramollescence, that is called putres- 
 cencj of the womb. My friend, Dr. Haines, some time since a 
 practitioner here, brought me the uterus which he had taken from 
 the body of a woman who died under his care forty-eight hours 
 after her delivery. The whole inner stratum, if I may so call it, 
 was soft or rotten, while the exterior, and much larger portion 
 was perfectly sound and normal. All this change must have 
 taken place subsequent to the labor, in a disease lasting only 
 forty-eight hours. 
 
 252. Where the phlebitis is situated in veins lying on the out- 
 side of the womb, and within the folds of the broad ligaments, the 
 destruction of life must go on more slowly, for, as in my case, sec. 
 242, it does not necessarily involve the womb itself, and kills at 
 last, only by purulent infection of the blood. It often admits of 
 recovery by the rising of the pus to the groin or iliac region, 
 where it is discharged through the skin, escaping along the course 
 of the abdominal canal, or underneath Poupart's ligament. 
 
 253. I cannot explain why it does sometimes happen that in 
 childbed fever, the inner layer of the womb only suffers this 
 ramollissement or putrescency, and at other times only the outer 
 layer, and at others, again, the whole womb. These peculiarities 
 cannot be independent of a state of the vascular apparatus of the 
 organ. If the whole endangial tissues within a recently delivered 
 uterus could be supposed to be inflamed, I can readily conclude 
 that such inflammation might, in certain cases, reduce the entire 
 organ to a state of putrescency, in the course of less than twenty- 
 four hours, as in Kiwisch's case. Perhaps, indeed, this is the 
 true rationale of uterine putrescency. See sec. 293. 
 
 25-i. No one ought to be surprised to find a woman die rapidly, 
 with such a state of such an organ, which ought to suffice, one 
 would think, to overthrow the functions of the entire nervous 
 mass in the course of a few hours. The nervous shock in such a 
 case, would be equal to the nervous shock experienced in certain 
 railway accidents, or in the crushing of important joints, &c. 
 10 
 
146 CHILDBED FEVER 
 
 255. When a patient dies with childbed fever consisting of 
 puerperal peritonitis alone, and there are many such victims, she 
 dies because the disorder extends to and involves many import- 
 ant organs, and in the course of it, interferes with many essential 
 functions, as I shall endeavor to explain ; but when she dies with 
 putrescency of the womb, she perishes speedily under shock, 
 and perhaps, partly from pyaemia. 
 
 256. Whenever the serous lining of the belly inflames, it has a 
 tendency to spread far and wide, wherever that membrane extends, 
 and it would undeniably always do so, were its progress of ex- 
 tension not interrupted by a cure on the bne hand, or on the 
 other, by the death of the individual, who succumbs, earlier or 
 later, according to her power of resisting the destructive impres- 
 sion of so vast an area of phlogosis : some women die before it 
 has ascended far above the plane of the strait, while others resist 
 the subverting and destroying force of the phlogosis, until it has 
 pervaded every portion of the peritoneum. This is the reason 
 why, in your dissections, you shall find either small patches of 
 inflammation, here and there, or signs of its extension throughout 
 the whole abdominal cavity. 
 
 257. You would call such a case by the name peritonitis, or 
 puerperal peritonitis ; and if inattentive to the meaning and im- 
 port of the word, you would fall into the error of regarding it 
 as a serous disorder only. But I beg to say this would be a 
 grave error, and one that might blind you as to the real state of 
 the woman; for all such cases are something more, and more 
 serious than would be a serous inflammation, regarded per se, or 
 singly. For example, the intestinal canal consists of the mucous, 
 areolar, muscular, and serous tunics, all of which, when combined, 
 make up the organs called the bowels. But, if a Student in the 
 dissecting room should show you an intestine from which he had 
 dissected off the whole of the serous, the muscular, and the areolar 
 tunics, you would say to him : "It is not an intestine that you show 
 me, but only the mucous tunic of one ; you have not got the 
 serous part of the bowel nor its muscles." Hence, it is quite true 
 to say that the peritoneal coat of the bowel is part of the bowel ; 
 and further, when this peritoneum is inflamed, it is an inflamma- 
 tion of the bowels also, and constitutes what De la Roche so 
 
IS NOT A FEVER. 117 
 
 properly calls "inflammation cFentrailles." The same is equally 
 true of the stomach, the liver, the spleen, diaphragm, &c, so that 
 if the whole peritoneum is inflamed, we have superficies-inflam- 
 mation of all that is contained within the whole belly. 
 
 258. Under such an aspect as this, the peritoneal inflammations 
 acquire an immense importance ; for no one can deny that the 
 body must inevitably perish, in which all the abdominal viscera 
 are wrapt in the blaze of a rapid inflammation. 
 
 259. It is good, too, to inculcate such a doctrine, because if it 
 is a correct and true one, then it will be believed that all such 
 attacks may have their beginning in a small circumscribed area 
 or areas, and we shall be convinced that to cure them at all, we 
 must begin at once, and act with that degree of energy that appears 
 indispensable, if we would crush the monster at a single blow. 
 This doctrine ought to render us vigilant in our duty, giving 
 timely warning and instruction to interested parties, in order that 
 we may be promptly summoned to witness, if possible, the very 
 first manifestations of the incipient mischiefs. Many of the 
 brethren are, I fear, blamable on this point. Gordon's great 
 merit, that for which he deserves a statue in England, consists in 
 his strong, earnest exhortations to his brethren to be very vigilant 
 on this point, declaring that if they should allow a certain number 
 of hours fatally to elapse, there is little hope, afterwards, of rescue 
 for the unhappy woman. You and I and every physician, owe to 
 Gordon an impayable debt. He was a great benefactor to all 
 society ; and if the study of his book will make you be watchful, 
 your whole clientage will in like manner fall in his debt. 
 
 260. I hope by this time, you comprehend the meaning of the 
 world's word childbed fever, and know that it comprises a 
 group of diverse inflammations within the belly, in women preg- 
 nant, or recently delivered ; and that it may be metritis, pure and 
 simple, with or without tendency to putrescency of the organ ; 
 phlebitis of the womb, tending to rapid ramollescence or putres- 
 cency ; or else phlebitis of veins external to the organ ; ovaritis, 
 with peritonitis, &c. &c. ; peritonitis, pure and simple, expanding 
 its area or areas so as to comprise within them many, or all the 
 viscera of the belly, which become superficially or more deepty 
 inflamed; or all the above, combined in the same individual case. 
 
148 CHILDBED FEVER. 
 
 261. These are the disorders you are to combat, and these the 
 mischiefs, which, if you can cure or prevent them, will cause you 
 to cure or prevent childbed fevers. In my next letter, I shall 
 inquire how it is that these diseases prove so destructive, and 
 point out the course they take. 
 
 C. D. M. 
 
LETTER IX. 
 
 DESCRIPTION OF A CASE OF PERITONITIS IN A WOMAN RECENTLY 
 
 CONFINED. 
 
 262. Let us to-day study the course and progress of a child- 
 bed fever that consists in a peritonitis pure and simple. 
 
 263. As soon as an area of phlogosis becomes fairly established 
 on some part of the intro-pelvic peritoneum, the nervous system 
 of the woman, perceiving the shock of the irritation, gives expres- 
 sion to its sensibility thereto by some pain or soreness of the 
 part, by an increased frequency of the pulsations, and by a state 
 denominated rigor or chills, soon followed by a febrile paroxysm. 
 
 264. It is not a very common event, for any febrile paroxysm 
 whatsoever, to be formed without an initiative stage of coldness 
 or rigor. It is certainly very rare for constitutional reaction 
 against a peritonitis, or other considerable inflammation, to begin 
 without this ushering and declaratory phenomenon. 
 
 265. The woman may, or may not have discovered the pain, 
 before the beginning of the rigor. If the incipient area of the 
 phlegmasia have been seated in a part undisturbed by motions of 
 the trunk or limbs, or if it have commenced during a deep sleep, 
 it is probable that the rigor will be the first perceived phenome- 
 non, to be immediately followed by the pain ; but I much question 
 whether the pain is not generally the first perceived affection, 
 though it is often wholly misinterpreted and misunderstood. 
 
 266. I have met with instances, when the woman knew no- 
 thing and felt nothing of indisposition, until, after turning in 
 bed, or after coughing, or making some movement ; whereupon 
 she has at once begun to perceive that she was in violent pain, 
 and has instantly afterwards begun to shiver or shudder with the 
 rigor; the pulse very soon acquiring a great frequency; the 
 
150 CHILDBED FEVER. 
 
 radial artery being at first very small and contracted; but, as 
 soon as the hot stage has fairly set in, the pulse acquiring a 
 considerable volume, and beating with a smart, or even^ violent 
 stroke ; and this particularly in the sporadic or accidental forms 
 of the malady. On the other hand, I have seen many persons, 
 whose first sign was in the chill or rigor. There are instances, 
 in which, at first, the pulse is really synochal, but in many 
 of them it never attains to a great degree of either strength or 
 volume. It is amazing to observe with what rapidity the areas 
 of inflammation do expand in certain women. I am sure that, in 
 many of them, only a few moments are required to carry the red 
 blush of the peritonitis throughout the whole pelvic cavity, and 
 afterwards lift it rapidly, and far above the plane of the strait, 
 and on the coecum, mesocolon, and whole colon and epiploon. 
 But, in such case, the inflammation is no longer intro-pelvic ; it 
 has become abdominal, and is now typhlitis, colonitis, enteritis, 
 &c. &c. &c, as far as it expands and embraces within its range the 
 organs contained within the belly. 
 
 The pain in peritonitis is anguish ; the least movement aggra- 
 vates it ; she must take a position upon the back ; she must draw 
 her knees upwards to flex the thighs, and let the abdomen be as 
 supple and relaxed as possible; for the woman cannot endure to be 
 touched there, nor can she bear the weight of her clothing ; she 
 dares not even cough nor sneeze ; and gently to draw in a full 
 breath, she cannot be persuaded to do, lest it should increase her 
 distress. 
 
 267. The whole nervous mass of the woman is in a state of 
 alarm or excitement, for it is continually receiving pungent patho- 
 genic impressions, and every nerve that reconducts the reflex in- 
 fluences to their proper destination within the organs, carries with 
 it a stream of neurosity that may be compared with the fires of the 
 electro-galvanic current. All the organs thus become excited, 
 and now we have this fever, which the world will 
 call childbed fever; not before, but after the establish- 
 ment of the phlegmasia. 
 
 268. As soon as the bowel begins to participate in the inflam- 
 matory attack, it at once ceases to resist any tendency to inflate 
 its tube ; and very early in the case, even as early as within 20 
 
DESCKIPTIVE OF CHILDBED FEVEK. 151 
 
 or 30 minutes, the belly becomes tumid and sonorous on per- 
 cussion, the tympany of childbed fever being so soon formed. 
 It is a very singular distinction that you should make between 
 ordinary peritonitis, as in males and non-pregnant women, and 
 that of lying-in women, that in the former, the disease is accom- 
 panied by an extraordinary rigidity of the abdominal muscles, the 
 belly being, for the most part, hard as a deal board, and strongly 
 contracted or drawn inwards; while in childbed fever, the balloon- 
 ing is an almost invariably present symptom. Do not be led to 
 believe that the tympanitis is caused by gases in the peritoneal sac, 
 as some have pretended ; neither imagine, with Gasc. 207, that 
 Dans lafievre puerperale, ce rneteorisme de Vabdomen, est du en general 
 au boursoufflement du tissu cellulaire voisin de Vorgane affectee ; la 
 presence des gaz dans les intestins y contribue pour fort peu de chose — 
 which, I think, is medical nonsense. 
 
 269. This tympany or ballooning in the belly increases rapidly, 
 insomuch that, between the onset and your visit, if you are dila- 
 tory or late, the abdomen shall have become almost as large as it 
 was before the labor began ; nay, even much larger. 
 
 270. The chill may continue for a quarter or half an hour, and 
 is even observed in some to last for two whole hours, before the 
 hot stage of the paroxysm becomes fully established; for the 
 whole case is a paroxysm, with its consequences. 
 
 271. The pulse usually beats 120 to 140 times, and in some cases 
 even 160 times a minute. The face assumes a brick or modena- 
 red color. There is great heat, and intolerable thirst. The head 
 aches, and the countenance assumes an expression not to be de- 
 scribed, but needs to be painted or seen, to know it. It wears an 
 expression of fright and distress. The French authors call it 
 figure tiree, by which they mean that the skin of the forehead is 
 tightened, or drawn upwards, giving rise to the singular physiog- 
 nomical expression. If the lochia have been before abundant, 
 they are now wholly or partly suspended. The breasts either 
 remain flaccid and without milk, or, if the secretion had before 
 existed, it soon lessens and makes haste to disappear. The skin 
 is hot and dry; the tongue, broad and flat, is covered with a 
 whitish induitus, that looks as if the woman had been recently 
 drinking milk — she has a milky looking tongue. 
 
152 CHILDBED FEVER. 
 
 272. As the areas of phlogosis expand wider and farther from 
 their original centres, greater and still more important mischiefs 
 continue to be perpetrated within the abdomen, and the nervous 
 mass reels and trembles under the load of irritations it can neither 
 overcome, nor even resist. The sanguiferous and nervous reac- 
 tions that flow out from their great centres, serve, not to cure, 
 but only to augment the mischief, and draw on the ultimate ruin 
 both of the organs and the centres, which fail, and faint, and die 
 beneath the exciting power of the topical lesions. 
 
 273. I saw a young creature here, a few years ago, who was 
 confined in the night after an easy labor. The physician left her 
 well, and went to his house. He was recalled early the next 
 morning to find her in the state above described. I visited her 
 with him in the forenoon. The pulse could scarcely be counted 
 for rapidity ; the belly was bigger than that of a woman with 
 twins, sonorous as a tambourine, on being percussed, and sore as 
 the apple of an eye. The breathing was short and imperfect and 
 singultiform, because the diaphragm could not go downwards in 
 inspiration, without crushing beneath it, in descending, a whole 
 inflamed mass of bowels and other abdominal contents, and so, 
 giving intolerable pain. It was impossible to procure any alvine 
 evacuation, or to do anything else that might save or even 
 relieve her; she died within twenty-four hours after her child 
 was born. 
 
 274. In many a case have I been astonished at the rapidity 
 with which the belly became thus tumid ; and so terrible have 
 seemed to me the influences of such a condition upon the vital 
 functions, that I can never perceive a speedy and great develop- 
 ment of the tympanitis, but as an unmistakable sign of pressing 
 danger to the patient. I except only certain rare examples of 
 enormous hysterical tympanitis following parturition, but that 
 are wholly unconnected with any inflammation of the contents of 
 the pelvis or the belly. I now ask you how it could be other- 
 wise than as I have herein above explained ? Let us inquire. 
 Say that the pulse was 180, and that the heart, in health, beats 
 70 times in a minute ; one hundred and eighty beats per minute 
 is 10,800 beats per hour ; seventy beats per minute is 4,200 beats 
 per hour. The heart, then, beat one hundred and eleven times 
 
DESCEIPTIVE OF CHILDBED FEVER. 153 
 
 per minute more than is normal, or 6,660 times per hour more 
 than it ought to have beat, and this in 12 hours would give 79,920 
 extra beats of the heart, or extra uses of the systolic force. One 
 might suppose that this, alone, should suffice to destroy the woman, 
 and that the heart, tired to death by so rapid a flight, would suc- 
 cumb under the over-stimulation and consequent exhaustion that 
 drove it to such excesses of activity. 
 
 275. There are three great vital functions: those of 
 the brain and nervous system ; those of the heart, or circulation ; 
 those of the lungs, or respiration, which serves as the oxygenating 
 function for the whole economy. ISTow, when the belly has become 
 enormously distended by gases contained within the tractus of in- 
 flamed intestine, the diaphragm will not go down, to crush beneath 
 its contractions the agonized mass of inflamed intestine below it. 
 The woman tries to breathe by the ribs, with a little assistance 
 from the diaphragm ; the respiration is therefore imperfect and 
 incompetent to its ends. She does not take in a full aspiration of 
 some 18 or 20 cubic inches of atmosphere for each breath she 
 draws. If you look attentively, and observe the rate and manner 
 of her breathings, you will see she does not breathe enough and 
 does not get breath enough, even though she breathe fast and 
 quick ; you will see that instead of 20, she takes only 8, or 10, or 
 12 cubic inches at each breath; and out of that small quantity, 
 consisting of azote 79 and oxygen 21, she can only appropriate 
 a lessened portion of the 21 per cent, of oxygen of the air at each 
 aspiration. But in health, she requires to get 18 or 20 cubic 
 inches with each act of breathing, in order normally to oxygenate 
 the blood in her lungs; or, in other words, to oxygenate her 
 system. Let us say that a healthy adult will breathe 16 times 
 a minute, and with each inspiration take 20 cubic inches of air. 
 Sixteen times 20 is equal to 320 inspirations per minute, which 
 is what is required in the normal exercise of the respiratory force. 
 Eeduce the quantity to 10 inches at each inspiration, and then 20 
 times is equal to 200 only, so that your patient acquires 120 inches 
 per minute less than is normal, which equals 7,200 cubic inches 
 per hour less than she requires. But with so great a reduction 
 as this, she would die, unless she should repeat the breathings 
 more rapidly; and so, in fact, she does. But the respirations that 
 ought to be only 16, rise to be 32 or 50 per minute, and that rate 
 
154: CHILDBED FEVEK. 
 
 is a most exhausting rate for any human being, and must soon 
 end in developing a state of cyanosis or asphyxiation. 
 
 276. Is it not easy to discern that with such incompetent oxy- 
 genation as this, she must rapidly succumb ? that all the func- 
 tions must give way, and be at last wholly overthrown and ruined ? 
 I declare to you, that whenever I see one of my patients in child- 
 bed fever afflicted with enormous tympanitis, I not only look on 
 it as an evidence of great inflammation within the belly, but as 
 almost sure to kill her, by cutting off, in the manner above 
 explained, the due supply of oxygen for the blood. 
 
 I have on many occasions of women dying with peritonitis, 
 watched with excited interest the gradual unfolding of this role 
 of appearances, manifested at first, in a bluish areola under the 
 eyes and about the upper lip, and a mortal and peculiar pallor of 
 the face ; then the first perceived blueness of the finger-nails, 
 followed by the cyanotic tint of the hands and feet ; and it seems 
 to me that you ought to consider that all such women when sink- 
 ing, are sinking, not merely under a load of intolerable constitu- 
 tional irritations, but they are also dying from the lessening power 
 of the blood in the lungs to take out of the atmosphere the pro- 
 per ratio of oxygen, because the diaphragm will not do its office 
 aright. They are dying with a real cyanosis. 
 
 If the blood be driven into the pulmonary artery and its 
 branches by 180 instead of only 70 pulsations a minute, and if 
 the breathings be repeated 50 or 70 instead of only 16 times per 
 minute, the greatest evils must arise as to both those important 
 functions, the circulation and the aeration of the blood. If the 
 oxygen is thus not transported in due amount to the encephalon, 
 the heart fails in its office, a failure which draws on, as an inevi- 
 table consequence, the failure of the respiration ; and when heart, 
 brain, and lungs together refuse to do their work, the patient dies. 
 The triple union between the heart, brain, and lungs, or the circu- 
 lation, innervation, and aeration, as explained by Bichat, can never 
 be broken up without drawing after it the fall of the whole. 
 
 Hence, a woman sinking under the overwhelming pain of 
 a constantly progressive peritonitis, always dies in a cyanotic 
 state, brought about long before she becomes really moribund, by 
 means of this Tympanitic interference with the respiratory pro- 
 cesses, j This cyanotic condition tends mightily to contravene the 
 
DESCRIPTIVE OF CHILDBED FEVER. 155 
 
 beneficent influence of all our remedies ; wherefore, I say that a 
 prime object of a practitioner's attention should always be, the 
 subduction of the meteorismus. I think that only a little clinical 
 experience and observation could be required to make this matter 
 perfectly clear to you. You would note the number and fulness 
 of each act of breathing, which you would find to be singultiform, 
 and very short ; and though the breathings might be more fre- 
 quently repeated than is natural, you should find that she would 
 not breathe enough or get the needful quantity of air, however 
 much she should strive for it, and so, the blood becoming less and 
 less reddened by oxygen, would develop in the encephalon less 
 and less of the neurosity. Such an effect allowing the heart and 
 the lungs to grow weaker and weaker, she would die at last, in a 
 good measure at least, because she had become cyanosed. 
 
 277. This tympanitis becomes in not infrequent instances, the 
 positive cause of a fatal termination of the disease in another way. 
 The cavity of the abdomen/which possesses only certain dimen- 
 sions, becomes too limited in capacity for containing the inflating 
 bowel without angulating it at the returns of the convolutions. 
 I have, upon dissection, after great tympanites, observed that the 
 large intestine was so distended, that it was not possible for its 
 return to take place, without acute angulation, at the point where 
 the bowel should turn to cross the abdomen again. 
 
 278. In a young lady's body, I found upon opening the abdo- 
 men, which previous to her death had been greatly inflated, 
 three parallel rows, each as large as a stout man's arm, lying ob- 
 liquely across the belly and extending as far as the abdominal 
 walls would permit. These parallel tracts of the colon returned 
 by such sharp angles that the bowel was effectually obstructed. 
 If you will take a sheet of paper, and roll it up, making of it a 
 hollow cylinder, say an inch or an inch and a half in diameter, it 
 might serve to represent a cylinder of intestine ; next, bend it at 
 a sharp angle, and you shall find that the tube is completely 
 obstructed by the sudden sharp angulation of it at the return, 
 so that you cannot force air through it, by blowing, even with 
 the greatest possible force, in one of the open ends of the roll. 
 This is exactly what happens in many cases of childbed fever, 
 when the tympanitis becomes very great, and I am sure I have 
 
156 CHILDBED FEVER. 
 
 seen several women die speedily, because the caliber of the intes- 
 tinal tube was thus completely closed. This was the case with 
 the young woman I spoke of in sec. 241, which I invite you 
 again to peruse. It was also the cause of death in a charming 
 woman, whom I lost here some five years ago. You may well 
 suppose that such a cutting off of the cylinder of the bowel, would 
 have the same tendency to bring on dissolution, as would a 
 strangulation of the gut by the abdominal ring, or Poupart's liga- 
 ment. Such people do suffer from a real iliaca passio, and show 
 it by the vomiting of feces, as I have witnessed in the cases. 
 
 279. I repeat, therefore, that I am always greatly alarmed for 
 my patient, when I discover that the tympany is very consider- 
 able, and that I am then always fearful that no aperient or purga- 
 tive medicines can possibly succeed in opening the bowels. So 
 I have found it in practice ; and so, I apprehend, will you find it, 
 and be able to explain the impossibility of obtaining any alvine 
 passages, on the hypothesis, or rather the assurance, that the 
 bowel is shut up by its angulation. Take care, therefore, to adopt 
 prudent measures for the obviation of so dangerous, and even fatal 
 an accident. 
 
 280. I have stretched the alimentary canal of a slaughtered 
 sheep upon the ground, and found it to be sixty feet in length. 
 In a gray squirrel, I have measured one of sixteen feet, and in the 
 human adult, I have found it fully forty -five feet long when 
 stretched across a long anatomical theatre. If you should, with 
 an enterotome, lay the whole tract us open upon its mesenteric 
 line, and then lay the intestines out like a broad flat ribbon, you 
 would probably find it four inches in width, by forty feet, or 
 four hundred and eighty inches, in length. The square of this 
 surface would therefore be 1,920 inches, or about thirteen square 
 feet. Add to this sum the rest of the peritoneal reflections, and 
 you have some sixteen or seventeen square feet of serous surface, 
 within the belly, the whole of which may be at the same time in 
 a state of inflammation. 
 
 281. Now you know that a man suffers no little constitutional 
 irritation, if he have an erysipelatous surface of six or eight 
 inches square. Such an erysipelas would create much fever, and 
 perturbation of the functions. From this it seems probable there 
 
DESCRIPTIVE OF CHILDBED FEVER. 157 
 
 are few women who could endure the expansion of the primary 
 areas of a peritonitis, until they should come to involve the whole 
 thirteen or seventeen superficial feet of the serous membrane: 
 indeed, most patients would and do sink before the area could 
 become so great. Yet I doubt not I have examined some bodies, 
 after death, in which the whole peritoneum had been inflamed before 
 the last sigh of the expiring victim. How can you, after this re- 
 presentation, wonder, when you observe the rapid overthrow of 
 all the nervous power, under such a vast inflammation as this ; or 
 why should you go aside to seek for some supposed typhus, or 
 some unimaginable poison, and bring it to explain why the 
 woman becomes so weak and exanimate? Take my word for it, 
 that in so dreadful a disease as this, there is, in general, no hope , 
 of any useful interference by the physician, or his drugs, except 
 he begin early, and, by the employment of a prompt, sufficient, 
 antiphlogistic remedy cut the disease off at a blow ; for if he should 
 be either dilatory in his ministrations, or weak in his processes, 
 but a few hours would elapse ere he should discover the signs of 
 that putridity, or that vitiation of the fluids, which, instead of being 
 causes are only inevitable consequences of the disorder. 
 
 282. In expanding peritoneal inflammations, not only does the 
 bowel soon begin to yield to the distending force of the gases 
 extricated within it; but the stomach itself grows sick, and shows 
 it, first, by a sense of weakness, then by eructations, and at length 
 by vomitings. The liver also soon begins to feel the disordering 
 influences of the obstructed meseraic circulation ; for, as the 
 whole of the blood that flows in the arteries, capillaries, and veins 
 of the digestive tube, and the mesentery and mesocolon, comes 
 out from the aortic torrent through the coeliac, and the two me- 
 senteries ; so the whole of it, except what is employed and used 
 up in the organic nutrition, and in secretions, must be gathered 
 into one stream in the portal vein, thence to pass into and be dis- 
 tributed within the liver. You cannot thus have an idea of a 
 great peritonitis, without at the same time inferring trouble in 
 the meseraic and hepato-portal circulations. But, when the peri- 
 tonitis has mounted up and spread upon the liver itself, inflaming 
 its serous coat, that organ becomes diseased ; and so, in fact, as to 
 every viscus within the belly. They all become inflamed as to 
 their serous coating, and therefore add to the confusion of irrita- 
 
158 CHILDBED FEVER. 
 
 tive perception or sensibility, under which the nervous mass 
 reels and dies. The nerve centres give up the struggle ; they can 
 no longer control the life of their subject-organs, for the nervous 
 mass is now like a drunken man ; it lies down in its intoxication 
 or exhaustion, and sleeps until it dies, while all its subjects perish 
 at the same hour. 
 
 283. In the progress of these events, when the inflammatory 
 lesions have affected the peritoneal surface of the stomach itself, 
 we might consider that organ as beginning to die ; the very first 
 signs of which are seen in an occasional eructation of air, next of 
 a small quantity of colorless fluid, then a verditer-colored mucus 
 and bile, which grows greener and darker, until, at last, great stores 
 of granular matter, suspended in thick greenish secretions, exactly 
 like the black vomit of yellow fever, show that the work of mis- 
 chief is completed, and the expiring woman dies perhaps while 
 rejecting from her stomach the last drops of cordial, that have 
 been urgently tendered to her by the hand of despairing charity, 
 still wishing friendship, or broken-hearted love. There is scarcely 
 to be met with in the whole painful mission of the physician, a 
 scene more heart-rending. He stands with folded arms, the un- 
 willing witness of a ruin, no wisdom, sagacity, or energy can 
 now prevent, or even oppose. My dear young friends, I earnestly 
 pray God to spare you from witnessing many such sights. If 
 you have hearts in the least sensible, they must be wrung when- 
 ever such occasions shall hereafter arise for you. 
 
 C. D. M. 
 
LET TEE X. 
 
 METRO-PHLEBITIS. 
 
 284. Having- exposed to you my opinions concerning the peri- 
 tonitic form of that group of inflammations denominated child- 
 bed fever, I wish now to call your attention more particularly to 
 another and most important one, I mean the phlebitic form of the 
 malady, though I have already laid before you M. Dance's views. 
 
 285. M. A. C. Baudelocque's prize-essay, entitled Traite de la 
 Peritonite Puerperale, was adjudged and crowned May 2-i, 1829 ; 
 and I beg you to note that it is a treatise on puerperal peritonitis, 
 and that it is not a work on those metro-phlebitic forms, which, I 
 expect, you will henceforth consider as the most serious and dim- 
 cult of the group of maladies collected under the general name 
 of childbed fevers. The imprint of Baudelocque's work bears 
 the date of 1830, the year in which Tonnelle's papers appeared ; 
 so that its author had not made that progress in the knowledge 
 of the pathology which became general after the appearance of 
 Tonnelle's essays. 
 
 286. Although I greatly admire Dr. Baudelocque's Treatise, I 
 may be allowed to observe that he begins it with a grave mistake, 
 in saying that "the puerperal peritonitis, which was long con- 
 founded with other diseases under the names of fevers of lying-in 
 women, puerperal fever, miliary fever, depots laiteux, inflammation 
 of the bowels, inflammation of the womb, inflammation of the 
 lower belly, &c, has always suffered under the yoke of the 
 reigning doctrines in Medicine," etc. etc. 
 
 287. I say that the author starts wrong, for he assumes that 
 peritonitis is the disease, and that metritis, &c., are the complica- 
 tions ; whereas, it is now conceded that the most deadly form of 
 childbed fever is that in which a rapid decomposition of the uterus 
 
1G0 CHILDBED FEVER. 
 
 takes place, under an inflammation which reduces the whole, or 
 large portions of the texture to the state called putrescentia uteri, 
 or putrescency of the womb ; and that, without the least implica- 
 tion of the peritoneum in the malady. Baudelocque expressly 
 states at page 161, where he begins to treat of the section of 
 "complications," that puerperal peritonitis does not always exist 
 alone, but frequently is complicated with another disorder, espe- 
 cially in hospitals; and, what is singular, he insists that the most 
 common complication is with pleurisy. 
 
 288. This is what a distinguished writer says, and I have no 
 objection to it except that it is by no means true, and that any 
 one of my Students, who should read the book, would be in 
 danger of falling astray from the truth, in childbed fever patho- 
 logy, by confiding in that author's opinion. 
 
 In a former paragraph, sec. 287, I adverted to the opinion ex- 
 pressed by the younger Baudelocque concerning the frequent 
 complication of pulmonary inflammation with childbed fever, and 
 it is true that such complications are sometimes to be met with, 
 though my own clinical experience furnishes me with few such 
 examples. 
 
 If we assume that pus excreted upon the surfaces of veins in 
 phlebitis may be transported by the torrent of circulating blood 
 that, passing through the vessels, washes away and so transports 
 the pus-corpuscles, we might infer that those corpuscles might be 
 detained in some portion of the capillary vessels of the lungs, and, 
 there arrested, give rise thus to inflammation. Perhaps this is 
 really the case, and so furnishes a good rationale of the occur- 
 rence of the pneumonia. Any person, however, who may have 
 had opportunities to observe the results of phlebitis as seen in the 
 post-mortem examination of the cases, will have observed that 
 not only is much pus to be detected in the hollows of the tubes, 
 but considerable quantities also of fibrina, or masses of exudation- 
 corpuscles, that are as liable to become detached as the pus-grains 
 themselves, and so carried forwards towards the heart. Suppose, 
 for example, a portion of solid fibrin as big as a pea to be washed 
 forwards and conveyed into the right ventricle, to be thence driven 
 into the pulmonary artery, and so impelled into a lung. It is in 
 vain to deny that the concrescible elements of the blood do, on 
 occasions, become concrete masses of various sizes, and that they 
 
OTHER INFLAMMATIONS. 161 
 
 really are to be floated in the venous currents towards the heart 
 and into the lungs. No person can deny this ; but the question 
 must come up as to what becomes of these concrete masses — when 
 will they be arrested — since they cannot traverse the fine capillaries 
 of the pulmonary arteries. The answer must be that they do stop 
 in the pulmonary vessels, and serve, like the tampon, to fill up 
 and close the channel into which they are driven to clog and 
 obstruct it. 
 
 What say you, then? Are not many of the lobular, and 
 even lobar pneumonias thus observed to attend upon attacks of 
 childbed fever, to be reasonably attributed to the lodgement of 
 concrescible materials of the blood within the delicate pulmonic 
 capillaries ? and by their intrusion, pressure, presence, and obstruct- 
 ing power, there awakening the trains of pneumonic inflammation 
 so much complained of as accidents in puerperal fevers, that 
 some authors, and among them Prof. Kitgen, are disposed to re- 
 gard the pneumonia as one of the common forms of the disease ? 
 for he uses the following words, which I here cite just as they are 
 to be found at p. 18 of Gemeinsame Deutsche Zeitschrift fur Geburts- 
 kunde, Band vi. Heft 1: "Steht aber dasjenige, was uber das 
 "Wesen des Kindbettfiebers aus der Natur des Zustandes Neuent- 
 bundener, und aus den erfahrungsgemassen Erscheinungen des 
 Kindbettfiebers entwickelt worden ist, richtig ; so muss einleichten, 
 dass hier keineswegs immer von einer Bauchfellentziindung und, 
 wo diese zugegen ist, keineswegs immer von ihr allein, die Eede 
 seyn konne, sondern dass alle Haute und selbst alle in sie gehullten 
 Gebilde der Unterleibshohle, sondern auch die der Kopf-und 
 Brusthohle, somit alle Eingeweide der drei Haupthohlen ohne 
 Ausnahme, beim Kindbettfieber entziindet sein konnen." 
 
 Now it seems to me very natural that, during the wild fury of 
 the blood, in these inflammation- fevers, the lungs, or any 
 of the contents of the three great cavities should occasionally be 
 found or become seats of inflammation. Yet I am far more in- 
 clined to adopt the rationale that they are pure results of the 
 mischievous presence of small masses of solidified concrescible 
 elements of the blood, driven into and detained within the capil- 
 laries of the organs. These incidents are far more likely to ac- 
 company the phlebitic than the peritonitic forms. 
 11 
 
162 CHILDBED FEVER. 
 
 289. There is no occasion for me to go over again an exposi- 
 tion of my views as to the nature of the true bloodvessel, or to 
 reiterate the deep conviction I have on the nature of its power 
 and office as the blood-membrane — the tissue which is 
 directly concerned in the acts of the hsematosis; I beg you to 
 refer to my sections for what I consider true and useful on that 
 point. 
 
 290. Phlebitis, which I have often treated, both as uterine 
 phlebitis, crural phlebitis, and phlebitis traumatica, is a most insi- 
 dious disorder, making considerable progress, before either the 
 woman's feelings as to disease are alarmed, or the nervous sensi- 
 bility aroused; indeed, it may exist, and prove fatal, without 
 giving pain, almost. See the following case from my notes in 
 1831 :— 
 
 Thursday, March 17, 1831 ; Mrs. F. A. J.'s second pregnancy, 
 in the seventh month ; attacked with uterine hemorrhage while 
 walking in the street, with which she became greatly alarmed. 
 Labor coming on soon, she was delivered at one o'clock this 
 morning. The infant, which was alive, came into the world with 
 a cyanosed face, and grew more and more livid, and, after a short 
 time, expired. The young lady was excessively nervous, and I, on 
 that account, directed the nurse not to allow her to see the child, 
 because its face, as black as the deepest colored negro's, might 
 dangerously shock her in her weak state. The wretched woman 
 promised obedience ; but when the young lady after wards ex- 
 pressed a strong desire to look at it, she consented, and having 
 dressed it all in white, and laid it in the little coffin, she brought 
 it to my patient's side, saying : " There, deary, there's your poor 
 little baby." My patient, who at the moment seemed as well as 
 any woman can be, under the circumstances, rose upon her elbow, 
 and looking fixedly at the object for some time, turned her eyes 
 upon the nurse, and with a wild stare and in a sort of shriek, 
 exclaimed : " That my child ! Do you dare to say I have given 
 birth to a black child ? I, I give birth to a negro !" Her ex- 
 citement was terrible. This was on Friday, the 18th. At twelve 
 o'clock she got a dose of castor-oil, that operated once slightly at 
 five o'clock, after which she had a chill, and violent pain in the 
 abdomen. I arrived again at seven o'clock, and when I reached 
 the chamber she began to laugh merrily, and said she was quite 
 
CASE OF PYEMIA. 163 
 
 well now. "Let me feel your hand, if you please, Mrs. J." "No 
 I sha'nt ; what do you want to feel my hand for ? I saw the 
 child, Doctor. I never before saw a coffin in our family. How 
 black the baby was ! But it wasn't a black child, Doctor, was it? 
 I didn't see my brother — do you know my brother was drowned 
 in Schuylkill? But I didn't see him, I only went to the stair- 
 head — I couldn't go any further." And so she rambled most 
 volubly, stopping, every now and then, to complain of pain " all 
 round" her. The skin was hot, the tongue clean, the lochia 
 abundant, uterus firm, pulse 130, belly tender to the touch. Sina- 
 pisms to legs ; dose of oil ; stupes with hot brandy. After the 
 sinapisms the delirium vanished ; oil operated freely, once. Effer- 
 vescing draughts. At twelve o'clock P. M. I found her in ex- 
 cruciating pain of the womb, which was closely condensed. No 
 tenderness, except of the womb itself. Camphor-emulsion, with 
 laudanum. On Saturday, 19th, all the signs of acute peritonitis 
 were present, and I bled her to fainting. I bled her again on 
 Sunday, the 20th. On Monday, 21st, great tympanitis. Tuesday, 
 22d, pulse 140 ; milky tongue ; tender and distended belly. I sat 
 up with her until half-past three o'clock this morning, during 
 which time she was dreadfully agitated about dying. Prayers • 
 hysterical excitement; then cataphora, with rigid locked jaws, 
 after which seemed much better; meteorism gone; pulse 150; 
 profuse warm sweats ; seven to ten alvine dejections. In about 
 two hours the hysteroid symptoms reappeared ; bad singultiform 
 respiration ; pumping up colorless liquids from the stomach. 
 Wednesday, 23d. Bad night ; a violent fit of screaming at four 
 o'clock this morning, with hysterical asthma or respiratory con- 
 vulsion; pulse 145, fuller and more vigorous ; face wears a good 
 expression; skin warm and moist, not hot; dorsal decubitus; 
 belly not in the least swelled. Has retained three enemata, one of 
 Spanish soap, and two with assafetida, making twenty fluid- 
 ounces in all. She is quite sensible. / now think she will recover. 
 Thursday, 24th. She was in a hysteroid state all day. Not much 
 tenderness, except immediately over the womb, whose fundus 
 seemed to be almost as high as the navel : it felt doughy and 
 inelastic. The pulse grew more and more frequent, and she died, 
 without struggles, and in her full senses, at three o'clock this 
 morning, having been ill for seven days. I did not examine the 
 
164 CHILDBED FEVEK. 
 
 remains. I treated this case very inefficiently, twenty-three years 
 ago — certainly, not as I would now treat a similar case. My error 
 was, in having considered the early attack as hysterical, and the 
 first severe pains as after-pains. The truth is, an area of inflam- 
 mation, rapidly becoming phlegmonous, was at the moment being 
 laid in the womb, and which afterwards became membranous, or 
 peritonitic. The latter I did cure, but I did not cure the former, 
 and it passed into phlebitis, with pysemic intoxication, evinced by 
 the symptoms I have related. I was also greatly mistaken and 
 misled, indeed, by the favorable symptoms observed on the Wed- 
 nesday, which flattered me my patient should recover, and so 
 only rendered my disappointment more bitter. 
 
 I pray you consider this case, and let it prompt you to act more 
 wisely than I did, and also let it warn you not to allow any ac- 
 eouchee to receive a fearful shock like that this poor girl had, 
 when the blackened visage of her dead baby started the wild idea 
 that her character was blasted — she knew not how. 
 
 291. Changes in the vital state of the membrana communis, 
 going on unperceived, are often found, when their existence be- 
 comes revealed, to have reached, already, an incurable stage ; and 
 it is, in fact, only when the inflammation of the vessel has really 
 passed downwards into the basement tissue upon which the mem- 
 brana communis reposes, that pain begins to be felt and alarm 
 taken. This is pre-eminently the case in the instance of crural 
 phlebitis, or milk-leg as it is vulgarly called. In many an in- 
 stance I have been the first to detect its existence for the patient, 
 who did not know, nor even suspect, that anything was wrong 
 as to the limb, until, by compressing the soleus and gastrocnemius 
 muscles against the tibia, I gave her sharp pain, and then 
 pointed out to her the swollen and painful tractus of crural vein 
 below Poupart's ligament, or the painful and hardened vessel dis- 
 tinguishable above the pubis, and along the brim of the pelvis. 
 
 292. In like manner I have seen phlebitis of the median vein 
 from venesection, which the individual knew nothing of until I 
 sought for the inflamed tractus in his arm, being led to suspect 
 phlebitis somewhere, on account of the constitutional symptoms ; 
 thus detecting an inflammation that soon afterwards destroyed 
 his life by purulent infection of the blood. 
 
PUTRESCENTIA — PYEMIA. 165 
 
 293. Professor Jorg, op. cit. 665, treats — Von der Schwache und 
 der Putrescenz der Gebarmutter im Wochenbette — of Weakness and 
 Putrescency of the Womb in Childbed. He does not refer to the 
 mere muscular debility that leads to hemorrhage, &c, but seems 
 to suppose a profound debility of the whole life of the organ, that 
 allows the tissues to undergo decomposition. In his § 710, he 
 remarks that if the weakness of the womb attains to a certain 
 degree, and is, at the same time, connected with loss of general 
 strength in the system and diminished assimilation-power, the 
 uterus passes into the condition denominated putrescency, which 
 commences in the inner surface of the cervix, without any ante- 
 cedent inflammation, and extends outwards, more or less involving 
 the entire structure. For my part, I cannot conceive of such a state 
 of a living organ, as that we observe in putrescentia uteri, being 
 brought about by any other causes than the most furious inflam- 
 mation. Inflammation is a bursting process, whenever it is rapid 
 or acute ; while slow or chronical inflammatory processes result in 
 the evolution of new forms and substances, as is finely explained 
 by M. Serres, at p^ 102 of his Recherehes aVAnatomie Transcend- 
 ente et Pathologique. Already, in sect. 252, have I expressed 
 the opinion that those rapid decompositions of the womb called 
 putrescentia uteri, are nothing else than a melting down of the 
 texture under sudden suppurations of the capillary Endangium 
 of the whole organ ; an opinion which, I apprehend, will not meet 
 the sanction of my readers in general — a circumstance I regret 
 the more, because, as it affords the only possible solution of the 
 problem why such putrescentia occurs with such hasty processes, 
 I shall conceive that they do not deem of it as they ought. 
 Look at p. 326 of A Pract. Treat, on the Dis. of the Uterus and its 
 Appendages, by Mad. Boivin and M. A. Duges ; London, 1834, 2 
 vols., 8vo., for what the authors say on this subject. But I shall 
 quote part of the paragraph : " Notwithstanding the doubts we 
 have raised, we shall perhaps be obliged to acknowledge more 
 distinctly hereafter, that partial softening is only the earliest stage 
 of phlegmonous metritis, infiltration the second, and abscess the 
 third. We are induced to think this is the case, from the circum- 
 stance of the softening being, generally, peculiar to recent and 
 severe metro-peritonitis, and abscess to the same affection, when 
 
166 CHILDBED FEVER. 
 
 approaching to, or having reached the chronic form," &c. &c. Dr. 
 Eobert Lee adopts nearly the same views. 
 
 294. I wish you to consider the womb as an organ supplied 
 with the materials of its sanguine circulation, principally by means 
 of the two uterine arteries, yet in part also, by inosculations with 
 branches of the ovaries ; these together are the only sources of 
 supply of blood for the uterus. Torrents of blood are thus driven 
 within the texture of the womb, through those afferent ducts of the 
 blood. This mass of sanguine fluid passes off through the efferent 
 or uterine and ovaric veins. Now, whenever, in a case of uterine 
 phlebitis, and under an excited state of the circulation, large 
 quantities of blood are propelled by the heart into the capillaries 
 of the womb, it must happen that, with a considerable degree of 
 phlebitis uterina, those inflamed, and, so, obstructed efferent vessels 
 shall not be able to deliver the fluid as freely as they can usually 
 do it, and therefore the womb can with difficulty be relieved from 
 the engorged and inflamed condition in which it is thus placed. 
 
 295. Whosoever is familiar with the course of a case of crural 
 phlebitis, must have observed the generally erfgorged state of the 
 whole lower extremity, and the difficulty, nay, sometimes the utter 
 impossibility of finally curing the swelling, owing to the ruin, by 
 inflammation, of the great crural vein, which is the principal 
 efferent duct for the blood of the whole leg. Certainly, all ex- 
 perienced practitioners have met with instances, in which the 
 engorgement and enlargement of the leg never could be got rid 
 of in thirty years of the subsequent life of the patient, because the 
 outlet by the efferent vein had been partially destroyed during 
 the phlebitis. Dr. Eobert Lee tells you of cases in which, by a 
 crural phlebitis, all traces of the internal iliac vein became lost, 
 like an African stream, that sinks in the sands of a desert. See 
 his account of Mrs. Jones's case at p. 294, Treatise on Puerp. Fev. 
 and Crural Phleb., Barrington & Has well's edit. His words are : 
 " On tracing upwards the obliterated vein, that portion which lies 
 above Poupart's ligament was observed to become gradually 
 smaller, so that, in the situation of the common iliac, it was lost 
 in the surrounding cellular membrane, and no traces of its 
 entrance into the vena cava were discernable." How could such 
 a limb perfectly recover ? and is it not a fact that a bad crural 
 
PHLEBITIS — PYEMIA. 167 
 
 phlebitis, though recovered from, as to the patient's general health, 
 generally leaves the extremity liable to swell, for months or years 
 afterwards, upon any excess of exercise with it, since the blood 
 conveyed to it by the femoral artery finds no easy return by the 
 ruined veins ? 
 
 296. These observations may serve to set before you, with clear- 
 ness, the idea that acute uterine phlebitis must be ever a dangerous 
 disorder, because the power of delivering the injected blood is 
 partially cut off, and, therefore, the inflammation within the tissue 
 is not likely to recover by what the authors call resolution of 
 inflammation, but strongly tends to effusion and suppuration. 
 
 297. M. Tonnelle has already shown you the ratio of cases of 
 pure metritis and phlebitis to cases of peritonitis ; see my sect. 226 ; 
 and his statements should convince you that it may even happen 
 that a woman shall die with childbed fever, consisting, essentially, 
 in inflammation of the uterine veins alone. Look at Win. Hunter's 
 famous plates of the gravid uterus, to see what is the magnitude 
 and number of those immense vessels, that he pictures as pursuing 
 their tortuous courses on the exterior of the organ, and observe 
 the effigies of their enormous openings on the cut surfaces. Those 
 plates alone are sufficient to give you the needful information as 
 to the magnitude and copiousness of the vessels, if, indeed, you 
 have not had the melancholy privilege of seeing them upon the 
 dead subject ; an opportunity that is certainly not often to be had; 
 for few men can say, with Noortuyck, "hocce opimum spolium 
 madus" for it happens to few to inspect a recent uterus at term. 
 
 298. That a woman, under these circumstances, should die, is 
 not to be wondered at ; nor even that she should quickly perish ; 
 for the whole mass of the blood has become infected ; that is to 
 say, the purulent corpuscles, formed by the inflamed inner mem- 
 brane of the veins and sinuses of the womb, are washed, by the 
 flowing blood, forwards into the heart, and thence dispersed 
 throughout the system. Blood, containing a considerable quantity 
 of pus, is singularly unapt for the purposes to which, when healthy, 
 it is destined. Xo sooner does it become somewhat charged with 
 these pernicious corpuscles than the character of the fever under- 
 goes a great and peculiar change. Some authors refer the typhus 
 character of the constitutional phenomena entirely to its presence 
 
168 CHILDBED FEVER. 
 
 in the blood, and, perhaps, with some show of justice; for one 
 cannot conceive of the transit of such corpuscles, along the capil- 
 lary routes within the encephalon, in the spinal cord, and in and 
 about the great nervous ganglions and plexuses of the sympathetic 
 system, without concluding that the greatest derangement must 
 ensue as to their vital states and the coincident forces. I am not, 
 however, prepared to attribute the typhous characteristic of child- 
 bed fever to purulent infection alone, since I am convinced that 
 many patients, dying with peritonitis pure and simple, do exhibit 
 those typhoidal characteristics during the last stages, though there 
 is not any reason to infer that purulent infection has taken place 
 in any mere peritonitic form of our disease. 
 
 299. Some persons appear to think that the pus-corpuscles, that 
 infect the blood in these grave cases, get into the stream by being 
 absorbed; and it is even imagined that pus may pass from the 
 hollow of the womb into the patulous orifices of the vessels, and 
 so, infect the mass of the circulating blood. 
 
 300. You ought, gentlemen, to consider that pus cannot be ab- 
 sorbed, because all absorptions and resorptions take place by 
 endosmose through diaphragms that shut all absorbing mouths. 
 If you answer me by saying that pus, when deposited within the 
 walls of an abscess, is known to be sometimes removed by absorp- 
 tion, I have only to make the rejoinder that this process cannot 
 take place save where a fatty degeneration of the material first 
 allows of the absorption. I repeat it, absorption of corpuscles of 
 pus, or of blood, as such, is impossible. They must previously 
 undergo a change in order to let them pass through the absorbing 
 diaphragms. If it were true, which I believe it is not, that the 
 mouths of absorbents may be open and pervious while bathed in 
 purulent matter, then you could, with some semblance of correct- 
 ness, say that the pus could be, and is, directly and in substance 
 absorbed ; but if the orifice of every absorbent is shut by a mem- 
 branous diaphragm, through which endosmose of the absorbed 
 fluid takes place, then granules or corpuscles of pus could not, 
 in any case, be absorbed; for it is as easy for you to conceive of a 
 charge of mustard-seed shot or buckshot passing by endosmose 
 within through these diaphragms, as of a drop of pus doing so, 
 since the corpuscles of it are solid substances incapable of transfer 
 
PUS-ABSORPTION — PYEMIA. 169 
 
 by endosmose. Every instance, therefore, of purulent infection of 
 the blood, has, as a condition of its existence, the inevitable com- 
 plication of a phlebitis somewhere that has passed on to the pyo- 
 genic stage. That is, the inflamed endangium has allowed the 
 formation of a purulent deposit to take place on its surface. This 
 being first done, the corpuscles of pus or the entire purulent mate- 
 rial being carried forward towards the heart in the veins, the 
 fluid becomes vitiated or infected with pus, which is p y ae m i a . 
 
 301. It will require no long years, nor any excessive application 
 to obstetric practice, to afford you opportunities to witness the 
 effects of this pyaemia, both upon the physical and intellectual 
 state of the woman; and when once you shall have become some- 
 what experienced in noting the signs of it, you will have become 
 ipso facto, able, with considerable accuracy, to determine the seat 
 of the inflammatory lesion of the veins. 
 
 302. I consider it would be a vain thing for any man to try to 
 portray the features of the case with any pretensions to give an 
 accurate delineation of them. It is, perhaps, sufficient to say that 
 in the beginning of the pyaemic affections, there is in the patient 
 an appearance of intoxication, which soon assumes an hysterical 
 or hystSroidal character. The same is, I believe, true of those 
 persons who take doses of arsenic, without speedily dying from 
 the escharotic effects of it, but who are, nevertheless, badly poisoned 
 by it ; and we are informed that, in Europe, there are numerous 
 individuals who make use of arsenic, with a view to the same 
 sort of exhilaration that others seek to obtain by alcoholic drinks 
 or opium, keeping themselves in a state of constant slight intoxi- 
 cation. 
 
 303. In some of the cases of pyaemia that I have observed, the 
 exhilaration was like that produced by champagne, with alterna- 
 tions of a sort of stupor like a drunken one, changing again to the 
 wildest delirium and the most furious violent mania, the fits 
 again giving place to the gentlest and sweetest tone of the temper 
 and spirits. I have heard such victims singing, like the dying 
 swan, while the departing soul was slowly dissolving the bonds 
 that had mysteriously connected it with its clay tenement ; and 
 surely some of these scenes are so touching that their deep traces 
 become ineffaceably impressed upon the memory, and can never 
 
170 . CHILDBED FEVER. 
 
 even be recalled without awakening those poignant regrets with 
 which they were originally connected. 
 
 My fourth letter contained a rationale of the hsematosis ; and 
 in that letter I particularly invited you to consider the manner in 
 which the haematosis of the foetus is carried on by its own blood- 
 membrane, or endangium. Now, so great must be the force 
 of that endangial tissue in its uses of inducting the nerve-force or 
 neurosity, from the solids, into the fluid materials of the blood, that 
 I cannot conceive of mutations in its vital state, as being unat- 
 tended with changes in the vital state of the blood itself. Inas- 
 much as all instances of extensive phlebitis must be regarded as 
 passing through different stages or periods in the development of 
 the inflammation, I think we may account for many of the consti- 
 tutional symptoms that are observable by referring them to pro- 
 gressive stages of the phlebitic disorder. The blood itself cannot 
 but suffer some qualitative change in passing over the surfaces of 
 veins actually inflamed, or even inflaming, and an experienced 
 discriminating eye may be able to discern, in the physical and 
 physiognomical appearances exhibited, the signs of such change 
 long before the disease has risen to the height of its pyogenic 
 stages. They say that straws show which way the wind blows, 
 and there is a something indescribable in the pulse that portends 
 the coming storm; and it has happened to me more than once to 
 prognosticate a violent phlebitis, when no taxis and no clear local 
 signs gave evidence of its forthcoming. 
 
 804. In your future cares for persons in childbed fever, I 
 warn you, to look among the general signs, as in the pulse, 
 respiration, moral and intellectual state, pain, decubitus, excre- 
 tions, &o. &c, for the motives that should lead you to the con- 
 clusion that what you have before interpreted as puerperal peri- 
 tonitis only, is, in fact, complicated with uterine phlebitis ; and I 
 now venture to aver that, whenever, under these circumstances, 
 you shall observe a combination of hysterical, or intoxicative, or 
 delirious excitement combined with the other and more general 
 phenomena of the case, you ought to suspect that you are to 
 combat one of the most dangerous forms of the whole group of 
 childbed fever inflammations; for a phlebitis will certainly par- 
 take of the nature of a phlegmonous inflammation. 
 
PHLEGMONOUS AND MEMBRANOUS. 171 
 
 305. In the forming stages of the phlegmasia, I conceive it not 
 to be possible, nicely to discriminate between the particular forms 
 the case may assume. Indeed, it might be deemed safest always to 
 suspect some complicity of the metritic or phlebitic phlegmonous 
 forms with every peritoneal or membranous one. M. Tonnelle's 
 statistic of the post mortem results cannot be safely taken as posi- 
 tively accurate. I say this, reflecting on the case that I related 
 in a former Letter, sec. 242, one, in which, I doubt not, I did per- 
 fectly cure the extensive peritonitis, and then vainly flattered 
 myself that the lady was rescued ; whereas, the dissection after- 
 wards disclosed the cause of her death, in that purulent deposit 
 in the uterine veins. I believe that you may hereafter find your- 
 selves as much misled as I was on that occasion; for, if you 
 should not treat your cases aright, you will, in many of them, 
 bring about complete resolution of the peritoneal inflammation, but 
 leave the venous inflammation unresolved, to exert its fatal power 
 some days later. I beg to suggest to you the proper reflections 
 upon the difference there is betwixt a phlegmonous and a mem- 
 branous inflammation, and that the former must, of necessity, prove 
 more difficult of resolution than the latter ; since, in the former, 
 there always is a quantity of exuded or unabsorbed materials to 
 be taken up and carried away, while in membranous inflamma- 
 tions, there being but little absorption required, it is necessary in 
 the treatment, only to impress upon the phlegmasia a resolutive 
 tendency ; which, being done, all traces of the disease may 
 soon entirely disappear. In September, 1854, I treated a case 
 of rapidly expanding peritonitis in a young girl, sixteen years of 
 age. The loss of blood by venesection and leeching was very 
 great. The area of phlogosis which had risen upwards on the 
 mesocolon must have been equal to 60 or 80 square inches. Im- 
 mediately after the bleedings the area contracted until it was less 
 than 10 inches, having a solid resisting mass of phlegmonous 
 nucleus, probably in the nature of typhlitis calculosa, the re- 
 moval of which required many days. I believe that where you 
 can cure a peritonitis by your venesection, and find some uncured 
 remainders, it will be because they are phlegmonous remainders. 
 
 306. It is thus manifest that there should exist a much greater 
 difficulty in procuring a resolution of inflammation, in uterine 
 phlebitis, than in a peritonitis on account of the obstructions in 
 
172 CHILDBED FEVER. 
 
 the efferent veins, as I explained in my sec. 242, as well as because 
 there is phlegmonous disorder. 
 
 307. In whatever members of the childbed fever group, if the 
 inflammation attains such an elevation as to transcend the power 
 of cure by resolution, the crisis must end either in effusion, 
 exudation, deposit, or gangrene ; i. e. in effusion of serum and 
 lymph, or sero-pus, or in the excretion of pure pus ; or in putres- 
 centia uteri, which is synonymous with ramollescence, or gangrene. 
 
 308. Let us suppose the case to be one of extensive peritonitis; 
 one involving the intestinal tractus, the epiploon, mesentery, and 
 mesocolon, as well as the entire intropelvic peritoneum. If it 
 attains to the stage of effusion, you are to consider that effusion 
 as the final act of the tragedy of the inflammation. In fact, the 
 effusion is the issue or last term of the disorder, the inflammation 
 ending with it. The turgescence ceases with it, the pain is 
 over, the intolerance of pressure is gone, and the woman herself, 
 as well as her friends, are rejoiced at the signs of amendment. 
 She no longer dreads the least motion ; she can turn, and even 
 sit up in bed, and receives your salutation with the confidence 
 that the danger and suffering are over. Let me advise you to 
 read the touching account given by Alex. Gordon, of the case of 
 Mrs. Low, the fifteenth in his table, to learn, how fatally her 
 friends were misled by the subsidence of her pains, when they 
 receive him " with transports of joy," while Gordon's own prac- 
 tised eye saw, in the stillness of the disease, only evidences of its 
 mortal power. 
 
 309. The effusions, though they bring the active processes of 
 the inflammation to a close, most generally, not always, lead to the 
 speedy dissolution of the victim. It is not invariably the case 
 that death follows effusions, so that all hope need not be lost as 
 soon as percussion of the belly, and other means of diagnostica- 
 tion, convince us that the cavity has become filled with fluid. 
 
 310. It is quite possible the effusion may consist in very pure 
 serum, and thus give rise to a real ascites, subject to a subsequent 
 absorption and consequent cure. I saw a woman, in the old 
 Philadelphia Almshouse, in Spruce Street, many years ago, whose 
 belly was filled and greatly distended with effusions from an 
 acute childbed peritonitis, which had assumed a hopeless charac- 
 
TERMINATIONS. 173 
 
 ter. The case was pointed out and explained to me by the late 
 Dr. Henry Neill, then one of the principal accoucheurs in Phila- 
 delphia. The patient had been long free from fever, had a good 
 appetite, and seemed in all respects comfortable, except from the 
 incommodity of so distended and heavy an abdomen. She had 
 been thus far recovered for some 14 or 15 days ; but as I after- 
 wards learned, her health declined, and she died in the house. 
 Other cases are noticed in which a spontaneous opening and dis- 
 charge of the matters of effusion have taken place, with complete 
 recovery of the women, one of whom subsequently bore chil- 
 dren. Yet alas ! when you shall hereafter meet childbed fever 
 that has passed to the stage of effusion, you may conclude that 
 nothing remains but to console and soothe the remaining few 
 hours of the woman's existence. 
 
 311. Inquiries should be often made as to the state and pro- 
 gress of the lochial discharge. It is scarcely to be expected that 
 the lochial excretion shall proceed, in cases of metritis or uterine 
 phlebitis ; and in discussing the differential diagnosis of perito- 
 nitis and the other forms, it will be always encouraging to learn 
 that the lochia proceed favorably. If the woman suffers pain, 
 referable to the womb itself; if its acts of involution be sus- 
 pended ; if the lochial matters cease to appear, or become abnor- 
 mal in their hue, consistency, and odor, you will have greater 
 reason to fear that the peritonitis is complicated with metritis or 
 phlebitis of the womb. 
 
 312. Most assuredly you should come to the conclusion that 
 this is the case whenever those singular intoxications, deliriums, 
 and fits of insanity, or mania, are conjoined with pains, tympa- 
 nitis, hurried pulsations and sinkings that are accompaniments of 
 some of the peritoneal phlegmasias of childbed fevers. 
 
 313. For the present, I shall allow my pen to rest, with the 
 purpose of continuing our communion in another letter, and I 
 rest, &c. 
 
LETTER XI. 
 
 ETIOLOGY — GERMAN NOTION OP ACUTE BLOOD-DISSOLUTION — XI- 
 WISCH'S CASE — SIZY BLOOD OF PREGNANCY — FEBRICULA OF 
 GRAVID WOMEN — CASE OF MRS. B — STATE OF THE UTERO- 
 PLACENTAL DISK— UNDISCHARGED LOBULI OF THE PLACENTA — 
 PRESSURE — CONTUSION — STATE OF CERVIX IN LABORS — OVER- 
 DISTENSION OF WOMB — RELAXATION OF ABDOMINAL WALLS AND 
 SUDDEN WITHDRAWAL OF TEXTURAL TENSION — TORPOR OF 
 BOWELS IN THE GRAVID — EXALTED VITAL STATE IN LABORS, 
 ANALOGOUS TO INTENSE HYSTERIA — .ESTHESIS— DEBILITY FROM 
 LABOR — COLD — UNREST — INDIGESTIONS — SEASONS ; TENON'S 
 TABLE OF THEM. 
 
 314. Let us to-day reason together concerning the causes of 
 childbed fever ; because if we can find ourselves well informed on 
 that subject, we shall be able, not only to make use of sound pro- 
 phylactic measures, but conduct our treatment more philosophic- 
 ally, in view of the real nature and force of the special cause in 
 any case. 
 
 315. I have already, in former Letters, said so much relative 
 to milk-metastasis, vitiation of the blood, epidemy, and contagion, 
 that there is reason for me to be watchful, lest I should here re- 
 iterate parts of what I have already said ; though, indeed, I do not 
 suppose I should present a clear exposition of childbed fever in 
 this Letter, unless I should venture on some iteration. 
 
 316. Women do certainly in some, but not in all instances, 
 become disordered in health as pregnancy advances nearer and 
 nearer to the term. They suffer from the weight, the volume, 
 the distension, the pressure, and even the presence of the gravid 
 womb. So vast a body as the uterus pregnant near term, could 
 
CAUSES. 175 
 
 not but affect the physical complacency of many among the 
 24,000,000 of women who are supposed to be pregnant throughout 
 the whole world in each successive year. Yet it is by no means 
 an uncommon thing to see them as merry and happy and as agile, 
 as in their ordinary health. Indeed, I do suppose that for the 
 immense majority of women who are gravid, their pregnancy 
 does not at all make them fit to be regarded as sick women. Nor, 
 indeed, could it be so, since the Divine Governor of the world would 
 not design that the fufilment of the most important office of re- 
 production should represent a diseased state. We should rather 
 look upon pregnancy and labor, not as states of disease, but as 
 the consummate expression of the highest physical power of the 
 gentle sex. 
 
 317. On the other hand, women, not a few, are observed to 
 suffer in gestation from torpid action of the alimentary canal ; to 
 have anorexia ; to lose, in some degree, their wholesome sleep ; to 
 have swelling, or infiltration of the limbs; to complain of renal dis- 
 tresses; to have a frequent pulse and warm skin ; a sense of fulness 
 of the head; to have cardialgia; to become emaciated; to have a dry 
 skin which is stained with ephelis ; a bitter mouth, and a foul and 
 yellow, or heated red tongue. Hydremia is a frequent concomi- 
 tant of pregnancy. 
 
 318. While, therefore, to be pregnant, does not in the majority 
 imply to be sick, it does in certain instances mean that the health 
 of the woman is disturbed. I need not remind you again of 
 Willis's theory of ferments in the blood, nor of metastasis of milk, 
 of which I discoursed so much at length in my third Letter; nor 
 does it need, perhaps, that I should cite for you the opinion of 
 Dr. Robt. Ferguson, in regard to a vitiation of the blood, which, 
 in his judgment, "is demonstrably sufficient to produce all these 
 phenomena," i. e. the phenomena of childbed fevers. Dr. Fergu- 
 son appears to have imbibed this notion from certain experiments 
 made by the French physicians MM. Gaspard (Joum. de Phys.) 
 and Cruveilhier (Nouvelle Biblio. Med). Those experiments were 
 made upon dogs, and consisted in injecting into their veins, and 
 also into the areolar tissues, fetid pus (exp. 1), recent pus (exp. 5), 
 and putrid pus (exp. 6). Likewise (exp. 14) half an ounce of 
 jputrilage made up of dog's blood and beef gravy ; putrilage with 
 
176 CHILDBED FEVEE. 
 
 vinegar and water into the jugular vein ; and lastly, ink and water 
 into the femoral vein. 
 
 319. These were some of the matters injected into dogs' veins, 
 to prove that, when a woman's peritoneum, womb, ovary, or 
 uterine veins or lymphatics become inflamed, "the phenomena 
 of puerperal fever originate in a vitiation of the fluids;" op. cit. 53. 
 I presume that a very large majority of medical readers, perusing 
 Dr. Ferguson's work, would be likely to swallow the above as so 
 much excellent gospel; and deem it a settled point, because the 
 French experimenters did such shocking things to those poor 
 dogs (some of them, by the way, got over it), that a lady in child- 
 bed fever must have vitiated fluids as the cause of her illness or 
 death. Don't you see, my dear young gentlemen, that though 
 such horrid cruelty was done on the dumb beasts, it did not give 
 them a childbed fever I and do you suppose that, if it could do so, 
 you have any grounds to infer from a " putrilage of dog's blood 
 and beef gravy," or ink and water in a dog's death, to a metro- 
 peritoneo phlebitis in a woman ! What a monstrous step in infer- 
 ring! The chaussure for such a reasoning as this must surely 
 consist in a pair of seven-league boots at least ! 
 
 320. What some of the German authors call Blut-dissolution 
 and Cholsemie, is a condition in which the blood has lost, in a 
 measure, its vitality, and along with it its cohesiveness, or rather 
 organization ; and it may happen that, in certain contingencies of 
 the health, we may meet with examples of cholasmia, where some 
 of the principles of the bile, either through loss of secretory force, 
 or through the resorptional operations, may exist in such excess 
 in the blood as to disqualify it, to a certain extent, for its offices 
 in the economy as either a nutrient or an oxygen-carrier. 
 
 321. Any person familiar with the phenomena and effects of 
 phlebitis as observed in practice, ought, with readiness, to conclude 
 that the vital state of extensive portions of veins may become alter- 
 ed in such a way as to give rise to a propensity to this blood- 
 dissolution and cholsemia; and, assuredly, whoever has 
 carefully studied the admirable essay of Mr. Dance, in vols. 18 
 and 19 of Archives Generates, must have no hesitation to connect 
 the supposed state of the blood with a morbid condition of a vein 
 or veins. Mr. Dance's essay is, Be la Phlebite Uterine, et de la Phle- 
 
BLOOD-DISSOLUTION. 177 
 
 bile en general, consider ees principalement sous le rapport de leurs 
 causes et de leurs complications. Every Student of Obstetric y who 
 can procure that admirable essay, is not excusable if he fail to 
 peruse it. Having preceded M. Tonnelle's paper, before alluded 
 to, those two essays taken together are of inestimable value in the 
 education of obstetric practitioners particularly. 
 
 322. Die Geburtskunde, &c. of Franz A. Kiwisch, II. Abtheil. 
 1 Heft, contains the remarks of that admirable writer on acute 
 blood-dissolution and cholasrnia of pregnant and lying-in women. 
 He says it is allied to a diseased state of the blood in gestation, 
 and that it sometimes exhibits its dangerous character in the 
 clearest manner ; and, as an example of the malady, he cites the 
 following curious case, which is that of a woman, twenty-two 
 years old, of a stout, well-developed frame, and who, on the after- 
 noon of the 21st of January, 1851, came from the country to the 
 Lying-in Hospital. She had hardly left the conveyance and 
 mounted the first step when she fell, and with difficulty was got 
 into the Labor Ward. It was her first pregnancy ; slightly jaun- 
 diced; face cyanotic; extremities cold; pulse scarcely discerned; 
 drops of dark thin blood from nostrils and genitalia ; small ecchy- 
 moses on skin ; could give no account of herself. The pains were 
 feeble ; os uteri large as a dollar, and tense; head high up ; foetal 
 heart plainly audible. At 10 P. M. she seemed to be sinking, and 
 was then delivered with the forceps, in half an hour after which 
 she expired. The dissection exhibited a tendency within the en- 
 cephalon, thorax, and abdomen, to oozing of blood here and there 
 from the tissues ; but there were nowhere any positive marks of 
 inflammation of the organs. 
 
 323. It appears to me that Kiwisch has here reported a case of 
 what is commonly regarded as purpura hemorrhagica, under the 
 title of blut-dissolution, and I have no objection to make to the 
 word, which, indeed, is far preferable to purpura. I pray you 
 note that this poor unfortunate, who reached the hospital but to 
 die, must have been affected in such a way that the blood had lost 
 its cohesive force or become disorganized, so that she no longer 
 possessed the strength natural to one of her apparently well-deve- 
 loped and vigorous frame. She sunk down on the steps, and died 
 in a few hours, with blood oozing from the nose, the genitalia, the 
 
 12 
 
178 CHILDBED FEVEB. 
 
 corpus mucosum cutis, the mucous membranes, aud numerous 
 points on the serous surfaces. What was this? If the power of 
 the membrana communis had not been broken down, could her 
 blood have become thus disorganized ? Her vessels were filled 
 with blood, which was already nearly dead when she arrived, be- 
 cause the blood-membrane was struck with a form 
 of disease under which it could no longer con- 
 tinue its office of nervous induction into th-e 
 blood it contained, and which it had created and hitherto 
 ruled over. 
 
 324. How often have I, in my Class-room, urged you in your 
 difficult cases to make the diagnosis by exclusions! There I 
 have repeatedly instructed you as to the manner of inquiring into 
 the state of the encephalon, and, rinding the malady not to be 
 there, to seek for it in the thorax, in the abdomen, in the articu- 
 lations, the muscles, the skin, and in the organs of the senses. If 
 the researches and interrogations addressed to the cavities, the 
 organs, and functions, show the malady to be in none of these, 
 then you have left only the blood to examine^ for that is all that 
 is left. But the blood's health and vitality is a direct dependency 
 of the Endangium, and you can make out a blood disease, or 
 endangial malady, with a certainty not at all less than that with 
 which you conclude as to a tuberculosis or a pneumonia by the use 
 of your percussions, stethoscopes, and other means of physical 
 diagnosis. 
 
 325. I am well pleased to have recited for you Kiwisch's case 
 of acute blood-dissolution, because it ought to show you that a 
 pregnant woman may, even before labor begins, have her blood 
 in such a condition as to destroy her suddenly, and also that the 
 blood might become so greatly changed, under the irritations 
 which, in pregnancy, supervene for some women, that there is 
 the highest probability of diseases following the birth of the 
 child. 
 
 326. I do not refer to such violent and fatal affections as that 
 above related, but to those lesser derangements of the blood's 
 crasis that leave the patient long imperfectly recovered from her 
 accouchement ; and in some instances, lead to topical embarrass- 
 ment and partial stasis of the circulation, that end in establishing 
 areas of phlegmasia. 
 
THE BLOOD IN" PREGNANCY. 179 
 
 327. When an area of phlogosis is once settled, it must ever be 
 uncertain to what extent it shall expand, and what mischiefs to 
 the health and life may ensue. 
 
 328. I have said in sect. 316, that to be pregnant does not, in 
 the great majority, imply to be sick. It is, nevertheless, very 
 true that you shall rarely observe that blood, drawn from a preg- 
 nant woman's arm, is without the evidences of a sizy condition, or 
 excessive evolution of its fibrin. In admitting this to be true, 
 forget not that, as the Bible says, " they that are sick need a phy- 
 sician, not them that be well," and that you will not bleed nor 
 medicate any persons who have no complaints requiring such a 
 remedy. Therefore, when you see this sizy blood, you are not 
 necessarily to infer to the sizy blood of all pregnant women, but 
 only as to those who, being sick, require the remedy. There is 
 good reason to suppose, however, that gravidity, with its last 
 attending inconveniences, does often develop a fibrinous excess 
 in the circulation, and that such excess comports with neither the 
 health nor security of the woman, who, in labor, and during the 
 consequent involutive processes, becomes extremely liable to in- 
 flammation of important tissues. In so far as this, I admit the 
 blood to be occasionally vitiated in the gravid. 
 
 329. There are many women who, toward the close of gestation, 
 become feverish ; they are constipated ; the urine is lessened, and 
 is highly colored ; the pulses are frequent ; the breath is hot and 
 accelerated ; the mouth parched with a loaded tongue ; they sleep 
 unsoundly; the appetite is lost, and they complain of pains and 
 aches, in the trunk as well as in the limbs. Such persons, when 
 you come to make the diagnosis, do not exhibit any precise topi- 
 cal lesion as manifest causes of the constitutional disturbances, 
 and we are compelled to attribute the evils complained of to the 
 irritation of the nervous mass by the fact of the weight, the tension, 
 and the intrusion of the gravidity. In these, the fluids cannot 
 remain healthy, since some change in the crasis of the blood is 
 an unavoidable dependency upon the vital state of the living 
 solids immediately related to the haematosis. One is always ap- 
 prehensive, therefore, as to the post-partum condition of such 
 pregnant women. 
 
 330. I presume it is but an aggravation of this general malaise 
 
180 CHILDBED FEVER. 
 
 that I have just mentioned, which takes the name of Febris gravi- 
 darum et parturientium, a most dangerous malady, that is apt, in- 
 deed, to show forth its whole strength and rage as soon as the 
 acts of labor are accomplished. 
 
 331. Such a state as this I have observed in several examples 
 during my long occupation as accoucheur, and I related the cir- 
 cumstances of one of them at the Phila4elphia College of Phy- 
 sicians, in whose summary of their Transactions it was published". 
 The illness in question was that of a young married lady in her 
 fourth pregnancy, who had suffered from dropsy of the ovum, 
 which had expanded the uterus so enormously, before the full 
 time, that inflammation was in consequence developed, leading 
 to her premature confinement, and resulting in her death a few 
 days afterwards. 
 
 332. Many eminent authors, as Hippocrates, Burns, Jacque- 
 mier, and Kiwisch, have pointed to the dangers that environ 
 women affected with fever at the end of the gestation. Kiwisch 
 says it may occur in any of the months of pregnancy, but is 
 more common at the seventh. That author, after describing the 
 symptoms of the fever as commencing with rigors, and going 
 on with headache, loss of appetite, dry tongue, inextinguishable 
 thirst, &c. &c, gives three cases, one of which was "in the 
 month of December, 1849. The fever began eight days before 
 the birth of the child. The patient was brought into the 
 hospital with a pulse of 140. The os uteri quite dry; violent 
 thirst ; altered expression of the face ; yellow skin ; faintness ; the 
 Uterine contractions excessively painful. But, though the labor 
 terminated naturally, the woman expired within six hours after 
 its close, and exhibited, on dissection, the evidences of incipient 
 puerperal fever, and blood-dissolution. You will, I presume, 
 meet with such cases in your own practice, though rarely. Will 
 you not be able to make out the diagnosis of such a malady, 
 especially if you should resort to the method of diagnosticating 
 by exclusions? What will you make of the signs? Shall they 
 be fevers ? Shall they be mutations of the blood's crasis depend- 
 ent upon affections of the solids of the vascular system ? Shall 
 they prove to be positive material phlegm asias — of the womb, 
 of the veins of the womb, or of the peritoneum ? 
 
UTEROPLACENTAL DISK. 181 
 
 You are to be the sole judge in the matter, and upon your de- 
 cision, probably will rest the life or death of the patient, since on 
 your decision is hinged all your clinical treatment. 
 
 333. In every labor there is an act of the greatest importance 
 to be performed by the woman — I mean the expulsion of the 
 placenta. Look at Eobert Lee's plate, and at Noortwyck's draw- 
 ing of the gravid womb, to see how the orifices of the vessels look 
 gaping into the womb's hollow, after the placenta is separated ; 
 or seize the first proper occasion to examine for yourself the pla- 
 cental superficies of a new-delivered uterus. You shall notice 
 many openings, or foramina, of various sizes ; some large enough 
 to admit only a probe, and others that can take in a goose quill 
 or a swan's quill. These openings lead into the hollow of many 
 a large uterine vein and sinus. It is from them that the blood 
 escapes after labor, in the shape of uterine hemorrhage, profuse or 
 moderate, and also of what is called the common lochia. 
 
 334. The involution of the womb reduces these apertures per- 
 haps to mere pores, or even closes them entirely ; but many very 
 discreet, wise persons of our Faculty insist that they are all and 
 invariably affected with adhesive inflammation after labor, and 
 that they could never recover but by that process. They aver 
 that the disorder which we call milk-fever, by some German 
 writers ivund-fieber, is nothing but an adhesive phlebitis, arising 
 as an indispensable process for the closing of these patulous 
 orifices. I do not wish you to understand me as adhering to 
 such an opinion as the above, but only as admitting that the 
 exposed state of these apertures leading into the uterine veins 
 does render the woman very liable to phlebitic attacks, and that, 
 in all probability, many of the worst forms of uterine phlebitis do 
 take their rise from these very points. A woman undergoing 
 this adhesive phlebitis for the restoration of these parts, might 
 well be supposed to be at risk, and that such risk consists in the 
 conversion of the adhesive into a suppurative or pyogenic inflam- 
 mation of the uterine veins and sinuses. 
 
 335. The fluids that accumulate in the cavity of the womb after 
 the extrusion of the placenta, though not always, yet they do some- 
 times become highly offensive ; to that degree, indeed, as to be 
 promptly noticed upon entering a lying-in chamber. There are 
 
182 CHILDBED FEVEE. 
 
 some women, for whom no cares of cleanliness will ever suffice 
 to quell this horrid odor of a quasi putrefaction. Indeed, there 
 must be a sort of putrefactive decomposition of the blood and 
 serum in the womb's cavity, into which air finds its way, in a 
 temperature of 98 or 100° of Fahrenheit. 
 
 336. The lobules of the placenta do not always come off com- 
 pletely, one or more of them being not unfrequently left adhering 
 to the surface; and even the most careful accoucheur cannot 
 always succeed in clearing the organ of every vestige of the 
 membranes and placenta. The deciduous coat of the womb is 
 also now and then in an abnormal or hypertrophied state, which 
 causes much of it to remain undischarged, though the practitioner 
 imagines no traces to be left within. You are not to understand 
 that on every occasion in which a lobule, or more than one, of the 
 placental mass is left in the womb after labor, a serious illness 
 will follow ; for it is by no means a very rare event to find that 
 even very large remnants of it are not expelled until the second or 
 third days ; and I have seen one case in which a portion weighing 
 perhaps two ounces, was not discharged until the fifteenth day. 
 You should know that a fragment of placenta left within the womb 
 because its adherence was preternaturally strong, does not always 
 at once die and become putrid, and so give rise to fever. If wholly 
 detached, it would certainly putrefy — not otherwise ; for Pouteau 
 speaks truly when he says "L'enfant tient a la mere, comme 
 l'arbre tient a la terre. Si l'ame vegetative a ete aneantie par 
 quelque cause dans les branches et le tronc, elle survit encore 
 dans les racines." Pouteau, OEuvres Posthumes, torn. iii. p. 14. 
 Yery well then, if large portions of placenta, and large plaques of 
 chorion and amnion are left within the uterus, they not only 
 undergo putrefaction themselves, but they entangle and detain 
 within the organ portions of coagula and of mucus that are prone 
 to rapid decomposition. Here there are fruitful causes of inflam- 
 mation, and of pernicious influence upon the nervous system; 
 causes sufficient to lay down the beginning of these childbed 
 fevers we are studying. Such causes, acting upon a constitution 
 rendered susceptible by pregnancy, by labor and its accidents, 
 stand ready, like the hair-trigger of a rifle, to hurl the mischief 
 at the slightest provocation, throughout all the parts within the 
 pelvis and the abdomen. 
 
CONTUSIONS. 183 
 
 337. In labors, the pressure of the child against the bladder 
 and urethra, the soreness consequent upon the distensions and 
 the obstructions of these parts, presently lead to what is called 
 strangury, or retention of urine ; and many a woman has such 
 strauge sensations after childbirth, that she cannot discriminate 
 as to their particular nature and causes. Hence it is, that some 
 of them allow the urine to collect within the bladder, until an 
 enormous quantity puts the cyst on the stretch, almost to bursting. 
 Many a time and oft have I abstracted with the catheter, forty or 
 fifty ounces of concentrated -urine ; and I not long since measured 
 sixty -five fluidounces that I drew off for a young woman, some 
 days after the birth of the child. All such carelessness or igno- 
 rance is totally inexcusable in the monthly nurse and attendants, 
 yet it is frequently to be deplored. Is there room to doubt of 
 the dangerous tendency of such distensions as I have here men- 
 tioned ? and is it not probable that the affluxions of an incipient 
 area of phlogosis are sometimes determined and reinforced by 
 these very states of cystic tension and painfulness ? 
 
 338. A wise, prudent obstetrician will not, in labors, suffer the 
 head of the foetus to rest too long upon the very same points, 
 knowing that the arrest of the hard cranium, and its impingement, 
 for hours together, upon the same points of resistance, cannot but 
 excite a tendency to inflammatory reaction in the parts. He will 
 always relieve it by raising the presenting part upwards in ab- 
 sence of the pains, or he will draw the head down with his for- 
 ceps; or he will lessen the head and remove it, in order to save 
 the woman's health, or life. When these cares are neglected, the 
 areas of phlegmasia, or the foci of phlogosis are planted, and the 
 expansion of them wakes up the whole train of a childbed fever. 
 
 339. The cervix uteri, in the virgin, is a cylinder; it becomes 
 a cone in the pregnant women at term. The process of dilatation 
 of the orifice, converts this cone into a wide open cylinder of four 
 inches bore, and of a capacity great enough to transmit the foetus. 
 In this process of dilatation, what a vast force of the pains is 
 sometimes required, and what resistance ! what distress, what an- 
 guish, what writhings, contortions, groans, and cries accompany 
 it ! The circle of the os is frequently torn and lacerated by the 
 irresistible energy of the contractions, hastening to expel the 
 
184 CHILDBED FEVER. 
 
 burden from the womb before the os can become dilatable. See 
 then, in these circumstances, the sufficient foundations of phleg- 
 masias, both membranous and phlegmonous, that readily pass 
 into dangerous metritis, or metro-phlebitis of the womb. Under 
 the tenesmic throes of labor, women bear down with enormous 
 force, and thus compress the whole globe of the womb by their 
 abdominal muscles and diaphragm. Coincidently with this 
 compression of the childbearing organ, everything within the 
 belly is in like manner compressed, as if stamped by an iron 
 heel, so to speak. Why then wonder, or why be astonished, to 
 find the peritoneum in a flame of inflammation, and its areas of 
 phlogosis spreading, like fire in a prairie, until everything that 
 can burn, is burned with the fire of childbed fever inflammation ? 
 
 340. The pregnant woman, at term, has the whole abdomen 
 filled with the mass of the womb, which contains, perhaps a child 
 of 10 pounds avoirdupois, a pound of water, a pound of placenta, 
 its own weight being meanwhile from a pound and a half, to two 
 pounds. I weighed two children, before I left the apartment in 
 which they were born ; one of them was 8 and the other 8J- 
 pounds in weight, besides the vast double placenta, and some 
 three pints of liquor amnii ; and I saw triplets, the sum of whose 
 weight was 21 pounds. In Aug. 1854, I weighed twins of 8J 
 each, and the placentas 2 pounds, and with probably 1 pound 
 water — 19 pounds in all. Neither of these women died, nor be- 
 came very sick ; yet it is well to call to your mind this distend- 
 ing effect of pregnancy, in order to suggest advertence to that 
 excess of sudden relaxation that follows delivery. In practice, 
 you will sometimes, in placing your hand on the abdomen, find 
 the belly like a quagmire, so utterly without textural tension is 
 it become after labor. I therefore wish you now to consider of 
 the tendencies of the sanguine circulation within the abdominal 
 cavity, brought about by this sudden and almost entire with- 
 drawal of the pressure and resistance of the abdominal walls, and 
 to inquire whether the whole tube of the aorta does not imme- 
 diately become larger, by the lateral, or latitudinal out-thrust of 
 the blood that is driven into it by every pulsation. 
 
 341. The conditions are such that this effect must ensue; and, 
 in fact, a chief if not the only motive for the use of the binder, 
 
DISTENSION — KELAXATION. 135 
 
 that universally is applied for new-delivered women is, that it 
 may safely counteract this tendency. Certainly, the failure to 
 use the binder materially increases the probability of uterine 
 hemorrhage and inflammatory turgor ; and I have seen women, 
 very faint for want of its support, who became comfortable soon 
 after its adjustment. If it may please you, I should be well con- 
 tent that you refer to my Letters to the Class, third edition, p. 557, 
 for the relation of a case that I explained upon the above-asserted 
 principles. I have seen a good many of the same kind. 
 
 342. But I wish to call your attention to the effect of this 
 suspension of the abdominal tension upon the rush of the streams 
 that issue from the coeliac and the two mesenteries, which must 
 be greatly augmented in quantity, and thus throw an excessive 
 or hypersemic circulation upon the vascular system of the entire 
 alimentary apparatus, as well as upon all its serous membranes. 
 I conceive it quite reasonable to infer, from this, to a general 
 blush of those membranes, and an accidental stasis therein of 
 masses of blood that become central areas, whence inflammation 
 radiates or expands as puerperal peritonitis; and the thought 
 suggests, that always, and most particularly in epidemic seasons, 
 we should use the binder with reference to this its real prophy- 
 lactic influence. 
 
 343. When the womb is gravid at term, the organ lies directly 
 behind the front portion of the abdominal peritoneum, and in con- 
 tact with it ; no part of the bowels coming forward, or before the 
 womb. In truth, the bowels are packed in a sort of triangular 
 cavity, where their movements are much restrained and hindered, 
 whence comes that tendency to torpor so generally complained of. 
 For the most part, women near term do suffer from unknown and 
 even unsuspected vast accumulations in the pouches, and in the 
 canal of the colon ; whence arises a heat and excitement, with 
 fluxional determinations, that are additionally provoked and aggra- 
 vated by the throes and struggles of the labor. I therefore con- 
 clude that constipation is a fruitful source of those vital conditions 
 within the belly that end in establishing the foci of inflammation. 
 Vide sect. 546. 
 
 344. Few women pass through the stages of labor without aug- 
 mentation in the number, volume, and force of those jets that are 
 
186 CHILDBED FEVER. 
 
 driven into the arteries by every systole of the heart. True, we 
 observe some of the sex who never exalt the circulation, in the 
 least, during the acts of parturition. Such, however, are cases of 
 exception, not of rule. My own experience teaches me that in an 
 active, energetic, and healthy labor, the pulse ought to become 
 greater in volume, force, and frequency ; and that this exaltation 
 should coincide with higher respiration and a fuller evolution of 
 animal heat. This gives a degree of excitement very analogous 
 to fever excitement. 
 
 345. Floods of perspiration streaming from every pore on the 
 head, neck, and thorax, keep down this paroxysmal state within 
 safe limits ; yet it is true to say, that the exaggerated rate of the 
 blood's flowing does, often, require many hours to allow of its sub- 
 sidence after the labor is over. I call upon you to reflect upon 
 the possible modifications of the blood itself, introduced by such 
 a quasi febrile paroxysm, and the eventual stasis of portions of 
 the intro-abdominal circulation, where areas of phlogosis may thus 
 be established. 
 
 346. The panic fear, the astonishment, the anguish of the labor 
 
 " Hsec volnera vitae 
 Non minimaum partem mortis formidine aluntur." 
 
 Lucretius, III. 63. 
 
 — are they of no influence to disorder and derange the protecting, 
 governing, providential power of the nervous mass over its sub- 
 ject organs? It is well, in studying this subject, to bear iu mind 
 the state of the woman's intelligent soul; that you may obviate, by 
 kind assurances, by reasonable expectations pointed out, by clear 
 exploration of her state and prospects, and by some "sweet 
 oblivious antidote," the mischievous tendency of unfounded alarms 
 and confounding terrors. 
 
 347. I went to a hotel to see a young lady, who, upon arriving 
 from a distant State, was suddenly seized with the unlooked-for 
 pains of her labor. She was much nearer to term than she had 
 imagined, and being in a land of strangers, accompanied only by 
 a young husband, you may well conceive of her fright under the 
 circumstances. One of the hotel servant-girls and the husband 
 were the only assistants. She was far from her father and mother 
 and her safe home. She was thoroughly panic-struck, and with 
 
PANIC ELEMENT. 187 
 
 every pain writhed like a wounded worm, uttering groans and 
 cries of anguish and affright. Seeing that her moral state was a 
 perilous one, I resolved to change it, and I said, " Look at me, 
 my dear! look steadily at me, and hear what I have to say." She 
 fixed her eyes upon my countenance for a short time, when I 
 added : " Do you know, my daughter, that you are behaving like 
 a little fool ? Do you know that if you are frightened for nothing 
 you will be really sick by and by; whereas, now, you are only in 
 labor, and not sick at all. Listen! when your next pain comes, 
 say to me in a soft and gentle voice, 'Doctor, I feel the pain 
 coming on [' Will you do so ? ' Yes, sir !' Yery well, then, I 
 will show you how to bear it." In a little while she said very 
 calmly: ''The pain's coming." " Yery well, then ; now, say not 
 a word. I shall press your shoulder very hard. There, now, the 
 pain is half over; now, it is three-quarters gone; and now — does 
 it hurt you still?" "Xo sir, not very much." From this time out, 
 until the child was born, she never uttered a complaint, and, in- 
 deed, went through her primipara trial with the most admirable 
 patience, and gentleness, and decency. Can you guide your 
 patients so ? It will be well for many of them if you can ; for 
 if you can quell the panic she can bear the pain, and will add 
 patience to the faith you have inspired. 
 
 3-i8. "Women, after their confinement, are often ill-guided by 
 the monthly nurses, who give improper food or drinks. Indigest- 
 ible food, or too much food of any kind, lays the foundation of 
 inflammation by the load, the acidity, the saburra thus intro- 
 duced. 
 
 349. Imprudent exposure to cold and damp blasts ; the drink- 
 ing copious draughts of iced water ; the eating of iced creams ; 
 too early rising in bed ; some ill news ; some shock to the feelings ; 
 all these have served as the foundations of a childbed fever in- 
 flammation. 
 
 350. The seasons of the year may serve as causes of childbed 
 fevers. Thus you will find in Jfemoires sur les Hopitaux de 
 Paris, by M. Tenon, Paris, quarto, 1788, at p. 261, a series of 
 tables, giving statistics of the number of children and of lying-in 
 women dying in the Hotel Dieu, in the several months of each 
 year from 1776 to 1786 inclusive. From Tenon's tables I have 
 
188 
 
 CHILDBED FEVER. 
 
 made out the following to show how many children were born in 
 each month of those ten consecutive years, and the number of 
 lying-in women who died in the same period: — 
 
 351. Table of births, with statement of the number of women 
 who died in each month, at the Hotel Dieu, for ten years, from 
 1776 to 1786 inclusive— 
 
 In January 
 In February 
 In March 
 In April 
 May . 
 June . 
 July . 
 August 
 September 
 October 
 November 
 December 
 
 Total in ten years 
 
 Births. 
 
 Deaths. 
 
 1604 
 
 127 
 
 1547 
 
 130 
 
 1623 
 
 101 
 
 1460 
 
 104 
 
 . 1438 
 
 91 
 
 1228 
 
 54 
 
 1237 
 
 58 
 
 1238 
 
 57 
 
 1224 
 
 57 
 
 1294 
 
 73 
 
 1242 
 
 137 
 
 1391 
 
 169 
 
 . 16526 
 
 1158 
 
 352. This table shows that while the mortality at Hotel Dieu 
 was so horrible, the least fatal months were June, July, August, 
 September, and October, while December was the most fatal of 
 the months for a period of ten years. Yet it should be observed 
 that, December, 1779, gave only four deaths, five in 1784, and two 
 in 1785 ; May gave thirty-three deaths in 1778. 
 
 353. To infer from the above table, as well as from one's own 
 private experience in practice, childbed fevers are less frequently 
 to be dreaded in the mild than in, the variable and cold seasons 
 of the year. Certainly, this may be stated with truth of the popu- 
 lation of Philadelphia. 
 
 354. As soon as labor is ended, the process of womb-involution 
 is fairly commenced. The evolution required a series of 280 
 days to make it complete; the acts of involution by which the 
 organ regains its non-gravid volume and quality, requires at least 
 thirty if not forty days. Now the utmost necessity exists for the 
 regular performance of these acts of involution ; any arrest, sus- 
 
SEASONS— INVOLUTION. 189 
 
 pension, or even considerable retardation of which is at once a 
 disease. The evolution of the gravid womb took place as a 
 normal physiological hypertrophy, whose limits are specifically 
 assigned. During the process of return, or involution, this 
 hypertrophy is continually being recovered from, and while the 
 reduction goes regularly on, it is normal hypertrophy ; but its 
 suspension or arrest, immediately converts the lying-in uterus 
 into a pathologically hypertrophied organ, a diseased organ. I 
 think that you will see in the above, reasons why childbed fevers 
 should be so destructive, not merely because they are inflamma- 
 tions, but because they interfere with one of the most important 
 acts of the economy of the woman. Having, perhaps, exhausted 
 your attention by these long details, I shall now close this com- 
 munication, intending to pursue another branch in the history of 
 the causation in my next. 
 
LETTER XII. 
 
 HUMBOLDT ON CLIMATE — EPIDEMY— LA ROCHE ON MIASM— COSMIC 
 
 CUVIER, AND FLOURENS, ON THE NERVOUS MASS — THE ANIMAL 
 NAUGHT BUT NERVE — MODIFICATIONS OF NERVE CRASIS CAUSED 
 BY EPIDEMY — M. CERISE — WEAKNESS OF A CAUSE THAT AFFECTS 
 ONLY ONE CLASS OUT OF MANY — ACCIDENTS. 
 
 355. "The expression climate, taken in its most general ac- 
 ceptation, serves to designate the ensemble of those atmospheric 
 variations, which in a sensible manner affect onr organs ; the tem- 
 perature, the humidity, the changes in barometric pressure, the 
 calm of the air, winds, the greater or less tension of the atmo- 
 spheric electricity, the purity of the air, or the presence of miasms, 
 more or less deleterious, and, in fine, the ordinary degree of trans- 
 parency and serenity of the sky. The last condition influences 
 not only the results of the calorific radiation of the earth, the 
 organic development of plants, and the ripening of fruits, but 
 also the moral state of man, and the harmony of his faculties." 
 — Cosmos I. 377. 
 
 356. I have extracted the foregoing paragraph from Baron 
 Humboldt's Cosmos, because, having a bearing on the evolution 
 of the disorders we are here studying, I think that you ought 
 to take into consideration not only the meaning of the word cli- 
 mate, but also the influence of it on the pregnant and parturient 
 portion of our people. Baron Humboldt's examination of the 
 influence of climate, following the excerpt above, would be highly 
 interesting to you as a study, which, I advise you to seize the first 
 opportunity to enjoy. Our common expressions in regard to the 
 
CLIMATE — EPIDEMT. 191 
 
 weather, as fine, bad, favorable, wholesome, unwholesome, bracing, 
 relaxing, exhausting, &c. &c, show that the people at large, do 
 appreciate its influence upon our vital state. Not only are we 
 affected by the thermometrical condition of the air, but by its 
 moisture and dryness, its pressure and electricity. We live, 
 indeed, here upon the earth's surface, at the bottom of an atmo- 
 spheric ocean, as Humboldt calls it, and we cannot but be influ- 
 enced by the state of the medium in which we live, and move, 
 and have our being. Hence, I say, that climate, or the conditions 
 included in the meaning of the word climate, may so affect preg- 
 nant and lying-in women, as to give, on the one hand, a great 
 tendency to fall into childbed fevers, or on the other, to hold them 
 in a great degree exempt from them. There is, it is true, much 
 difference of opinion to be found in our medical authorities, in 
 regard to the influence of particular meteorological states on the 
 bringing about of frequent childbed fever cases. It is by no 
 means a settled proposition what sort of weather is most favor- 
 able to its rise among the population. I may refer you to my 
 table from Tenon in section (351), and if you desire to follow a 
 very learned discussion on the subject, I may also point you to 
 that very singular book, Die Kindbettfieber, ein naturhistorischer 
 Versuch, von Dr. Eisenmann, Erlangen, 8vo. 1834. The author 
 is of Munich, in Bavaria. He treats the question sec. 60, and 
 page 150. I may not use space to make excerpts from his inter- 
 esting volume. 
 
 357. It is by no means just to inculcate the idea that epidemics 
 are dependencies upon the weather merely, yet it is true that we 
 meet among the population, occasionally, very numerous cases of 
 some particular forms of disorder that are suspected of being 
 epidemical ; whereas, they are not epidemic, but only weatherly 
 or climatic affections, beginning and ending with certain states of 
 the weather. You may hereafter find, therefore, in your practice, 
 that many women shall fall sick with childbed fevers, and in such 
 numbers as to lead you to say that the disease is epidemic, when, 
 in fact, it is not epidemic, but only sporadic, or let me say acci- 
 dental, weatherly and accidental. 
 
 358. As to epidemic cause, I know not what it is. I know not 
 what miasm is. Pray, open Dr. Dunglison's Med. Dictionary, at the 
 
192 CHILDBED FEVER. 
 
 word Miasma, and see for yourselves what that learned author has 
 set down for our information. I beg also to refer you to that most 
 learned and admirable volume of our townsman, Dr. E. La Koche, 
 on Pneumonia; its supposed Connection, Pathological and Etiological, 
 with Autumnal Fevers ; including an Inquiry into the Existence and 
 Morbid Agency of Malaria. At page 116, he discusses the question 
 that the non-detection of malaria is no proof of its non-existence 
 and agency : " It has been urged time after time," says Dr.La Eoche, 
 "in opposition to the malarial origin of fever, that the existence 
 of the effluvia, to the agency of which the disease is ascribed, has 
 never been proved; that their presence, in the atmosphere has 
 been inferred from the effects observed rather than positively 
 demonstrated; that they have so far eluded detection; and that 
 the air of sickly localities, whenever subjected to chemical ana- 
 lysis, has been found to contain the same ingredients, and in 
 nearly the same proportions, as that of salubrious places. Much 
 of this is doubtless true, and will not be denied by any one who 
 has endeavored to make himself acquainted with the state of know- 
 ledge on this subject. All are aware, for the fact has been often 
 referred to, that the experiments of Gattoni, and others, led to the 
 conclusion that the air of the marshes of Fuentes is as pure as 
 that of Mount Legone, one of the Grison Alps, at an elevation of 
 8,040 feet above the level of the sea. They are aware that, at 
 Martinique, Moreau de Jonnes found no difference between the 
 chemical composition of the air of Mount Tartanson, at a height 
 of some six hundred feet above the level of the sea, and the 
 valley of Case Navire; and that the atmosphere of the wards 
 of the hospital at Fort Eoyal, during the prevalence of yellow 
 fever, differed from neither. They know that Julia de Fonte- 
 nelle could detect no deleterious gases or foreign chemical in- 
 gredients in the atmosphere of infected localities ; that the latter 
 did not vary from that of healthy places in any of the principles 
 which chemical analysis enables us to discover; a result he 
 obtained in the marshes of Cerde, near Narbonne, at the Pond 
 of Pudre, at Salces, Salanque, Capestang, Cette, at Barcelona dur- 
 ing the fever of 1821, and at Paris during the cholera of 1833. 
 They also know that a distinguished chemist and professor in the 
 school of Montpellier, Bdrard, reached the same conclusions from 
 his experiments on the pestiferous air of the marshes of the coast 
 
LA ROCHE — MONFALCON — SYDENHAM. 193 
 
 of Cette; and that De*ssage obtained the same elements in the 
 most confined marshes as on the most exposed hills." The careful 
 study of Dr. La Eoche's work will prove to your satisfaction, not 
 only the existence of malaria, but convince you that mankind 
 are able to obviate its force, and even abolish its source on many 
 occasions, by sanitary measures. I am sure, you could desire no 
 stronger proofs of the power to abolish the very sources of the 
 foulest aria cattiva, or mal-aria, than that I have brought forward 
 in sects. 133-7, relating Prof, von Busch's success in disinfecting 
 his lying-in hospital by heat, or Dr. Collins's disinfecting methods 
 at Dublin Hospital. 
 
 359. I have long since said that the causes of Epidemic disorders 
 may, with probability, be assigned to certain relations that exist 
 between the deep-seated structures of the earth and the atmo- 
 spheric ocean at the bottom of which we live. Nor is it at all an 
 objection to such an hypothesis that the chemists have been un- 
 able, hitherto, to detect, as you see, by my excerpt from La Eoche, 
 any substances, gaseous or other, in the atmosphere, that might 
 serve to render it deleterious. See also the admirable work of 
 Dr. Monfalcon, Sur les Marais, for the results of many eudiome- 
 trical and chemical examinations of the atmosphere in celebrated 
 malarious places, for many confirmations of Dr. La Eoche's state- 
 ments. 
 
 The catalogue of simple substances and of gases, whether simple 
 or compound, is far from being as yet complete ; and it is no wild 
 stretch of the imagination to suppose that what Sydenham calls 
 constitutions of the air, may derive their morbid cha- 
 racteristics from the presence of deleterious substances that rise 
 from beneath the lowest strata of our globe to render the atmo- 
 sphere poisonous over vast regions of the earth's surface. Cer- 
 tainly, those modifications of the atmosphere, which introduce 
 epidemical constitutions of it, have no known relation to its 
 heat, its humidity, its pressure, its electric state, or its chemical 
 composition. Yet they do exist ; and poison not without a cause. 
 They not only exist, but are capable of concentration in certain 
 places ; as in jails, hospitals, and ships, where they exert with 
 peculiar intensity, their destructive powers ; while, at the same 
 time, malaria undeniably exists in the calmest plain, on the 
 13 
 
194 CHILDBED FEVER. 
 
 steepest hill-side, or out on the open sea ; as if a cloud, invisible, 
 should rest above a city, a nation, a continent, or a sea-tract, 
 containing within it the elements of death, fatal as the sword of 
 the angel above the sleeping hosts of the Assyrians of old. 
 
 860. There are then atmospheric causes, that render pregnant 
 and lying-in women, at particular times and in certain places, 
 uncommonly liable to attacks of childbed-fever-inflammation. 
 What the real principle of this Epidemy is, I believe there is no 
 man can say. Be it what it may, one of the most extraordinary 
 conditions connected with it is this : that it should not 
 poison men, nor boys, or girls, or non-pregnant 
 women, but only the pregnant or lying-in por- 
 tions of society. This appears to me to be its greatest 
 mystery ; and this, I think, it is, that has led to the adoption of 
 the erroneous and mischievous idea of its communicability, trans- 
 missibility, contagiousness, or infectiousness. Choose you the 
 expression most befitting. 
 
 361. It is common to attribute epidemic disorders to circum- 
 stances connected with filthiness or impurity. But who can 
 impute filthiness and uncleanness to a charming petite maitresse, 
 who is more scrupulous about dirt than about her religion, and 
 acts under the dogma that cleanliness is next to Godliness. To 
 be sure, when childbed fevers are epidemic, you would be more 
 apt to fear the attack for women crowded together in ill- venti- 
 lated hospital- wards, and packed, four in a bed, as at the Hotel 
 Dieu; and this fear is well founded; but at the same time, 
 in epidemic seasons, you are almost as anxious in regard to 
 patients in your ten-thousand-a-year-dom, as for your poor ; and 
 it is unhappily too true, that in the general and wide-spreading 
 comprehensiveness of epidemic childbed -fever, those women, who, 
 from education, habits, and modes of life, are become most 
 highly sensitive and aesthetic, are among the first victims, owing 
 perhaps to the exceeding impressionability connected with their 
 social position and rank. Do not then bring your accusations of 
 uncleanness here, but rather look into the epidemic constitution 
 of the air, if haply you may descry some oozone, some ova of 
 animalcula, some spores of vegetables floating in the breeze, and 
 entering, like a thief in the night, into the fold of the body, to 
 rob it of its treasured soul. 
 
TENON — OKEN — CUVIER. 195 
 
 362. Lying-in hospitals, with rare exceptions, have proved 
 rather a curse than a blessing to the poor. Hear what Tenon, 
 op. citat. p. 238, says of the celebrated Hotel Dieu, at Paris, 
 in 1788. 
 
 363. "The situation of the accouche*es at the Hotel Dieu is 
 most deplorable ; they are often placed two, three, andsome- 
 timesfourinabe d, some in their lying-in, and some at their 
 other epochs ; their natural evacuations infect them the more as 
 these beds become heated by this state of pressure, the health of 
 the women giving way, as the humors grow more corrupt. The 
 torments they endure are aggravated by the events that follow the 
 labor, such as tension and pain in the breasts, head, and belly ; 
 milk-fever, and an acid sweat that supervenes. Is it not in 
 those beds, where the well are confounded with the sick ac- 
 couchee, and with those seized with puerperal fever, that the cause 
 of so many deaths exists ? What is the health that could hold 
 out under such frightful circumstances? What disease might 
 not arise ? Open one of these beds of misery, and there escapes 
 from it, as from the mouth of a cavern, a damp hot cloud, which 
 floats, spreads about, thickens the air, and gives it a body so 
 manifest, that in a winter morning it opens to let one pass through 
 it, although that cannot be done without an insurmountable feel- 
 ing of disgust." 
 
 36-i. After looking then at Tenon's picture, are you surprised 
 at the table I made for you in sect. 351 ; or do you wonder how 
 it could be that Tonnelle had the opportunity to dissect two hun- 
 dred and twenty-two women dead of childbed fever in a Paris 
 hospital? Vide sec. 226. 
 
 365. But no matter what it is that gives a propensity to the 
 attack of childbed fever in its epidemic form ; whether it be sea- 
 son, climate, atmosphere, or rather epidemic constitution — malaria, 
 idio-miasm, or koino-miasm : what we have to learn is this ; in 
 what way or manner does this influence, poison, or nebula affect 
 us? What part of us does it attack, on what does it impinge, 
 and how doth it afterwards effect its morbid modifications? These 
 are the questions for us to solve ; if we could but do so great a 
 thing ! 
 
 366. Professor Oken, Baron Cuvier, MM. Flourens and Unzer, 
 
196 CHILDBED FEVEK. 
 
 have ascribed to the nervous material of living bodies, not only 
 the sensational faculty, but that of originating all vital motion ; 
 and if this teaching be just and true, then Oken is correct in say- 
 ing that an animal is naught but nerve — a sentiment fully sustained 
 by M. Flourens, in his admirable Resume of the Labors of Georges 
 Guvier. 
 
 367. For my own part, I long ago yielded up my faith, upon a 
 conviction that the physio- philosophers are right in regarding the 
 animal as naught but nerve, or as productions and evolutions from 
 nervous mass ; and I must beg you to have patience with me, 
 while I here reiterate the opinions I have elsewhere advocated 
 on the subject ; for I can by no means expose to you my whole 
 thoughts on childbed fever, unless I be allowed first to explain 
 my opinions upon the nervous system. 
 
 368. No impression can be made on any living body unless it 
 be upon the sentient extremity of a nerve, whence the impression 
 proceeds, in order to its reference to the brain or to the spinal cord 
 or to some ganglion, or some system of nerves within an organ, 
 or a tissue. Every impression must awaken a reflex force, whose 
 operation determines a motion in some part of the animal machine. 
 
 369. In breathing hot-blooded animals, the oxygen they require 
 is transmitted into the blood flowing in the capillary branches of 
 the pulmonary artery, and the blood is therefore the 
 common oxygen- carrier for the whole economy. 
 The blood, then, is an oxygeniferous body, and there is no point 
 or tissue to which the blood does not carry this oxygen, without 
 whose presence there is and can be no life. One of the conditions 
 of the problem of life, is the presence and agency of oxygen. 
 Wherever it moves within the economy, it makes impressions on 
 sentient extremities, or on nervous mass, and motion is determined 
 as the next effect. But the living blood may carry, not oxygen 
 only, but chloroform, ether, and various odoriferous substances 
 and medicinal things, which each makes its specific, peculiar 
 impression within, and awakens a resultant peculiar motion. If 
 now, the atmosphere be replete with the physical cause or poison 
 of cholera, of yellow fever, or ship fever, &c. &c, why should it 
 not, in like manner, be replete with a material that shall so modify 
 action as resultant of impression, as to make hundreds of women 
 
NERVOUS MASS — ITS FORCES. 197 
 
 prone to childbed-fever -inflammations, and yet not be of force 
 to awaken diseased action in any other class of persons in all 
 society ? 
 
 370. In the human being, and in all the higher animals, the 
 animal machine consists in its nervous mass, and the organs and 
 tissues that have been first created and evolved by it, and through 
 its power afterwards fully developed and sustained, and controlled 
 by its force. 
 
 371. Thus, the eye is but the tuber cula quadrigemina, that 
 has protruded itself into the bony orbit, and there fashioned its 
 lens, its iris, its cornea, and all the apparatus by which it is enabled 
 to receive the impressions of light. So of the ear, and the organ 
 of smelling and tasting. The arm and hand is a prehensile organ, 
 that the nervous mass protruded from the bud-like germ that 
 existed on the early embryo, and which, itself, budded out from 
 the spinal cord. The same is true with regard to the locomotive 
 members, the legs, which are dependencies and productions from 
 the cerebro-spinal and sympathetic nervous masses. 
 
 372. A lung is a breathing or oxygenating nerve, immensely 
 subdivided, expanded and clothed with the machinery indispens- 
 able for the exercise of the respiratory acts. The liver, the spleen, 
 and pancreas, the kidneys, and the alimentary canal, the skin — in 
 fine, all the organs and tissues, are but the agents, servants, and 
 absolute dependents for existence, sustenance, and power, upon 
 the regent and dominant nervous and creating nervous mass — the 
 sole perceptive and sole motive-power in an animal economy. 
 
 373. Everything within the circumference of a body dies, ex- 
 cept it be kept alive by the continual operation of the nervous 
 force, proceeding from the nervous mass. 
 
 The blood itself, dies immediately, upon the dissolution of the 
 connection between it and the living solid of the endangium 
 on which it depends, and which is itself a dependency, equally 
 absolute, upon the nervous mass that created, evolved, and sus- 
 tains it. 
 
 374. I am very sure, my young friends, that what I have 
 above said will excite a smile in many a reader, and possibly 
 many of you who have so often heard me express these opinions 
 
198 CHILDBED FEVEK. 
 
 in our class-room, will prove equally incredulous as to my exposi- 
 tion. If the limits of this volume could permit, I should here 
 endeavor to sustain my views by many an excerpt from M. 
 Cerise's paper on nervous sur-excitement, in the Trans, of the 
 Roy. Acad, of Medicine at Paris. But I am obliged to forego the 
 satisfaction of showing you, from that author, how reasonable is 
 the thought that every emanation of the nervous power from the 
 centres, is the result of contact of arterial or oxygen-blood with 
 nervous matter. But I will here cite M. Cerise's words from a 
 part of his analytical resume and conclusions, vol. ix. p. 290. 
 
 " All nervous excitation is, therefore, the. result of the concur- 
 rence of a sanguine with a nervous element. All nervous ex- 
 citement, therefore, may be represented by a product formed 
 by the contact of these two elements. 
 
 "This product, considered in its elements, may 
 be denominated neuro-arterial product, or neu- 
 rosity. Neurosity is a force, which, being dis- 
 engaged in a peripheral excitation, is trans- 
 mitted to a determinate point of the nervous 
 centre, and reciprocally; in the former case, it 
 is an act of impression; in the latter, of innerva- 
 tion." 
 
 375. But I must not yield to the temptation which would 
 seduce me to more copious excerpts from that admirable ex- 
 egesis ; and perhaps what I have premised may suffice to show 
 you that I suppose certain conditions of the nervous mass of in- 
 dividuals, or even of vast numbers of a population, may be brought 
 about by epidemic forces, that allow the subject organs to fall into 
 certain specific modes of disease, which disease will depend upon 
 the original and peculiar impression made by the morbific cause; 
 e. g., marsh miasm shall make impressions resulting in intermit- 
 tent, remittent, and continued bilious fever. Other miasms shall 
 develop the innervations peculiar to yellow fever, to Syrian 
 plague, sweating sickness, miliary and petechial fever, cholera 
 asphyxia, jail and ship fevers, childbed fevers, and so through the 
 whole catalogue of idio and koino-miasms, or zymotic disorders. 
 
 376. Now what difficulty, what hesitation, indeed, should we 
 have to admit that the nervous mass, being placed by the force of 
 
WHAT IS THE POISON? 199 
 
 epidemical impressions in a certain condition, and imbued with 
 certain dispositions and propensities, the circumstances attending 
 pregnancy and labor, should admit of or provoke the explosion 
 of the otherwise inappreciable force of those qualitative states of 
 the nervous mass, that unquestionably can be established by such 
 poisons, venoms, malarias, and epidemies ? 
 
 377. Whatever may be the nature of those agencies that render 
 childbed fevers epidemic, it is clear they must be feeble as to 
 human beings in general. Since they can exhibit their force only 
 under the favoring and inviting conditions, in which pregnancy, 
 labor, and lying-in, place our women. 
 
 378. Is it a peculiar principle or force? Look over 
 the table of epidemics at section 197 ; remember the one presented 
 at section 172 ; recall the 222 dissections by Tonnelle', or open 
 your eyes to the too obvious clinical manifestations that occasion- 
 ally shock every much employed accoucheur. 
 
 379. If the above exposition carries with it even the resem- 
 blance of reasonableness, then where shall a man stand that he 
 may preach the doctrine of the contagiousness of childbed fevers, 
 a doctrine which I am profoundly convinced could not dwell in 
 the spirit of any person who is truly well educated in Obstetricy, 
 whether as a science or as an art ! 
 
 380. I shall say nothing of wounds and other accidents, which, 
 in women pregnant, or recently delivered, might bring about 
 those terrible intro-pelvic and abdominal inflammations, that con- 
 stitute the essence of childbed fever, and which are indeed the 
 ipsissimus morbus in all the cases ; not because I fully concur in 
 the opinion of Kiwisch, that such as these ought to be excluded, 
 but that I may not unnecessarily extend these pages. Nor shall 
 I spend my time and yours by further essaying to prove that 
 there is no such disease as childbed fever, but only grave inflam- 
 mations of the womb — its veins, its ovaria, its ligaments, its peri- 
 toneum, or the general serous lining of the interior of the belly. 
 It will be my duty to show that in the treatment, you will have 
 to address your therapeutical power to the 
 subduction of these inflammations, and that 
 the measures which are inapplicable to this 
 
200 CHILDBED FEVEK. 
 
 end, are futile for all other ends in the cases. 
 In short, I shall endeavor to inculcate the opinions and practice 
 of Alexander Gordon, who was truly our reformer and guide in 
 this especial part of practice, and whose memory should on that 
 account be cherished by every Scholar of the Class of Medical 
 men throughout the whole wide world. 
 
 C. D. M. 
 
LETTER XIII. 
 
 COLLINS CITED TO SHOW THAT TYPHUS FEVER IS CONFOUNDED 
 WITH CHILDBED FEVER — PREGNANT WOMEN IN CHOLERA — 
 EIWISCH'S TESTIMONY — TYPHOID FEVER NOT CONNECTED WITH 
 CHILDBED STATES— SMALLPOX AND CHILDBED FEVER — THE 
 WOMB COMPARED TO A STUMP IN AMPUTATIONS — REMARKS 
 ON THE CONTAGION OF TYPHUS AND OTHER ZYMOTIC DISEASES. 
 
 381. In attempting to lay before you my views -upon the etiology 
 of childbed fevers, I have restrained my pen within what I deemed 
 the proper bounds of those disorders ; but I have nowhere stated 
 that all women, perishing during the lying-in, must be held to die 
 of childbed fevers. 
 
 382. The volume now lying before me is a very celebrated 
 one ; celebrated for the copiousness, accuracy, and conscientious 
 severity of its relations. It is a Practical Treatise on Midwifery, 
 containing the result of sixteen thousand six hundred and fifty -four 
 Birtlis, occurring in the Dublin Lying-in Hospital, during a period of 
 seven years; commencing November, 1826. By Robert Collins, M. D., 
 late Master of the Institution. London, 8vo. 1836. This cele- 
 brated volume has added a world-wide fame and honor to the 
 name of its excellent author, because, not only is it richly stored 
 with valuable facts, but when one looks for the truth among its 
 pages, he may not fear to find a falsehood. 
 
 383. Dr. Collins was Master of the Dublin Lying-in Hospital 
 for seven consecutive years; and what he saw and did there is put 
 down on these honest pages of his. I should be very glad to 
 believe that every Student of my Class will read it with care, for 
 it is too large and too full for me to bring forward all even of 
 what he says on the " Puerperal fever." Let me, however, quote 
 
202 CHILDBED FEVER. 
 
 from 380. "In private practice among the higher classes in 
 Dublin, puerperal fever, accompanied by the low typhoid symptoms 
 so prevalent in hospitals, is ' scarcely known." He adds, that 
 Dr. Joseph Clark, in forty -five years, had lost only "four patients 
 from this disease" by which, we are to understand, this low 
 typhoid form. Further; it does prevail among the "lower 
 classes in Dublin," and of "the same character as is observed 
 in hospitals," but never to any extent. 
 
 384. I believe that typhus is frequently met with among the 
 very poor classes, not in Dublin only, but in many parts of Ire- 
 land, as well as in other countries ; and I Jiave no objection to 
 offer, if you should say, that, during the reign of epidemic typhus, 
 women in hospitals and in ill- ventilated private houses, ought to 
 be considered very fit subjects for the action of typhus malaria, 
 during their pregnant and lying-in states. Dr. Collins, at 381, 
 mentions two instances of women brought in sick with typhus 
 fever, and placed in wards with other women, not sick at the 
 time. Some of these women, however, sickened and died ; though 
 in another case, when a typhus patient was admitted, and died on 
 the second day, no sickness ensued among the women of the 
 ward. 
 
 385. Dr. Collins gives us very plain relations of the cases of many 
 of his patients who recovered, as well as of many who died. I am 
 not sure that all who died, in this class, ought to be ranged among 
 the victims of childbed fever ; for there is no more reason why a 
 jail fever or a typhus fever patient, should not perish in her 
 lying-in, than there is why a pregnant, or new-delivered woman 
 should not perish with epidemic cholera or epidemic smallpox. 
 Dr. Collins's patient, No. 95 (vid. p. 447), "aged 36, was delivered 
 Feb. 19, at 6 A. M., of her 8th child, after a labor of one hour." 
 At 11 J P. M. same day, slight pain and tenderness of belly. Had 
 had 4 grs. calomel, and 8 of jalap some hours before delivery ; it 
 had not operated, and she now got enema with turpentine, and also 
 stuping. Pain rapidly augmenting, became in half an hour "ex- 
 tremely acute." Enema acted well. Four dozen leeches ; stupes. 
 20th, 6 A. M., pulse 120, feeble; 6 drachms castor-oil,, and 6 dr. 
 turpentine were given, and other ordinances were made which 
 need not be here cited ; but, at 9 A. M., pulse 120, not to be felt 
 
WITH TYPHUS— WITH CHOLERA. 203 
 
 in left arm ; belly soft, but full ; countenance sunk ; bowels free. 
 9 P. M., pulse 130, scarcely distinguishable ! 21st, 10 A. M., pulse- 
 less ; belly soft and little painful on pressure. Died a few minutes 
 past 11 A. M., after an illness of thirty-six hours. 
 
 386. There is Dr. Collins's case for your consideration. "What 
 do you find to say of it ? Was this one of our childbed fever 
 cases, or no ? " On dissection, not more than two or three ounces 
 of bloody serum were found in the abdominal cavity, without any 
 lymph : The serous membrane exhibited very little, if any vascu- 
 larity ; chest healthy ; no other morbid appearances. She was a 
 poor starved creature." P. 449. 
 
 387. And now that you have learned the post-mortem revela- 
 tions, what say you ? Was this a childbed fever, or no ? You 
 can decide for yourself; as for me, I admit that she died in child- 
 bed ; but if she died of childbed fever, thenthis doctrine of 
 mine is wholly wrong, in that it denies the very 
 existence of a childbed fever. 
 
 388. Kiwisch had 15 cases of cholera, in pregnant and lying-in 
 women, in his hospital, during the epidemic there. Some of them 
 recovered. 
 
 I saw a young woman in advanced cholera, confined at seven 
 months, in 1832. She recovered happily, but if the psorenteric 
 stage of the cholera had been reached, she would, probably, have 
 perished with supervening childbed fever. Many is the case of 
 sporadic childbed fever, that issues forth from what was origi- 
 nally merely a "weed," or irritation of the mammary gland; and 
 why should not a milk-fever convert itself into a metro-peritonitic 
 or phlebitic fever, or why should not an accidental rigor, result- 
 ing from a slight exposure of the person to cold damp, or follow- 
 ing some moral shock, end in laying the foundation of those areas 
 of phlogosis, which, once established, tend rapidly to expand, and 
 afterwards prove the dominants in those metamorphoses of the 
 tissues and excretes, that lead to dissolution? Within the past 
 twelve months, I witnessed the dissolution of a young lady, a 
 primapara, who perished with metro-peritonitis developed near 
 the third week of her confinement, by means of a most painful, 
 extensive mammary abscess, that, awakening the train of an in- 
 flammatory fever, fell, to use a common parlance, upon the womb 
 and peritoneum with mortal violence. 
 
204 CHILDBED FEVER. 
 
 389. Not many examples are met with of what is called typhoid 
 fever, among our class of patients; and, when they do occur, they 
 have been known to pass through all the phases of abdominal 
 typhus, until the close, without developing our peculiar phleg- 
 masia. 
 
 390. In like manner, women in labor and confinement, attacked 
 with variola or scarlatina, though exposed by the circumstances 
 to extreme peril, do, as I have witnessed, pass unharmed through 
 those diseases. Yet it is generally to be deemed a fatal thing to 
 be assaulted by either of them. 
 
 391. Though I am not prepared, with certain writers, to com- 
 pare the new-delivered womb to a stump after an ampu- 
 tation; I am, nevertheless, convinced that the condition of the 
 organ, especially as to its placental superficies, is one extremely 
 critical, owing to the compact nature of the human afterbirth, all 
 whose lobuli are united into a single cake-like disk. The pachy- 
 derms, the ruminants, the carnivora, and other creatures in whom 
 the placenta, which is an excrescence from the exterior of the 
 chorion, is more universally distributed over the inner face of the 
 uterus, escape many dangers and accidents to which our women 
 are exposed. Those accidents seem to have an almost indefeasi- 
 ble tendency to light up the fires of inflammation, in the child- 
 bearing tissues, after delivery; and the fact, undeniably, is, that 
 no accoucheur who thoroughly understands his mission as a pro- 
 fessional man, is ever completely exempt from a feeling of un- 
 certainty and anxiety as to the safety of his patients in childbed, 
 until time sufficient has elapsed to permit the involutive pro- 
 cesses of the womb to make a certain progress towards the non- 
 gravid condition. 
 
 392. I beg you now to understand me as asserting, that while 
 childbed fever is a phlegmasia, and that while there is not, in our 
 nosology, such a thing as a true idiopathic childbed fever, I yet 
 admit the possibility of typhus, jail, hospital, and ship fevers oc- 
 curring in our class of patients. Some of the cases proceeding to 
 their solution in recovery or death, without interesting, in a par- 
 ticular manner, the childbearing organs, or the peritoneum; 
 while there are others, that early establish areas of phlogosis 
 which may or may not take up the mastery in the subsequent 
 progress of the malady. 
 
IS TYPHUS CONTAGIOUS? 205 
 
 393. But all such cases as these are fevers, jail, ship, or hospital ; 
 and the childbed-fever-inflammations are occurrences after the 
 fact, and not before it. Let us endeavor to keep our minds clear 
 and free from the shackles of generalization. 
 
 394. If typhus is contagious, then in typhus among pregnant 
 women, there may be a power of transmissibility by contact or ad 
 distans, and a convertibility into childbed fever complications. 
 But I never have believed that typhus is contagious, nor never 
 can, though I can readily comprehend why a person should be 
 seized with it, on going into the malaria which causes it. While 
 I deny the contagion of cholera and yellow fever, I should prefer 
 not to inspire the choleric El Hawa of the Arabs, and would gladly 
 avoid the local sources of the latter. Even so, with my patients 
 in childbed fever inflammations, persons to whom I should be 
 very loth to communicate the inoculable virulency of a dissection 
 wound ; not purely because erysipelas and metritis are contagious 
 disorders, but purely because a newly-delivered woman, like a 
 bundle of flax, or like a pistol-pan of powder, is likely to be in- 
 flamed and go off for the smallest spark. 
 
 C. D. M. 
 
LETTER XIV. 
 
 erysipelas and peritonitis compared — error to consider 
 childbed fever an erysipelas, since it is a group of both 
 phlegmonous and membranous inflammations — dr. philip 
 pitt walsh's views on puerperal fever — dr. j. y. simpson, 
 of edinburgh, on identity of erysipelas and phlebitis — 
 ontologists. 
 
 395. You have long since become acquainted with the fact 
 that some relation, or perhaps, identity is believed to exist be- 
 tween childbed fever and erysipelas, and that, during the reign 
 of an epidemic erysipelas, particularly in general hospitals con- 
 nected with lying-in hospitals, much anxiety is usually felt for 
 the safety of pregnant and puerperal women. I presume that in 
 giving your thoughts to this topic, the very first reflection you 
 would make would be to examine the nature of your opinions 
 as to the primary or cardinal nature of the diseases that you 
 denominate erysipelas, and childbed fever. If, upon so doing, 
 you should determine that my words are quite erroneous, and 
 that childbed fever is not a primary inflammation followed by a 
 reacting fever, but a cardinal fever complicated with a peritonitis, 
 &c. ; and if you should resolve that erysipelatous inflammation 
 is but an accident or co-sign of a primary febris erysipelatosa, 
 then I see no difficulty in your adopting the sentiments of some, 
 who say that childbed fever and erysipelas are one and the same, 
 or, rather, are results of one and the same morbific cause. I 
 need not say that, in such a view, I cannot agree with you ; and 
 that, regarding the erysipelatous fever as a result of the erysipe- 
 las, I can no more conceive of it as a contagious disorder than I 
 can conceive of childbed fever as a contagious disorder. 
 
 396. There is an Euglish writer, Dr. Philip Pitt "Walsh, who 
 
P. P. WALSH— DR. SIMPSON. 207 
 
 gave us a treatise, entitled Practical Observations on Puerperal 
 Fever, &c, which was printed in 1787. Though a very incompe- 
 tent practitioner, as I conclude from his book, he was a very 
 sincere observer and reporter of what he presumed to be the truth. 
 As a full believer in the cardinal nature of the fever, he could not 
 but be an earnest contagionist of the most strictest sect. J)r. 
 Walsh does not agree with the writers, that erysipelas and child- 
 bed fever are one and the same in cause. " If," says he, "we allow 
 that erysipelas can only come on a surface covered with cuticle, 
 or its continuation, which cannot extend to the peritoneal coat of 
 the abdominal viscera; and with every accurate observer, that 
 erysipelatous inflammation is not, when pure, attended with the 
 formation of pus, the morbid exudation of coagulable lymph, and 
 the consequent agglutination of neighboring parts, we shall soon 
 perceive that something more than mere erysipelatous inflamma- 
 tion occurs here," p. 18. Dr. Walsh could not believe that puer- 
 peral fever is a "disorder, sui generis, confined to lying- 
 in women, but merely an unusual form of a very common 
 disease, and is, in reality, no other than the common infectious 
 fever complicated with a more or less extensive inflammation of 
 the peritoneum," p. 18. How could a man, holding such opinions, 
 not be a contagionist as well as a denier of the erysipelatous iden- 
 tity of our malady ? 
 
 I perceive by a late number of the Medical Examiner, that 
 Prof. Simpson, of Edinburgh, has recently put forth the opinion, 
 that erysipelas and phlebitis are diseases in the " same category 
 as puerperal fever ;" and I am free here to acknowledge the satis- 
 faction with which I thus behold the gradual development of a 
 sounder pathology of many diseases by means of a closer atten- 
 tion to, and acknowledgment of, the concern of the bloodvessels 
 in them; and I confidently trust that the day is not remote, when 
 the claims of the membrana vasorum communis, or endangium, 
 as one of the chiefest seats of the lesion in many affections now 
 wholly misinterpreted, shall be fully established and universally 
 admitted. But while it is quite true that erysipelas is endangitis 
 of the capillary vessels of the corpus mucosum cutis, that truth 
 does not make it true that peritonitis is erysipelas, any more than 
 it is true that the inflammation of smallpox is identical with that 
 of measles or scarlatina. All inflammations, being essentially 
 
208 CHILDBED FEVER. 
 
 forms of endangitis, or affections of the vasa vasorum, it would 
 seem a very difficult thing to limit the range of such inflamma- 
 tions by computing the diameters of the vascular tubes that hap- 
 pen to be the seats of them. In larger veins, or in the more 
 delicate vessels, they should be qualified as phlebitis; in the capil- 
 laries of the corpus mucosum cutis they would be erysipelas, scarla- 
 tina, measles, varicella, erythema, molluscum, and the great variety 
 of cutaneous inflammations and exanthemes, each of which would 
 present characters peculiar to the operation of the peculiar cause. 
 In the serous inflammations, we should have pericarditis, pleuritis, 
 and peritonitis, while the inflammations of the mucous membranes, 
 whether respiratory, digestive, or genito-urinary, would also be, 
 in principle, endangitis of their special capillary systems. To say, 
 then, that phlebitis, and erysipelas, and puerperal peritonitis — 
 much more the whole varied group of diseases comprised under 
 the denomination childbed fever — are one and the same in cause, 
 is going further than any man has a right to go, and further than 
 any one would go, should he take a dispassionate and critical 
 view of the cases. 
 
 As for me, I am not prepared to say that the epidemy might 
 not have power over the nervous mass so to qualify its operations 
 as to determine, in one individual, an inflammatory attack of 
 the corpus mucosum of the skin, and in another, an attack of in- 
 flammation of the serous coat of the belly; but while I say this, 
 I am very far from admitting that the facts are so ; on the con- 
 trary, I do suppose that neither you nor I are possessed of any 
 positive knowledge to warrant us in so saying. If it be true that 
 the special malaria, or the epidemy which provokes so many 
 attacks of childbed fever in epidemic seasons,, does also occasion 
 those inflammations of the corpus mucosum of the skin called 
 erysipelas, I am very sure that we do not as yet know it ; and 
 our whole duty, at the present is, to collate facts already ascer- 
 tained, to observe with care all the new examples presented in 
 our clinical experience, and leave it to our successors in a future 
 age, to deduce the law of the case. For the present, therefore, I 
 am opposed to these vain imaginings of facts and laws, and am 
 not capable to believe that there is any greater identity of putres- 
 centia uteri and metro-peritonitis, than of smallpox and yellow 
 fever. If, in a surgical hospital like Hotel Dieu, where, accord- 
 
EEYSIPELAS. 209 
 
 ing to Tenon, the air was absolutely poisonous, a wounded man 
 should be seized with erysipelas, and an inlying woman with peri- 
 tonitis, or metritis, or phlebitis, I shall not, on that account, con- 
 fess that in either of them the disease is zymotic; any more than 
 I should do so if the woman's illness were produced by laceration, 
 contusion, or other accident, and the man's erysipelas brought on 
 by intemperate habits, or irritating dressings to- his wounds. 
 
 397. The error against which I most desire to guard you, is that 
 of falling into ontologism. I mean to say that I would warn you 
 against adopting the opinion of a materies rnorbi, which I spoke 
 of already. Should you take up the notion that there is, in 
 cardinal fevers, some entity floating in the blood, or mixed up 
 with the tissues and juices of the body, and which maintains the 
 diseased actions until it is itself eliminated and cast forth by the 
 emunctories, then I am sure you would be ever astray in your 
 therapeutical indications and ministrations, and be ever fighting 
 with ontological shadows, instead of directing all the force of your 
 intelligence and skill to the removal of a disease of the living 
 solids. You are ever in your practice to oppose and cure affections 
 of the living solids; it is there you shall meet and combat the 
 material enemy of your patients' health or life, and not some 
 hypothetical ens, floating in the air of the atmosphere, and entering 
 by direct contact into the recesses of the body, or wafted from 
 great distances as halones or nebulge, to poison and change the 
 physical substance and faculties of the victim within whose body 
 it has taken up its abode. 
 
 398. Erysipelas is a disease of the skin ; and although in some 
 instances it does take on a phlegmonous character by extending 
 perpendicularly downwards into the connecting areolar texture, 
 it does so only by accident, and not as a normal process of that 
 special phlegmasia. Erysipelas is therefore a membranous, but 
 not a visceral disorder, and one of its chief characteristics is found 
 in its propensity to expand its areas of phlegmasia far and wide 
 over the plane of the membrane. Puerperal peritonitis, pure and 
 simple, is also a membranous disease, and possesses the same 
 propensity to expand its areas over the entire plane of the peri- 
 toneal membrane. In this, erysipelas and peritonitis are alike ; 
 but erysipelas and metritis are not alike. Peritonitis is also like 
 
 14 
 
210 CHILDBED FEVER. 
 
 erysipelas in this, that it has a tendency to plunge or descend 
 vertically in the basement textures of it, and so destroy the 
 epiploon, or gangrene the bowel, or produce ramollescence of the 
 exterior stratum of the uterus, or exo-metritis. In erysipelas, 
 this vertical plunge or down-sinking of the morbid status of the 
 corpus mucosum often carries it quite through and below the 
 corium, and far down into the substratum of areolar tissue, where 
 it may become either phlegmonous or oedematous erysipelas, as 
 the case may be. 
 
 399. In like manner, when you shall hereafter examine the 
 mortal remains of individuals who have died with pure childbed 
 peritonitis, though you shall not, in general, observe any other 
 than the results of a purely membranous inflammation, or inflam- 
 mation of the peritoneum, yet in some specimens you may find 
 the epiploon softened and suppurated, the ovaria reduced to a 
 pulp, or the outer stratum of the womb completely reduced to a 
 state of ramollescence or softening. In so far, then, as I have 
 drawn a parallel between the two disorders, you discern a very 
 great similarity in them ; but I would not have a Student of mine 
 leap to a conclusion, or make up his mind concerning a great 
 matter upon some sudden impulse. 
 
 400. If you will be ontologists, then you may say that erysipe- 
 las and puerperal fever are identical; but your saying so will 
 never induce me to believe that a man with erysipelas has a 
 childbed fever ; or that a woman with only a childbed fever peri- 
 tonitis, pure and simple, is laboring under an attack of erysipelas, 
 or St. Anthony's-flre in her belly. Don't you see such a conclusion 
 would be as ridiculous as it appears under my statement of it ? 
 
 401. Besides, why should you vex yourself with this foolish 
 question at all, when you are already so well informed in your 
 profession as to know that childbed fever is not puerperal peri- 
 tonitis and nothing else; and that peritonitis, in numbers of the 
 cases, does not come in question at all, the disorder being pure 
 womb-phlebitis alone, or a dissolving inflammation of the inner 
 stratum of that organ alone ; or an oophoritis, &c. &c. If you 
 must insist that erysipelas and childbed fever are one, then pray 
 leave out of question all the pure metritis and phlebitis, and 
 confine your alliance between the two, to the serous and dermal 
 
EEYSIPELAS. 211 
 
 (denticles, if they must be so considered. For my own part, I 
 could never discover any real motive for discussing this question 
 in any way, except, perhaps, it were for the purpose of giving a 
 handle to such, as, by means of it, desire to demolish all those who 
 can discern neither the philosophy nor the charitableness of the 
 contagionist party, who, themselves believing the contagion of 
 erysipelas, do not hesitate to proclaim that you may give a woman 
 childbed fever by taking care of her in her labor, after having 
 visited or handled an erysipelatous patient or subject ; thus cre- 
 ating, by force of a vivid imagination, an ens out of nothing ; and 
 then endowing it with power to produce a disease like itself — itself, 
 meantime, being an ens in posse, not in esse. Do I, then, advise 
 my Students to soil their hands with the putrilage of an erysipe- 
 latous ulcer, and go without precautions of cleanliness to deliver 
 the lady next door ? God forbid ! As soon would I advise you to 
 plunge a wounded hand into the cavities of a patient dead with 
 peritonitis, and so run a most dangerous and often fatal risk from 
 dissection wounds. If you carry your impure hands, and inoculate 
 the abraded genital surfaces of a woman in labor, with the poison 
 of the cavities, you will be as apt to give her a dissection wound, 
 as you would be to have one yourself if using a cut hand in 
 your necroscopic researches. You. would poison her as by the 
 bite of a rattlesnake, and so make her sick, and her sickness 
 would be prone to assume the characteristics of a childbed fever. 
 Is this your contagion ? Far from you, Students of my Class, 
 be the silly thought ! 
 
 C. D. M. 
 
LETTEE XV., 
 
 DESCRIPTION OF A CHILDBED FEVER CASE. 
 
 402. I heartily wish I were possessed of the power of describ- 
 ing in such a perfect degree that I could write down in this Letter 
 a circumstantial account of the appearances, incidents, feelings, and 
 all the circumstances of childbed fever cases, and do it in such a 
 way that, reading my relation, you would seem to be present and 
 witnessing the whole scene ; but this I cannot do. Many writers 
 have given us the bare histories of cases, but not one, so far as I 
 know, has really painted it for us, unless, indeed, Andrew Low's 
 wife has been brought before us bodily, as she was, in her illness, 
 by Alex. Gordon ; and unless, also, some of the stories in Eobert 
 Gooch's work possess so graphic a character that, in reading them, 
 one seems to be partaker in the incidents and sentiments he por- 
 trays. But Gooch was one of our best writers, and even he has 
 failed. 
 
 Many critics, who dislike my books, clearly declare that I can- 
 not write intelligible English, and would almost make me believe 
 that my words are all gibberish and pedantry. If Gooch even, 
 who was one of the ornaments of our Medical Literature, could 
 not fitly describe a case of childbed fever, how, then, should I 
 hope to compass so difficult a thing? Yet, I once attended a 
 young lady, the mother of three most beautiful children, who sent 
 for me in a severe winter's night, to take care of her in her labor. 
 She was a very small and delicately formed creature, of the most 
 cultivated understanding, and so thoroughly well bred that you 
 may readily suppose she would go through the pains of her par- 
 turition with the fewest possible expressions and acknowledg- 
 ments of distress, since perfectly well-educated persons always 
 behave so. 
 
A CHILDBED FEVER. 213 
 
 403. The labor was rather a trying one, in consequence of the 
 abnormal action of the womb ; for the pains, being irregular, and 
 serving at times rather to restrain than to advance the progress 
 of the presenting part, brought frequent disappointment of the 
 hopes they raised. An experienced accoucheur, meeting with a 
 case of the kind, and unable clearly to explain why such non- 
 conformable action of the several parts of the womb should occur, 
 will, for the most part, be inclined to suspect that the placenta is 
 abnormally attached, and to fear, therefore, that he may have to 
 deal with an hourglass contraction before the deliverance is com- 
 pleted. 
 
 This proved to be the case in regard to my patient. There was 
 at the time some slight epidemic disposition to childbed fevers in 
 Philadelphia, which increased my anxiety for the lady. 
 
 "When I found that the hourglass prevented the escape of the 
 placenta, as it aivvays does, I also knew that I should be obliged 
 to separate it with my hand, as I have always been, and so it 
 happened. The contraction in the uterus was slowly and gently 
 overcome by the hand, and the after-birth removed without much 
 pain or delay ; certainly with no exclamations or the least impa- 
 tience on the lady's part, and without any hemorrhage. The lochia 
 were favorable, the milk began early to come into the breasts, and 
 the pulses were good ; but, on the third day, at an early hour, she 
 had a rigor, followed by hypogastric pain, incipient tympanitis, 
 dorsal decubitus, hot skin, cephalalgia, and pulsations at 120 per 
 minute. The uterine discharge became rapidly less, paler, offen- 
 sive, and then died away, except for a dark satin left on the guard- 
 napkins, which were in the highest degree fetid. The breasts also 
 became flaccid. She was bled, the bowels were well moved, and 
 she was kept, after that, under the influence of tartrate of antimony 
 and potassa. I have no doubt the peritoneum was inflamed at the 
 time she was bled, nor have I any doubt the inflammation was 
 cured; but there was a deeper-seated, immedicable, phlegmonous 
 nucleus of disease in the womb and in its veins, that remained 
 unresolved by the treatment, and that must have some other termi- 
 nation than by resolution. 
 
 404 I need, perhaps, say nothing of the moral state of the 
 family and friends of the lady ; their anxious, scared looks, as 
 they waited on the stairs, or in the hall, or at the door, to learn 
 
214 CHILDBED FEVER. 
 
 "What of the sickness?" "Is there great danger?" "Will she be 
 well again?" nor can I tell you how that one great heart of all 
 who cherished and loved her, throbbed so, that we might almost 
 seem to hear its throbbings in many a breast that was aching. 
 The domestics walked softly, and spoke in whispers ; you could 
 hear no loud voices in that house. 
 
 What shall I say, in a weak vain hope of portraying the feel- 
 ings with which the physician approaches the bedside of one so 
 perilous: what of the deep inner conviction with which, on glanc- 
 ing at the countenance, the decubitus, the gestures ; or on touch- 
 ing that hurrying artery, or on perceiving that morbid heat or 
 coolness; on hearing those expressions that lift him, on the one 
 hand, to the height of hope, or whisperingly tell that the vein is 
 inflaming more and more, that the purulent infection is begun, and 
 that his art, like his wishes, prayers, hopes, are all alike in vain? 
 
 The pulse had fallen a little, and, the sharp pains being gone, 
 she was deemed much and hopefully better ; everybody thought 
 so — but the pulse would not go down in its frequency below 120, 
 and the skin, though not so heated as before, was still warm. The 
 tongue was white and moist. Various applications, in the way of 
 stupings of the belly, cataplasms, anodyne enemata, doses of Do- 
 ver's powder, portions of calomel with kermes, &c. &c, made no 
 real impression upon the disease within the uterine veins. Yet, 
 though the pulse remained too quick, and it was evident the lady 
 was very ill — not really better, still, she would sometimes meet me 
 with brilliant smiles and cheerful sallies of conversation, and would 
 even rise up in bed, as though a little intoxicated or out of her 
 head with her gayety. She was unnatural in her naturalness. If 
 she slept, it was but by snatches and with light flying slumbers, 
 disturbed occasionally by her own murmurings. The counte- 
 nance was usually animated by a peculiar lively look, though she 
 was pale. 
 
 At times, however, there would rest a cloud upon her counte- 
 nance, and she was mournful in her physiognomical expression. 
 The keenest anxiety now pervaded all hearts of those who were 
 about her and loved her ; for, though she did not converse or look 
 like a person very ill, and doomed, there was a deep-seated con- 
 viction in all opinions that the spirit which animated this charming 
 woman was soon to be recalled to its home beyond the skies, leaving 
 
A CHILDBED FEVER. 215 
 
 the body in this dark and mourning world, a lifeless, inanimate 
 form of clay. Who is he that can paint the trembling anxieties, 
 the flitting hopes, the more permanent terrors, the heart-swelling 
 pity and tenderness that wait on such scenes? By and by she 
 would sleep, and filled all with the hope that such benignant slum- 
 bers could not but be the harbingers of good. Then she would 
 awake from her sleep and ask if she was better — would she recover 
 again? and this with sweet smiles, amidst which the doubt was 
 nestling. She rose in bed and sat up, combed out her hair, and 
 bound up her tresses in tasteful arrangement. She sang the 
 sweetest and softest harmonies, and looked so arch and so be- 
 witching, that one could not avoid the suspicion she was acting a 
 part. No actress could be so like a sense-stricken Ophelia. 
 
 Meanwhile, the pulse at 120 to 130, the rapid absorption of the 
 fat and the growing marcor, and the viscid sweats on the arms, kept 
 marshalling the way to the grave. Little complaint was made of 
 pressure on the hypogaster, though on firm contact pain was felt. 
 The tympanitis was over. A small diarrhoea began to grow trou- 
 blesome ; and now and then very violent fits of excitement, with 
 restless jactitation, showed that the pus-corpuscles were poisoning 
 the sources of life in the nervous centres, to which they were 
 transported with the blood. Then came calm tranquillity, the 
 greatest gentleness, scrupulous politeness, and careful attention to 
 her personal appearance and array. But the pulses ever beat faster 
 and weaker. Eructations of gases; then of colorless fluids; then 
 porraceous vomitings ; then darker ones, and at last black vomit ; 
 lessening pulses; increased respiratory efforts; cooling hands and 
 feet, that turned bluish in their cyanosis ; until at last, a death-like 
 coldness overspread the limbs, and the icy king advanced slowly 
 to the conquest he made over what was most enchanting among 
 educated, elegant women. Stupor, lethargy scarcely to be roused, 
 then deep coma, and at last death — rest for the victim, and tears 
 and suppressed moanings for the bereaved. Why say all this? 
 Why, a physician to practise Midwifery must be made of stone if 
 he would not feel on these occasions; 'and, if he have a heart of 
 flesh, he surely deserves the sympathy of all good people when 
 he turns away a baffled man, after faithful, well-conducted efforts 
 to save one whom no art could save. 
 
 405. I have described one of the scenes of fatal childbed fever. 
 
216 CHILDBED FEVER. 
 
 I have not done it merely to excite your sensibility, but in order 
 that you might, if possible, see how it is that, in one of those 
 cases, even when early called, and applying conscientiously and 
 wisely too, all the resources of your professional skill, you shall 
 be disappointed of any good fruits from them, because the deep 
 and peculiar seat of the disorder in the uterine veins, makes it 
 impossible to determine, in cases of metro-peritonitis, whether or 
 no your early administrations have destroyed the monster at a 
 blow. It is, as Legouais told you, like fighting the Hydra ; when 
 one head is cut oflj there is another to rise more fierce and furious. 
 I do believe, however, that in those cases that consist mainly in 
 the peritoneal form of the inflammation, you will cure the far 
 gseater majority of your patients whom you shall visit very soon 
 after the formation of the attack; and besides these there are many 
 worse ones to be rescued by science and skill, governed by cou- 
 rage. For Grod's sake, then, omit no means that may serve to early 
 notify you of the assault, and never stop short of the greatest 
 precision and certainty in all your diagnostic proceedings. 
 
LETTER XVI. 
 
 DIAGNOSIS OF CHILDBED FEVERS BY INQUIRIES AS TO PAIN, RIGORS, 
 THE BREATHING, SORENESS OR TENDERNESS OF THE BELLY — 
 THE MAMMARY GLANDS AND MILK — INTERMITTENCE OF THE 
 PAIN — THE BLADDER OF URINE — IS IT A URINARY OR A UTE- 
 RINE PAIN? — THE EARLY PHLEBITIS NOT PAINFUL — DATE OF THE 
 ATTACK, AND THE TIME ALREADY ELAPSED — MILK FEVER — M. 
 CHEVILLARD'S CASE— REMISSIONS IN THE CASES — ONE DESCRIBED 
 BY TONNELLE — MILK FEVER WITH AFTER-PAINS, OR INCIPIENT 
 CHILDBED FEVER? — TOUCHING, AS A DIAGNOSTIC PROCEEDING IN 
 CHILDBED FEVER — THE TYMPANITIS — COMPARE PAINS OF PHLE- 
 BITIS AND PERITONITIS — THE MIND — PUS — INTOXICATION. 
 
 406. A physician entrusted with the care of a lying-in woman, 
 ought to be so well versed in the nature of all acute diseases that 
 he should almost never err in his diagnostications; and I think 
 there is almost no disorder he could be called to treat, in which 
 it is more important that his diagnosis should be early and dis- 
 tinctly ascertained, than in these. 
 
 407. Childbed fevers, however, are, perhaps, not always to be 
 at once ascertained, because there are other affections of puer- 
 peral women, that possess features strikingly similar to them. 
 For example, one of the most considerable marks of childbed 
 fever is pain in the iliac and pelvic regions, following a chill, and 
 accompanied with a frequent pulse and soreness of the hypogas- 
 trium on pressure, and unwillingness to move for fear of pain in so 
 doing. But there is many a woman whose womb, after delivery, 
 becomes very sore if moved by a hand placed on the hypogas- 
 trium, or by a cough or by any change of position ; and in these 
 very cases the woman hardly shall avoid suffering from after- 
 
218 CHILDBED FEVER. 
 
 pains, as they are called. Now, whenever the muscular tissue 
 of the womb contracts forcibly, the womb being thus sore or 
 sensitive, the patient experiences the greatest distress, and some 
 women are liable to a return of the contractions every five or six 
 minutes. 
 
 408. How will you distinguish these pains from those of a peri- 
 tonitis ? It is to be expected that the nervous centres, feeling these 
 impressions, shall send back a stream of reflex innervations, and 
 so augment the number of the respirations as well as the animal 
 heat. Chilly fits are likely to attend these occurrences, and when 
 you come in to make inquiries, how shall you decide? Is there 
 an area of phlegmasia already laid, or no? that is the question to 
 be settled; for, if there is such an area, then you surely should 
 adopt convenient measures for its cure; and if not, then the suf- 
 fering of the woman may be probably relieved by a purely anae- 
 sthetic method, less costly to her health and patience. 
 
 409. The doubts and uncertainties that wait upon such circum- 
 stances, are extremely painful to the quick-minded physician, 
 who, unwilling to take severe, and perhaps unacceptable measures, 
 balances between two opinions when he is most desirous to know 
 the absolute truth. I could not if I would, tell you what pun- 
 gent distress I have experienced in this way on many an occasion, 
 depriving me of all comfort and driving sleep far from me through 
 the perturbations of my soul. I endeavored to relate such an in- 
 cident in my Letters on Women, &c, 3d edit. p. 559. 
 
 410. I have striven earnestly to carefully ascertain in such cases, 
 whether the pain, or rather the soreness, were permanent or no ; for 
 I supposed that where a red, hot, painful inflammation has been 
 really formed, there could occur no moment of time in which the 
 soreness or painfulness would not be detected by careful pressure 
 with the hand, at the same time calling the patient's attention to 
 the objects of the inquiry, and so, deriving good inferences from 
 her replies to questionings. In what are called after-pains, the 
 globe of the womb becomes hard as a stone, and will not then 
 bear the least pressure without complaints from the woman ; but, 
 as these contractions, like labor-pains, rarely last more than 
 twenty-five to fifty seconds, and as the womb, after the contrac- 
 tion is over, becomes soft and flaccid 3 and painless, the woman 
 
DIAGXOSTICATION. 219 
 
 can now bear to have the lower belly and the iliac region freely 
 moved by the hand, and that without any complaint whatever. 
 Not so when the womb or peritoneum is really inflamed. This 
 is a good diagnostic sign or difference, for interrupted soreness 
 and pain leads to inferences different from those produced by 
 uninterrupted pain and soreness, or tenderness of the belly. 
 
 411. You ought not, however, to confide absolutely in this dif- 
 ferential diagnosis; for it is quite true, as I have said in a former 
 section, that an inflaming vein does not, at first, prove painful ; 
 but when the basement-tissue, on which it rests, has begun to 
 participate in the inflammatory turgor, then it becomes exceed- 
 ingly painful. There is, therefore, some liability to mistake in 
 the beginning, if you rely exclusively on the patient's answer to 
 your inquiries: "Does this hurt you?" u Is this point sore or 
 painful?" for the constitutional reaction may, all the while, have 
 its source in the painless phlebitis ; painless, I say, except when 
 the muscular organ of the womb, by crushing under its spasmodic 
 force of contraction, all the textures it incloses, brings out evi- 
 dence of the secret or hidden painfulness, now rendered obvious 
 by moans or cries. Take care that you do not make a serious 
 mistake which might lead to her destruction, by giving you a 
 false indication of treatment. I shall hereafter (section 496) tell 
 you that the loss of time is equal to the loss of a life. 
 
 412. As to the chill, the quick pulse, how are you to infer con- 
 cerning them ? 
 
 You should minutely examine the state of the breasts, and the 
 milk secretion. Does the rigor, and does the hurried pulse, &c, 
 refer to a constitutional disorder called milk-fever ? If the 
 breasts are large, warm, tender to the touch, and filled with un- 
 drawn milk, you have a very legitimate inference from those cir- 
 cumstances to the constitutional disturbance ; and it is generally 
 though not uniformly the case that, as soon as the womb or the 
 intro-pelvic peritoneum begins to give way to diseased action, the 
 breasts shrink, become flaccid, and secrete little or no milk. 
 
 You could hardly suppose, gentlemen, that in a furious inflam- 
 mation of the parts contained within the pelvis and abdomen, and 
 when the circulation and the nervous forces are so violently shaken 
 and disturbed, the quiet, gentle operation of the mammary glands 
 
220 CHILDBED FEVER. 
 
 should go on with an even tenor of their functioning. On the 
 contrary, the extreme disorder of all the parts below the dia- 
 phragm, might be expected to exercise a kind of cumulative life 
 action, on the principle that pars dolens trahit. To find, therefore, 
 a full breast of milk in a woman laboring under severe childbed 
 fever, would be something strange. Even when the attack of the 
 inflammation does not come on until the breast has already be- 
 come fully distended, and rife with abundant secretion of milk, 
 the production becomes lessened soon after the attack of the 
 phlegmasia, and rapidly ceases altogether, leaving the breasts 
 quite flaccid and shrunken. Walsh says of his patients, p. 9, that 
 they appeared in some of the women as flat, as the generality of 
 persons of the male sex, even of a spare habit, are found to have 
 them. 
 
 Your studies in this line will show you that hundreds of our 
 brethren have used all the means in their power to provoke the 
 breasts to the fulfilment of their lacteous functions, and to invite 
 back the secretion when it has failed. For my part, I expect it 
 to disappear, and I do not believe anything we can do can pre- 
 vent it. Neither, indeed, do I suppose that if the secretion con- 
 tinues and the woman recovers, we ought to attribute the escape 
 to the continued production of the milk, but rather that we should 
 allow for the continued secretion, on the hypothesis that the dis- 
 ease was not violent enough either to suspend the mammary 
 action or to destroy the life of the woman. Attention to the 
 breasts, therefore, seems to me less important than it is usually 
 imagined to be. 
 
 Though this loss of the milk is one of the most common inci- 
 dents in the practice of obstetricy, and one, therefore, familiarly 
 known to all physicians, I will take the liberty to put down here 
 a very remarkable relation of one that was deemed so important 
 by MM. Halle* and Vicq D'Azyr, as to be reported on by them 
 for the Eoyal Society of Medicine. It is to be found in the Hist, 
 de la Soc. Royale de Med. vol. viii. p. 261. The case occurred in 
 the practice of M. Chevillard, physician at Lons le Saulnier, pro- 
 bably in 1784 or '85. The date is not given. You will please 
 notice in the relation the then prevalence of the milk dogma. 
 
 413. " The patient, who was nursing a child, had for some time 
 been troubled with a double quartan ague. She weaned the child 
 
THE MAMMARY GLANDS. 221 
 
 without taking any precautions, because she suspected that she had 
 become pregnant again. The milk coagulated in the left breast, 
 and the engorgement became painful. During five or six days, 
 many applications, good and bad, were made, but there was great 
 surprise one morning, upon taking off an emollient poultice mixed 
 with saffron, to find the swelling entirely gone, and from that 
 morning the tertian also wholly disappeared. The abdomen had 
 become meteorized and excessively painful ; the pulse hard and 
 small. There were frequent faintings, accompanied with efforts 
 to vomit ; both stool and urine were suppressed, and the use of 
 the catheter became necessary. The administration of the ipeca- 
 cuanha, which, notwithstanding the pregnancy, and certain other 
 unpleasant circumstances, was repeated four times, removed in 
 succession some of the symptoms. At the third dose the urine 
 became more abundant, but the right hypochondrium became 
 swelled and painful. The loins, the hips, and the thighs were 
 successively attacked with pain after the hyopchondrium became 
 relieved, and then the double tertian resumed its course. The 
 woman slowly recovered, and was, in the end, safely delivered, 
 and suckled the child, notwithstanding the paucity of the milk 
 and the unhealthy state of her bowels, not yet wholly recovered 
 from." MM. Halle and Yicq D'Azyr remark upon the strangely 
 sudden metastasis of milk, that was supposed to be coagu- 
 lated within the breasts, but which, nevertheless, "transferred 
 itself bodily in a few hours, into the abdominal 
 viscera." They doubt, however, that what was considered 
 coagula, was nothing more than knots of milk vessels, over dis- 
 tended. Yet both these eminent gentlemen regarded the whole 
 affair as a case of milk-metastasis. 
 
 411. You may interpret the above case according to your 
 own judgment; as for me, I have related it to you for the pur- 
 pose of exemplifying the disposition of the breast to lay aside its 
 vital activity, whenever some other more important organ or 
 viscus calls around itself the reacting forces of the nervous and 
 sanguine system. I wish you to read in it a lesson, teaching you 
 that, in those doubtful diagnoses, you ought cautiously to con- 
 sider the state of the breasts, and draw from them inferences, 
 which, added to others, become at last the accumulated evidences 
 
222 CHILDBED FEVER. 
 
 if not proofs, that the pains, heat, soreness, immobility, &c, &c, 
 are, or are not dependencies of areas of phlegmasia within. 
 
 415. I onght to pnt you in mind that you are occasionally to 
 treat cases of childbed fever that tend to embarrass your judg- 
 ment by a set of remissions which prompt you to suspect them of 
 possessing a malarious or intermittent origin and nature. These 
 remissions often become so considerable as occasionally to induce 
 the attendant to look upon the disease as conquered, just as hap- 
 pens in yellow fever at the close of the paroxysm ; but the calm 
 is treacherous. When the paroxysm is renewed, it will gene- 
 rally be found accompanied with evidences of purulent infection 
 of the blood. Here is one of Tonnelle's cases that I cite for you 
 from page 365. Marie M., set. 28, good constitution, was attacked, 
 three days subsequent to a natural labor, with symptoms of 
 serious puerperal fever. The disorder, which was treated by 
 means of copious topical depletion, soon showed signs of amend- 
 ment, and on the 8th clay seemed to be completely cured. But 
 there soon came on headache, buzzing in the ears, agitation and 
 depression, and by turns a little delirium. The 13th day she had 
 chills, and the pain in the abdomen, that had wholly disappeared 
 for a long time, came back again. These signs of relapse were 
 combated by means of mercurial frictions, of two ounces, twice a 
 day ; she grew better under it, and seemed again convalescent ; 
 began to get up and to take food. Nevertheless, she was a little 
 feverish every day, and grew thinner. On the 22d day, the legs 
 were enormously infiltrated. On the 29th, the abdominal pain, 
 vomiting, and fever returned, and did not again cease until, on 
 the 31st, she fell into a state of extreme prostration, and died. 
 There was pus in the peritoneal sac, with false membranes. The 
 womb was perfectly natural. The hypogastric veins contained 
 pus. The iliac and part of the cava had a clot, with pus in the 
 centre of it. 
 
 416. But, after all, you have a very sure resource for satisfying 
 your conscience in those instances wherein you cannot clearly 
 determine whether the disease is only milk-fever with after-pains, 
 or whether it is really incipient childbed fever ; and that resource 
 consists in your power to act. I have many times, amidst hesi- 
 tations, doubts, fears, and the extremest anxiety, resolved them 
 
DIAGNOSTICATION". 223 
 
 all by taking the safest view of the question, which I did by pro- 
 ceeding as if I were healing a case of childbed fever. That is to 
 say, I made my venesection, ad jugular -e febrim, and rested in an 
 ever unresolved doubt, whether by doing so, I had cured my 
 patient of a milk-fever, or of a childbed fever. I advise you 
 always to take the same method, believing that this is the best 
 practical direction I can possibly offer you, under such circum- 
 stances. If the milk-fever is violent enough, and attended with 
 neuralgia of the uterus sufficient to make you doubt of the diag- 
 nosis, it will, ipso facto, present motives sufficient to induce you to 
 prescribe a proper venesection, and that is the safest and best 
 thing you can do. 
 
 417. Alas! you will not always come in early to visit the 
 patient stricken with these dreadful disorders. You may be 
 called, in consultation, after many days of the disorder are 
 already past, and when great doubts still exist concerning the 
 nature of the malady. A very excellent resource for clearing 
 up your doubts will be found in referring to the state of the 
 bladder of urine — whether it acts well, and without pain or hesi- 
 tancy; whether its containing power is normal, or whether it 
 expels its contents as soon as half an ounce or an ounce is accu- 
 mulated within it. The examination of the parts within the 
 pelvis, gives you a very good rule to judge by, because if there 
 is inflammation within the pelvis, you can thus reach with your 
 hand, the sore and painful organs, and in a sort thus interrogate 
 them and find the answer. 
 
 418. Tympanitis, or ballooning of the belly is an invariable 
 symptom, but it is greater or less in different cases and times. 
 You ought to expect to find a smaller and softer abdomen in 
 metro -phlebitis than in peritonitis. 
 
 419. The pains of metro -phlebitis, after the first few hours, are 
 not so great as those that attend on inflammation of the peri- 
 toneum. 
 
 420. In peritonitis, pure and simple, the mind is clear; the 
 nervous system not being disturbed by the presence of pus-cor- 
 puscles in the blood; the woman recovers, or dies, without those 
 hysterical or rather hy steroidal and even maniacal symptoms, that 
 invariably mark a purulent infection of the blood. 
 
224 CHILDBED FEVEK. 
 
 421. The respiration is less distressed by the course of a metro- 
 phlebitis, or a putrescentia uteri, by reason of the less soreness, 
 and less interference with the play of the diaphragm. The dia- 
 phragm may be compared to the piston of an engine, that moves 
 in the cylinder of the trunk of the body ; its descent draws in 
 air from the trachea, its ascent allows of its escape from the lungs. 
 If this respiratory piston, then, in descending in the cylinder of 
 the trunk of the body, must compress beneath it the inflamed and 
 inflated masses of intestine, it is evident the motion will be modi- 
 fied by the sensations and necessities of the patient attending the 
 acts. She will not breathe freely ; she dares not, she cannot. Not 
 so, when the disorder is confined to the womb alone, and that 
 situated in the cavity of the pelvis, out of reach of the com- 
 pressing, crushing power of the descending diaphragm. 
 
 422. In attending a case of questionable diagnosis, you will, not 
 rarely, observe states of the mind, physiognomical expression, 
 speech, conduct, gesture, that shall lead to expect an hysterical 
 state. Ah ! let me already alarm you as to this curious condition 
 of lying-in women. Without doubt, inasmuch as all hysteria 
 proceeds from the reproductive system as its radiant point or 
 source, you will meet, in practice, with exquisitely-marked in- 
 stances of hysteria related solely to some suffering state of the 
 uterus or ovaria, &c. But the alarm I wish to awaken in your 
 mind is one connected with the very great probability that hyste- 
 rical or hysteroid affections, in women recently delivered, and 
 assailed with fever, are really the exhibitions of that curious in- 
 fluence that pus in the blood, or pyaemia, exerts upon the nerv- 
 ous system. Here is, then, a source of difficulty in your diagnosis; 
 for if it be that the signs are hysterical, merely, there need, in 
 general, be no resulting alarm ; but if they are hysteroidal, and if 
 they do arise from purulent infection, then the prognosis is most 
 unfavorable ; not fatal, but most unfavorable ; since, whoever she 
 may be that exhibits them, during a fever with pulses at or above 
 120, she will be more apt to die than to recover. 
 
 423. You should not disregard the just reflection that childbed 
 fevers do, in the majority of cases, consist, in part, of metro-phle- 
 bitis. M. Tonnelle says, Archives, xxii. 1830, p. 355, that "sup- 
 puration of the venous and lymphatic canals is an alteration 
 
HYSTEROID SYMPTOMS. 225 
 
 whose frequency is so great, that I meet with it in two or three 
 out of every five cases of puerperal fever." 
 
 424. I have, on various occasions, treated patients ill with fevers, 
 whose real nature was only disclosed to me when, after many days 
 of attendance, I observed these hysteroidal phenomena to be pre- 
 sented by them. It was then that I knew them to be- cases of 
 pyaemia, or, in other words, endangial inflammations that had 
 proceeded to the stage of pus-production. In all the individuals, 
 male or female, that I have attended in mortal illness, from wounds 
 of veins in venesection, I have invariably noticed this kind of 
 hysterical intoxication, caused by purulent infection of the blood. 
 I advise you, therefore, to keep watch for these appearances, and 
 thereupon to take such measures as you may. I fear that those 
 measures, however, will generally prove of little avail. I say 
 they will generally prove unavailing ; but I have conducted not 
 a few women through such great dangers. One of these ladies 
 was delivered, in a very tedious first labor, with the forceps. I 
 did not observe any particular difficulty in the- operation, which 
 she bore without much complaint or repining. A few days after- 
 wards she evidently labored under pygemic fever, seated, I appre- 
 hend, principally in veins lying in the ligamenta lata of the womb. 
 Her life was long in great danger, but at last she began to form 
 abscesses on the lower extremities, on the forearms, between the 
 thumb and forefinger, above the elbow, on the inside of the left thigh, 
 on the region of the sacrum and loins, &c. &c, so that I visited 
 her almost daily for a period of seven months before she was 
 fully recovered. In observing and healing these abscesses, some 
 of them of vast magnitude, I never could persuade myself that 
 the major part of them were not abscesses of transportation, that 
 is, pus brought to the part and poured out there, and not formed 
 there originally. She went to sleep one night with her left hand 
 perfectly well; at my visit on the next morning, I found an ab- 
 scess, big as an English walnut, round and plump, distending the 
 folds of skin between the left thumb and index finger. I dis- 
 charged the collection by means of a lancet, and the part was 
 cured in twenty-four hours. The quantity of pus that this lady 
 excreted during her illness was very great indeed. Since her re- 
 covery she has enjoyed excellent health. 
 15 
 
226 CHILDBED FEVEK. 
 
 425. I believe I need say nothing further concerning the dis- 
 appearance of the lochia and the milk. The presence or absence 
 of those secretions will afford you some items of a collective 
 diagnosis, which it were tedious and needless to go over with in 
 this place. 
 
 426. Think of these things, young gentlemen — treasure up all 
 good means of diagnostication — for upon your diagnosis must 
 rest, as its sole basis, the prognostics as well as the therapeutics 
 of your cases. 
 
 C. D. M. 
 
LETTER XVII. 
 
 PREPARATION" FOR LABOR. 
 
 427. I wish to say something in these Letters concerning the 
 methods by which you ought to hope that the attack of child- 
 bed fevers may be prevented for women under your charge. 
 
 428. All pregnant women ought certainly to be held as obliged, 
 by the very fact of their imminent accouchement, to act circum- 
 spectly as to diet and exercise, which, being conducted with pru- 
 dence and wisdom, should allow them to expect a favorable getting 
 up after the birth of the child is completed. 
 
 429. Labor, for many women, is a great and terrible conflict ; 
 it is attended with enormous efforts and followed by great fatigue. 
 No woman, who has a little common sense, would be willing to 
 march up to such a conflict with the fullest and most brilliant 
 health. She would prefer to be rather delicate than strong, for 
 there is never to be dreaded any lack of power, but only excess 
 of resistance is to be feared. If the resistance is great and 
 obstinate, the needful power must be developed, and that costs, 
 sometimes, more than the health can bear. These observations I 
 conceive to be applicable to all puerperal women, in all seasons, 
 and they should teach the necessity of attending to the amount 
 and kind of food and drinks, the state of the bowels, and the 
 condition of the blood. The woman may require more food than 
 she takes, or less ; or she may require astringents, or aperients ; 
 or she may be in need of wine on the one hand, or of free blood- 
 letting in opposite circumstances. 
 
 430. There is not, and there cannot be any specific drug that you 
 may order as a sure antidote to the cause of childbed fever. Your 
 duty will be done whenever you shall have so ruled her conduct, 
 as to lead her to the fulness of her time in good health, by which 
 I mean neither excessive plenitude nor great weakness. 
 
228 CHILDBED FEVEE. 
 
 431. It was formerly, in this quarter, almost an invariable rule 
 for pregnant women to be bled once or twice at the seventh or 
 early in the ninth month, as a prophylactic. That good custom 
 is now generally abandoned. I presume that, where you may 
 have reason to fear any post-partum bad effects of repletion, ple- 
 thora, a tendency to heats, or inflammations, you will resort, as 
 your best prophylactic, to an occasion of bleeding for the woman. 
 There is excellent reason to believe that one or two venesections, 
 well timed, may enable the woman to pass through the pains and 
 perils of childbirth with greater ease and less risk than those who 
 refuse to adopt such a precaution. 
 
 432. There is a general tendency in women far advanced in 
 gestation to a costive state of the bowels, or, rather, to excessive 
 accumulations of feces in the great colon. In pretending to give 
 advice of a prophylactic kind, you should not lose sight of this 
 tendency, but give directions for its removal. 
 
 433. The air of the place which the woman inhabits is to be 
 inquired into. It may be too damp, or too hot, or insalubrious on 
 account of marshes or standing pools in its vicinity. Even the 
 chambers of the house ought to be considered, relatively to the 
 season of the year, and the patient directed to take an upper or 
 lower, a south or north room, according to your judgment of its 
 comparative salubriousness. Precautions of this kind it is worth 
 while to attend to for all cases, but the propriety of them in 
 seasons of epidemics is not to be called in question. 
 
 434. Where there is some alarm of the sort, a prudent woman, 
 in ordinary health, ought to prepare herself by a proper regulation 
 of her diet. There are many who refuse to eat meat for thirty 
 days, and some for only fifteen days before term, thinking there- 
 by to obviate a supposed inflammatory or febrile diathesis, deve- 
 loped by their gravidity. If there should be some difficulty in 
 persuading a woman to leave off her meat diet for so long a time, 
 you may come to an equally useful result by ordering a meat 
 diet for every other day only. Thus, if you allow meats every 
 alternate day, for twenty days, your patient would be on a vege- 
 table diet for ten out of those twenty days, and with less reluc- 
 tance or objection on her part. Many of my people follow this 
 rule of alternating days, and it is a very excellent one, which I 
 advise you to adopt in your practice. 
 
PRECAUTIONS FOR THE SICK. 229 
 
 435. You have seen, in a former page, how important it is 
 deemed that the milk secretion should be formed and maintained 
 as a means of securing the patient from the danger of a childbed 
 fever. You cannot be too careful, on this head, in recommending 
 the early application of the child to the mother's breast. It is 
 true that the granules of the milk-glands will, some time between 
 the forty-eighth and seventy-second hour after the labor is over, 
 commence to excrete the milk ; but it is no less true, that the 
 normal irritation of the nipple, by the mouth of the new-born 
 child, does greatly favor the early coming and readier flowing of 
 the nutritive element. I should consequently regard it as an 
 essential duty, to cause the infant to be presented, as soon as the 
 woman's state should warrant it. Moreover, the nurse should be 
 instructed to keep the breasts properly covered ; for there is little 
 doubt, that cold and damp air, or dresses imperfectly covering 
 the bosom, do prove repercussive of the mammary secretion. 
 
 436. The foul excretions of the womb, gathered in the lower 
 part of the vagina, and retained about the perineum and vulva 
 by napkins or receivers, not frequently enough changed, are 
 observed to be pernicious to the health. Every such patient 
 should be scrupulously cleansed by the nurse at least twice a day 
 in cool, and oftener in warm weather. It may seem strange that 
 I should give such an advice, supposing that no decent woman 
 would require such counsel ; but you can yet little know how 
 much of barbarism exists even in polished society, or how stupid 
 mankind are in presence of time-honored opinions ! There are 
 many women who think it is as much as a life's worth to use any 
 method of ablution for many days after a confinement. Not only 
 so, but there are many very reputable people who believe in 
 table-turning, spirit-knocking, homoeopathy, and other things 
 equally absurd, equally incredible. 
 
 437. Labor often produces an effect on the neck of the bladder 
 that causes the woman to retain the urine, until a very large 
 quantity accumulates in the cyst. I drew off sixty -two ounces 
 for a patient some time ago. She was in dreadful distress, and 
 though attended by her physician, no suspicion of the cause of 
 her sickness arose until I came to her chamber. Do you doubt 
 that over-distension of the bladder misht determine the establish- 
 
230 CHILDBED FEVER. 
 
 ment of an area of inflammation, to end in childbed fever ? Take 
 great care, then, of your patients, and never leave them without 
 this needful instruction as to the state of the bladder of urine. 
 It is amazing how stupid some people are on this point, and to 
 what an enormous extent they do allow the bladder to overfill 
 itself, with great pain all the while. When you come to them, 
 and touch them, and ask, "is that a urinary pain — a pain to make 
 water ?" they at once answer in the affirmative, though so dull 
 as not to have conceived of it before. There are some people in 
 this world who do not know even how to get out of the rain ! 
 
 438. Some authors think the bed, by overheating the woman 
 and detaining odors about her, may provoke to attacks, and so, 
 they order the patient to sit up too soon. I cannot adopt this 
 view, and I am very sure many of my bad cases have been 
 brought on by too early sitting up. 
 
 439. The chamber should be well ventilated, but the woman 
 should be kept out of cold draughts of air. Here is an old dis- 
 tich : — 
 
 " If the wind blows on you through a hole, 
 Make your will, and mind your soul." 
 
 If the patient is very tired after labor, you may give her a 
 half-glass of wine with water. It will do no harm if the pulse is 
 right. The diet for the first three or four days is bread with tea, 
 sago, or arrowroot jelly, and cold water to drink. Don't let any- 
 body take oatmeal gruel until the milk has come abundantly, and 
 the lochia which are checked at the coming of the milk are re- 
 established. Drive out all chattering folk and bearers of bad 
 news. If she is restless and suffers from after-pains, let her 
 have an anodyne, and repeat the doses until she is relieved. 
 
 C. D. M. 
 
LETTER XVIII. 
 
 MEANS OF CURE. 
 
 440. In the management of cases of childbed fever inflamma- 
 tions, you are to employ what are called remedies, by which is 
 meant some drug or medicine, or some application, or act that 
 may give the disorder such a bias or direction as to cause it to 
 cease and allow the woman to recover. And I do sincerely believe 
 that your success or failure will in chief depend upon yourselves, 
 and not upon any known tendency of the disorders to come, after 
 passing through certain regular stages, of their own nature to a 
 happy conclusion. There are many disorders whose tendency is 
 to a cure, but these do not belong to the category of self-curing 
 diseases ; and it is to be believed that women attacked by them, 
 and not cured by art, do, for the most part, certainly and miser- 
 ably perish. 
 
 441. In coming, in this portion of my work, to advise you as 
 to methods of treatment, I am more than ever struck with the 
 incomprehensible differences of opinion I find among authors of 
 all epochs and all countries. Many of those who are esteemed to 
 be the highest authority, declare that these dreadful diseases are 
 to be cured by a tonic and alexipharmic method, and that blood- 
 letting is, in the main, a most dangerous thing, and unsuited, ex- 
 cept for a few and peculiar cases. Other authorities having, it is 
 said, equal pretensions to our confidence, aver that venesection 
 is the principal remedy, and that it may be depended upon with 
 great assurance of its safety and efficacy. 
 
 442. Are we not all physicians ? How, then, are we like a 
 house divided against itself, and how can we stand ? The fact is, 
 we do not stand ; for we are so fallen in the esteem and confidence 
 of the public, as to this particular matter, that they do not believe 
 in us, and are frightened and panic-struck by the very name of 
 
232 CHILDBED FEVEK. 
 
 childbed fever, when it comes to interest them directly or nearly ; 
 and though they employ us, because they can do nothing else, 
 yet they do not believe in us. 
 
 443. You have observed what great pains I have taken in 
 these Letters, to lay before you a clear, undeniable doctrine as 
 to the nature of childbed fevers ; and I know not yet, whether 
 I have carried your judgment captive, by means of my argu- 
 ments and citations, or what views you shall take concerning a 
 fitting treatment of such maladies. If you remain contagionists, 
 putrefaction] sts, vitiated-humorists, &c, you will grope about 
 among the bottles and drawers, filled with drugs in an apothecary's 
 shop, for some specific thing called a drug or medicine wherewith 
 to cure your childbed fever patients, and you will try to cure 
 them Chemically, or Empirically ; but if, on the other hand, you 
 do regard the causes as consisting in inflammation of those parts 
 I have told you of, then you will not put your trust in physic 
 alone, but employ such measures as are best suited to oppose the 
 existence and progress of phlogosis, and so take your choice of 
 the whole armamentarium of the antiphlogistic measures that 
 have been approved good during the long lapse of our Medical 
 Histories and experiences. 
 
 444. I have shown you, with tolerable clearness, what has been 
 thought, and what done, concerning the nature and treatment of 
 our disorder from very remote times ; and, indeed, it appears to 
 me that, though two thousand five hundred years have passed 
 away since we began to inquire into the methods by which we 
 should hope to rescue our friends threatened with childbed fever, 
 the entire catalogue of all our acquisitions has been fully and. fairly 
 made out by the younger Baudelocque in his work on the subject. 
 What, then, is the treatment we have learned in twenty -five cen- 
 turies to apply ? 
 
 1. Bloodletting. 
 
 2. Emetics. 
 
 3. Purgatives. 
 
 4. Sudorifics. 
 
 5. Antiseptics, tonics particularly, camphor, and bark. 
 
 6. Blisters and other revulsives. 
 
 7. Cold douches and cold stupes, or hot stupes to the belly. 
 
 8. Sub carb. of potash. 
 
MEDICINES. 233 
 
 9. Oil of turpentine. 
 
 10. Mercurials : he ought to have added opium. 
 
 445. Let us, in this Letter, inquire cursorily concerning the 
 power of certain of the above-named remedies, to oppose the pro- 
 gress of intro-pelvic and abdominal inflammations. 
 
 446. Persons who, by accidental wounds or from diseases, lose 
 large quantities of blood, are brought to a state of weakness, greater 
 or less in proportion to the waste of the vital fluid they may have 
 sustained; yet some, who have been excessively weakened by 
 such hemorrhage, even after being apparently nigh to death, are 
 found to suffer very little inconvenience beyond the temporary 
 loss of strength, soon regaining all their activity and energy by 
 the use of convenient food and drinks. There is no class of people 
 who can be more familiar with the effects of hemorrhage on the 
 bodily health than physicians in the extensive practice of mid- 
 wifery ; for they frequently meet with enormous wastings of the 
 blood, in cases of abortion and of labors, whether before or after 
 delivery, whose occurrences and incidents familiarize them with 
 the effects of loss of blood. Many a time and oft have I stood 
 aghast at the rapid effusions and almost exanimate condition of 
 patients of mine in hemorrhage. Years of experience have, how- 
 ever, convinced me that as soon as the effusion is arrested the 
 trouble is over, and no bar exists against the rapid and perfect 
 recovery of even exuberant health. I have stood for hours near 
 the bedside of a sick woman, applying all the resources of my art, 
 and in great doubt, at times, whether the absent pulses could pos- 
 sibly return, or the pallor of impending death give place to the 
 hues of health again. Well, these very people I have often ob- 
 served to be in brilliant health at the end of the lying-in month. 
 It is, I think, a great mistake to say that loss of blood, even enor- 
 mous loss, is in any degree injurious to the constitution of the 
 individual. The story told of Agrippina, who, by order of Nero 
 being compelled to have her veins opened,' was near dead when 
 the tyrant countermanded the order and caused the wounds to be 
 bound up, seems to me to have some influence on the general 
 opinion concerning losses of blood. That lady is said to have been 
 ever afterwards pale, having lost, on the occasion, the power of 
 tinting her skin of a flesh color. But Agrippina's single case is 
 
234 CHILDBED FEVEE. 
 
 not fit to furnish an argument or proof for the many, since thou- 
 sands of women in labor and abortion pass as near to the brink 
 as the good princess could have done, and yet in three or six weeks 
 are even in better health than they were ever before. 
 
 447. Practitioners of physic, even the busiest surgeons, can 
 have no such familiarity with the effects of loss of blood, as the 
 accoucheur ; and this being the case, it is probable they are less 
 timorous as to venesection as a remedy fot inflammation, than 
 most general practitioners and surgeons. 
 
 448. The use of the lancet as a remedy, seems to me to be sub- 
 ject to an influence of the nature of fashion ; for there are cities 
 and countries where venesection is much approved and made use 
 of, and others where it is equally disapproved ; and also, in the 
 same places or countries, there occur series of years in which 
 bloodletting is resorted to on all occasions, and other series in 
 which no one seems to resort to it, except under extraordinary 
 circumstances. When Fagon was Physician to Louis XIV., all 
 the French doctors were the bloodiest practitioners in Europe. 
 
 449. But at the present day, a French physician, if he bleeds 
 at all, scarcely goes beyond what he calls une pallette, which is, I 
 believe, about six ounces. Twenty years ago, in Philadelphia, 
 the use of bloodletting was far more general than it is at the 
 present day. We had then, and for many years previously, 
 numerous individuals who earned a good living as bleeders, &c, 
 but for many years past that class of people depend for their 
 profits far more upon their leechings and cuppings, and most of 
 them have added dentistry to the list of their avocations as means 
 of profit. 
 
 450. Are we to attribute this difference in practice to the im- 
 proved knowledge of our art, or to the influence of fashion ? Will 
 not the day return when the bleeders shall again be as busy as 
 of yore ? I doubt not the lancet will recover its vogue, and the 
 sooner the better. Neither do I doubt of some slight influence 
 of fashion and custom in this matter ; but I attribute the change 
 in our practice, as bleeders, neither to improved skill and know- 
 ledge, nor to fashion in chief, but to epidemic constitution, 
 which causes us to resort, less habitually, to venesection as a 
 remedy now, than we were wont to do a few years since. Such 
 
EEMEDIES. 235 
 
 changes in modes of practice must frequently coincide with the 
 mutations in our epidemic constitutions, and as there will reign, 
 for series of years, an atmospheric constitution to render venesec- 
 tion less needful and useful ; so there must also arrive other series 
 of years, during which the epidemic constitution of the air shall 
 compel all discreet and wise physicians to oppose the progress 
 and subdue the very existence of disease, by the promptest and 
 most powerful of the antiphlogistic resources of our art : I mean 
 bloodletting. Hence, when I listen to sneers on our forefathers 
 for their bloody-mindedness, I seem to perceive, in a not distant 
 future, the smile of scorn or pity for us of the present generation, 
 who fear the click of a spring lancet as a struck fowl or a hurt 
 wild duck, the report of a caliver. 
 
 451. What are you going to do to save the woman who, 
 having been put to bed the day before yesterday, you find now 
 attacked with rigors, intolerable pain and soreness of the lower 
 belly; violent fever and headache, and pulses at 140? Come, 
 young gentlemen, let us see what it is that you will do. 
 
 452. Tn the first place, I presume you will go about to settle 
 the question of the diagnosis, and if your examination should re- 
 sult in a conviction that it is a childbed fever that has fallen on 
 the patient, you must admit that she has inflammation, that 
 began somewhere within the pelvis ; that is, either in the womb, 
 in its veins, or in the peritoneum ; and upon this conviction is 
 superimposed the grave reflection, that this inflammation may be 
 justly deemed to carry in its own nature no dispositions whatso- 
 ever towards a cure of the patient, the termination of them being 
 almost invariably, either a suppuration, or effusion with adhe- 
 sions, and occasionally gangrene ; results, either of them, that must 
 prove mortal to the sufferer. 
 
 453. If you should agree with me, then, that 
 childbed fever is an inflammation, and not a 
 fever, and also allow that such inflammation, 
 running its course to a term, destroys at that 
 term, then assuredly you will resolve to do something that may 
 probably check further expansion of its area, and haply i m- 
 press upon it a tendency to recover by resolu, 
 tion. And what shall that thing be? shall it be an emetic? 
 an emetic to cure a phlebitis or metro-peritonitis ! 
 
236 CHILDBED FEVEE. 
 
 454. Hem ! shall you bleed her ? Yery well. Shall you give 
 her calomel, to the same wise end ? Some turpentine ; some Je- 
 suits' bark; some camphor; some opium; some kermes; some 
 tartar-emetic ; a blister ; some leeches ; a cupping of the hypo- 
 gastric region ; or a poultice on the whole belly ? "Will any one, 
 or all of these medicines together check the progress of that phle- 
 bitis, or peritonitis, that is to drag her down to the grave, pro- 
 vided it is not cured, and promptly cured ? , 
 
 455. It matters little what shall be the precise and definite re- 
 sult of your diagnostical researches, as whether you conclude the 
 case is purely peritonitic, or whether it is metritis with the well- 
 known frequent complications ; for, whether it be the one or the 
 other, or all of them combined, you must, after all, rely upon the 
 power of one or more of the above-named remedies. The great 
 matter is, to begin soon and to act strongly and decisively. 
 Whatsoever you find to do, I pray you do it with your might ; 
 for as there is little time to work, the loss of a few minutes may 
 be irreparable. Have I not mentioned an instance in which 
 death ended the scene in eight short hours after the commence- 
 ment of the disorder ? but if such be the precipitancy with which 
 the areas may possibly expan'd, the necessity of beginning early 
 cannot be questioned. Obsta principiis is a good motto 
 for all who are to treat such disorders as these. 
 
 456. I find that I am now come to the most difficult part of 
 my task in this work, that of pointing out a proper and hopeful 
 method of treatment. I am but too well aware that there must 
 occur many cases in which no treatment can be of avail to save 
 the life of the patients. It is the same with cholera and yellow 
 fever — diseases that demand, and must have their quota for the 
 grave. This I freely admit ; yet it is a source of the highest con- 
 solation, that of believing that one acts, not only with conscien- 
 tiousness, but with wisdom and great prudence. 
 
 457. In selecting the proper remedies, and determining the 
 proper times for their application, the physician best displays his 
 power. I have given you a general catalogue of those remedies, 
 and I shall in my next Letter discuss seriatim the question rela- 
 tive to the choice and way of exhibition of them ; but now I rest, 
 with respectful regard. 
 
 C. D. M. 
 
LETTER XIX. 
 
 ON THE TREATMENT BY MEANS OF BLOODLETTING, AS THE REMEDY- 
 IN-CHIEF FOR CHILDBED FEVERS — ESTIMATE OF THE QUANTITY 
 OF BLOOD MOVED BY THE HEART IN GIVEN TIMES, IN HEALTH 
 AND IN DISEASES — THE POWER OF BLOODLETTING AS A CON- 
 TROLLER OF THE CIRCULATION, AND CONSEQUENTLY, OF THE IN- 
 NERVATIONS — ANODYNE POWER OF VENESECTION — INSTANCES 
 
 WITH AND WITHOUT VENESECTION — GORDON — RULE AS TO TIME 
 — HOW TO BLEED — GORDON'S PUPILS — LATE VENESECTION — A 
 FATAL CASE — TWO CASES SUDDENLY CURED — A SUDORIFIC MIX- 
 TURE — CASE OF VENESECTION AFTER VIOLENT HEMORRHAGE. 
 
 458. My purpose in writing this letter is, to lay before you my 
 thoughts on the subject of bloodletting as a chief 
 remedy in the conduct of those alarming disorders we have 
 been discussing in the previous pages of this work. In doing 
 this, I hope I shall be able to point out, with precision, those 
 forms and stages of our disease, in which you could scarcely err 
 in adopting the use of venesection, as well as those more ques- 
 tionable cases in which an experienced physician might hesitate ; 
 and also such as are clearly gone beyond the bounds within 
 which bleeding is curative, and outside of which it would prove 
 dangerous, or perhaps fatal. Unhappily, it must hereafter, too 
 often happen for you to be called in to persons, on whom the 
 hand of death has already been laid, long before your arrival; 
 leaving you only to act as reluctant, but sympathizing spectators 
 of a ruin for which Providence has ordained no remedy, and for 
 
238 CHILDBED FEVER. 
 
 which you could scarcely find, in all the resources of your Art, 
 even some slight alleviations. 
 
 459. The opinions I shall put forth in this Letter, are the 
 same as those I have held for a great number of years; that 
 have governed my conduct as practitioner in the cases ; and which 
 in various publications, and in public lectures, I have main-' 
 tained, in opposition to many writers, and many friends and ac- 
 quaintances, who prefer other modes of treatment than mine. 
 The criticisms with which I have been honored in medical jour- 
 nals — some of them, it is true, very rude ones — have not had the 
 least influence to change the convictions forced on me by reflec- 
 tion and clinical observation ; nor shall I, on account of such disa- 
 greements among my brethren, living and dead, refrain from giving 
 you my whole thoughts. I am not one of those persons who 
 deem their sentiments upon a point in Science or Art, as of kin 
 to their morals; and who feel insulted when the whole world do 
 not consent to and admire their own particular way of thinking. 
 Indeed, it is to me, in general, a matter of indifference what men 
 do think on questions of science or rules of art ; though, I confess, 
 I sometimes feel sorry for those sick people who fall under the 
 guidance of incompetently educated doctors. My own views as 
 to the indispensable necessity for bloodletting in childbed fevers, 
 can never be abandoned because there are multitudes of people, 
 in and out of the profession, who look upon a venesection as a 
 great and important thing, that ought never to be undertaken, 
 except under the most urgent necessity. Why, indeed, should I 
 withhold from you my sincere opinions because of the class of 
 people just referred to; since there are, on the other hand, vast 
 numbers of the brethren, as well of those who died centuries ago 
 as of living physicians, who go with me in regarding this as the 
 chief sanative means delivered down to us from ancient times? 
 I know not how it is that I have, by some critics, been accused 
 of possessing a presumptuous, dogmatical style of thinking and 
 writing, which has proved offensive to them ; for I do not feel at 
 all disposed to cram my opinions down the gentlemen's throats ; I 
 merely present them for acceptance or rejection, at their own good 
 pleasure. To me it is nothing whether they be received or 
 spurned, for I cannot make them true if they be false, nor can 
 any man convert them into a lie if they be really true. Truth is 
 
VENESECTION. 239 
 
 no man's. Truth, is God's. Wherefore, then, should any reader 
 of mine become incensed on account of the warm zeal with which 
 I design to set forth what I deem to be the most important — most 
 salutary truth! During my tedious studies of the subject on 
 which I am now writing to my Class, I have observed the most 
 irreconcilable differences of opinion : it might be considered 
 almost correct to say, that these differences are national or even 
 ethnological ; for while, in one country, and among one people, the 
 lancet is freely and boldly employed, in others it is taken up with 
 a seeming terror of its power. In Germany, from the time of F. 
 Hoffmann, who bled in the foot (vol. ii. p. 158), and in France, 
 from the time of Fagon and Puzos, down to the present day, the 
 former, with some rare exceptions, are not bold bleeders, while 
 the latter are bleeders coup sur coup, as old Puzos expresses it. 
 These differences are among the most surprising things in Medi- 
 cine ; and as their existence proves the utter incompetency of 
 nature and observation, at least hitherto, to bring us all into one 
 line of opinions, they appear to me to be disgraceful to physicians 
 as a learned class. I conceive that these differences clearly prove 
 that, as a class, we learn more by tradition than by observation 
 and reflection; for, as well might one present a bright daguerreo- 
 type plate to a scene, and expect it to give us the representation 
 of a different scene, as to offer the human understanding as a 
 vasa tabula to the facts before it, and look for so many different 
 interpretations as we find in the most simple questions, e. g. this 
 of venesection in childbed fevers. I say, therefore, that if we do 
 not agree, it is not because nature does not agree with herself, 
 but because we take our notions traditionally, and not from care- 
 ful observation. But, whether we have learned by relation or by 
 inspection, we cannot help thinking what we do think; and I 
 hold myself, therefore, free to say that, inasmuch as I consider all 
 treatment of childbed fever both futile and ridiculous, when 
 based on any other views than that of controlling the blood's 
 force, both in its substance and its motion, by means of the lancet, 
 I shall as warmly and as zealously as I can, strive to convince 
 you that bloodletting is a convenient, safe, effective, and most in- 
 dispensable means, and constitutes by far the chiefest, if not sole 
 resource of our Art, in those dreadful disorders. 
 
 460. Let no man, therefore, I pray, take offence at a Medical 
 
240 CHILDBED FEVEE. 
 
 brother for Lis Medical opinions; nor let me be charged with 
 dogmatism and presumption for maintaining opinions that have 
 struggled for the mastery these two thousand years, during which 
 they have actuated many of our best men, in practice, in various 
 countries, as they do now. I wish you, my Students, to believe 
 that my heart's desire and my hope is, that you should learn the 
 truth as it is, and not my opinions. What are my opinions to 
 you, or to any reader of these Letters ? I shall very soon be num- 
 bered with the forgotten dead, and as indifferent to you then, as 
 you will then be to me. It is not my opinion, then, that it. inte- 
 rests you to know ; but, rather, the whole idea of the dis- 
 ease and its cure that is to be formed in your minds, by 
 your own direct observation and reflections upon facts observed. 
 Do I state facts in this Letter? Then let them have the force of 
 facts. Do I set forth opinions, hypotheses, conjectures? Then let 
 them have only the force of surmises or guesses at truth. It is 
 yours always to judge of the truth of facts, and the value of re- 
 flections presented by any writer whose work it may please you 
 to examine. I here again assure you, I am heartily ashamed of 
 the scandalous discrepancies, and the pitiful insufficiencies I find 
 in our library books upon the subject of childbed fever, and that 
 I fervently wish it were in my power to set the whole truth of 
 the matter so clearly before every one of you, my Students, that 
 you should, each and every one, be able to perceive and know 
 the Truth on a subject, so important to society, and to us, as a 
 class of the learned. To use words of Quintilian, I could wish, 
 in writing these Letters: "Ut ipsse sermonem finxisse Gratise 
 videantur, et, quod de Pericle Yeteris comoedise testimonium est, 
 in hunc transferre justissime possit, in labris ejus (mine) sedisse 
 quandam persuadendi Deam." (Inst. Orat. x. p. 81.) Alas! forme; 
 no such testimony will be accorded to my speech, nor such 
 Goddess, sweet S u a d a, inspire my pages ! ! 
 
 461. As a physician, in practice, I could not but be much 
 given to confide in phlebotomy as a means of conservation 
 against threatened attacks, as well as of cure for sickness already 
 formed; forasmuch as in all my views of vital action, v/hether 
 physiological or pathological, I have never been able to conceive 
 of either sense or motion as things possible, independently 
 of a quantitative state of the circulating blood. I speak here of 
 
VENESECTION. 241 
 
 the capillary blood, in the part wherein the sensation is perceived, 
 or the motion effected. I think I shall never become able to 
 view this matter in any other light ; for I am convinced that all 
 acting power of the nervous mass is an absolute direct conse- 
 quence of the combination of oxygen, in the blood, with the albu- 
 minous element of neurine. It is only by this combination with 
 oxygen, that the nervous mass can evolve or extricate and send 
 forth along the nerve-tracks, the nervous force or neurosity — or, as 
 a Frenchman, M. Cerise, writes the word, nevrosite. Febrile dis- 
 eases, and all inflammations, are, manifestly, conditions or states 
 growing out of over-production of this neurosity, in the whole 
 or in the parts. In the idiopathic fevers, the nerve-centres are 
 the parts first affected and modified by quantitative states of the 
 blood, as well as by its qualities; and the constitutional perver- 
 sions flow out of those quantitative and qualitative states. — The 
 oxygen taken up by the blood in the pulmonary capillaries, ex- 
 cept the capillary branches of a branchial artery, is given off 
 again in the systemic capillaries, which are thus a sort of 
 strainers, in which the oxygen is separated and detained for 
 the uses of the organs and tissues. The brain capillaries give 
 out the oxygen, whose combination with neurine, elicits the flash 
 of life as the biotic force or nervous force: hence, quantitative 
 states of blood in the encephalon, determine the quality or force 
 of the nerve stream. In inflammations, on the contrary, it is 
 the organs or tissues that are first to be affected ; and from such 
 affections or modifications of their vital state, flow the constitu- 
 tional disorders, reactions, or perversions. The former are centro- 
 peripheral ; the latter are periphero-centric maladies. They are 
 diseases of opposite poles ; the idiopathic fevers being 
 affections dependent on states of the encephalic pole, while in- 
 flammatory diseases and disorders of the organs are results 
 of failure or derangement in the organ-poles of the body. 
 
 462. Tissues in a state of inflammation may be said to tend 
 always to expand or augment the areas of the phlegmasia, in a 
 ratio, compounded of the force of the blood's motion "within their 
 capillary vessels, and the vital power of vascular resistance to the 
 injecting force of the heart. A strong, full, frequent pulse, tends 
 more to the expanding of the inflamed areas, than a weak, small, 
 16 
 
242 CHILDBED FEVER. 
 
 slow one. Therefore, to diminish the injection-power of the heart 
 is to lessen the tendency to expansion in phlogosed areas ; and 
 this truth is daily seen in clinical practice, where we constantly 
 observe that inflammations do speedily terminate by resolution, 
 after bloodletting, which, but for the curative power of that 
 remedy, would certainly seek and find their term in effusion, in 
 suppuration, or in gangrene. 
 
 463. A patient having a strong, large, and frequent pulse, with 
 cephalalgia, or pleuritic stitches, or a peritonitic pain, immediately 
 acknowledges the relief that ensues upon a free venesection ; the 
 headache lessening at once, the pleuritic pain vanishing, and the 
 anguish of the peritonitis giving place to a freedom from pain ? 
 and tolerance of pressure, before insupportable. The senses 
 are become freer, the respiration is more natural, and heat and 
 fever, and indeed all the excitement and turbulency of the life 
 are reduced, by the venesection, to states of a comparative 
 calm physical complacency. But not only does a proper blood- 
 letting procure such relief, it is also true that it is frequently fol- 
 lowed by a prompt cure of the whole disorder; for, it many times 
 happens that an inflammatory disease, such as childbed fever, 
 which has made regular progress from bad to worse, up to the 
 moment of the operation, does from that moment wholly change 
 its rate, and as steadily change from worse to better, until no 
 vestiges of the disorder are left behind. The disease, even a 
 dangerous and advanced one, is not unfrequently cured by a sin- 
 gle bleeding. I think I have described such a case in sections 
 4-67, 493, 497, 501, and 502, to which I beg to refer you; and our 
 books are filled with examples which cannot be gainsayed. Dr. 
 Armstrong has, in particular, the following one at p. 200 : Mrs. 
 E., a stout woman, set. 28, delivered June 2d, had, on the 4th, 
 rigors, headache, nausea, and retchings. Ten hours after this at- 
 tack, Dr. Armstrong found her with pulse 134; skin pungently 
 hot, tongue white and dry ; milk and lochia nearly suppressed ; 
 dysury ; quickened breath ; belly so tense and sore as not to bear 
 the weight of the clothing; countenance anxious. She com- 
 plained of oppression, pain, and weakness. She was bled 24 
 ounces, and took 20 grains of calomel, followed by su]phate of 
 magnesia; drank barley-water with isinglass. At 6 P. M. was 
 bled again, 12 ounces, and took 20 other grains of calomel with 
 
VENESECTION. 243 
 
 sulphate of magnesia. On June 5th, 6 A. M., the blood drawn last 
 evening was found to be much buffed ; the patient had been freely 
 purged, and the belly was now soft, and bore pressure well. 
 Pulse 100 ; skin moist and warm. Took an anodyne enema, and 
 slept several hours, and from that time might be considered con- 
 valescent. 
 
 464. Now, if you will pause a moment and reflect upon the 
 condition and prospects of that woman, when Dr. Armstrong 
 was called in to cure her; upon the then existing state of the in- 
 flamed tissues within her pelvis ; the convulsive movement of her 
 blood ; the exceeding derangement in the innervative operations 
 of her nervous mass; it seems to me, you cannot well deny that 
 the physician did save his fellow-creature's life; and that her 
 rescue was due, in chief, to the venesections ; for, assuredly, you 
 will not permit yourselves to think the calomel, the salts, and the 
 anodyne enema could have so rapidly appeased her greatly dis- 
 turbed constitution, and so quickly brought her into a state of 
 convalescence. 
 
 465. Legouais's Reflexions et Observations sur Temrphi de la 
 saignee et des pargatifs dans le traitement de la Peritonite Puerperale, 
 at p. 66, gives us the case of a certain Augustine Lef * * * ast. 
 36, a seamstress, at the hospital called La Maternite, at Paris. 
 She was delivered of a daughter at 4 o'clock P. M., August 17, 
 1818, by a 24 hours' labor, in which she had been bled for ri- 
 gidity of the cervix. May 18, she had a mental shock, and im- 
 mediately after it was seized with a chill that lasted an hour and 
 a half, followed by pain in the lower belly, soreness of the right 
 hypochondrium, and difficulty of breathing. At 10 P. M. the belly 
 tender and painful over almost the entire surface; very hot and 
 moist skin ; pulse hard, full, and very frequent ; face flushed and 
 excited; venesection 22 ounces; a purgative dose ; diluent drinks; 
 cataplasm to belly. Four hours subsequent to the venesection she 
 was much better; the pain and general symptoms continued only 
 in the slightest degree. She was better all night, and, on the 19 th 
 August, in the morning (second day), almost no pain, though the 
 pulse was still somewhat accelerated, and skin warm. Aug. 20 
 (third day), the pulse still a little frequent, and skin warm — she 
 was much better; on the 25th of the month she went out cured, 
 
244 CHILDBED FEVER. 
 
 being only a little weak and pale. Such is M. Legouais's account, 
 and I ask you to pause again for a moment to inquire whether 
 this woman's recovery, as well as Elspet Eobertson's, below, would 
 probably have taken place, if venesection had been omitted. I 
 think not. 
 
 466. As cases of this sort are highly illustrative, as well as in- 
 structive, I shall beg you to take one from Alexander Gordon, p. 
 82, who says: " I was called to Elspet Eobertson, No. 58, a few 
 hours after the attack of the puerperal fever, which took place on 
 the day after the delivery. The patient complained of a very 
 acute pain in the abdomen, which had succeeded a severe shivering 
 fit, and the pulse was at the rate of 160. She was bled to the 
 extent of 24 ounces, and got a purgative at 2 o'clock in the after- 
 noon, immediately after the bleeding, which produced six or 
 seven plentiful motions; and, when I saw her at eight 
 o'clock in the evening, to my great surprise, the pulse 
 had come down from 160 to 108, and the pain of the abdomen 
 was gone. Next morning, when I called, I found her without 
 fever, pain, or any other complaint." Mrs. Thompson's case, 
 which he also relates, gave precisely similar results, as did also 
 Mrs. Forbes's, which I intend to quote for you in another page. 
 
 467. Here is a case from my own note-book. Saturday, Feb. 
 26, 1853, Mary Anne Alii * * * primipara, 93t. 29, after severe 
 labor for sixteen hours gave birth to a healthy boy, at 2 o'clock 
 P. M. She continued quite well until 12 o'clock P. M. of 
 Monday, the 28th, which is fifty hours. She was now seized 
 with severe chill, and intro-pelvic and hypogastric pain. I did 
 not visit her until 12 o'clock on Tuesday, 29th, when I found 
 her already enormously tympanitic, and in violent abdominal 
 pain; red face; hot skin, and pulse 180; belly sore to the touch. 
 I concluded she was attacked with metro-peritonitis, of which I 
 am not now in any doubt. I bled her, and measured in the 
 bowl thirty-one fluidounces, that I took from a large orifice in 
 the arm. I gave this woman no calomel; she had cataplasms 
 of Indian mush to the belly, and took Chaussier's aperient mix- 
 ture of castor-oil and syrup of rhubarb. She also got several 
 aperient enemata. From the time I bled her, I never felt any 
 anxiety about her safety, and, in fact, she got rapidly well, being 
 
VENESECTION. 245 
 
 cured by the good bleeding that I gave her when her areas of 
 phlogosis were already twelve hours old. It would have been 
 better to have bled her at 4 A. M. or 6 A. M. of the 29th. On 
 Thursday, March the 9th, I found her sitting up, with the child 
 at the breast, quite in good health. 
 
 468. I again pray you consider the above relation, and judge 
 whether this woman would have lived, had I made an attempt to 
 cure her without employing that fortunate bleeding. Consider, 
 also, that I gave no mercury, and administered only a very 
 simple and gentle aperient, with enemata. You, the least among 
 you, would have cured her in like manner. 
 
 469. These venesections did no injury to the women, or to 
 others that I have treated in like manner ; on the contrary, they 
 were, under Providence, the means employed to save their lives ; 
 and I consider the use of bloodletting to be peculiarly appro- 
 priate to the congestive and inflammatory disorders of lying-in 
 women, whose nature and want it. is, in and after labor, to dis- 
 charge considerable quantities of their blood. While it is true, that 
 I have a thousand times been startled on witnessing the immense 
 effusions that have occurred in the course of my obstetric expe- 
 rience, it is also true to say I have been equally surprised at the 
 little inconvenience suffered from uterine hemorrhages, after the 
 cessation of the flowing. And this I present to you as an argu- 
 ment to be addressed to your own reason, whenever you shall 
 stand hesitating and doubting as to your duty, in the treatment of 
 the inflammatory or congestive disorders of your lying-in patients. 
 As a general rule, it does no harm to such a woman to bleed her 
 very abundantly. Among the older writers who had the good 
 sense to perceive this truth, was Mons. Deleurye, Traite des Ac- 
 couchemens enfaveur des EUves, who, at p. 471, says: "The public, 
 as well as some physicians, still think that bleeding at the arm is 
 not suitable in these cases. This is an error, and there is no bet- 
 ter remedy to be found in the early stages. They should be 
 repeated every three hours, and the first venesection 
 should be copious, without paying any attention to the vaginal 
 discharges, and being persuaded to adopt the principle that this 
 disorder is to be treated as a very decisive inflammation, that 
 soon runs into gangrene." 
 
246 CHILDBED FEVER. 
 
 470. Having in a former page, expressed my admiration of the 
 signal ability of the celebrated French physician Puzos, I wish 
 here to cite a passage, in which he urges the use of the best of the 
 antiphlogistic measures, in the treatment, even, of questionable 
 cases. I mean cases where, though there is hypogastric pain and 
 fever, and persisting lochia, the diagnostic may not be clearly 
 established. As an answer to these objections, he considers that 
 we ought to reflect that a smart fever, attacking a woman within 
 a few days after her labor, should be compared to a pleurisy, a de- 
 fluxion on the breast, an inflammation of the liver, or a violent 
 fever with strong determination of blood to the head. Now if it 
 should happen in any such case for the patient to be seized with 
 Haemoptse, or epistaxis, or hemorrhoidal hemorrhage amounting 
 to five or six ounces in twenty -four hours, do we rest satisfied 
 with such an evacuation ? Do we not rather take away two or 
 three pints of blood, and sometimes more in the same space of 
 time ? p. 369. 
 
 In a subsequent paragraph, after admitting that he had seen 
 some persons recover without venesection, and by means of abun- 
 dant bilious discharges or sweats, &c, he confesses that he takes 
 no credit to himself, or his method, for such results, as they are 
 attributable, rather to the powers of nature, than to the art of the 
 physician. De La Eoche, op. cit. p. 158 says: "I believe that in 
 almost all grave attacks, it (venesection) is the essential 
 remedy, and that on which we must principally depend for 
 the cure. It must be used to prevent suppuration and gangrene 
 in the abdomen, just as we employ it to prevent empyema in 
 pleurisy." He insists upon an early recourse to it. The longer 
 we put it off the worse for the woman ; for if the disease is well 
 established it cannot be cured without larger bloodlettings, which 
 are the more dangerous the longer they are postponed. What a 
 strange thing it is that the French and English practitioners 
 should mostly rely upon the vigorous use of bloodletting, while the 
 whole mass of the German physicians appear most reluctant to 
 employ the lancet, depending upon drugs and medicines to pro- 
 duce effects on the living economy, that the Author of nature never 
 did vouchsafe to those articles. If a German should bleed a wo- 
 man with her peritoneum on fire with inflammation, he would 
 scarcely venture to abstract more than eight or twelve ounces, 
 
VENESECTION. 247 
 
 lest he should interfere with the lochia or the milk. What is the 
 use of lochia or milk for a woman hastening to end her childbed 
 fever inflammation by its most ready term ; I mean effusion, 
 suppuration, or gangrene ? 
 
 471. Dr. Robert Lee, of London, in Lectures on the Theory and 
 Practice of Midwifery, &c, at p. 457, presents a table of 160 cases 
 of severe inflammation of the uterus and its appendages; with 
 notes of the symptoms, treatment, and results. Of the 160 wo- 
 men, 72 died and 88 recovered. Some of them were treated by 
 venesection, and others were not bled at the arm at all; certain, 
 only, of them having been subjected to leeching. Of the 72 who 
 died, 32 were bled and 42 were not bled; but of the 88 who re- 
 covered, 70 were bled and the remaining 18 treated with or with- 
 out leeching, so that, out of the whole number of 160 cases, 102 
 were bled and 68 not bled, except with leeches for some, while 
 for the others, no sanguine depletion was prescribed. It ought 
 to be observed that, in a good many of the above 160 women, 
 nothing was attempted, in consequence of their perishing state 
 when first seen by Dr. Lee. 
 
 472. It appears to me that any person well-informed concern- 
 ing the inflammatory lesions as to childbed fever, and acquainted 
 with its indefeasible tendency towards a termination in effusion, 
 suppuration, or gangrene, should agree that the happy recovery 
 of 88 of the 160 women was, in a good measure, due to the vene- 
 sections, which were doubtless reinforced by judicious after-treat- 
 ment The table does show, in the clearest manner, that the use 
 of the lancet is not so hazardous as many suppose it to be, and 
 that used as Dr. Lee employed it, with boldness, it not only does 
 no harm, but many more women recover under its exhibition 
 than in any other way. 
 
 473. There is much room for congratulating Dr. Lee on his 
 rescuing so many women, attacked with this dangerous dis- 
 order ; and it is to be reasonably supposed that though venesec- 
 tion did not have power to save the life in 32 of the cases in which 
 it was employed, while it was not prescribed in, 40 of the 160 
 women, no person should, from this want of success in the 32 
 cases, go about to decry bloodletting, because, if in 40 cases it was 
 not ordered at all, there must have been notable good reasons for 
 
248 CHILDBED FEVEK. 
 
 the omission, in the hopeless condition of the women, when brought 
 under notice; as well as a very strong inference to the violent or 
 advanced stage of the attack in those who were bled, but without 
 fortunate results. It is not likely that Dr. Lee would order blood- 
 letting for a woman to whom he should be called when she was 
 already in a dying state ; and it is equally probable that he would 
 give the patient the best chance of a cure, by bleeding her, even 
 where there might be some doubt as to the success of the opera- 
 tion. 
 
 474. I confess I cannot but take great encouragement from Dr. 
 Lee's table, as to the efficacy of the treatment by venesection. You 
 ought here to observe that, in many of the cases enumerated in the 
 table, Dr. Lee did not himself direct the treatment, and in many of 
 them the dissolution was imminent previous to the exhibition of any 
 remedies, and that such cases present no indications of the use of 
 the lancet. You will learn, presently, that the disorder often pur- 
 sues a course so rapid that, for many women, the curable stages are 
 already past, before the attention of the physician is called to them, 
 as was many times observed in Dr. Collins's cases at Dublin Hos- 
 pital. Having shown, by the foregoing histories, that these inflam- 
 mations do yield to venesection, and that it is a safe and conve- 
 nient, if not indispensable, means of cure, let us now return to 
 a more direct consideration of the power and effects of bloodletting 
 in these childbed fever inflammations : and here I invite you again 
 to notice the state of a circulation in which the contractions of 
 the heart are repeated at the rate of 130 beats a minute. I say 
 130, though it is very common to count 150, or even 160 pulsa- 
 tions to the minute. Each systole of the heart expels from the 
 systemic ventricles, perhaps an ounce, possibly only half an ounce 
 of blood into the aortic trunk. When the pulse is full and strong, 
 it is to be presumed that a larger injection is driven into the artery 
 with each beat of the heart. If you assume one ounce of blood 
 as the quantity expelled from the ventricle at each pulsation, then 
 you find rather more than nine pounds avoirdupois of arterial 
 blood is injected into the aorta, to be distributed throughout its 
 branches, in every consecutive minute, with pulse at 150=540 
 pounds per hour. I have no doubt that in some cases, when the 
 synochus-fortis pulse is observed,, particularly in the first hours 
 after the attack, this computation is far from excessive ; but, if 
 
VENESECTION. 249 
 
 you please to reduce it to only the half of the estimated quantity, 
 you must be struck with the enormous effort by which the transfer 
 of nine pounds of blood per minute, or 270 per hour, in its circuit, 
 is effected ; and how dangerous must be so impetuous a torrent, 
 driven into the inflamed capillaries of a metro-phlebitic patient, 
 or an extensive and extending peritonitis in a lying-in woman ! 
 
 475. It is to oppose this morbid vital state, that you attend at 
 the bedside, with remedies in your hands; and very certain it is, 
 that, seeing the nature of the lesions, and reviewing the corporeal 
 condition of the woman, just escaped from the fatigues of preg- 
 nancy and labor, and about to undergo those essential, indispensa- 
 ble, involutive processes that alone can reduce her to a natural 
 non-gravid condition again, you will make a fatal mistake if you 
 begin by a wrong or futile way of treatment. What will you do? 
 You may give her an emetic that will cause vomiting ; but what 
 will it do more ? You may dose her with Dr. Brenan's oil of tur- 
 pentine, yet with what influence on all this perturbation of her 
 brain, heart, and lungs ? You may dose her with quinia, but what 
 is your hope, and prospects ? You may crush or overwhelm her 
 sensibility under your anaesthetic doses of opium. But can all 
 these surely change the disordered relations betwixt the intro-pel- 
 vic and abdominal tissues and the nerve-centres, that are extricat- 
 ing, as if by a sort of electrical diruption, or explosively, the 
 neurosity produced by the combination of oxygenated blood with 
 the neurine? Will you try it with calomel? Why, some women 
 have taken 900 grains, and died ! Calomel ! Look again at my 
 sect. 322, for Kiwisch's patient, who died in eight hours, and mul- 
 titudes like it in the books everywhere. Calomel ! How long 
 will it be before the calomel shall begin to control and moderate 
 this furious torrent of the circulation ! There is not time for 
 calomel. Calomel cannot compose this passion. It is of educa- 
 tion Ovid speaks when he says, " emollit mores, nee sinit esse 
 feros," not of calomel. There is no time for the action of calomel ; 
 the disorder is swifter than the winds, and your calomel moves 
 with the reptant pace of the tortoise ; don't depend on the calomel ; 
 these are not the cases for drugs alone. 
 
 476. I solemnly aver that, after almost half a century of medical 
 studies, and most extensive and copious practice, I do not know 
 
250 ' CHILDBED FEVEE. 
 
 a situation in -which a medical man can be placed, wherein he 
 should require a more perfect intimate knowledge of the powers 
 of remedies, or be able to estimate their differential value, with 
 keener perception of even the shades of difference between their 
 several worth, than this of a childbed-fever-inflammation just 
 begun. It is a time to look upwards and pray to God for both 
 judgment and courage; to reflect upon the heavy responsibility, 
 and then take it, with an upright heart, and a mind resolved. I 
 am not speaking to you as my children and pupils, without earnest 
 thought, nor unadvisedly ; for I strongly remember, not only my 
 own experiences, but Gordon's distress when pursued by the fatal 
 epidemic at Aberdeen. Gordon was, at the time, most sorely beset. 
 He knew r that the lives committed to the protection of his ministry 
 depended upon the right employment of his great antiphlogistic; 
 yet his sentiments, or heart, revolted against his judgment, when- 
 ever he beheld the appalling weakness, or looked upon the tj^phoidal 
 exhaustion that would scare him from his purpose. What says 
 he ? " Now, nothing can be more applicable to the puerperal 
 fever than the observations of Botallus ; for, when I took away 
 only ten or twelve ounces of blood from my patient, she always 
 died ; but when I had courage to take away twenty 
 or twenty-four ounces, at one bleeding, in the beginning 
 of the disease, the patient never failed to recover ;" op. cit. 78. 
 Again, at p. 79, "unless a practitioner venture to take away 
 the quantity mentioned," &c. " And I felt this prejudice in its 
 full force when I had not courage to take more than 
 twelve or fourteen or even sixteen ounces, &c. &c. But when I 
 had resolution to take twenty or twenty -four ounces at one 
 bleeding, I disregarded it, because I was sure that that quantity, 
 taken away within six or eight hours after the attack, would cer- 
 tainly cure the disease," &c. &c. 
 
 477. Though I have examined with greater or less diligence 
 all the treatises, very numerous, on these disorders, that have come 
 within my reach, yet I cannot but consider the above words of 
 Alexander Gordon as worthy, more than any others, to be printed 
 in letters of gold, and I consider the granting of them to man- 
 kind as a great and useful bequest to human society. Any man 
 who will read and comprehend them, and apply them according 
 to their real meaning and intent, is fit to be entrusted with such 
 
VENESECTION. 251 
 
 important interests as these ; and there can be none greater in 
 the entire range of the physician's ministry. Gordon speaks of 
 having courage to do the bidding of his judgment, and of 
 resolution to carry out the dictates of his conscience, unbi- 
 ased by minor considerations, and unterrified by appearances, 
 which, however well calculated to deter some men, could not make 
 him flinch from the exercise of his power, under convictions of 
 duty. 
 
 478. I have represented you as attending at the bedside with 
 remedies in your hands, and interrogating your judgment as to 
 the selection of the proper ones. 
 
 If the disease should not have already proceeded so far as 
 to render it clearly impossible to prevent the termination in 
 either effusion, adhesions, suppuration, or gangrene; then, I con- 
 jure you, that, laying aside all other remedies as futile, you resort 
 to venesection as the sole hopeful resource in the case. But if, 
 judging from the appearances, you cannot indulge the hope of 
 preventing those internal effusions and suppurations, you should 
 consider that the time for the application is quite past, and that 
 you would, by administering it, only hurry on the fate of the 
 victim. 
 
 All that I have above said ought, I think, to convince you that 
 venesection has been in numerous instances used as a remedy in 
 childbed fevers with a striking success; and though I have not 
 had the happiness to show you all the minutiae, of the cases in 
 which it was employed, the naked fact stands out before you, that 
 sick women recovered speedily, conveniently, and perfectly ; and 
 this might suffice to show that it is not only an allowable, but a 
 most reasonable and hopeful remedy. You ought, of yourselves, 
 to settle the question whether the use of venesection does or does 
 not moderate the force of the circulation, and whether that mode- 
 rating influence ought, a priori, to be looked upon as the best 
 adapted of all our means to promote or favor a cure by resolu- 
 tion. Compare the mollifying influence of a proper bleeding 
 with those of calomel, turpentine, emetics, or opium ; take notice 
 of the length of time occupied by each in bringing about the 
 good results expected from them, and see for yourselves whether 
 you will venture to wait, even an hour, to procure a benefit by 
 one, which you can secure in five minutes or less, by the other. I 
 
252 CHILDBED FEVER. 
 
 hope these remarks may lead you to conclude that the greatest 
 vigilance, as well as promptitude, should be always observed, 
 since the loss of a few moments, in so rapid a disease, might com- 
 pel you to change your entire plan. You must be present very 
 early, for there is an hour in the case, subsequent to which you 
 neither can do nor even hope to do any real service. 
 
 479. I do not, however, conceive that any person has a right 
 to fix, beforehand, the precise date under which venesection may 
 be or may not be prudently employed, because the rate of the 
 disorder varies greatly in different women, some of whom com- 
 plete the whole of the inflammatory processes and die, within 20 
 to 40 hours, while others maintain a doubtful conflict during 5, 
 10, or even 15 consecutive days. Gordon, op. cit. 74, says : Two 
 died in the space of 24 hours after the attack ; one in 36 hours ; 
 three on the 3d day of the disease ; fifteen on the 5th day ; three 
 on the 7th ; three on the 11th ; and one on the 23d. Those of 
 our brethren who most distrust the lancet as a remedy, agree 
 with the warmest advocates in recommending an early resort to 
 it, if any. Gordon, 91, says: "After much experience in the 
 disease, and mature deliberation concerning the conduct most 
 proper to be pursued in my peculiar situation, I came to the fol- 
 lowing resolution : if called to a case within twelve 
 hours after the attack, I insisted on bleeding 
 the patient, and promised for its success; but if 
 at a later period, viz : from twelve to twenty-four hours after the 
 attack ; in that case, like Sydenham, with the same remedy in the 
 smallpox, I thought it incumbent on me to propose it as the only 
 effectual remedy; but I neither insisted on it, nor 
 promised for its success." 
 
 480. I consider that the extract from Gordon that preceded 
 this one ought to weigh more than his assertion as to the lapse of 
 precisely 12 hours; for it is certain that if, in the two women 
 who died in 24 hours, and in the three who died on the 11th day, 
 there had arisen a question as to venesection as a remedy, it 
 would be far more urgent to adopt it very early in the first two, 
 than in the latter three women. Nevertheless, I am well satisfied 
 with Gordon's preciseness, which serves, at least, to prompt us to 
 be more vigilant and active, and so, more fit depositories of the 
 public confidence. 
 
VENESECTION. 253 
 
 481. I do not think it worth while here to attempt to point ont 
 to you the precise and distinctly marked signs out of which you 
 are to gather the indications, pro or con, as to the use of venesec- 
 tion in your cases. I have observed that, for twenty-five centuries 
 past, this could not or has not been done, at least with the effect 
 of making the matter clear to all minds. Yet these signs do exist, 
 and are susceptible of a rational interpretation. They are not to 
 be discovered in books, but they are abounding and superabound- 
 ing in nature. In the difficult cases, a man cannot master them 
 by studying the pulse alone ; indeed, it would sometimes be safer 
 not to feel the pulse at all, as the pulse is capable of entirely 
 misleading us. Neither shall you know the truth by means of 
 auscultation of the heart, to determine its rhythm and force, for 
 they may mislead like the radial pulses; nor by any spirometric esti- 
 mates of the respiration, its amount, its rate, and its efficiency in 
 oxygenating the blood and the tissues, and in evolving the animal 
 heat ; neither the muscular strength, that often fails, as an expositor 
 of the vital forces ; nor the intellection as exhibited in speech, in 
 reasoning, or physiognomical expression. It is rather from an 
 examination of the whole of these, than from a part only of them, 
 that a man may come to his conclusions. Time, or the past dura- 
 tion of the case, is an important element, that should always be 
 taken into the account with our decision. To touch the pulse 
 alone, therefore, and find it flying; to observe the artery as being 
 soft, compressible, and fluctuating, and at the same moment to note 
 the appalling, and, so to speak, mortal pallor of the countenance ; 
 the hurried and broken respirations ; and to hear the trembling 
 voice, and see the unsteady tongue, might lead one to infer that 
 the time of rescue is past, the disease gone too far, and the chiefest 
 of all our resources barred out forever in the case. It is better, 
 therefore, to pause and consider the conflicting elements of a diag- 
 nosis and prognosis; to reflect that the nervous centres are suffer- 
 ing from a state analogous to what surgeons call shock, which 
 here leads to, and gives hope for, no reaction like that which may 
 be expected in surgical shock, but is progressive to an issue which 
 is only in suppuration, effusion, or gangrene — death. Dr. Hulme, 
 Treatise on Puerperal Fever, Syd. Soc. edition, p. 76, says: "Nurses 
 and women in general seem, in a great measure, ignorant of such 
 a disease as this being incident to lying-in persons. I dare venture 
 
254 CHILDBED FEVER. 
 
 to say that the very name of it is as much a stranger to most of 
 them as if no such malady existed; and yet there never was a 
 time when this disease did not exist. The consequence is, that, 
 knowing no danger, they fear none; whereas, on the contrary, 
 they should be taught to dread the name of puerperal fever as 
 they would the name of pestilence or plague, for I fear the one 
 destroys not more than the other. Like a fierce and untamed 
 enemy, the one spreads his hostile banners in open day, and feasts 
 on carnage and destruction till, glutted with slaughter, he himself 
 sinks down and dies. But the other, like a secret, revengeful foe, 
 stabs in the dark to the very vitals, and, though he kills one only 
 at a time, yet he is privately slaying every day, and is never 
 satiated ; thus making up by length of time what the other does 
 by a sudden devastation. They (nurses) should be taught to know, 
 I say, that pain and soreness of the belly, coming on soon after 
 delivery, unless speedily relieved by judicious assistance, will 
 prove mortal in a few days. * * * I cannot say how it may 
 be with other physicians, but, for my part, I never hear a childbed 
 woman complain of a pain and tenderness of the abdomen, but I 
 look upon her disorder with as much anxiety and circumspection 
 as if I knew her actually laboring under an inflammation of the 
 bowels, or a hernia with a strangulated gut ; and I think it my 
 duty to be as expeditious in relieving the one complaint as the 
 other." What a pity it is that every woman who is about to be 
 confined should not have before her the privilege of reading the 
 above clear, strong, and most true words of Dr. Hulme. 
 
 482. How, then, young gentlemen, shall we judge? Who shall 
 be able to teach us our duty? Such, it seems to me, are your ques- 
 tions. I, for one, cannot teach you, nor, I believe, no man else. 
 You must learn it yourselves, out of the ample page of clinical 
 observation, and by the exertion of your faculty of reason and 
 judgment; not as empirically, but rationally, founding yourselves 
 upon the sciences of anatomy and physiology. You alone must 
 ever judge of the case and its wants, in the presence of the case. 
 It does not require a long series of years to learn this ; but it can 
 only be acquired by the diligent, conscientious student of our 
 Literature and of Nature, who must be from the beginning pre- 
 pared to observe, and to know the truth of what he observes. 
 
 483. I have reflected long and anxiously upon Gordon's words 
 
VENESECTION. 255 
 
 relative to early venesection, and the absolute dependence to be 
 placed upon it as a remedy, when promptly, resolutely, and 
 courageously executed. Those words of Gordon seem to have 
 been uttered by him as in a moment of enthusiasm and elevation 
 that carried him beyond his ordinary and phlegmatic modes of 
 mind. These reflections have led me to imagine that a physician 
 placed under such circumstances ought always to be vividly on 
 the watch, lest he should be blinded and misled as to the appear- 
 ances and the facts before him. Such a man should possess an 
 intellectual power capable of lifting him, as it were, to some great 
 advanced height, from which to survey and overlook the entire 
 scene, and discern all, not here and there parts of it only. He 
 should be able, while clearly discerning the prominent objects 
 beneath him, as the circulation, the respiration, the heat, the 
 coloration, and the general innervation of the economy,. to con- 
 ceive of and comprehend the real condition of the textures, their 
 vital state and reacting power, and so, become the prognosticator 
 of issues and events wholly hidden from the eyes of the more 
 casual and less eminently stationed observer. He would look 
 into the actual condition, phase, and progression of the phlegmasia, 
 and its tendencies as to the whole economy of the life. This is 
 the monster cause of all the mischief, hidden in mists and fog, 
 that he is to seek for and destroy at one blow. Thus it is that 
 Gordon would instruct him to do, that the victim may be saved, 
 and the Divine Art triumph in the rescue. A physician thus 
 placed, and surveying the whole field from some great intel- 
 lectual elevation, and scrutinizing each particular, bearing upon 
 his duty and power, would be like unto the studious orator, sup- 
 posed by Quintilian, in the tenth book : "Turn intendendus animus, 
 non in aliquam rem unam, sed in plures simul continuas ; ut, si 
 per aliquam rectam viam mittemus oculos, simul omnia quae sunt 
 in ea, circaque intuemur, non ultimum tantum vide- 
 mus, sed usque ad ultimum." A man capable of acting 
 thus will never be scared away from the performance of his duty 
 by the outward aspect of the sick woman, her apparent exhaustion 
 or debility ; but, as Quintilian says, he will see not only to the 
 end, but everything intervening betwixt the present and that end 
 — in plain words, he will exert the highest power of medical 
 men, that of making absolute diagnosis, in which are always con- 
 
256 CHILDBED FEVEE. 
 
 tained the prognoses of diseases. The conditions of the problem 
 of recovery or death are, that he shall do his duty, or leave it 
 undone; in the former, the issue is in recovery; in the latter, 
 death. When will our art reach to the height of excellency ? 
 
 484. I hope, my dear young Gentlemen, you will rely, then, 
 upon venesection as the most effectual, and indeed, only trust- 
 worthy power vouchsafed to you in these trying circumstances ; 
 and I pray you in executing this delicate task, to observe the 
 following methods : Let the woman be raised in bed, upon pillows 
 that may support the trunk in a highly inclined position, though 
 not in an absolutely upright one, unless she be still possessed of 
 considerable strength. Select the most proper, which is the largest 
 and most turgid vein in the arm, and open it by a free incision, 
 to produce a copious jet. A clear, bright light should invariably 
 fall on the patient's countenance, to enable you to judge by its 
 hues and its psychical expression, of the influence of your opera- 
 tion, during the time while it is in progress. You should invariably 
 require such a light, since the progress of your operation may be 
 prolonged, or suspended, or arrested, or renewed, by inferences 
 drawn from the tints of the face, and the state of the features. 
 The design of the operation, in childbed fevers, should never be 
 to merely fulfil some purpose of presumed expediency, to lessen 
 a little some pain, to diminish a somewhat troublesome cephalalgia, 
 or a vexing heat. It is to be done with a view jugulare febrim, 
 by impressing upon the motive powers of the circulation such an 
 overmastering influence, that the inflamed tissues may afterwards 
 successfully resist the overbearing power of the general vascular 
 reaction, which was first aroused by them alone. This impression 
 you will not and cannot make, by timidly shrinking from your pur- 
 pose, at the first observed signs of the coming influence you sought 
 to obtain, but which is only coming and not yet come. Stop 
 the jet now for a moment, to retard the arrival ; and, drawing 
 away one or more pillows, allow the head and trunk to take a 
 lower inclination ; then let the jet fly again, and with your eyes 
 on her countenance ; by inquiries addressed to her, and by your 
 hand on the pulse, judge whether the influence is now come in 
 truth and in power. If you will be but bold, resolute, resolved, 
 as Grordon charges you to be, you will overlook the 
 whole scene, and perceive that the heads of the monster are cut 
 
VENESECTION THE CHIEF REMEDY. 257 
 
 off at one blow ; or that, as Legouais expresses it, one head retains 
 its vitality, and will revive more terrible than before. Leave off 
 with 8, 12, or 16 ounces abstracted, and you may go away from 
 the bedside saying " she will surely die ;" but if you will cou- 
 rageously and resolutely persevere until twen- 
 ty-four or more ounces, not too many more, are 
 taken away, you may retire after your ministration, feeling assured 
 that the duty is well clone, and believing that the life of the patient 
 will be saved. If she should not be rescued, it would not be 
 because you had not fulfilled your professional duty as to this, the 
 most important part thereof. 
 
 485. At the age of sixty -two years, and after a life in which 
 my medical studies, commencing in 1809, and a copious clinical 
 experience, and no little reading of authors, have continued until 
 the present day, I am become immovably fixed in the conviction 
 that for the cure of a childbed fever, bloodletting is the chief, 
 not to say sole reliable remedy; I go further, and say that 
 the dreadful mortality that marks the epidemic forms is discredit- 
 able to our class ; and I say this founding it upon the irrecusa- 
 ble truth, that the disease is always a phlegmasia, and that it has 
 a stage during which the application of the proper remedy is 
 possible, and that only a lack of proper vigilance, or a lack of 
 perception and judgment, too often, allows that evanescent stage to 
 be over and passed, while we, alas! doubt and hesitate, and at 
 length judge wrongly of the duty. Let me cite for you a strong 
 passage from Legouais, who, in urging you to a proper, bold use 
 of venesection says: "Nous croyons done qu'on doit avoir pour 
 but, dans le traitement de la peritonite puerperale par la saignee, 
 d'aneantir pour, ainsi dire, tout a coup, la maladie par l'emploi 
 puissant et energique de ce moyen. C'est l'hydre de la fable ; on 
 ne peut la vaincre qu'en abattant d'un seal coup toutes ses tetes ; 
 si Ton en epargne une seule, elle suffit pour entretenir un principe 
 de vie qui bientot fera renaitre le monstre plus terrible que jamais." 
 — Op.ciL, 23. 
 
 486. Dr. Joseph Clarke, of Dublin, Obs. on Puer. Fever, &c, 
 Syd. edit. p. 351, says : "It may be difficult in the beginning to dis- 
 tinguish puerperal fever from accumulations of feces in the ali- 
 mentary canal, especially if joined to an ephemera or weed." If 
 
 17 
 
258 CHILDBED FEVEK. 
 
 the symptoms continue beyond twenty-four hours, and after the 
 operation of purgatives, then "I consider the existence of puer- 
 peral fever absolutely ascertained, and it will be found to 
 prove fatal to a great majority of those whom it 
 attacks." ISTo wonder, because, at 361 he continues: " Vene- 
 section, which is strenuously advised by Leake, Denman, and' 
 others, I have never seen of any use, excepting in a few cases 
 where there seemed to be a combination of peripneumonic symp- 
 toms along with the peritonitis ; and even in such cases it only 
 had the effect of alleviating the severity of the symptoms." 
 
 Dr. Walsh takes up a large part of his book in a vain attempt 
 to show that bloodletting is not the best, or even a generally pro- 
 per remedy for the disease. He argues to the abandonment of 
 venesection, from its injurious effects in scrofulas and rheumatism, 
 and from the abuses of venesection in various maladies that he 
 particularizes, but which I shall not here quote. — See Walsh on 
 Puerp. Fev., pp. 28-41. 
 
 Dr. Charles White, of Manchester — A Treatise on the Manage- 
 ment of Pregnant and Lying-in Women, &c, London, 1791, 8vo., 
 has at page 217, the following remarks : "In regard to phlebotomy, 
 especially at the beginning of this disorder, authors are much di- 
 vided ; some of them obstinately insisting upon its efficacy, and 
 others as warmly rejecting it. That some women may be subject 
 to such inflammatory disorders during their lyings-in as may re- 
 quire bleeding, cannot be denied ; but cases of this kind are not 
 very common in the present age, especially among those who 
 inhabit large towns. In the puerperal fever, however, which gene- 
 rally, sooner or later, affords striking symptoms of putrescency, we 
 should be extremely cautious how we do anything to debilitate 
 the vis vitce, to weaken the circulating powers by unnecessary 
 evacuations, or waste the strength, which may be wanted to sup- 
 port the patient under looseness and vomitings, &c. &c.;" and this 
 is the way he discoursed on a topic he did not understand. Yet 
 he is a man much quoted for his wisdom and experience as a 
 practitioner of physic. And can it be that men in our profession, 
 men having the very same sort of eyes, do see the same object 
 green, black, or white, according to the point of view from whence 
 they look upon it? yet, surely no one will contend that our child- 
 bed fever is like the chameleon in Merrick's rhyming story. 
 
WHITE — HULME — VAIN FEARS. 259 
 
 How various are the views and opinions of men, upon the very 
 same subjects. The illustrious Boerhaave thought it a most seri- 
 ous thing to let blood for a lying-in woman, and not to be attempted 
 except under urgent necessity. The genius and learning of Ki- 
 wisch could not save even him from the German ethnological 
 inaptitude to adopt venesection as a remedy, except with many 
 precautions, misgivings, and doubtings, and even then not well. 
 Yon Busch, his countryman, is also one who dreads the lancet, 
 even in these unquestionably furious phlegmasias; and good, 
 modest old Dr. Hulme, p. 96, says of bleeding for puerperal fever 
 that, " the first quantity taken away should barely 
 exceed eight ounces, but that the draught may be repeated, 
 if required, in a few hours afterwards ; but it should be always 
 remembered that bleeding in the puerperal fever (I speak it with 
 submission), is only to be considered as a secondary 
 relief, though the first in point of time; and that the greatest 
 stress is a 1 w a y s to be laid upon evacuations by stool. In the 
 quantity of bleedings, therefore, allowance should always be made 
 for these evacuations, which must, at all events, take place, and if 
 too much blood be taken away, it may weaken the patient so 
 much as to prevent her supporting the other evacuations." To 
 me, it seems that such reasonings as these are fit to excite only a 
 smile. I seem to discern in them the dim and ghostly shadows 
 of the defunct milk-metastasis dogma, wandering abroad half seen, 
 half hid in a humoralism, not less pernicious in its practical in- 
 fluences than the notions of errements de lait, coctions, and len- 
 tors. They implicate, as a condition of their own existence, the 
 idea of an existing morbid entity, and they demand the abso- 
 lute elimination of a substantial thing, a materies morbi, as essential 
 to the cure ; whereas, it strikes me that our first and greatest duty 
 is to prevent the woman from dying outright, and so, leave these 
 evacuations to take care of themselves. All such morbid entities 
 should be treated as tails of the lost sheep in the nursery rhyme — 
 
 " Little Bo-peep 
 
 Has lost bis sheep, 
 And knows not where to find 'em ; 
 
 Let 'em alone, 
 
 And they'll come home, 
 Bringing their tails behind 'em." 
 
260 CHILDBED FEVER. 
 
 I pray you pardon my humble illustration, which smells of the 
 nursery. 
 
 487. The state of the patient is sometimes such as to balk one's 
 intentions, and compel him, however reluctant, to desist, after 
 taking away only ten or twelve, or even only sixteen ounces of 
 blood. I may be so compelled by the fainting of the woman; 
 by some perceptible alteration of the pulse, the respiration, or 
 the physiognomy. I shall always endeavor, however, to carry 
 out the design, by waiting for renewed power; by exhibiting some 
 cordial; by lowering the pillows; by causing the woman to make 
 repeated powerful aspirations of air into the lungs. But, in all 
 cases, without exception of any, where I am wholly baffled, and 
 compelled to stop short of twenty-four ounces, I shall retire from 
 the chamber a disappointed and downcast man ; because I fix my 
 faith on Gordon's words ; and, far more, because my own long 
 bitter experiences in a physician's life, have proved to me that 
 his words are words of truth, and soberness. I am not to be 
 understood as saying the patient will die, if not bled to twenty- 
 four ounces; but only that it is to be expected she will not be 
 cured in the end ; when I leave such a person, I leave her little 
 hoping that she shall be saved. 
 
 488. I readily conclude that some, and, perhaps, many of my 
 renders will here call in question the reasonableness and modera- 
 tion of these opinions of mine, so confidently asserted, as to the 
 power of a venesection, to a certain amount, to check the further 
 progress of the seinternal inflammations, and impress upon them a 
 tendency to vanish by resolution. But all such cavillers ought to 
 understand that, however decided my convictions of the truth of 
 these propositions are in general, I do not pretend to answer for 
 each particular case, since there may exist propensities in certain 
 constitutions that should ever baffle the best directed means and 
 efforts of art. I have spoken of twenty-four ounces as the quan- 
 tity to be commonly relied upon, from Gordon's experience, and 
 that of other physicians, and my own. But, in sec. 339, I have 
 related cases in which I took a much larger quantity, and I now 
 assure you that while, in a well-found adult, I should always 
 desire to abstract at least the twenty-four ounces, I would not 
 arrest the flow in such an individual as long as the pulse should 
 
TWENTY-FOUR OUNCES. 261 
 
 remain firm, and the face, lighted as above advised, should exhibit 
 no proofs that I had yet sufficiently impressed the nervous centres, 
 and, through them, the injection-power of the heart. I shall 
 never bleed any patient of mine with any other purpose or from 
 any other motive than this, viz : to enable the heart to act gently, 
 and so, allow the organs or tissues that are tyrannically op- 
 pressed, and threatened with ruin from its overbearing force, to 
 recover their conformable power ; I mean the power of receiving 
 and transmitting just so much blood as the physiological rate 
 imposes it on them to do. 
 
 489. Some, nay many women /that I have bled for puerperal 
 fever, have fainted after the loss of eight, ten, or twelve ounces ; 
 which leads me to say that every instance of fainting under vene- 
 section, is not to be taken as a consequence of loss of blood. A 
 patient of mine, whose basilic vein I was touching preparatory 
 to the operation of venesection, fainted so badly that I entertained 
 serious doubts v» r hether the woman would not die in the syncope, 
 for in the course of my life I have rarely seen a more threatening 
 one. Many persons do faint from emotion — a pathemate mentis as 
 the books express it ; and you ought not too hastily, upon seeing the 
 patient faint, to conclude that your work is clone, and that it would 
 be imprudent, and even very dangerous to proceed any further. 
 But, even when early syncope is due to the loss, I believe, it may 
 be stated as a fact that, after the sick person has revived, it is 
 possible to take even a larger quantity without reproducing the 
 syncopal state ; for, after a too small bleeding, the vascular reac- 
 tion, in inflammatory diseases, becomes greater than before ; so that 
 it is better not to bleed at all, than to do the work imperfectly. 
 It is on this account that, when I stop short of twenty -four ounces, 
 I always retire burdened with anxious doubts ; but when I can 
 conveniently abstract twenty-four ounces or more, I know that 
 quantity must permanently affect the pulse, and diminish its 
 frequency ; whereas, a small ineffectual bleeding often causes the 
 rage and violence of the circulation only to augment. 
 
 490. If the woman be raised as I have advised, and as is uni- 
 versally done, I believe, and the face be properly illuminated, 
 observation of the physiognomy reveals the very earliest signs of 
 the coming change of rate; so that by withdrawing one of the 
 
262 CHILDBED FEVER. 
 
 pillows, and then another, to let the head and trunk become less 
 inclined, one may, without interruption, succeed in abstracting a 
 much larger quantity than could be spared if the person were in 
 an erect or highly inclined attitude. 
 
 491. If, in any case, you should abstract as much as twenty-four 
 or thirty ounces of blood at one bleeding, the impression made by 
 such an artificial hemorrhage will, like that of considerable spon- 
 taneous or traumatic hemorrhages, be permanent. The woman 
 is permanently weakened, and her power of expanding, and even 
 maintaining at a present state the areas of phlogosis, is weakened 
 at the same time — often absolutely nullified. It cannot be but 
 that the heart shall now beat less frequently, and expel a smaller 
 quantity into the aorta at each systole. You have seen, by a com- 
 putation in a former section, that nine pounds are driven into the 
 capillaries per minute, in certain excited conditions of the circula- 
 tion. If you reduce this injection only ten per cent., or even only 
 five per cent, by your venesection, the inflamed textures may, 
 under its lessened violence, take occasion to recover by passing 
 onwards now, what they could by no means previously transmit, 
 and so could not avoid expanding the phlogosed areas by loading 
 their conterminous capillary vessels. 
 
 492. Is it hazardous to take blood in this way that I have 
 pointed out ? It is by no means hazardous to do so, provided 
 knowledge and attention preside at the operation. As the blood 
 leaps from the open vein in bleeding, an instant pressure of the 
 ringer, or dossil, can instantly stop the jet, and let it fly again, 
 to be again stopped at pleasure. With a finger on the pulse, and 
 the eyes directed to the patient's countenance; by a question, or 
 even by a surmise, the operator arrests or resumes the course of 
 his operation — saying, it is enough — it is not enough — the work 
 is done. Jugulavi fehrim. 
 
 493. Eead the following pleasing relation, in which Gordon 
 gives a history of the conduct of two of his pupils, Messrs. Gordon 
 and McRae, who seem to me to have become very thoroughly 
 imbued with their master's principles, and familiar with his 
 modes of practice : " An express came for me one night, to go to 
 the Printfield to Mrs. Forbes, No. 62, who had been seized with 
 the puerperal fever, which made rapid progress, and was attended 
 
263 
 
 with symptoms which alarmed the patient's friends, and made 
 them send for me. I dispatched Mr. John Gordon and Mr. Jo- 
 seph McKae, with instructions how to act ; and they managed the 
 case with great propriety ; for, when they had taken away about 
 twelve ounces of blood, the patient fainted; but the young gentle- 
 men were not alarmed at that, but waited till she recovered, 
 when they took away other twelve ounces ; and, after the bleed- 
 ing, they gave a brisk purgative, which operated well, producing 
 ten or twelve plentiful motions." Gordon, on visiting Mrs. 
 Forbes the next day, found that both the fever and the pains in 
 the abdomen were quite gone, and the woman well enough. 
 
 ±94:. But, though the decision to commence the cure by blood- 
 letting is easily come at in early stages, and in persons where the 
 powers of the constitution have not yet fallen beneath the burden 
 of irritating morbid impression, the question appears, for some, 
 to be surrounded with difficulty where the attack has already 
 grown old, or where the nervous centres are already reeling, 
 trembling, and almost failing under their load. What shall 
 enable you to decide ? 
 
 •±95. Examine the pulses carefully in different parts of the 
 body. Study attentively the heart by auscultation of its impetus. 
 You may, often, better know the real rate of the function of the 
 circulation by interrogating the heart, than by the most careful 
 study of any of the other pulses. Let the patient project the arm 
 horizontally, and hold it as still as possible, while you estimate 
 by observing the act, the equal or unequal tension-power of its 
 flexor and extensor muscles. I have made use of this latter test 
 many times, and have resolved to perform the venesection, because 
 I perceived, in the steadiness of the extended arm and hand, such 
 evidence of muscular force as to neutralize, or even wholly dissi- 
 pate objections to the operation, derived from other sources of 
 observation; or I have desisted from my purpose, upon so observ- 
 ing the exhaustion of the muscular forces. I may safely venture 
 here to say, that in those difficult questions as to the ability of a 
 sick person to bear depletive measures, where strong inducements 
 yet lead to desire them, one may freely decide in their favor upon 
 such a test. The individual who can hold forth the arm and 
 hand horizontal and steady, can certainly bear the loss of blood 
 
264 CHILDBED FEVER. 
 
 by venesection when it is judged needful. Such a power is in- 
 compatible with a perishing frame. 
 
 496. Gordon, you have seen, confides in the power of the 
 remedy, up to the twelfth hour of the attack ; later than that he 
 is willing to adopt it, but not to make confident predictions of its 
 success. Perhaps this view is entirely sound, in so far as it relates 
 to the cases of endo-metritis and metro-phlebitis, but it does not 
 concur with my own experience or reasoning as to peritonitis, pure 
 and simple. In phlebitis, as in pseudo-membranous laryngitis or 
 croup, there is a stage, antecedent to the establishment of the 
 exudative process, in which venesection ad deliquium animi ope- 
 rates with almost unfailing certainty to cure. But the stage of 
 curability by venesection, in croup, is very soon past, and a cha- 
 racter assumed with which venesection is wholly incompatible. 
 The same may be stated of phlebitis of deep-seated vessels, and 
 these are the cases to which Gordon's rule strictly applies. Not 
 so in the merely serous inflammations, which, when not compli- 
 cated with other organic or phlegmonous phlegmasias, pursue a 
 gentler though not less persistent course to the term by effusion. 
 Here, twenty-four hours, or even forty-eight hours may have 
 elapsed, and yet leave you, after your skilful, perfect diagnosis, 
 with a reasonable hope to arrest and repel the progress of the 
 inflammation by a decided impression on the nerve-centres through 
 bloodletting. I will not presume to say how long, in any case, the 
 curable stage by venesection may extend; but I implore you 
 ever to consider the weakness of our drugs and medicines, when 
 brought alone, to oppose these persistently progressive diseases, 
 and, using your own sound discretion, choose that which, under 
 such fearful circumstances, may seem both best and safest. 
 
 497. I treated a case, in which I was much interested, as follows, 
 and I shall relate the circumstances that preceded the attack : Satur- 
 day, April 17, 1852. Mrs. T. K, set. about 32, in her seventh preg- 
 nancy, at the eighth month, was delivered at a quarter-past one 
 o'clock this morning, after an easy labor, with forceps. My motive 
 for using the forceps was, that she was seized during the labor 
 with spitting of blood, and I could not suffer her to apply the 
 w r hole force required for delivery. I therefore aided her with the 
 instrument. Sunday, 18th. Has had a good night; lochia rather 
 
THE TWELFTH HOUR. 265 
 
 too free. Monday, 19th. Being detained, I did not pay the visit 
 until near one o'clock P.M., when I learned that I had been sent 
 for on account of a severe pain in the pelvis and abdomen, which 
 came on about 10 A. M. She lies on the back, with feet drawn 
 up ; breathes quick and short, on account of the pain in the belly, 
 which she cannot allow to be touched, for the soreness of it ; the 
 pain and soreness, mainly, in the region of the left broad ligament 
 and ovary. The uterus is very sore; the pain unceasing, but aggra- 
 vated from time to time by after-pains. Face flushed. Tongue 
 moist and broad. Heat of skin very great. Pulse 144. Upon 
 much examination, I diagnosticated peritonitis, and therefore took 
 from her arm seventeen ounces of blood, ceasing only because the 
 failure of the pulse compelled me to stop, to my great regret. She 
 had, shortly before her labor, been bled twelve ounces for a head- 
 ache, and not long before that, lost six ounces from the arm. After 
 the faintness the pulse was slower. Took forty drops of laudanum, 
 and got six one-grain pills of opium, of which to take one every 
 hour, unless much relieved. She took only one of them, and at 
 10 P. M. was comfortable, the pain not having returned since the 
 bleeding. Before I had taken the whole quantity, she said it 
 was gone. Tuesday, 20th. Slept well; pulse at noon above 100; 
 at 6 P. M., nearly natural. The bowels have been moved by a 
 dose of castor-oil. I consider her cured. I have no doubt the 
 areas of phlogosed tissue were already risen above the plane of 
 the superior strait when I bled her, by which operation I consider 
 her life to have been conserved. Wednesday, 21st. I found she 
 had had a wakeful night ; pain in the belly, with soreness to the 
 touch; pulse 120, and rather full; face flushed; skin warm ; some 
 (very little) milk in the breasts ; tongue a little furred. Took 
 castor- oil, which gave three operations, and at the evening visit 
 the pain and soreness was gone; pulse calm, and the lady cheerful. 
 I had no further trouble with, the case, for she was well from 
 that hour. 
 
 Mrs. S., in fourth pregnancy, delivered of a girl of seven and 
 a half months, Friday, April 9, 1852. On Monday, 12th, saw her 
 at 9 A. M., perfectly well ; but at 10 J A. M., a violent chill, with 
 intense pain of the lower belly. Lies on the back ; excessively sore 
 and tender to touch; breath short; countenance anxious; greatly 
 alarmed. Tongue milky; no headache; pulse 132. This was 
 
266 CHILDBED FEVER. 
 
 her state when I returned at meridian. Not a strong woman. I 
 took eighteen ounces and stopped, compelled by her fainting. In 
 ten minutes, opened the arm and removed six ounces more. Two 
 drachms liq. morph. In evening, comfortable. Tuesday, 13th. 
 Out of danger. Much better on Wednesday, 14th ; and on Sun- 
 day, 18th, quite well again. 
 
 498. I shall next state the circumstances of a case that proved 
 fatal, taking it from my notes of the date, Monday, Jan. 11, 1853. 
 Mrs. S. E., aet. 32, primipara, gave birth to a healthy male child 
 at half-past one o'clock P. M. She was of a highly nervous san- 
 guine temperament; had threatenings of labor for about three 
 weeks ; I have seldom observed a more distressing case of rigidity 
 of the cervix uteri. The labor occupied thirty- six hours, during 
 which her distress was so great, and the resistance to powerful 
 labor-pains so obstinate, that I greatly feared a dangerous lace- 
 ration of the cervix, and was at times sorely tempted to incise it 
 in order to expedite the escape of the head from the circle of the 
 os, but at last it gave way and disappeared above the head. I 
 extracted the child very gently with the Davis's forceps, leaving 
 upon the infant's cranium and cheeks not even the slightest im- 
 pression of the clamps, which I take to be proof that it was gently 
 and skilfully done. Throughout the whole course of the dread- 
 ful labor, the circulation was torpid to that degree that I gave 
 her small portions of wine and water, and could not think to 
 bleed her. 
 
 499. She was passionately delighted with the child, which she 
 caressed with marks of the greatest satisfaction. In all respects 
 she went on satisfactorily, yet with strict injunctions to call me 
 upon the occurrence of any, the least unpleasant symptom. Four- 
 teen hours after the close of the labor, she was attacked with 
 childbed fever at about 3 o'clock in the morning of Tuesday ; but 
 I was not called until 10J A. M. of that day. I was busy else- 
 where, and so, lost the first seven hours of a most dangerous case, 
 which proved to be an irreparable loss. I found that the topical 
 had now become a frightful constitutional disorder; for the pulse 
 was 180 already, the pain and tumefaction or ballooning of the belly 
 horrible, and the urine and lochia suppressed. The aspect of the 
 case struck me as one of hopeless violence and progress. I raised 
 
RAPID CURE OF A CASE. 267 
 
 her on pillows and opened a vein, but she fainted so badly at nine 
 ounces, that though I lowered the head, I was compelled to desist 
 in spite of my urgent desire to the contrary. An hour later, I 
 opened the vessel and drew off nine or ten ounces more, when, de- 
 sisting under compulsion of the case, I applied leeches freely to 
 the hypogastric region, which bled abundantly. The symptoms of 
 peritonitis now abated so much as to fill me with hopes, not con : 
 fidence. It was not long before the metro-phlebitic constitutional 
 diseases, by their unmistakable presence, showed me that my 
 remedies had in so far failed. I need not recite the various but 
 futile measures thenceforth adopted, though with little prospect of 
 advantage, until she died. The cervix had been lacerated as to 
 its inner and lower posterior portion, though the laceration was 
 only upon its inner superficies, not being torn through. The 
 substance of the womb was healthy in appearance, except on its 
 inner cervical portion, which was black, and softened by inflam- 
 mation. The abdominal and visceral peritoneum was healthy, 
 but upon the fundus uteri and posterior aspect, were observed 
 marks of inflammation, with a small deposit of albumen coagu- 
 lated. An ounce of serum was found in the Douglass's cul de 
 sac. 
 
 500. This woman was certainly cured of a most violent perito- 
 nitis, except as to the small remainder, above noticed. She died 
 with putrescentia uteri proceeding from the wound by laceration 
 of the inner stratum of the cervix. The violent hysteroid symp- 
 toms that attended the recrudescence of the disease were evidences 
 of purulent infection of the blood, or p} r 8emia. 
 
 501. I know not what may be your views on the subject, but 
 I shall never consider that the loss of this woman was due to 
 anything save the stupidity of her nurses, who criminally allowed 
 more than seven irreclaimable precious hours to elapse, before 
 they summoned me to observe a pulse of 180, the most misera- 
 ble abdominal pain, and a tympany of the utmost magnitude, 
 and tense as a drum-head. An early visit, at 5 o'clock, or 4 A. M., 
 would have enabled me to perform a Gordonian venesection, by 
 which to cure not only the peritonitis, but the traumatic metritis 
 itself. 
 
 I pray you accept the account of another case, that of Mrs* 
 
268 CHILDBED FEVEK. 
 
 S. A., who was delivered of her sixth child on the same day, Jan. 
 11, 1853, with the foregoing. She is a very short delicate wo- 
 man, with small limbs, and of a nervous bilious temperament. 
 She was attacked on the same day with Mrs. S. E., and sent for 
 me immediately, the attack having come on at 9 A. M. of the 
 12th Jan. I found her in the chill, with violent peritonitis and 
 uterine pain, and flying pulses. The rapid abstraction of twenty- 
 two ounces from this feeble, exhausted little woman, destroyed 
 the disorder at a blow. It cured her, and I never had a moment 
 of anxiety for her after I had drawn the blood away. An early 
 venesection failed to cure the patient whose case I have related 
 in sec. 224. 
 
 502. At 11 J P.M., January 23 (Sunday), 1853, 1 delivered Mrs. 
 B. of a male child that weighed ten and a half pounds. She was 
 well until Wednesday, 26th, at 3 A. M., when she was attacked 
 with coldness, violent pain in the pelvis and belly, and great 
 fever. She now spoke to her nurse, saying: "I am attacked with 
 puerperal fever; get up and call my husband." " He can do you 
 no good," was the hag's reply, and so, I was not informed until 10} 
 A. M. The childbed-fever phlegmasia was already seven and a half 
 hours old; pulse 136; pain in belly intense; decubitus dorsal; so 
 sore as to bear no touch on it ; tympanitic. I drew away by mea- 
 sure twenty-seven ounces of blood from the arm, and then gave her 
 a posset as follows : Take a tablespoonful of sherry, a wineglassful 
 of milk, and a dessert-spoonful of sugar ; pour over the mixture 
 three quarters of a pint of boiling water, and strain the liquor — to 
 be taken rapidly, and as hot as it can be borne (whosoever swallows 
 this posset will infallibly sweat profusely within a few minutes 
 after swallowing it). Mrs. B. sweated like a squeezed sponge. 
 
 At 2 P. M. she took ol. ricin. com. Ij. syrup, rhei simp. 3ij. 
 M. sig. The dose, a tablespoonful every hour, until the opera- 
 tion. At 5} P. M. had taken only one dose. I reiterated the 
 order, and directed mush-poultice for the belly. At 10 P. M. 
 pulse 130, but soreness and heat all gone. Bears pressure of the 
 abdomen and moves the legs without pain. Enema of salt and 
 water ; had copious alvine discharges, and the pulse fell to 120, 
 whereupon she took two drachms liquor morph. sulph. She re- 
 covered, giving me no further anxiety or trouble. Will you 
 
CASES CUBED. 269 
 
 please to observe that these women recovered though 
 they took no calomel? 
 
 503. On Tuesday, Feb. 8, 1853, I visited, in consultation, Mrs. 
 * * She had been healthfully confined on Friday night, Feb. 4. 
 On Sunday morning, Feb. 6, rigor, abdominal pain, and balloon- 
 ing of the belly. Signs of metro-peritonitis with phlebitis. I 
 found at noon on Tuesday, the 8th, a pulse of 135. She was very 
 weak, and complained of pain on pressure. When first attacked 
 she had been treated with calomel and opium, and leeches to the 
 hypogastrium. Upon consultation, it was determined that she 
 should now be let blood at the arm. Upon drawing away fourteen 
 ounces she had a great deliquium, which lasted a long time, but 
 she began to recover from that moment. I had occasion to visit 
 her only the 8th, 9th, 10th, 11th, and 12th of the month. She 
 recovered well. 
 
 Am I warranted to infer that the venesection was the reme- 
 dial measure on which the case turned? If yea, then it is not, as 
 some have said, wrong to bleed in an advanced stage, for this 
 lady's childbed fever inflammation was fifty -two hours old when 
 she was let blood. 
 
 501. At p. 664, of my work on Obstetrics, 2d edit., I mentioned 
 the case of a lady whom I attended here during a season of epidemic 
 childbed fever, the circumstances of which made a great impres- 
 sion upon me, and it was so interesting at the time, that I shall beg 
 to state some of the circumstances of it. She had reached the full 
 term, and sent for me in the night, at about 11 P. M., when I was 
 too much indisposed to go out. She was flooding before delivery. 
 At 11 on the following forenoon I was again summoned, the at- 
 tending physician having gone away. The os was about half 
 dilated ; the hemorrhage was still going on with alarming rapidity ; 
 but she had lost at least 70 ounces. I immediately ruptured the 
 membranes, and when the uterus had contracted, the bleeding 
 stopped, and the child was soon born, leaving the lady quite ex- 
 hausted. Puerperal fever being prevalent in the city, I accord- 
 ingly gave very earnest charges as to conduct, and particularly, 
 as to giving early information should any signs of indisposition be 
 presented. Two days afterwards she was attacked, towards morn- 
 ing, with furious peritonitis, and I was not called, but visited 
 
270 CHILDBED FEVEE. 
 
 her on my ordinary round near noon. The pain was intense; the 
 tympanitis, the decubitus, the pulse, skin, face — all showed that 
 she was most dangerously ill. I knew, or think I knew, that, if 
 left without venesection, no other remedy could save her life, and I 
 deemed it most probable, seeing how old the attack was, and how 
 exhausted she was by the preceding hemorrhage, she would die, 
 notwithstanding any treatment that could be devised. If doomed 
 to die with this disorder, any person who should advise venesec- 
 tion, after so great a hemorrhage, could not escape blame, and even 
 severe accusation of malpractice. I found the situation a very 
 trying one ; tempted on the one hand to yield to what would be 
 a popular clamor, and urged on the other to do what conscience 
 and judgment dictated to be done. 
 
 505. I bled this lady until she became faint, and had no trouble 
 with the symptoms afterwards, as she recovered perfectly, so that 
 in a few weeks she exhibited no signs of hydremia, nor of any 
 injurious effects of her illness. I think I was never more sorely 
 beset to determine how I ought to act. 
 
 506. Baudelocque the younger, op. cit. 319, tells us of a very 
 strong sanguine woman who had been happily delivered, but who, 
 twelve hours afterwards, was seized with an intense peritonitis ; 
 violent chill of two hours long ; atrocious pains of the whole belly, 
 which in four hours became as large as it was before delivery ; the 
 weight of her chemise insupportable; pulse 110; hard, contracted; 
 flushed face, with altered expression. She was brought into the 
 infirmary of Sainte Marthe during Chaussier's visit. Baudelocque, 
 under orders, took by a free orifice a pound and a half of blood. 
 Towards the close of the operation she became pale and felt faint; 
 but the pulse was fuller and less frequent ; the pains were less- 
 ened. The tension of the belly began to diminish, and in the 
 evening there was no further cause of anxiety. The rest of the 
 treatment consisted in emollient poultices and injections, and a 
 rigorous diet. We should not, according to Dr. Lee (Led., &c. 
 505), be deterred from bleeding because the pulse is small and 
 contracted, provided it does not exceed 120-30 in the minute; 
 for, in some cases, it has become fuller and stronger for the vene- 
 section. Even when it is rapid and feeble, if the local pain 
 be very great, this is, here, a far safer guide 
 
VENESECTION AFTER HEMORRHAGES. 271 
 
 than the pulse; we must not be deterred from bleeding to 
 the requisite extent, &c. 
 
 507. Dr. Hey's account of puerperal fever contains, in his 17th 
 case, a history very similar to the above. He deferred his vene- 
 section, but finding, after the waste of many precious hours, that 
 she would die else, he bled her freely to a bad deliquium, and 
 cured her. Hey gives it as his opinion that, in no cases of puer- 
 peral fever is it more important to let blood than in those which 
 occur after excessive uterine hemorrhages. And he adds, "If, 
 then, venesection be found in such cases, not only a safe but an 
 effectual remedy, its necessity will be less disputed in other and 
 more favorable circumstances/' p. 157. I beg you to bear in mind 
 this sensible remark of the English practitioner ; it is an excellent 
 argumeut against those who are opposed to the abstraction of 
 blood in all cases, and may confirm you in the right when, in some 
 doubtful case, your own judgment may be vaccillating. 
 
 508. How long, then, after the onset of a childbed fever is it that 
 a physician must positively decline to attempt the cure by blood- 
 letting ? (see sec. 479.) The answer to such a question must be 
 deferred to the special occasion, and then it will turn upon the 
 actual diagnosis. The tendency of the inflammation is to effusion, 
 which is its commonest term. As long as that effusion has not 
 commenced, it appears to me both lawful and highly expedient to 
 attempt a cure by resolution, since other terminations are mortal, 
 and since the most powerful means in our possession to that end, 
 consists in bringing about those modifications in the blood's force, 
 that we commonly try to effect by diminishing its sum ; that is, 
 by venesection. I cannot, therefore, agree that any man should, 
 a priori, determine the time-limits within which the case admits 
 of a prudent and hopeful treatment by the lancet. As I have 
 already said, we ought to hope for and attempt a resolution, as 
 long as the exudative or secreting stages are deferred, and we 
 must judge of the fact upon the evidence brought up by our 
 interrogations of the patient herself, as well as of her organic func- 
 tions and powers. 
 
 509. Dr. Lee (Lectures, &c, p. 501) says expressly: "The great 
 point is to institute this remedy before effusion of sero-purulent 
 fluid has taken place, or at least before it has gone to much ex- 
 
272 CHILDBED FEVEE. 
 
 tent ; but as nothing is known regarding this, further than that 
 it will take place at different periods in different cases, it is mani- 
 fest that no general rule can be established, and that the practi- 
 tioner must draw his conclusions as to the propriety of using it, 
 from the history of the case and the existing symptoms." 
 
 It may seem very strange to you that, after all I have in this 
 Letter written on the indispensable necessity of bloodletting in 
 the treatment of our cases, I should confess that I am now (Sep- 
 tember 25, 1854) treating a most distressing example of childbed 
 fever inflammation without the aid of either lancet or leech. The 
 patient is a lady about twenty-two years of age, a very small and 
 delicate person, of the highest sensibility, and occupying an ele- 
 vated position in society. She was in her first pregnancy, through 
 which she passed to full term on Wednesday last, September 20, 
 when her labor began with rupture of the ovum, which was im- 
 mediately followed by regular labor pains. About six weeks ago, 
 being then residing at her country-seat, some miles from town, she 
 was seized with what seemed a remitting bilious fever, during the 
 progress of which I suffered considerable anxiety, for she was so 
 ill with fever that I much apprehended fatal consequences. She 
 was- treated on the occasion, after venesection and leeching, with 
 very mild remedies, that had a happy conclusion ; so that, upon 
 recovery, she came to her town house to be confined, under my 
 care. In the country fever, I observed the pulse to become ex- 
 cessively hurried, and at the same time soft; and, as there was 
 considerable delirium, I imagined that the blood must have suffered 
 serious injury from the state of its membrana vasorum communis. 
 Upon rising from the sick-bed, there came on rapidly an enormous 
 oedema gravidarum, extending up to the perineum and labia, which 
 were much distended by the infiltrating serosity of the blood. 
 The urine became heavily charged with albumen, as tested by 
 heat, and she was pale, weak, and nervous; in which state she 
 began the labor, as before said, by rupture of the amniotic sac. 
 Touching showed a fifth vertex position, and a hard, unyielding 
 cervix and os. The pulse at first was not much disturbed. 
 
 The waters broke early in the morning of Wednesday. She 
 suffered very sharp anguish with the grinding pains, and much 
 sense of pressure within the pelvis. I drew off the urine, as she 
 passed none spontaneously. As the head descended, I occasionally 
 
RELATION OF A CASE. 273 
 
 endeavored to bring the vertex from the left saero-iliac junction 
 towards the left acetabulum, but without the least success. About 
 midnight, the dear little ladj was dreadfully fatigued with her 
 efforts and sufferings, and though I had indulged the hope to see 
 the child descend towards morning, I found the pain lessening in 
 force and frequency, until it gradually became null. Nevertheless, 
 constitutional irritation, connected, as I supposed, with the inward 
 tension, packing, and jam of the head, which seemed to be locked 
 by a sort of gomphosis in the pelvis, excited my alarm, The sacrum 
 was flat, and it was impossible to cause rotation either forwards 
 or backwards, the cranium being fixed in a manner to cause the 
 sagittal sutures to cross from right to left. The pulse became 
 greatly hurried — alarmingly so — and, after vainly attempting, by 
 means of Davis's oblique forceps, to cause it to rotate, and after 
 many efforts made with the hands, I gave it up, and was compelled 
 to resort to the forceps. Carefully adjusting a pair of Dubois's 
 powerful forceps, constructed for me under M. Cazeau's direction, 
 by Charriere of Taris, I concluded that I should now certainly 
 extract the head ; but no skill nor force of mine made the smallest 
 impression on it. I might have as well tried to move a church 
 with the instrument. I did not move it one iota ; and her distress 
 was so great, notwithstanding that she inhaled ether, I was com- 
 pelled to give it up. By this time, the pulse was running, and 
 she was bathed in clammy sweats, and seemed to be passing into 
 that state of nervous shock which I have seen in labors, but have 
 not seen recovered from. The question now was to deliver her, 
 or see her perish undelivered, a finale that could not be long- 
 deferred if undelivered. 
 
 It was necessary to use the Holmes's perforator, with which the 
 encephalon was discharged, and then, the cranium collapsing, I 
 expected readily to draw it away in some six or ten minutes, with 
 Meigs's embryotomy forceps. Would you believe that, though I 
 could take a perfectly good hold of the part with the jaws of the 
 instrument, so as to enable me to exert great force with two very 
 strong arms, I was busied for two hours and a half in getting 
 away the head, after which the trunk came away also, after a 
 hard pull. 
 
 By this time she was utterly exhausted, and more likely to die 
 than to live six hours, the pulse being 180 to 200 per minute, and 
 18 
 
274: CHILDBED FEVER. 
 
 the breathing very bad. The foetus was extracted about 5 J A.M. 
 of Thursday, September 21. . . . She got a full anodyne of mor- 
 phia, and was not moved for many hours ; carefully bandaged ; 
 wine whey and arrowroot, with a little brandy; cool water to 
 drink. 
 
 All day of Thursday the pulse was flying; the lower parts 
 enormously swollen; immovable in dorsal decubitus; pains in 
 hypogaster. By aid of the morphia, at night slept a little, not having 
 closed the eyes the preceding night. On Friday morning, 22d, 
 unmistakable signs of peritonitis; that is, rapid pulse; pain on 
 pressure or coughing; enormous tympany; retention of urine: 
 great weakness ; womb hard, and strongly drawn by broad liga- 
 ment and round ligament towards the right iliac region. There 
 was membranous inflammation, with phlegmonous nucleus, for 
 who can doubt that this sore and tired womb, and the tissues 
 within the pelvis, were in a state to be called phlegmonous in- 
 flammation. As to phlebitis I could not speak, nor can I now 
 with confidence. Her life has appeared to be suspended upon a 
 thread during Friday, 22d, Saturday, 23d, and Sunday, 24th. To- 
 day, Monday, 25th, I cannot detect the slightest hysteroid. 
 The pulse has become slower and fuller. The vast tympany has 
 almost disappeared ; pressure with hand is tolerated ; the legs can 
 be drawn up and pushed down without pain; the urine flows 
 abundantly ; the oedema gravidas is gone ; no headache ; tongue, 
 that was furred from 22d to 24th, is much cleaner. Spirits good 
 and cheerful, so that at this moment, 12 o'clock P. M., I feel a 
 considerable confidence in the hopes that are raised of her re- 
 covery. She herself thinks she will recover. 
 
 Why, do you ask, did you not bleed her ? I can by no means 
 express the fervent desire I had to open a vein in the arm and 
 remove twenty or thirty ounces of blood, but it was impossible 
 to think of it under the circumstances. I gave her wine-whey, 
 and chicken-broth, and arrowroot, and brandy and water, with 
 repeated doses of sulph. morphia ; also, a small potion made with 
 turpentine. I believe I may now expect her to escape, but, I 
 confess, I scarce know how or why. I have given her many 
 baths with hot spirits and water, the nurse using sponges squeezed 
 in the liquor to bathe the whole surface underneath the bed- 
 covering. The case seems to me very much like one told by 
 
RELATION OF A CASE. 275 
 
 La Koche when he practised at Geneva. You may read it in my 
 section 566, where I have quoted it. I did not use his powders of 
 bark, however. Tuesday, 26, 9 P. M. She will sink. Wednes- 
 day, 27. The lady expired at two o'clock this morning; very few 
 persons can be expected to survive these childbed fever inflam- 
 mations, whether accidental or unavoidable, when the circum- 
 stances forbid a resort to bloodletting. 
 
 510. With these remarks, in making which I seem to have 
 unbosomed myself upon what I deem one of the most important 
 questions in obstetric practice, I shall bring this long letter to a 
 close, but not without expressing an earnest wish that my Students 
 would give to the subject a very large and earnest attention. 
 
 C. D. M. 
 
LETTER XX. 
 
 ON LEECHING, AS A REMEDY FOR CHILDBED FEVERS, WITH A COM- 
 PARISON OF ITS ADVANTAGES WITH THOSE OF VENESECTION. 
 
 511. I think there are a great many physicians who have con- 
 ceived an aversion to bloodletting as a remedy in childbed fevers, 
 but who feel no apprehension at all as to the use of leeches, which 
 they suppose to be as capable as venesection of allaying the in- 
 flammatory turgescence of the affected parts. In consultations, 
 you shall sometimes meet the greatest opposition to your proposal 
 to bleed the in -lying woman, on the part of Doctors who fear the 
 click of a spring lancet as a " hurt fowl, or a struck wild duck" 
 fears the "report of a caliver;" but, if you say "leeches," those 
 very people meet you more than half way; and though they are 
 thunderstruck if you propose to take some ounces from the arm, 
 they entertain not the least feeling of concern about the noiseless 
 and unseen absorptions of some dozens of leeches. 
 
 512. No person doubts that the leech is, in some instances, a 
 very desirable adjuvant, nor that the blood it draws does lessen 
 the amount of the balance left in the circulatory system ; neither 
 does anybody deny that a great leeching does let down the con- 
 stitutional excitement, in fevers. But this is not the important 
 question here, and I anxiously solicit you to consider that while 
 both methods, venesection and leeching, may produce such results, 
 the methods are not alike in either celerity or power ; since you 
 can, in the course of five minutes, bring about by a venesection, 
 and with greater certainty, an effect which it would require some 
 hours to accomplish with leeches, with great inconvenience, if not 
 pain and serious risk. If this is true, and if, when you take eight 
 ounces of blood by the lancet eight ounces are lost to the economy, 
 and if the same is true where you take eight ounces by leeches, 
 then I see not wherein the leeches are more desirable. 
 
LEECHING. 277 
 
 513. A venesection is both a much neater operation, and 
 devoid of many objections, that attend the bleeding by leeches. 
 There is no fatigue; it may be arrested, suspended, and renewed 
 again, in a moment, without inconvenience. You can stop the 
 jet for a minute, or for ten minutes, and let it fly again, after a 
 few minutes' examination, during which you are weighing the 
 question of how much, what appearance, or what is the effect, so 
 far. In leeching, the abdomen must be uncovered; the punc- 
 tures are exceedingly irritating, and, for some people, very pain- 
 ful; the long-continued rest, in an unchanged position, exhausts 
 the woman's patience; there is water spilled about her person and 
 dress, and she is moreover smeared with blood, and afterwards 
 incommoded by the necessary dressings. In twelve hours after 
 a leeching, the patient may complain, on being touched, of pain 
 that you know not whether to attribute to the internal disorder, 
 or to the erythematous areas that always follow the bites of 
 leeches, and so you are liable to be a little in doubt about your 
 diagnosis. In fine, you cannot venture to take so much, and 
 you cannot get it so speedily, as you would draw away from an 
 opened vein ; and if you could do it, it would be of less influence 
 upon the blood's force — in motion. My own clinical experience 
 has convinced me that leeches ought not to be used where we 
 durst employ venesection, and so, speaking generally, I greatly 
 disapprove of them in the treatment of our cases. 
 
 514. There is a false impression made upon the mind on this 
 matter : leeches are usually employed with a view to secure the 
 effects of a direct depletion of the affected tissues. Could there 
 be a greater mistake than to suppose that leeches on the lower 
 belly should exhaust the capillary vasa vasorum of a uterine 
 phlebitis or a metritis, or even of a pure and simple peritonitis ? 
 You are to observe that the peritoneal inflammation you dread, is 
 that of the mesorectum, mesocolon, epiploon, and intestines gene- 
 rally, as well as the whole intro-pelvic serous tissue. What pos- 
 sible direct relation, then, can there be betwixt the capillaries of 
 the corpus mucosum cutis of the lower abdomen, and a'congeries 
 of capillaries supplied from the inferior mesenteric, or the uterine, 
 or the ovaric arteries ? There is no such anatomical relation ; and 
 I believe that in leeching for childbed fevers, you could apply the 
 leeches as usefully to the arm, or the calf of the leg, as to the 
 
278 CHILDBED FEVEK. 
 
 hypogastrium of the woman, where they are usually set by ope- 
 rators. 
 
 515. My mind has long been impressed with a sentiment that 
 amounts to the force of a conviction, that leeches, when used 
 during a strong febrile excitement, for the subduction of a topical 
 engorgement, do to a certain extent, rather promote than lessen 
 the hyperemia of the part; at least they do so, provided the ab- 
 straction is not carried so far as to cause a great diminution of 
 the injection-force of the heart with coincident lessening of the 
 quantity transferred, per minute, by the force of the systoles. I 
 am equally persuaded that, provided, in fevers, leeches are indi- 
 cated as topical depletives, they should follow, and not precede a 
 bloodletting at the arm. When a full venesection appears to be 
 insufficient to disengorge the phlogosed areas, then a topical bleed- 
 ing seems more likely to be useful. But upon the whole, I have 
 a positive distrust of and dislike for them in all inflammations 
 accompanied with high fever. 
 
 516. The same opinions I have above expressed, you will find 
 have been sustained by the younger Baudelocque, at 332 ; and 
 though Gasc, in his Dissertation on Puerperal Fever, p. 285, a man 
 much afraid of the lancet, praises the leech, he applies it to the 
 vulva or the perineum — operations, either of them, in the highest 
 degree objectionable in such cases as these. The woman is too 
 sick to be worried in this disgusting way. 
 
 517. D. Gooch, p. 47, observes that, in the treatment of acute 
 inflammation in the vital organs, it is common to consider local 
 bleeding as a milder means than general bleeding, and to postpone 
 it until the stage for venesection is over. " To me it appears that 
 they are calculated to effect two different objects, both of which 
 are necessary at the beginning of this treatment ; the one to re- 
 duce the violence of the general circulation, the other to empty 
 the distended capillaries of the part. As long as the pulse is 
 quick, full, and hard, it is in vain to take blood 
 from the affected part; if we could completely empty its 
 engorged capillary vessels, they would be instantly gorged again 
 whilst the heart and arteries are injecting them with so much 
 violence." Now these observations of Gooch are admirable, ex- 
 cept for the false impression they are likely to produce upon the 
 
LEECHING. 279 
 
 unreflecting reader, as to the ability of the physician to take blood 
 directly from the inflamed parts, by leeches ; a thing he cannot do, 
 because there is no blood-connection between the capillaries of 
 the hypogastrium and those of the womb, or those of the meseraic 
 circulation. 
 
 518. There are many very able physicians whose opinions are 
 wholly at variance with mine, above expressed, as to the uses of 
 leeching in our cases, and among them there is none of higher 
 authority than Dr. Meissner. In Die Frauenzimmerkranlcheiten, 
 vol. iii. 820, he contends, it is true, as he formerly showed, in Sie- 
 bold's Journal fur Geburtshulfe, Bd. vi. St. 2, S. 306, that four 
 ounces of blood, taken by leeches, in a childbed fever, from the 
 affected parts, are more efficacious to the cure than twelves ounces 
 drawn from a vein. Notwithstanding the great respect I have 
 for Dr. Meissner's learning and wisdom, I cannot agree with him 
 here, nor believe his assertions to be based upon clinical expe- 
 rience, but only on a ratiocination, and should willingly agree 
 with him in the opinion, were it possible, which it is not, to take 
 the blood by leeches from the affected part. One is deceived 
 who thinks he draws it from the affected parts because he is 
 taking it from the skin over them or above them. 
 
 519. M. Dance, Archives Gen., 199, t. 19, is not unfavorably dis- 
 posed as to the use of leeches, which he also seems to regard as 
 capable of producing direct depletion of the engorged parts. Of 
 this you are to judge. Yet, he says the proper treatment of ute- 
 rine phlebitis is to be effected by the early and energetic use of 
 antiphlogistics, and that venesection depletes more effectually than 
 any other method ; but we should apply leeches afterwards, and 
 adjust them first au niveau — that is, opposite to the parts in- 
 flamed, and rise, afterwards, in applying them, higher and higher 
 as the inflammatory areas extend upward — their usual direction. 
 
 520. Another writer of great authority and merit, distrusts 
 bloodletting, particularly in epidemic hospital cases — I mean, Di\ 
 Eobert Collins, of Dublin. In his Midwifery, 393, he says : " Where 
 the state of the patient was such as to encourage a general 
 bleeding, we used the lancet; I am satisfied, however, that in 
 hospital, the immediate application of three or four dozen of leeches, 
 followed by the warm bath, in which the patient should remain 
 
280 CHILDBED FEVER. 
 
 as long as her strength will bear it, will be found, in the great 
 majority, the most judicious means of removing blood." 
 
 521. Such are Dr. Collins's remarks; whereupon, I shall only 
 ask you to consider how much blood would be removed by three 
 or four dozen leeches, the patient being afterwards placed in a 
 warm bath; and whether, if a certain quantity is to be removed, 
 it would not be as promptly, and as safely and pleasantly done 
 by the lancet ? 
 
 522. Think of the meaning of the word centro-peripheric, and 
 ask yourself whether all your means of subduction for the or- 
 ganic lesion are limited to the peripheric, while you have no inte- 
 rest in the central influences. If such is your conclusion, I must 
 wholly differ from you. I strove, in my last long Letter, in ex- 
 plaining the uses of bloodletting, to persuade you that, wherever 
 you can control the heart's injecting power, so as to modify it 
 according to your wishes and judgment — in all these cases you 
 will be likely to cure your patient. Both Dr. Collins and Dr. 
 Meissner, as well as Grasc, and the leechers generally, appear, in 
 controlling the disorder, to expect to effect a cure by impressing 
 the periphery only — overlooking, as I consider them to do, the 
 centre, which it is vastly more important, as well as more easy 
 to modify or bias according to our will. 
 
 523. Legouais, op. cit. p. 38, says, that topical bleedings, par- 
 ticularly by leeches set to the vulva and on the abdomen, in 
 numbers sufficient to abstract a considerable quantity of blood, 
 have, under his own observation, been too many times followed 
 by success to allow him to doubt of their efficacy, especially in 
 hospital, where reasons existed to make one fear a general bleed- 
 ing. But, outside of these cases, general bleedings appear to have 
 always been indicated in a more precise manner, because their 
 influence on the economy is far more marked in a case where the 
 inflammation is so extended, and so, convenient to abstract 
 promptly and with certainty the entire quantity deemed neces- 
 sary; a quantity much more easily to be appreciated than one 
 withdrawn by leeches, &c. &c. Many of our brethren are used 
 to direct cupping-glasses to be applied to the belly, in their cure 
 of childbed fever. This is a practice I have never yet adopted 
 in a single instance in my whole life as practitioner. It has 
 
CUPPING. 281 
 
 always appeared to me that such treatment is a mere barbarity, 
 seeing the relaxed condition of the abdominal integument soon 
 after childbirth. The same motives that lead me to disapprove 
 of leechings, apply to the case of cuppings ; but with far greater 
 force in the latter. 
 
 524. Upon the whole, then, I wish you to regard me as one 
 very distrustful of leeches and cupping, believing them likely to 
 mislead us , by begetting within us a false opinion that we can by 
 them directly deplete the affected areas — which we cannot do; and 
 also as seducing us to suppose that, because we draw blood only 
 from the capillaries, we are not, in reality, bleeding the woman, 
 bit only leeching her. But, I repeat it, I will not presume to 
 a-ver that, after a good bleeding, it may not be, sometimes, 
 judicious to apply leeches over the ligamenta rotunda as they 
 pas? along through the abdominal canals; but I do ask you to 
 think well and distinctly, whenever you are halting between the 
 two opinions as to bleeding and leeching the childbed fever 
 ^atieit ; and I shall close my communication with these requests. 
 
 C. D. M. 
 
LETTER XXI. 
 
 EMETICS IN CHILDBED FEVER — REPORT OF THE COMMISSION ON 
 DOULCET'S SPECIFIC — DR. JNO. CLARKE'S VIEWS OF THE DOULCE? 
 TREATMENT — DR. WHITE AND DENMAN FAVOR A MODERATE USE 
 OF THEM — FERGUSON'S OPINIONS — DE LA ROCHE'S GUARDED 
 RECOMMENDATION — TONNELLE'S EXPERIENCE, WITH CASES. 
 
 525. It is now a long time since the Treatment of childbed 
 fever by emetics was considered by persons high in author icy as 
 a way almost specific to cure it. Dr. Stoll, of Yienna, seems to 
 have abhorred the use of the lancet ; and the reason of it was that 
 he took an erroneous view of the malady, which he chiefy con- 
 sidered to be a bilious disorder, although capable of assuming an 
 inflammatory character. Stoll, looking upon the disorder as 
 bilious, was led to confide in the use of emetics; for he thought 
 that if the inflammatory constitution of the attack did depend 
 upon bile, the most efficacious of antiphlogistics mast be an 
 emetic, capable of casting the life forth — which seems to me a 
 lame way of reasoning. But, leaving out of question Dr. Stoll, 
 and all the lesser lights on this topic, let us refer to a Report, oy 
 order of the Government, upon a Memoir containing thi Method of the 
 late Dr. Doulcet, Docteur -regent of the Faculty of Paris — one of the 
 Physicians to the Hotel Dieu — in the treatment of a Disease that attacks 
 lying-in women in that Hospital, and which is knoivn under the denomi- 
 nation of Puerperal Fever. Eead at the sitting of the Eoyal Soc. 
 of Medicine, Sept. 6, 1782. 
 
 This report is printed in Hist, de la Soc. Roy. de Med. 1780 
 and 1781, vol. iv. p. 254. After describing the disease, and relating 
 the history of some post-mortem researches, to show that the malady 
 in question was puerperal fever, the account proceeds as follows, 
 at page 255 : — 
 
283 
 
 " Equally rebellious against the efforts of art and the resources 
 of nature, this swift disorder has constantly resisted the most wisely 
 applied remedies, whether selected as means to obviate inflamma- 
 tion, or to turn aside the humors from the viscera of the lower 
 belly, or to recall the milk to its real path, to oppose a tendency 
 to putridity, or to procure salutary evacuations. Everything has 
 been tried — everything has failed. Ipecacuanha itself, which is 
 the basis of the present method, met with no better success than 
 other remedies, until, as chance would have it, M. Doulcet was 
 present at the very moment when the disease made its attack in 
 a woman recently delivered. It began by producing vomiting. 
 M. Doulcet, immediately seizing upon the indication, ordered 
 fifteen grains of ipecacuanha, which the patient took in two doses, 
 that were repeated the next morning. The medicine operated 
 upwards and downwards. The evacuations were followed by a 
 notable diminution of all the symptoms. The looseness was kept 
 up by an oil- potion, with two grains of kermes, and the patient 
 was saved." 
 
 The account next goes on to show that, enlightened by this 
 success, M. Doulcet felt the importance of the moment, and the 
 necessity of seizing it before the malady should have time to settle 
 itself; and, acordingly, the attendants were directed to give the 
 doses, day or night, at the first moment of the assault. The suc- 
 cess was everywhere the same ; so that, during four months that 
 the epidemic raged with fury, near two hundred women were 
 restored to existence. Only five or six persons, all of whom 
 refused the emetic, fell victims to their own obstinacy. The post- 
 mortem appearances presented by their dissection showed that they 
 had perished with the puerperal fever. In fine, the method in use 
 at the Hotel Dieu, and which has not failed since it began to 
 be employed, consists in seizing the very moment of 
 attack to give, without loss of an instant, fifteen 
 grains of ipecacuanha, in two doses, at an inter- 
 val of an hour and a half; to repeat it the next 
 day, whether the symptoms have changed or not; 
 and, if they persist obstinately, to reiterate the 
 same dosings as much as three or four times, ac- 
 cording to their obstinacy. In the intervals, the effect of 
 the ipecacuanha is sustained by means of a potion compounded 
 
284 CHILDBED FEVER. 
 
 of oil of sweet almonds, an ounce of syrup of guimauve, and two 
 grains of kermes mineral. The drink is plain flaxseed tea, or scor- 
 zonera tea, sweetened with syrup of guimauve. Towards the 
 seventh or eighth day of the disease, the patient takes a mild 
 laxative, which is repeated as circumstances may demand. 
 
 This new method, which might be called the specific method, 
 was published in a paper through the Faculty de Me'decine of 
 Paris, and, as I have said, the news of the discovery was hailed 
 with joy; not because no physician had ever before that time ad- 
 ministered a dose of emetic medicine, but because of the signal 
 success that attended Doulcet's particular method, " to whom it 
 was reserved," to use Doublet's language, page 204, "to give to 
 the exhibition of emetics in puerperal fever a greater value, and 
 to find a mode of using them far surer and more beneficial than 
 any that had been tried before his time." 
 
 526. Such, gentlemen, is an account of the report on Doulcet's 
 specific for childbed fevers, the announcement of which, 
 made almost as much noise as Sigault's operation, or Jenner's 
 discovery. Dr. Doulcet was looked upon as a benefactor of man- 
 kind, and every yobe-monche of a doctor, from Landsend to Arch- 
 angel, I presume, laid to his soul the flattering unction that a cure 
 for the most terrible of diseases was at last found. This was in- 
 1782, just seventy-two years ago; and to-day nobody thinks of 
 giving an emetic in a childbed fever inflammation. 
 
 The treatment or method, which was anxiously and thankfully 
 taken up everywhere, was soon dropped, and, as commonly hap- 
 pens, its disappointing results brought it into utter contempt 
 and after-neglect. Dr. John Clarke, Observations on Puerperal 
 Fever, &c, Sydenham Society's edition, thinks a repetition of 
 vomits, on the plan of Doulcet, has been attended by obvious 
 disadvantages; and M. Doublet, Nouvelles Recherches sur la 
 Fievre Puerperale, p. 206, says : "Emetics, in English hands, have 
 never had the same success as in those of M. Doulcet and his col- 
 leagues at the Hotel Dieu at Paris ;" and he mentions that Dr. 
 Eothergill, the learned and benevolent London physician, admitted 
 lie and many other English practitioners had often exhibited 
 emetics without obtaining the same beneficial results as Doulcet, 
 and that Dr. Fothergill's paper in the London Medical Journal, vol. 
 iii., informs us that the method (Doulcet's) ought to be considered 
 
OPINIONS ON THE SPECIFIC. 285 
 
 rather as a conservative than a curative one ; but that, far from 
 detracting from Doulcet's merit, the circumstance ought to enhance 
 it in the opinion of such as think it' best to err on the right side, 
 and that it is more desirable to prevent than to cure diseases. I 
 perhaps spoke too strongly when I said just now that nobody 
 thinks of giving an emetic in childbed fever nowadays ; it would 
 be more correct to say that they are rarely resorted to out of 
 Paris, where, I understand, they are still sometimes administered 
 in the hospitals ; and Dr. Ch. White, of Manchester, Treatise on the 
 Management of Pregnant and Lying-in Women, page 195, states the 
 conditions of headache and pains in the back, with swelling, pain 
 and tenseness in the lower belly ; nausea, vomiting, diarrhoea, tenes- 
 mus, strangury, thirst, white or brown tongue; or any of these 
 symptoms, as motives to give a gentle emetic of ipecacuanha, &c. 
 Denman also recommended emetics as part of the curative method ; 
 but White and Denman are long ago dead. 
 
 527. Dr. Ferguson, op. cit., commences at page 202 his remarks 
 on the method by emetics, and signalizes the disappointment that 
 followed in succeeding years the flattering hopes excited by Doul- 
 cet's success. Dr. Ferguson, whose notions on puerperal fever are 
 inextricably interwoven with his ideas of vitiated blood, thinks 
 that where there is a bilious complication they should prove in- 
 valuable as remedies. " Where there is an obvious struggle in 
 nature to cast off the poison through the liver and in- 
 testinal canal, and where that effort is marked by nausea, 
 bilious vomiting, bilious suffusion, or bilious diarrhoea, it will be 
 requisite to resort to Doulcet's treatment." P. 204. He advises 
 that they will be injurious where none of these symptoms are 
 present, and says he has not had many opportunities of exhibiting 
 emetics, chiefly because he saw the patients late in the disease, the 
 remedy being useful only in the very early stages. 
 
 528. Tonnelle's celebrated publication strongly vindicates the 
 propriety of using the ipecacuanha. You may find his observa- 
 tions upon this subject in his fourth and last article, which is at 
 p. 184, vol. xxiii., 1830, of Archives Gen. He says, that persons 
 who are preoccupied with the " exclusive idea of inflammation, 
 receive, with distrust, everything foreign to the range of ordinary 
 antiphlogistic measures. Trained up in the deceptive and mis- 
 
286 CHILDBED FEVER. 
 
 chievous notion that inflammation is incompatible with anything 
 but bloodletting and emollients, we reject every other species of 
 treatment as in opposition to our preconceived ideas of the nature 
 of inflammation, whose nature, meanwhile, is utterly unknown to 
 us." You here see how strongly Mr. Tonnelle takes ground, be- 
 fore he commences to make his exhibit of the power of emetics in 
 the cure of childbed fevers ; and you will bear me witness that . 
 I am not desirous to keep in the background the sentiments of so 
 able a man as he was, because they are opposed to my own. In- 
 deed, I wish you to observe that he says, that although sanguine 
 evacuations do combat inflammation in one of its principal effects, 
 they do not attack it in its cause. Now, asks he, are there no 
 therapeutical agents that are capable of fulfilling this object? 
 Are there not agents, by means of which it may be annulled or 
 neutralized by exciting, in the economy, certain diversions, like 
 those we see brought about by the power of nature every day ? 
 
 529. Such are Tonnelle's queries, which I leave you to judge 
 of, but with this remark only, viz: if they have no greater influence 
 upon you than they have had upon me, you will promptly answer 
 no; there are none such of any value in clinics. 
 
 530. I have in these pages so often pointed out the tendency of 
 these childbed fever inflammations to attain to their natural term 
 in effusion, that I somewhat apprehended you might accuse me 
 of believing a spontaneous resolution to be a thing impossible. 
 "While I am far, I hope, from such an extravagance, I avow my 
 belief that one of these inflammations, fairly aroused, and reacted 
 upon by the fever it has itself developed, is far more likely not to 
 end in resolution, if left uncared for, than otherwise. But, a ter- 
 mination in effusion or gangrene, may be assumed as in general a 
 mortal result. It is true that Tonnelle gives a series of five cases 
 cured by ipecacuanha, administered in accordance with Doulcet's 
 plan, as nearly as possible. Yet the last two cases were treated 
 at the same time by means of leeches. He adds a series of six 
 other cases cured by ipecacuanha, aided by certain other measures, 
 as leeches, &c. &c. 
 
 531. I freely admit that these ipecacuanha cases were cases of 
 the disorder, and that they recovered without the intervention of 
 general bloodletting. Yet I am not willing to infer from the facts 
 
287 
 
 that the treatment was either so safe, or so prudent in all respects, 
 as it would have been had the lancet been wisely employed: 
 for, I take for granted, that since the women did recover from the 
 disorder, they would not only not have been injured or hazarded 
 by venesection, but that they would have been far better managed. 
 They could have borne a venesection, else they would not have 
 been cured by ipecacuanha. Tonnelle^s eleventh case, p. 200, 
 
 was that of Lori , ast. 26 ; sanguine but vigorous constitution ; 
 
 attacked five days after accouchement with puerperal fever. On 
 the 6th, violent pains in hypogaster, especially in left iliac fossa 
 where slight pressure is intolerable. Took the ipecacuanha, and 
 vomited enormously of bilious matters, with prompt relief. Even- 
 ing, no fever, but pain continued in iliac fossa, whereupon she had 
 forty leeches there that bled copiously. 7th, the belly still some- 
 what sore, but the uneasiness disappeared in a few days, and she 
 went out in good condition. Such was the case, which gives no 
 state of the pulse and other important circumstances. Upon the 
 whole, I should have felt safer to bleed than trust to ipecacuanha 
 in such a patient. 
 
 532. As to his Chap. IV. on emetics (in childbed fever), where 
 Tonnelle gives five cases cured by ipecac, as he says, though 
 two of them were treated with leeches also, and where he adds 
 six others treated by ipecac, and other remedies, I cannot look 
 on these as fair instances to prove the power of emetics, at least 
 to such a degree as to lessen one's reliance on the best of the 
 antiphlogistics and venesection; nor can I regard it as conducive 
 to the advantage of practical science that any man should set up 
 such a stone idol, and worship it, to the disparagement of better 
 and safer gods. 
 
 533. And here I must quote from that most sensible physician, 
 De la Eoche, op. tit. 196, who says: "I believe, therefore, that 
 emetics, and especially antimonials, may be advantageously em- 
 ployed in puerperal fevers. But let no man deceive himself as 
 to their mode of action, and, attributing the success to the evacu- 
 ations they procure, imagine that drastic purgatives that have an 
 entirely opposite effect on the sanguiferous system, can be sub- 
 stituted for them. Care should be taken, also, in exhibiting them, 
 not to make large doses, which excite violent efforts to vomit, 
 
283 CHILDBED FEVER. 
 
 lest strong and sudden compression by the abdominal muscles, 
 of the inflamed textures, should occasion dangerous irritation." 
 
 Let any one read Tonnell^'s tables, at the end of his paper, 
 intended to show the number of the cured by emetics, and 
 consider also the juvantia by which they were supported or 
 reinforced, and it seems to me he will scarcely, after all, place 
 great reliance on Doulcet's practice. But, perhaps, the most co- 
 gent reason to distrust that method, may be found in the fact 
 that it is now rarely confided in anywhere. I would by no 
 means, however, dissuade you from employing the ipecac, in 
 those instances where a bilious or mucous saburra might lead you 
 to fear bad gastric complications of your childbed fever inflamma- 
 tions. You should, as an act of duty, make yourselves acquainted 
 with Dr. Stoll's views of the bilious character of the whole dis- 
 order ; but, I hope you will never suffer yourselves to be led 
 astray from the simple, absolute truth, that there is no such 
 thing in nosology as a childbed fever, as the title 
 of this book would erroneously lead a person to suppose; but 
 only a group of disorders, that, whatever their particular seats, 
 are properly to be called childbed fever inflammations. 
 
 534. In my next Letter, I propose to discuss with you the sub- 
 ject of mercurials, as remedies for childbed fever; and I now rest, 
 with much respect, 
 
 Yours, &c, C. D. M. 
 
LETTER XXII. 
 
 MERCURIALS IN CHILDBED FEVERS, WHETHER USED IN" THE FORM 
 OF CALOMEL OR BY INUNCTION. 
 
 535. It seems to me that the doctors have, in a small degree, 
 gone crazy on the subject of calomel and mercury, so that when 
 a man is sick, calomel ; broken leg, calomel ; pleurisy, calomel ; 
 encephalitis, calomel ; scarlatina, calomel ; yellow fever, calomel ; 
 ophthalmia, calomel; dropsy, calomel; syphilis, calomel; amenor- 
 rhoea, calomel; menorrhagia, calomel; strong, calomel; weak, 
 calomel : as to cholera, I doubt whether of the sixty millions of 
 persons who have died with it since the Jessore epidemic broke 
 out in 1817, T S oths of them did not reach the banks of Styx, car- 
 rying in their stomach the current metal that rejoices in the name 
 of that god who marshals souls along the way to Hades. In 
 ancient times, men went down there with a silver obolus in their 
 mouths to pay the ferryman. Perhaps Charon is dead now, and 
 it is found that argentum vivum ; lucus a non lucendo, is the very 
 thing for dead men. Most certainly, there be few dead men un- 
 provided with a treasury of the subtil metal. 
 
 But mercury is one of the reliances of modern practitioners for 
 the cure of childbed fevers ; and, as you with the rest of the med- 
 ical world, are likely to use it, let us consider what are the 
 circumstances to which it is adapted. I am far from even hinting 
 that there are no circumstances of a childbed fever in which it 
 may not be prudently and usefully employed. I do only complain 
 of its too much use. 
 
 536. It is very long that I have been no lover of the calomel 
 
 practice, as it is used in the United States, where I feel assured 
 
 that it disappoints a thousand great expectations, usurps often 
 
 the place of better remedies, and in a vast number of instances 
 
 19 
 
290 CHILDBED FEVEK. 
 
 produces great distress, and sometimes irreparable mischiefs : 
 nevertheless, mercury is a strong medicine, and is not always to 
 be dispensed with in our practice. But what are the powers of 
 mercury, used as a medicine? The generality of practitioners 
 in this country would probably reply to this question, that it is an 
 alterative, while many would regard it as anaplastic, or a 
 medicine capable of opposing the development of that state of the 
 blood that leads to inflammation. Some would insist that its 
 therapeutical value is in a main degree allied to its power to pro- 
 mote the hepatic activity, and other some look to its direct 
 impression upon the nervous system, as they say, for the bene- 
 ficial results of its operation. It is hardly requisite to refer to its 
 well known cathartic property, or its salivating, in other words, 
 poisoning powers. 
 
 537. But mercury is a specific ; and, perhaps, if you add cinchona, 
 one of the only two specifics we at present possess; unless, indeed, 
 you prefer to regard all medicines as specific, either for the eco- 
 nomy at large, or for particular organs or special functions : in the 
 latter sense, ipecac, is specific in its power on the stomach to 
 provoke emesis, and rhubarb and other aperients and purgatives 
 are specific for the bowels, to produce alvine evacuations; as 
 mercury is a specific for the production of ptyalism. As to the 
 operation of mercury commonly assumed to be alterative, we do 
 not know what we precisely mean by that word ; the idea, a con- 
 fused one at best, being empirically derived, and not rationally. 
 "We cannot even know, according to Dr. Eenouard, Hist de la 
 Med. &c. &c, torn. ii. p. 434, precisely what we mean by the anti- 
 syphilitic power of mercury, and we can only have an experi- 
 mental or empirical knowledge of the fact or consequence. " I 
 know not," says that ingenious author, " how a minim quantity 
 of a mercurial salt compels all the symptoms of a syphilis to dis- 
 appear as by a charm, in a multitude of cases. But what matters 
 it to me or to the patient? What is essential to us is, to know 
 that the effect will take place, and the circumstances in which it 
 will take place." * * " Without seeking, then, to know why 
 mercury dispels the syphilitic symptoms, or why vaccination pre- 
 vents smallpox, or cinchona cures intermittents, &c, I shall em- 
 ploy these means whenever they are indicated, with as much 
 certainty and reason, as I should use venesection in a phlegmasia." 
 
ALTERATIVES. 291 
 
 435. Pray ponder for a while, upon Dr. Kenouard's words above 
 cited, and then, after what yon already know of the nature, seats, 
 and propensities of a childbed fever, say whether, instead of re- 
 sorting, in it, to mercurials with the same confidence as in syphi- 
 litic disorders, whether mercury, used as it has been used, is not 
 rather to be classed among the perturbative, or shock-remedies. 
 M. Eenouard, op. cit. 535, says : " The practitioner, after exhaust- 
 ing all the rational means that science has placed within his reach 
 without any satisfactory result, due to some idiosyncrasy or other 
 inexplicable circumstances, the practitioner, I say, has recourse to 
 an indirect method, by which he proposes to impress upon the 
 whole economy or only upon the diseased part, a shock (secousse), 
 in order, thereby, to produce an advantageous and curative per- 
 turbation. This was the object of the old methodic sect, in the 
 invention of their metasy ncritic circle ; such is the end proposed 
 every day, when we order our patients to the sea-bath, to travel, 
 to visit mineral springs, &c. &c." 
 
 538. I am inclined to believe that the trust in calomel, as an 
 anti-childbed fever medicine, arises, in part, from this over-anxious 
 desire to do something useful, even at a guess ; to perturb either 
 the whole economy, or the part, in hope to find, after the 
 shock or disturbance, a new sort of action, or some different vital 
 status induced, somehow, we know not how or what. The idea 
 of the word alterative appears to me to be this, and nothing 
 more ; and I am greatly mistaken if this word alterative is 
 not uppermost in the minds of physicians generally when they 
 are prescribing doses of mercury and mercurial application for 
 the treatment of childbed fevers ; else I am so dull and stupid 
 that I cannot comprehend them even when they " touch the bile," 
 act on the liver, and do a thousand other queer things with their 
 universal dose. Of course, I except those instances, where calo- 
 mel, &c, are ordered with a sole view to their aperient or cathartic 
 qualities, for I can understand a purgation as a something real, 
 and even very salutary. I have, in sections 467-8, related some 
 cases of my own, wherein I specially called your attention to the 
 omission of mercurials from my method ; and I showed you, in 
 section 239, that I used calomel freely enough. I was, formerly, 
 cruelly and flagitiously devoted to calomel, but I have learned 
 better now. 
 
292 CHILDBED FEVER. 
 
 539. Dr. Robert Collins, op. cit. 395, generally combined ipeca- 
 cuanha with calomel, because not only of the useful therapeutical 
 influence of the ipecacuanha, but also because " the ipecacuanha, 
 where it does not sicken, seems to have the best effect, preventing 
 the calomel exciting irritation in the bowels and producing moist- 
 ure over the surface." Now, this is a sample, as I take it, of the 
 exhibition of mercury with a view to its alterative or shockr 
 power; for the calomel appears to be attended with the great in- 
 convenience, if not risk, of irritating the bowels, therefore it must 
 be guarded with ipecacuanha. Would it not be safer to leave 
 it out altogether, and take the ipecacuanha alone, as the ipecacu- 
 anha serves as a guardian angel to obviate the mischievous attri- 
 butes of the metallic devil? Hence, I say, let it alone. Dr. Collins 
 proceeds to show that' " the quantity of calomel and ipecacuanha 
 taken in this way, in many instances, was very great ; to the 
 amount of three, four, or five hundred grains, or upwards. With 
 some, in order to hasten its effects on the system, friction with 
 strong mercurial ointment was diligently employed, and blistered 
 surfaces dressed with the same * * in several instances, a scruple 
 of calomel was given every second or third hour, and carried to 
 a great extent ; one patient took more than an ounce. I could 
 not observe any better effect from the large doses than the small : 
 the system was not more speedily influenced ; and when they 
 did so act, it was often with violence, so as to endanger the de- 
 struction of the soft parts about the palate." Why, then, give 
 such a medicine? The woman is ill enough already. 
 
 540. The patient, No. 102, p. 456, took 520 grains of calomel. 
 She seems to me to have had the disease while in labor, and died 
 on the fourth day. Of the women who recovered, some took 
 (as No. IX., p. 421) 264 grains, and No. VII., p. 41 7, "308 grains 
 of calomel in the course of little more than forty-eight hours, in 
 the early period of the attack." 
 
 541. I deemed it best to cite for you this high authority of Dr. 
 Robert Collins, and I am sure you will feel as much obliged as I 
 am, by his clear and candid instruction : yet, I presume, at the 
 same time, that the effect of the excerpt upon your minds will 
 be to excite a degree of distrust in the powers of mercurials, if 
 not so great as Dr. Collins's, or as my own, yet some degree of 
 
SALIVATION. 293 
 
 distrust and hesitation ; and that you will, in fine, pause and de- 
 cide within your inner self what the precise purposes may be, 
 that shall lead you to write the prescription for calomel in the 
 cases. I shall, perhaps, on future occasions, prescribe calomel for 
 my patients in childbed fever, but when I do. so, it will be mainly 
 in view of securing its action upon the peristaltic muscles — one 
 that I can comprehend; for I have a continual dread of that rest, 
 or that sort of paralytic debility or inaction that seizes upon them 
 whenever the peritoneum becomes inflamed. I have, in section 
 279, explained the grounds of this fear of injury, and also in sec- 
 tion 278 the nature of that fatal angulation of the intestine with 
 which she is menaced whenever the tympany becomes enormously 
 great in a lying-in patient. Here, I say, I might prefer the calo- 
 mel for its aperient and cathartic power. 
 
 542. Again: in the progress of a childbed fever case, when 
 the inflammation appears to have come to a stand-still, or to make 
 no progress in expansion or intensity, I might gladly avail me of 
 the medicinal qualities of calomel, to combine with it, a portion of 
 kermes and nitrate of potash or camphor, or all of these together 
 with a view to their united influence upon the heart's rate, as 
 well as upon the cutaneous excretions ; an influence of whose ex- 
 istence and salutary nature I cannot for one moment doubt. 
 
 543. Perhaps, too, under certain circumstances, I might be 
 happy to note the first signs of a ptyalism — out of an empirical, 
 scarcely out of a rational inference that a ptyalism must super- 
 sede a moderate metritis or peritonitis. In the latter case, how- 
 ever, I may say that I should suspect the woman who can be 
 cured by means of a salivation, could more safely, conveniently, 
 and certainly be cured without it; for I regard it as one of the 
 most improbable of things that a salivation, in our cases, could 
 be brought on until a large moiety of the danger should first 
 have passed away. It would, of a surety, be an extremely difficult 
 task to produce a salivation while the phlegmasia should be upon 
 the ascending grade. Many cases are on the record, however, 
 of profuse ptyalism occurring during the course of treatment. 
 
 544. Among others, see Mr. Wood's case, by Bradley, in the 
 Somersetshire Epidemic, Aug. 1811. I find the case in Ozanam 
 (Epidemics, vol. ii. p. 290), and Baudelocque (Fi&vres Puerperales, 
 
294 CHILDBED FEVER. 
 
 p. 422) says tie has noticed, in practice, many very severe saliva- 
 tions attended with considerable swelling of the tongue, gums, 
 and cheeks — the parts being covered with aphthae, and with 
 exceeding painful ulcers. I have myself seen very bad saliva- 
 tions in in-lying women, but I repeat that such an incident is not 
 to be wished for. 
 
 545. It is contended that mercurials do exert a great force of. 
 counteraction against what is denominated the inflammatory 
 diathesis ; and that the fibrinous element of the blood, too largely 
 developed in inflammations, is lessened quantitatively by its use. 
 The justness of this sentiment admits of questioning ; for is it not 
 true that a person, being bled, and exhibiting no siziness of the 
 blood, but who takes soon afterwards mercury, so as to bring on 
 a salivation, does immediately thereupon show what is called 
 buffy or sizy blood, or inflamed blood? I believe it is invariably 
 so ; but were it even not so, we ought to remember that time is 
 short and art long, and that Gordon quotes Horace's words, horce 
 momento cita mors venit aut victoria Iceta; and this is very applicable 
 to our contests with childbed fevers — so that, in the generality of 
 cases, we have no leisure to wait for the tardy power of mercu- 
 rials, except those connected with their cathartic powers. Many 
 patients begin to die as soon as they are found to be attacked. 
 Have I not already said that neither is pain nor constitutional dis- 
 turbance awakened early in all cases of uterine phlebitis ; and that 
 the fatal lesion is often effected before the alarm is taken or given? 
 In such cases, I repeat it, there is no leisure to wait for calomel. 
 
 546. For thousands of persons, calomel and mercurials induce 
 a gastric distress of a nature indescribable. This qualm, or sick- 
 ness is, however, attended, for the most part, with a softer beat of 
 the arteries, and that I take to be equal to a lessened violence of 
 the sanguine injection into the inflamed vascular areas ; but it is 
 at the same time highly irritating to the bowels, and on that very 
 account, less to be esteemed than milder aperients or purgatives. 
 
 547. You cannot make out of the study of the Mercurials, which, 
 as M. Eenouard says, sect. 537, are specifics in syphilis, any spe- 
 cific properties of those drugs as to our childbed-fever phlegmasias. 
 You can only appeal to them as perturbators, or shock-giving 
 medicines, and to that perturbation, or shock-cure, as a cure by 
 
MERCURY. 295 
 
 chance — merely a cure by guess. If I might be allowed by you, 
 to introduce a homely but strong figure : those that depend upon 
 them, are people to make a spoon or spoil a horn — whenever they 
 employ mercurials without a clear understanding of the objects 
 in view, and the probability of attaining to the ends proposed. 
 Do you intend to purge the patient? Then use calomel, in God's 
 name, if you prefer it. Do you intend to lessen the hardness and 
 volume of the pulses by means of the qualmish state super- 
 induced by calomel? Calomel will do this for you, somewhat. 
 But do not resort to the shock merely to see what the shock 
 may haply produce. 
 
 548. The majority of puerperal women go into labor with 
 overloaded bowels, as I have said in sec. 344. This oppressed 
 state of the alimentary tube is the cause of irritation that might 
 well suffice, in epidemic times, to invite the afnuxions of an in- 
 curable inflammation. Seeing, then, the strong empirical reliance 
 to be placed in calomel as a purge, I consider it very discreet 
 and prudent, in such a case, to exhibit calomel in the dose of ten 
 of fifteen grains, after having premised the indispensable vene- 
 section; and, to insure a cathartic operation after calomel, where 
 the meteorism is not already great, few things are preferable to 
 Chaussier's mixture of syrup of rhubarb and castor-oil; two 
 ounces of the syrup, with one of the oil, gives a mixture, of which 
 half a fluidounce is a proper dose ; to be repeated every hour or 
 two hours until the bowels are freely enough moved. It appears 
 to me that a dose of ten grains is a proper medium in the dosing 
 with calomel; though, I believe, it is a matter of indifference 
 nearly, whether we choose to exhibit six, ten, or sixteen grains 
 for the dose; the effect being about the same for each of those 
 quantities; such, at least, is the forced conviction produced in me 
 by many years of observation. I may here refer you to what was 
 on this point by Dr. Collins, in my sec. 539. 
 
 549. I cannot then advise you to repeat large doses of calomel 
 every day. You should dread their power to irritate the bowels. 
 Your patient has already irritation enough and more than enough, 
 and it is by no means agreed, on all hands, that the influence of 
 calomel on inflammation of the womb is so favorable as is by 
 many supposed. Dr. Jorg, p. 667, observes ; " Since the period 
 
296 CHILDBED FEVER. 
 
 when calomel became with physicians so favorite a medicine, it 
 arose into a custom to prescribe it in cases of this weakness (tend- 
 ing to putrescency) of the womb, without reflecting that, under 
 these circumstances, it is not a resolution or discussing of inflam- 
 mation that is indicated, but an arousing of the muscular action 
 of the organ. Such administrations have, therefore, been produc- 
 tive only of harm. Calomel, even in the smallest doses, when- 
 given to lying-in women, does not lose its effect on the alimentary 
 canal. It adds in this way to the uterine irritation, and thus 
 carries the greatest disorder into the puerperal functions." Un- 
 doubtedly, where calomel does produce salivation, the inflamma- 
 tory element in the blood, I mean the size, is at the same time 
 greatly augmented in quantity, and though we rarely find that 
 mercury has power to develop a salivation during the active 
 stages of puerperal inflammation, we ought to suppose that it often 
 approaches to that state, and so, that it often renders the blood 
 more sizy or inflammatory, instead of less so, as is by most Ameri- 
 can practitioners falsely believed. 
 
 I never could get a clear idea of the meaning of the technical 
 word alterative. I often see it, and daily hear it pronounced, 
 for it is in every man's mouth, and thousands of us, when asked 
 the question, Why do you give the calomel ? reply, "We give it as 
 an alterative. An alterative to alter what ? If to alter the blood, 
 we shall alter it for the worse — if it be true, as it is true, that 
 whenever mercury touches the gums, the blood becomes at once 
 buffy or sizy, or inflamed, to use the common expression. 
 
 Your success will generally turn on the promptitude of your 
 action. If you commence early and aright, you will have a success 
 to console you, but in all these examples, you will have cured the 
 disease, so to speak, at once. I do not mean here to say that all 
 indisposition is at once to disappear: far from it. The shock 
 the nervous and sanguine apparatus have endured by some eight 
 or sixteen hours of childbed fever, may have so perverted the 
 blood's crasis, so impressed the membrana vasorum communis 
 (the endangium), so disturbed the nervous mass, that many days 
 must elapse before the innervations shall become natural again. 
 Some fever will remain ; some local turgescence ; some rebellious 
 engorgements; and the sullenly retiring inflammation that you 
 have conquered, but not wholly destroyed, may yet demand at 
 
MERCURY. 297 
 
 your hands further proper remedies. In such circumstances, I 
 should not in consultation practice, object to a formula like this : 
 R. Calomel gr. vi. 
 
 Sulphur, antimon. aurant. gr. xii. 
 Potass, nitrat. gr. xxx. 
 Camphor xviii. 
 M. ft. sec. art. pulv. in chartul. No. vi. dividend, sig. 
 One of the powders mixed in syrup of gum, for the dose ; to be 
 repeated every second hour, or every third hour, pro re nata. 
 
 550. In exhibiting such a drug, I should look to the moderat- 
 ing influence of the qualms produced by it, upon the force and 
 volume and frequency of the pulse; to the cutaneous transpiration 
 and the excretion of sebaceous matter and carbonic acid from the 
 skin ; while I should also, with some confidence, expect that under 
 its operation, the mucous, bilious, and pancreatic, as well as urinary 
 secretions, should be somewhat increased, with a positively amelio- 
 rated circulation in the meseraic, hepatic, and emulgent system of 
 vessels. 
 
 551. Baudelocque, op. cit. p. 404, speaks of mercurials as part 
 of the treatment for puerperal fevers ; at 411, he attributes the 
 glory (la gloire) of having proposed and exhibited mercurials as 
 remedy in chief, to Dr. Yandenzande, of the Civil Hospital of 
 Antwerp. I regard such a one as a very small glory indeed, or 
 rather as only a gloriole-, for if it could be established universally 
 I am very sure it would not enure to the benefit of society, 
 for whose good we exist, as a body, authorized by the common- 
 wealth, to heal the sick with remedies according to our con- 
 sciences. 
 
 552. I believe there are a great many of our brethren who 
 confidently think that to touch the mouth — that is, to provoke 
 a state of ptyalism — is among the most certain methods of cure. 
 But I apprehend that as a general thing, the best informed mem- 
 bers of the profession will not, under ordinary indication, seek to 
 bring on salivation in our cases — the violent disorders of the 
 constitution making it always unlikely that a salivation can be 
 brought about until the most dangerous stages are past. As to 
 a salivation effected with a design to rescue the patient from 
 danger, in some of those very protracted and complicated disorders 
 
298 CHILDBED FEVER. 
 
 that women fall into in the course of certain attacks of childbed 
 fever, I shall only say that I have no doubt it might, in very rare 
 instances, be deemed a useful and found even a laudable practice. 
 Yet, after all, the poisoning by mercury is so dreadful a thing, 
 when the use of mercurials is pushed to that extent, that a Christ- 
 ian and charitable man would, it seems to me, pause long before 
 resolving on the course. 
 
 553. I have only further to notice the use of mercurials as a 
 remedy in our disease, by inunction of the unguent, hydrarg. I 
 have witnessed this mode of treatment at various times for more 
 than thirty years past, and have attended patients for whom the 
 application has been prescribed in consultation. I can very 
 honestly aver that the only sensible effect I have ever observed 
 from the method was, that it produced in me a feeling of utter 
 disgust, and never did any good for the patients ; and certainly, 
 nothing could be more disgusting than to see the thighs or abdo- 
 men of a sick woman all begrimed and stained with that detestable 
 compound of grease and quicksilver — a belly scarred with leech- 
 bites or cup-marks, raw with a recent blister, and then befouled 
 with black mercurial ointment, is a thing not to be conceived of 
 for a lady, or for any other woman. If you will shock — if you 
 will salivate, I pray you do so with calomel or Yan Swieten's 
 liquor ; but do not, I beseech you, employ mercurial ointment, it 
 is too nasty ; and this is all I shall say on the subject. 
 
 C. D. M. 
 
LETTER XXIII. 
 
 PURGATIVES IN THE TREATMENT OF CHILDBED FEVERS. 
 
 554. You cannot get along, in the management of childbed 
 fevers, without the use of remedies calculated to maintain the 
 peristaltic power of the bowels; and this thought brings me to 
 the consideration of purgatives as a treatment in part or in chief — 
 for, you must know, that there have been persons disposed to rely 
 on cathartics as the remedy in chief for the cases. To this effect, 
 examine the early cases that fell under the younger Hey's conduct 
 in the sad epidemic at Leeds, and observe how fatal was the 
 malady until he became suddenly enlightened and reformed by 
 the revelation from Dr. Gordon's work, which happily came into 
 his hands. Indeed, Gordon himself fell at first into the same 
 miserable error. 
 
 555. It were well for you here to make the reflection, that the 
 ordinary contents of the bowels are normal contents, and that 
 their presence in due amount is an essential condition of health 
 and comfort. Any excess becomes productive of disquiet or 
 disorder. But this applies only to the state of health. When 
 diseases assail, and especially violent febrile diseases, then the 
 contents of the bowels, though they be normal in the healthy 
 individual, become absolute abnormities, for the vital state of the 
 intestine is changed, and so the normal relation of it to its con- 
 tents is destroyed. Hence, all mankind know that in fevers it is 
 useful to cleanse the bowels of their contents, and afterwards fur- 
 nish them with materials suitable to their new and diseased vital 
 condition. I say, then, that in febrile diseases, methods of pro- 
 ducing evacuations are indispensable to a successful treatment. 
 
 556. I believe there is a considerable difference in the opinions 
 of medical people on the question of purgative doses in child- 
 
300 CHILDBED FEVER. 
 
 bed fever; and although upon the naked proposition or question, 
 are we to rely upon cathartic medicines in the case, I should 
 promptly answer in the negative, yet I repeat, you cannot get on 
 without the use of them. But they should be employed under - 
 standingly, and not with a blind rage to cure by evacuations alone. 
 They cannot cure the patient by what is properly called catharsis — 
 that is, by causing such abundant excretions from the mucous 
 and other secreting apparatus of the intestine as to effect a com- 
 plete disgorgement of the inflamed capillaries, and so bring the 
 case to a close by resolution. 
 
 557. I consider it behooves every accoucheur to be not a little 
 chary of his purgative medicines as to all women recently de- 
 livered; and whenever, from observation, he is led to suspect the 
 approach, or the actual existence of an epidemic of childbed fever, 
 he should use them, at the beginning, only with the greatest 
 circumspection and reserve. A physician always has reason to 
 suspect an epidemical influence, when he finds it unusually diffi- 
 cult to get his patients out of bed; for while, under the ordinary 
 circumstances of practice, he finds it a difficult task to keep them 
 in bed long enough, it does sometimes happen that in patient 
 after patient, he is vexed with the delay to get up and go about; 
 and that too, without any perceptible inflammation or any strong 
 fevers, but from indisposition so vague as scarcely to be de- 
 scribed. Dr. Joseph Clarke found this to be the case in his hos- 
 pital practice, and I believe you will find it so likewise, in 
 general practice — at least, I have made the observation again 
 and again during my medical life. Dr. Joseph Clarke, Observa- 
 tions on the Puerperal Fever, &c, Syd. edit., p. 355, says : " It was 
 a general observation, that our patients recovered slowly, or, to 
 use the language of the nurses, it was much more difficult to get 
 them out of bed than usual." Dr. Clarke is here speaking of the 
 health of the hospital previous to the breaking out of the epi- 
 demic there in 1787. 
 
 558. I say. then, I consider that the accoucheur should be a 
 little, and sometimes very chary in the use of purgative medi- 
 cines for women in the first days of a lying-in, because the opera- 
 tion of a smart purge, which ;s attended with griping pains and 
 intense muscular activity of the bowel, is not rarely the first stage 
 
PURGATIVES. 301 
 
 of an irritation that shall end in forming an area of phlogosis 
 that must hasten to end only in death. I am most confident that 
 I have repeatedly seen women suddenly attacked with peritonitis 
 or metro-peritonitis, solely because they had been imprudently 
 and intempestively dosed with purgative medicines. Hence, 
 while I am invariably inclined to be very watchful against cos- 
 tive ness in the accouchee, I am as habitually disinclined to pro- 
 cure the first motions bv means of strong medicines; and in the 
 majority of my cases, prefer to cause the required dejections by 
 means of the simplest enemata, or mildest aperients, as of pure 
 water, or water animated with a little salt, or with Spanish soap, 
 or at most, a dose of oil, or magnesia ; and I now earnestly ad- 
 vise you, especially when the season is a suspicious one, to follow 
 my example. What the woman requires is, to have the bowels 
 properly opened, once, and not in general more than twice. One 
 can hardly fail to get at this effect by means of a water-injection. 
 The woman is not a sick woman, in the sense of being sick, she 
 is only a woman confined, and liable to sickness. The bowels 
 will not move spontaneously ; let them, then, be moved by enema 
 only, since she has no need of a cathartic. It is time enough to 
 give the enema on the third day, as a general rule ; and the ape- 
 rient dose on the sixth or seventh days ; if, indeed, she should at 
 all require such a prescription; a thing probable, owing to the 
 almost uniform costive habit of body in the latter weeks of utero- 
 gestation, as I have explained in my sects. 244-247. 
 
 559. But, as we are considering in this Letter, of the use of 
 cathartics as proper remedies in childbed fevers, I shall here beg 
 you to discriminate betwixt the cases of metritis and metro- 
 phlebitis, and those of pure and simple peritonitis. In the two 
 former, without concurrence of the latter, we have not to contend 
 against those terrible distensions caused by tympanitis; for the 
 belly may be soft and supple, instead of enlarged beyond the 
 volume of the abdomen at term. It is against this frightful tym- 
 panitic distension, that the use of purgatives should be directed. 
 Tympanitis is over-distension of the bowels, and nothing else; 
 and I see not how any one could reasonably expect to conduct 
 to a term, in resolution, a tympanitic case of puerperal peritonitis 
 without the use of aperients or purgatives. Indeed, the inconve- 
 niences and dangers of that state are so alarming, that I can con- 
 
302 CHILDBED FEVER. 
 
 sider no other part of the case more so. When the distension 
 reaches a certain magnitude, the gut threatens to shut by its 
 angulation, at the return, as effectually as if it were tied with a 
 surgeon's ligature, or fatally closed by the strangulating edge of 
 Grimbernat's ligament, or the ring of the abdominal canal. 
 
 560. A bowel inflamed in a lying-in woman, always yields to 
 the lateral pressure of the gases extricated within its tube : and 
 it is far less a matter of moment to purge forth the remains of the 
 digestions, the bile, the mucus, &c, than to expel the gases that, 
 by distending them,- not only prevent resolution, but, by adding 
 unspeakably to the pain and constitutional irritation, exert the 
 most noxious influence on the aeration of the blood, and the re- 
 spiratory power in general. A woman with an inflamed belly as 
 big as that of a woman with twins, and more sonorous than a 
 tight drum-head, cannot possibly breathe aright ; she must take 
 two breaths for one ; and even at that rate, procure less oxygen 
 than she requires ; so the blood turns slowly, less oxygenated. 
 Her tint grows paler or livid ; and at last, a good share in her 
 death is attributable to the sort of cyanosis thus superinduced. 
 Yet this sort of half-way, half-suspected, half-seen asphyxiation in 
 childbed fevers is a strong thick bar against her recovery-power. 
 How can the neurosity that is essential to the life of the organs 
 and the play of the functions, be extricated, when the respiration- 
 power, like a steam piston cut off at half stroke, checks the de- 
 scent of the diaphragm in the respiratory cylinder of the chest. 
 I implore you to be watchful here, and employ the best means 
 in your power, to obviate the direful tendency to tympanitis in 
 all the peritoneal childbed fevers ; for a great tympanitis is equi- 
 valent to a great cyanosis for the dying woman. 
 
 561. The alarm I always take at such occurrences, and the im- 
 pending danger to the woman, makes me willing, in the com- 
 mencement, to seek for the powerful cathartic qualities of a strong 
 dose of calomel ; and therefore, I should willingly prescribe a 
 dose of ten grains — though uncertain whether five or six grains, 
 or sixteen grains, might not be as well for her. Yet I should be 
 unwilling to confide in the mercurial alone, and, therefore, should 
 administer a secondary dose, consisting of castor-oil, magnesia, 
 senna, or a combination of syrup of rhubarb with castor-oil. 
 
PURGATIVES. 303 
 
 562. Provided the alvine evacuations from the calomel and its 
 adjuvant should prove to be stercoraceous, and in such quantity 
 as to justify an opinion that the intestinal canal was cleared of 
 its ordinary contents, I should forego for many succeeding days, 
 any further intention of causing purging in the ordinary sense 
 of the term, and taking due care as to the ingesta to be allowed 
 during the continuance of the disease, I should, for the rest, con- 
 tent me as to the duty of moving the bowels, with relying upon 
 enemata, of a simple, and generally the least irritating kind. 
 
 563. ^Nevertheless, there is constant need to obviate the tend- 
 ency to distension from meteorism ; and, therefore, there is need 
 sometimes for aperient doses. My master, who inducted me into 
 Medicine in my early student life, was accustomed, in cases 
 of tympanitis, greatly to rely upon a combination which he de- 
 rived from his own instructor, Dr. Brown, of Maryland. I was 
 in the habit of frequently preparing the doses for my master's 
 patients, as well as of witnessing its effects in the subduction of 
 the symptom. This was so long ago as 1809 and 1810 — now 
 forty-five years ago. I have repeated Dr. Brown's method many 
 times during this long period, and now advise you to resort to it 
 when the proper occasion may present itself in your own practice. 
 The medicine is prepared by pouring eight ounces of boiling 
 water upon an ounce of manna and a drachm of anise seeds. 
 After the mixture has rested for half an hour it should be strained, 
 and the cold infusion then added slowly to three drachms or four 
 drachms of carbonate of magnesia, in a wedgewood mortar, taking 
 care to reduce the mixture to a state of complete smoothness, or 
 freedom from grains. 
 
 56i. The dose is a wineglassful or less; to be repeated once in 
 an hour, or two hours, until it excites the action of the bowels. 
 I confess, I do not know a better carminative dose than the 
 above, and time has not altered my conviction that it is a most 
 safe, convenient, and efficacious medicine for such purposes as 
 I have above indicated. 
 
 565. I may here mention that I have found doses of tincture of 
 nux vomica to act very fortunately in reducing the tympanitic 
 distension, in certain cases of childbed fever. The doses, say 
 five drops every two or every four hours, may be safely exhibited. 
 
304 CHILDBED FEVER. 
 
 566. There is farther a mixture much used here that was a 
 favorite prescription of our beloved Dr. Ph. S.Physick, Professor 
 in the University of Pennsylvania, which consisted of: — 
 
 Carbonate of potash 5j ; 
 
 Gum-acacia 3j ; 
 
 Tinct. of opium 40 drops ; 
 
 Water 6 ounces; 
 To make a proper mixture. The dose is a tablespoonful, which 
 may be repeated from hour to hour. Sometimes an aromatic 
 distilled water, as spearmint or cinnamon water, is used in place 
 of the pure water. I think you will find, upon trial, this mix- 
 ture of Dr. Physick is a convenient and useful medicine in the 
 cases. De la Koche, p. 213, tells of a case of frightful tympany 
 that occurred early in his practice at Geneva. He saw the woman 
 the morning after her delivery in a bad labor by the forceps. 
 She was in agonizing pain, and excessively weak; with the 
 abdomen so greatly distended as to be much beyond what is 
 usual at the ninth month of pregnancy. It was excessively 
 sore, and intolerant of pressure; the pulse small and frequent. 
 He says that, at that period, he was unacquainted with puerperal 
 fever; though, since that time, he wrote, as I should think, one 
 of the very best accounts of it that has ever appeared in the 
 medical library. The weather (July 1) was very hot, and her 
 apartment particularly so, which filled him with apprehensions 
 of putridity; wherefore, to give renewed activity to the mus- 
 cular apparatus of the intestine, he made powders of 12 grains 
 cinchona, and 5 or 6 grains of rhubarb, each one of which must 
 be given, for the dose, every third hour. The medicine brought 
 on a gentle purging, without pain, and considerably reduced the 
 volume of the belly. He next substituted a decoction, of one 
 ounce of cinchona, to be taken in the day, and repeated it several 
 times, without recourse to any other essential remedy ; the alarm- 
 ing symptoms were dissipated, and the patient found herself, 
 shortly, cured. I thought it might be interesting, and, perhaps, 
 at some future time useful to you to read this account of De la 
 Eoche's conduct in the case ; but I should warn you that he was a 
 believer in the supremacy of venesection, as much as I am. But 
 that is no reason why his well- conceived combination should not 
 
TREATMENT OF THE TYMPANITIS. . 305 
 
 have rescued the woman, whom he would most certainly have 
 bled, had he attended her at a later period, and when he had 
 become better informed. 
 
 567. As a useful and mild aperient, it is convenient to direct 
 a pill composed of 2 grains rhubarb, 1 grain extract hyosciam., 
 and 1 grain extract gentian. Two such pills, repeated every 
 three or four hours, are likely to excite the peristaltic fibres to 
 such a degree as to enable them to expel the distending gases of 
 the bowels. In like manner, a powder of 5 grains rhubarb and 
 one of calomel, repeated every four hours, is a probable means of 
 effecting the same purpose, which is not to purge the bowels, but 
 to get rid of the gas of the tympany. 
 
 568. Enemata often succeed better than aperients or cathartics. 
 A pint of warm water, with half an ounce of salt, or with 2 scru- 
 ples of jalap, or with an ounce of Spanish soap, or with a table- 
 spoonful of oil of turpentine, made by means of the white of an 
 egg into an emulsion, and united with an ounce of castor-oil ; any 
 of these may answer the purposes sought to be obtained. 
 
 569. Where all these methods fail, a complete success occa- 
 sionally follows the use of a large catheter introduced into the 
 intestine. I am convinced that I rescued a woman in Lombard 
 Street from an otherwise inevitable death with childbed fever, by 
 this method. I procured a male catheter of the largest size, and 
 fortunately, conducted it along the colic sigma, its whole length. 
 The horrible tympanitis disappeared immediately, but recom- 
 menced upon the removal of the tube. I replaced it, and kept it 
 in the bowel for more than twenty -four hours, so that all the gases 
 she developed within the intestine passed freely through the tube 
 of the catheter, and so, gave her no inconvenience. A person 
 moribund from tympanitis, and completely insensible at the time, 
 and nearly pulseless, was rescued by me from impending death, 
 in the course of a few minutes, by the same means. It must be 
 admitted, however, that in endeavoring to procure relief and 
 safety for the sick by such a method one is frequently foiled, in 
 consequence of the packing of the bowels, and the short, quick 
 returns, amounting almost, and sometimes quite, to irremediable 
 angulation of their tracts. 
 
 570. I have been much struck with the frequent accounts and 
 20 
 
306 CHILDBED FEVER. 
 
 complaints, of the French writers in particular, as to diarrhoea, 
 which seems to have been for them one of the most troublesome 
 and unmanageable complications of childbed fevers. I do not 
 conceive that the English writers have made the same complaint 
 to a similar extent ; and, as to mj personal experience, it is null 
 as to this point, though I am sure, having long been aware that it 
 was regarded in Europe as a common and very bad complication, 
 I could not have ignored it, had it been common here. 
 
 Legouais gives us a dissertation upon this diarrhoea, in arguing 
 the question as to the propriety of using purgatives, at page 55, 
 where he speaks of it as " cet accident si redoute dans cette circon- 
 stance!'' Legouais appears to me to have been led into his fond- 
 ness for purgative doses in childbed fever cases, by his terror at 
 what he denominates, page 53, " ce symptome effrayant de la consti- 
 pation ;" and well he might ; for there can be no more frightful 
 condition for a perishing woman than that, which, by the way, 
 Legouais did not at all comprehend, because he never caught the 
 least idea of that angulation of the bowel which I have so often, 
 in these Letters, spoken of, and which is the cause, uniformly, of 
 the constipation that excited his apprehension. 
 
 571. I am happy to find that my own experience and personal 
 convictions concerning the use of purgative medicines in our dis- 
 ease coincide with those of Legouais, who advises that they should 
 be employed rarely, if at all, and that the after-use of evacuants 
 should be restricted to a choice among the gentler aperient drugs. 
 
 572. It appears to me unnecessary to present any further re- 
 marks or suggestions on this particular topic. I now close this 
 Letter, with assurances of that regard with which I always rest 
 your friend and servant, C. D. M. 
 
LETTER XXIV. 
 
 OPIUM AND TURPENTINE-OIL IN CHILDBED FEVERS. 
 
 573. How should a physician think, tuto cito acjucunde, that is, 
 safely, speedily, and gently, to conduct a case of childbed fever to 
 its close, without the assistance to be derived from anaesthetic 
 and anodyne medicines ? There is too much irritation, too much 
 pain, and too much restlessness and discomfort, to allow us to do 
 so ; and this is the reason why, in the management of the cases, 
 almost all medical people do, with greater or less confidence, re- 
 sort to the employment of some of the preparations of opium : 
 opium has repeatedly, among physicians, been pronounced to be 
 a magnum Dei donum, a special blessing given to us by the bene- 
 ficent God. There is an eminent German philosopher who says : 
 " The universe is not, in deed and truth, that which it seems to 
 be to the uncultivated and natural sense of man ; but it is some- 
 thing higher, which lies behind mere natural appearance. In its 
 widest sense, this foundation of all appearance may be aptly 
 named the Divine idea of the world." Professor Fichte, 
 in the above sentences, only reiterates the sentiment of Plato, who 
 saw, in all matter and form, nothing more than the material reali- 
 zations of the Primary and Eternal Ideal — that which precedes all 
 real and finite ; itself being the principle, the force, and the mould 
 upon, by, and through which, all things exist as nature. Nature, 
 therefore, according to this philosophy, is fashioned and sustained 
 in conformity with a Divine Idea of it, which precedes all form, 
 all substance, and all force in nature. All things, therefore, hav- 
 ing been created according to a pre-existent Divine Idea of them, 
 things, or the real, are only representatives of the absolute, or the 
 True Ideal. To know the real truly, it is necessary for us to 
 attain to, and possess ourselves of the Divine Idea of the world. 
 
308 CHILDBED FEVEK. 
 
 Such are the opinions of the German author above named, and I 
 have cited them here, only that I might use them to show you 
 how grateful we should be, as ministers of nature, for the multi- 
 plied benefits it is our privilege to scatter broadcast among our 
 fellow-creatures, of whom we find so many in sickness, in pain, 
 and in fear. 
 
 574. It is from the Author of Nature — the giver of every good 
 and perfect gift, that we derive our privilege to know his laws, 
 his world of matter, his forces of things. It is to him that all 
 things tend and turn, at last; and as HE is all-wise, we shall 
 never become truly his servants and ministers in our great mission 
 as Physicians, until we can seize, and hold the Divine idea, as to 
 all that concerns our own ministry. Hence, as physiologists, we 
 should inquire into the laws of life, as pure and simply expressions 
 of his will; for as a sparrow falls not to the ground but through 
 his agency, so no vital function — no medicinal power can be, for 
 the twinkling of an eye, independent of his purpose and power. 
 Every due performance of the functions of the body is consistent 
 with its health, while every aberration from the law of its normal 
 life, is infraction, and like moral turpitude and sin, brings with 
 it the inevitable consequences, sickness or death, as infractions of 
 the moral law draw after them remorse, with sorrow and shame. 
 Consider how good was God to give to mankind the sleep-giving 
 poppy! The plant existed before the pain I The Divine idea 
 preceded the form and the substance : yet it was fashioned and 
 moulded, and endowed with its powers, because pain must be. It 
 was never an accident — it was already become, while pain was 
 yet becoming. The idea of it existed before its root was set 
 in the soil, or its germ was formed within the secret chamber of 
 the ovary. It was in conformity with the pre-existent idea of it, 
 that those strange, mysterious chemical powers were bestowed 
 that stored up its sanative juices in its capsules, and converted 
 them into opium; for it was He who saw those material pains we 
 could not wholly avoid, and He who foreordained for us the "sweet 
 oblivious antidote." I cannot think of the gift of opium to man- 
 kind, without finding in it my warrant to become a physician, 
 nor without feeling, at the same time, the spur of conscience that 
 pricks every rational being on, and still on, in the course of duty 
 — duty to learn daily more and still more concerning the Divine 
 
opium. 309 
 
 idea of the universe — duty to search after, and to the utmost of 
 ability comprehend the nature and laws of the animal economy 
 in its health and its diseases, with the rules of its subjection to 
 the powers of medicines. 
 
 575. All medicines are the gift of God, and all true physicians 
 are ministers for those gifts, worthily to apply them, with wisdom 
 and virtue, for the obviation and the consolation of many inevi- 
 table ills that attend the physical and moral nature of man. 
 
 576. The cereals, the leguminous vegetables, the fruits, and the 
 grasses, are severally endowed with powers and with qualities, 
 designed and adapted to fulfil ends foreknown in the Divine Idea 
 of them. We are all commanded daily to express our gratitude, 
 as well as our dependency for our " daily bread," and there is no 
 wise man can look out upon the scene of the world without a feel- 
 ing of gratitude to the Beneficent Disposer of all. Yet, among 
 a thousand blessings, what is there more strangely good, more 
 curiously kind, than those medicinal things that we bring to the 
 wounded and the sick ! We have not, it is true, the direct, ener- 
 getic, voluntary force of Christ and the Apostles, to say unto 
 men: ®£%eis vyirj$ ysviaOai) 'Eyatpat, xai 7tsptrtdtsi ; but we have dis- 
 cerned a thousand means by which to bring about results almost 
 as miraculous. How studious, then, should every man of us be- 
 come to attain to a clear and plenary comprehension of the nature 
 and power of the substances employed as remedies in the practice 
 of Medicine ; to go behind them, and discover and possess the Di- 
 vine Idea of them! Considering the peculiar relations to society, 
 and more than that, the intensity of the interests of family and 
 offspring, concerned in those dreadful and dangerous circum- 
 stances it is the object of these Letters to explain, we have abun- 
 dant reasons to felicitate ourselves upon the possession both of the 
 material and the knowledge, which puts it in our power, by means 
 of the various preparations of opium, sometimes to withdraw our 
 friends out of the dark and difficult ways of disease and pain into 
 the repose and happiness of dangers past, or health and pleasures 
 regained with the life we have saved ! 
 
 577. I can readily conceive of cases of childbed fever that 
 should be curable by opium alone, and unaided by any other 
 means of treatment ; for I can suppose, that in certain epidemic 
 
310 CHILDBED FEVER. 
 
 constitutions of the atmosphere, injurious influences, exerted by 
 the epidemy upon the nervous system, may and do develop the 
 phlegmasias of childbed fever, where those influences are allowed 
 to go forth unchecked to work mischief in the subject tissues. 
 Even when this influence has. gone so far as to cause the earliest 
 areas of inflammation to be laid, a powerful dose of opium might 
 suffice to recall the wild energy, or the confused disorder of the 
 nerves of the part diseased, back to an habitual obedience, and 
 recompose the harmony of the disturbed organisms. 
 
 578. Many a painful or molesting sensation, that was inter- 
 preted as nervous or^spasmodic, and that was quelled by anodynes, 
 was, perhaps, due to the incipient stages of a phlegmasia, which, 
 but for a happy conservative intervention should have progressed 
 to the open, unmistakable, and mortal phases of a childbed fever. 
 I conceive that the supposed after-pains so often checked and 
 dispelled by our prescriptions of camphor, or of opium, are often, 
 in reality, only the beginnings of these mortal phlegmasias, and, 
 therefore, I say that opium is capable of curing them, without 
 extrinsic aid. 
 
 579. There are physicians who have been, and, perhaps, are 
 still willing to heal all their childbed-fever cases with enormous 
 doses of opium alone — making use of no other medicines, at least, 
 during the violence of the disorder. And too many facts are 
 before us to allow us to doubt that successful results have, in this 
 way, been obtained. I have been informed by a physician in a 
 neighboring town, that, in his treatment by opium, he has carried 
 the narcotization so far as to keep the patient's respiration, for 
 hours, as low as five or six breaths per minute ; and I have heard 
 of its being reduced so low as four respirations per minute, the 
 treatment being followed by the escape of the woman from death 
 from both causes, the phlegmasia and the drug. Any successes 
 obtained in this way, ought not, in my opinion, to be regarded as 
 triumphs of our art, but rather as misfortunes, that serve to re- 
 tard its progress in usefulness and in the confidence of the people. 
 Even though one, or twenty persons should recover from child- 
 bed fever, after such a poisoning by opium, no man can expect 
 that the method shall ever receive the general sanction of the 
 sober portion of our class ; and there is danger, in the mean time, 
 
OPIUM. 311 
 
 of the adoption of that way of cure by many silly young people, 
 and of the greatest mischiefs to the sick, following their impru- 
 dence. ^Nothing but the greatest familiarity with the operation of 
 opium, and the most precise knowledge of the physiology of man, 
 should warrant, if even they could warrant, so extravagant an 
 employment of the poisonous power of the drug. 
 
 580. From all that I have heretofore said in these Letters on 
 the subject of childbed fever inflammations, and of bloodletting as 
 the chief, if not sole reliable remedy for them, you could not sup- 
 pose that I should advise the use of opium in the first hours of 
 the treatment. Far from doing so, I consider that you ought to 
 regard the most important ends of all treatment to be in a good 
 way of being secured, by first impressing upon the phlogosed areas 
 a disposition, and affording them a power to recover by resolution, 
 not of the membranous phlegmasia only, but even the phleg- 
 monous nucleus of it, if any there should be. When this first 
 and all-important step has been taken, the opium comes in most 
 fortunately as an adjuvant, and it may be exhibited in combina- 
 tion with calomel or tartar-emetic before the time has arrived to 
 confide in its force pure and simple. If, therefore, you should 
 deem it advisable for the woman to be placed under the influence 
 of calomel or an antimonial, I advise that opium be conjoined, 
 and that, in a very positive dose, such as one to three or five 
 grains. I should recommend the omission of the opium, in a 
 case where it might be urgent to secure the speedy evacuation of 
 the bowels, in which case calomel is not the most desirable arti- 
 cle. Probably, a majority of our physicians do prefer to conjoin 
 the opium with the calomel, to give which, alone or uncombined, 
 is a thing, I believe, rarely done; it being in fact the custom to 
 exhibit, at some moderate interval after the mercurial, an aperient 
 or cathartic medicine, which, being designed, no objection can 
 arise against the administration of opium along with the mild 
 chloride of mercury at the beginning. 
 
 581. In all the subsequent treatment, the woman should have the 
 benefit of that tranquillizing power attributed to opium. By its 
 means she may be in a considerable degree protected against those 
 reflex influences, which, in their great irritation, the nerve-centres 
 are likely to throw back and expend upon the various organs; 
 
312 CHILDBED FEVEE. 
 
 thus spreading the mischiefs far and wide throughout their centro- 
 peripheral domain. To procure this protecting influence, the 
 doses of the opium should be full ones, and, I may here suggest, 
 that the consumption of the drug should amount to from four to 
 six grains per diem, when a chief reliance is placed upon it. 
 
 582. The opium may be employed as pills, as laudanum or 
 black drop, or as morphia; or the state of the skin and the primae 
 vise may indicate the use of Dover's powder, in preference to any 
 other formula. Dover's powder, made into pills of four grains 
 each, and repeated every second to every fourth hour, does, in 
 many of the cases, answer our reasonable expectations. In this 
 way it may be continued pro re natd indefinitely. The dose rarely 
 provokes nausea, while it promotes a highly desirable diapho- 
 resis. 
 
 The Amer, Journ. of the Med. and Phys. Sciences, edited by Dr. 
 Isaac Hays, Jan. 1852, contains, Art. XI. : u Case of Puerperal 
 Fever treated successfully with Opium in large doses. By Wm. 
 Kelly, M. D., Eesident-Physician to Blackwell's Island Hospital, 
 New York City." The patient, ast. 24, primipara, was delivered 
 Dec. 14, in the morning, with a labor of thirty-six hours. No 
 case of puerperal fever had been in the house for months, though 
 two cases of erysipelas were, at the time, in an adjoining ward, 
 and had had the attention of the ' author. At 4 A. M., 15th, less 
 than twenty four hours, the woman had a severe rigor. Dr. E. 
 saw her at 5 o'clock. The face anxious; deep sighing; pulse 120, 
 small and hard; pain and tenderness in right iliac region in space 
 as large as a palm; no lochia; milk not yet come. 
 
 Dr. K. gave a teaspoonful of laudanum, which was repeated in 
 twenty minutes. Afterwards, three grains pulv. opii ordered 
 every half hour until asleep. At 7 P.M. pulse 150, quick, hard, 
 small; pupil contracted ; sleeps, but not profoundly ; easily roused ; 
 whole body bathed in perspiration ; tympanitic and tender in 
 right iliac region ; a blister 12 by 12 on belly; 12 P. M* no change 
 of condition; has taken sixty grains of opium; soon after 12, vo- 
 miting, which probably threw off most of the opium. Dec. 16, 
 6 A.M. pulse 120, fuller and softer; less sighing; no lochia; 
 breasts painful; vomiting continues; no more tympanitis; vesica- 
 tions from blister. Two grains morphia sprinkled on the blis- 
 tered surface every two hours. At night } one grain morphia in 
 
opium. 313 
 
 solution every two hours until asleep. By a mistake she got, by 
 morning, six grains morphia, and had ten grains on the abdomen. 
 At seven, somewhat narcotized ; pulse 120; breathes seven 
 per minute, with gasping; pupil a point ; yet she did not 
 sleep ; heard all in the ward ; replied to remarks not addressed 
 to her. Sinapisms and Granville's lotion to back and chest; re- 
 spiration normal ; pulse 140 ; cold water to the head. 17th, 2 
 A. M., pulse 140; sleeps lightly. At 3 o'clock, three grains mor- 
 phia. At 4 o'clock, respiration seven in the minute. At 8 o'clock, 
 pulse 125; sweating most profuse; no pain. Two alvine dejec- 
 tions yesterday ; urine free ; face flushed and pinched ; morphia 
 one grain every two hours. During this day, pulse 120. 18th, 
 morphia continued at same rate ; bowels and bladder freely eva- 
 cuated. 19th, she says she is "first-rate;" three dejections to-day 
 and three yesterday. 20th, six dejections yesterday, soup-like 
 consistency and pea-green in color; lochia came on in evening. 
 23d, pulse 100; has a "bed sore;" cannot sleep without morphia; 
 milk in breasts. 27th, well, lacking strength; bed-sore ; morphia 
 in lessening doses. Jan. 1851, milk not re-established fully; child 
 given to a wet-nurse; otherwise the woman "seems to have quite 
 recovered from her sickness." " Within nine days" of the attack 
 she was well. In this time had taken ten grains morphia applied 
 to a blistered surface, eighty-four by the mouth, besides seventy 
 grains of opium. For six days she took twelve grains of morphia 
 daily; was seen every hour either by Dr. Kelly or Dr. Jenkins: 
 The medicines were of good quality. The treatment, he says, 
 "produced semi-narcotism for twelve hours. No function seemed 
 to be injuriously affected by these large doses. Indeed, the bowels 
 were kept in a relaxed condition. The kidneys performed their 
 office as usual." Such is the very interesting account given us by 
 Dr. Kelly, one which, I should think, you will examine with 
 much pleasure, because you will learn from it that an adult has 
 taken so very large a quantity of opium and morphia, without 
 being destroyed by them. Computing that eighty-four grains of 
 morphia are equal in force to 13,440 drops of laudanum, and 
 that seventy grains of opium are equal to 1,440 drops of laudanum, 
 we may conclude that the opiates used were equal to 14,840 drops 
 of common laudanum, all taken in the course of nine days, which 
 is equal to 1,648 drops of laudanum per diem during nine con- 
 
314 CHILDBED FEVER. 
 
 secutive days. You will see, from the perusal of this statement, 
 that Dr. Kelly cured his patient, and you will also see that the 
 opium practice, though fortunate in its result in this instance, is 
 not one that can be recommended as a method to be always, or 
 even often taken, but only in the very worst and most exceptional 
 instances. 
 
 583. Seeing that the chief seat of the mischief, in certain of 
 the forms, is within the pelvis ; and further, reflecting that opium 
 doses are not much less active when used as enemata, we have 
 many inducements to bring about the anaesthetic effects of the 
 drug by anodyne enemata; and when the circumstances do not 
 oppose it, I presume it may be more convenient, as well as more 
 useful, to employ the injection. In my opinion, your anodyne 
 enemata should never contain more than forty-five drops of laud- 
 anum for each dose. This, to many of you, will appear to be a 
 very feeble practice; but I hope you will not consider it so upon 
 second thought. Indeed, I now earnestly advise you to set it as 
 an invariable rule, as long as you shall continue in the practice 
 of Medicine, never to go beyond this quantity. Otherwise, you 
 will be exposed to the risk of committing a gross error in your 
 closings; for some persons are of a nature to be dangerously nar- 
 cotized by the imprudent teaspoonful doses of laudanum that are 
 commonly, in the United States, used in each enema. If you say 
 that forty -five drops is too small a dose, you have the power to 
 reiterate it until the desired effect is produced; but if you give 
 an overdose, you cannot readily repair the mischief you have 
 done. This habit I have had for more than twenty years, having 
 engaged in it at the earnest solicitation and protest of our good 
 and wise Dr. Physick, who told me that he had not broken the 
 same rule, he had formed for his own guidance fifty years before. 
 
 584. The anodyne enemata are designed to procure both dimi- 
 nution of pain and sleep. I should think, therefore, you would 
 provide for the repetition of the medicine, pro re natd; that is, as 
 long as the pain and vigils seem to require. 
 
 585. Many years ago, when I was young in the profession, I 
 was accustomed to hear much and favorably of Brenan's remedy 
 for childbed fever ; for the celebrity that writer had obtained in 
 Dublin, had wafted his name to this side of the Atlantic. I saw 
 
BKETTAN". 315 
 
 his method tried in vain. Still, as years lapsed onwards, the 
 name of Brenan and his method was often echoed, and many a 
 sick woman was subjected to the Brenan treatment. This Dr. 
 Brenan, who rose into notoriety by giving oil of turpentine to 
 cure childbed fever, appears to me to have been a person of very 
 imperfect education and worse temper, as any one would opine 
 upon reading his pamphlet, now lying open before me. This 
 pamphlet is, Thoughts on Puerperal Fever, and its Cure by Spirits 
 of Turpentine ; Illustrated by Cases in the Lying-in Hospital, Dublin. 
 Also, Cases of Inflammation and Spasm cured by the internal and 
 external Use of that Medicine, with Correspondence on the subject : by 
 John Brenan, M. D. London, 1814 ; 8vo., pp. 24 
 
 586. Dr. Brenan commences by referring to the confusion of 
 opinions concerning the disorder, its terrible nature, and the fail- 
 ure of the methods of cure, both in private practice, and in the 
 great establishments at Paris, Edinburgh, and London, as well as 
 Dublin. He speaks of the fatal epidemic in Dublin Hospital, of 
 1812, when "whole wards were swept away" — of the intervention 
 of many of the city physicians, who humanely proffered their 
 assistance, which was in vain — of the bleedings that were tried, 
 and the blisters and purgations, with all which, " the malady was 
 no way arrested." p. 6. He next proceeds to tell as that about 
 this period he was called to see private patients with bilious 
 fever, whom he was much astonished to find laboring under " all 
 the symptoms that he (I) saw in the patients laboring under fever 
 in the Lying-in Hospital." He " generally found that, after even 
 the most favorable labor, the patient sickened on the third or 
 fourth day, with what nurses call the weed," but which proved to 
 be fatal childbed fever. 
 
 587. Brenan says he had extensive practice among the lower 
 classes, and that his reputation for success led to his being called 
 in consultation by the ablest of the faculty. It struck him that 
 by beginning early with evacuating the bowels, the weed might 
 be prevented from going on into puerperal fever, which he deemed 
 contagious, and that by a little calomel and antimony, it could be 
 prevented from assuming the type of putrid fever. I shall not 
 annoy you by citing his stupid 8th page, filled with idle hypothe- 
 ses, worthy of a very lame first-course Student. You shall, 
 
316 CHILDBED FEVER. 
 
 however, judge of him by his saying: "I should think that no 
 woman has died of this complaint whose bowels have yielded to 
 proper medicines ;" as if such a thing commonly happens as that 
 of a woman getting out of this world, and the hands of our pro- 
 fession, without having had such dejection. You know such a 
 case would not happen except in those instances of what Legouais 
 calls constipation, but which I have explained as depending upon 
 angulation of the intestine. Omitting his paragraphs in succes- 
 sion, we come to page 11, where his words are: "My manner of 
 healing this disease has been so marked with success as to cause 
 much astonishment. The exhibition of the spirits of turpentine 
 in a disease termed inflammatory, was not without the tribute of 
 censure that useful novelty never fails to extort ; however, its 
 effects have borne it through (a sad mistake) ; and though theorists 
 could not understand its mode of acting, and though some great 
 men were not pleased that one not so great as themselves should 
 make a discovery that revolutionizes medical practice, the appli- 
 cation of it has met with success, and the good effects I have 
 witnessed from it has consoled me for the displeasure that my 
 success occasioned." You see already that Brenan had brought 
 himself into conflict with the Dublin brethren, who doubtless had 
 good reasons to distrust his temper, if not his clinical results. 
 
 588. Margaret Eogers had been bled twice, to the amount in 
 all of thirty ounces. She was sitting up, vomiting green and 
 yellow bile incessantly ; could not bear the weight of a paper card 
 on the belly. The hospital physician considered that effusion had 
 already taken place, and as the woman was in a rapid state of 
 dissolution, he desired to know what Brenan would give her. "I 
 told him the spirits of turpentine. He started, and asked me how 
 much ; I told him a tablespoonful. This appeared to him a mad- 
 ness, but as the woman seemed dying v he said I might give a few 
 drops, but that he would not stand by whilst I gave it." 
 
 He gave three teaspoonfuls of spirits of terebinth, at 2 P. M., 
 in water. At five o'clock he returned, and the assistant said she 
 was better, " and had the courage to stand by when I gave her a 
 tablespoonful." "He asked her what she thought it was; she 
 replied, Geneva water." "At nine o'clock, she lay at her ease." 
 From the time she took the dose she never vomited; the belly 
 
BREXAX. 317 
 
 became flaccid, and insensible even to violent pressure. The next 
 day, she had renewed pain, which vanished after more turpentine. 
 Complained of hunger, and asked for food. She never complained 
 afterwards of uneasiness in the region of the uterus, but in about 
 four days began to spit pus, whereon her pulse sank and she died. 
 Brenan " put her death down to the bleeding." The second case 
 was that of Margaret Conolly, in hospital. Two days in labor, 
 " and got the fever ;" bled thirty ounces at two bleedings ; belly 
 tense and sore to an exquisite degree. Brenan poured the spirits 
 of turpentine "on her abdomen, covered with flannel." In about 
 three hours afterwards, she told him he had cured her ; the abdo- 
 men flaccid as in health, and bearing any pressure ; the breathing 
 easy. "I gave her two teaspoonfuls of the turpentine in hot water 
 and sugar," which disagreed with her stomach. Cold water he 
 thinks a better vehicle. On the next day her symptoms returned, 
 and she was bled eighteen ounces in the morning, and eighteen 
 other ounces in the evening. The day after, she begged him to 
 apply his remedy as before, which he did without permission, for 
 humanity's sake. The belly became flaccid again, and could bear 
 any pressure on it. She sank, but with no distress in the uterus, 
 and after death the abdomen was flat. " I put down her death to 
 the bleeding." P. 15. 
 
 His third case was that of * * * Headache ; sore abdomen ; 
 a burning in her stomach. Moaned much, and complained severely. 
 " I gave her a tablespoonful of the oleum terebinthinse, and a sup 
 of water after it. In about fifteen minutes I came to her; she told 
 me she got ease. On coming into the ward next morning, 1 missed 
 her ; she was sitting at the fire, very well." 
 
 In case four, the woman had symptoms, the usual forerunners 
 of the disorder. Brenan "contrived by stealth to give an ounce 
 of the turpentine in some saline mixture." All the pain and 
 vomiting abated, and the consulting doctor said next day nothing 
 was the matter with her. She went home that day, and, the symp- 
 toms returning, she was visited by a hospital attendant, who blis- 
 tered, bled, and gave her the usual remedies. She died, vomiting 
 green bile, with her belly swelled. "In this woman I stopped all 
 the symptoms." 
 
 Mrs. Murray, case five, confined on Saturday, was seized on the 
 Tuesday following. Had cough, with severe pain. Brenan applied 
 
318 CHILDBED FEVEK. 
 
 turpentine to the abdomen, and gave her a tablespoonful in sweet- 
 ened water. She was next day free from pain, and ate bread and 
 milk for breakfast. Then took cold milk, and got as ill as ever. 
 Turpentine repeated as before. The next day, she ate "stir- 
 about, and got a relapse from cold beer ;" very ill till Monday, 
 when the doctor showed her to Brenan as "a forlorn case." "He 
 showed me the blackness of her hands, which he said was the sure 
 forerunner of death, and that Denman said no woman ever re- 
 covered that had it." Another physician present said she was 
 moribund. Took nothing this day (Monday). She was sitting at 
 the fire vomiting green bile. "I gave her an ounce of the turpen- 
 tine, repeated it in an hour, and applied it to her belly. The next 
 morning I found her asleep." On Tuesday, he gave her castor-oil 
 and tincture of senna, with two drachms of turpentine in the 
 draught, which purged her much. Wednesday, breakfast of stir- 
 about and milk. Thursday, idem. Friday, she sat all day at the 
 fire, and slept at night with the next case. On Saturday, requested 
 to be left in the hospital, but on Sunday walked home to Barrack- 
 street, with the child in her arms. Brenan evidently looked on 
 this case as a great triumph. 
 
 Bridget Cullen was the subject of case sixth. Had twins on 
 Saturday, February 12, with hard labor. On Wednesday she 
 was severely ill, with headache, and " turning of her stomach." 
 Next day she had the turpentine applied to the belly by a flannel 
 " sopped in it, and got a tablespoonful by the mouth." In about 
 two hours began to " roar" with the pain in the abdomen, from 
 the scalding sensations produced by the oil of turpentine, I sup- 
 pose, which had proved a "severe rubefacient." In some hours 
 she was easy, but the pains returning the following day, she got 
 another tablespoonful, which was occasionally given for three or 
 four days. On the 25th she was put in the same bed with Mary 
 Murray, above named, and on the 26th went home well. 
 
 589. The rest of Brenan's pamphlet is filled with accounts of 
 the use of turpentine, in cases foreign to our present subject, and 
 with letters from various persons, among whom should be men- 
 tioned John Burns, of Glasgow, and Dr. John C. Douglass. Both 
 these gentlemen speak of his violence of temper, and Douglass 
 concludes his epistle with, " I have only to add that I would feel 
 
BRENAN. 319 
 
 more pleasure in making this communication if you did not so 
 frequently indalge your pen in personal abuse." 
 
 These letters from Burns and Douglass are answers to Brenan's, 
 which were accompanied with his pamphlet — a publication differ- 
 ent, I presume, from the one now before me, but which I have 
 not been so fortunate as to procure. I believe that the Doctor 
 never fulfilled his promise, "shortly to publish a Systematic Essay 
 on Puerperal Fever and the application of Turpentine in the cure 
 of that dangerous malady," &c. 
 
 590. I have now presented to you a very fair and full abstract 
 of the essential parts of Dr. Brenan's paper, which I am glad to 
 do, since the publication is rare, at least in this country, and be- 
 cause, as everybody talks of Brenan's method, it is fitting that 
 you, my Students, should have a just notion of what it is. 
 
 591. I believe that many of our brethren in this country do 
 still use it in the cases where they cannot see their way clearly, 
 both as an internal dose and as an endermic remedy ; but my im- 
 pression is, that little dependence is placed upon its curative 
 power; certainly no person considers, if even there ever was a 
 person to believe in it, as a revolution in medical practice, effected 
 by the felicitous genius of the quarrelsome Irish physician. 
 
 592. Dr. Gooch, op. cit. 61, gave it to some out-patients, but 
 had no cause to rejoice in its curative powers, and evidently lost 
 confidence in it. It is true, however, that he used smaller doses 
 than those of Brenan. He informs us that having applied it to 
 the abdomen, in a bad case after venesection, " it had been on 
 about twenty minutes, and I was about to leave the hospital, when 
 my attention was arrested by a clamorous voice from the ward in 
 which the patient lay. On going in with the matron, we found 
 her vociferating most furiously that the turpentine had killed 
 her." But it appears not quite intirely, for in a few hours after- 
 ward the deep-seated pain and tenderness had disappeared, and 
 the woman recovered her health. 
 
 593. Dr. Ferguson, op. cit. 224, has no experience of the use of 
 spirits of turpentine ; Davis does not praise it ; Baudelocque, op. 
 cit. 400, remarks concerning Brenan's practice, that of six cases, 
 three died, and two of the others were treated by venesection ; and 
 he regards Dr. Atkinson's results as not at all more conclusive 
 
320 CHILDBED FEVEE. 
 
 than those of the inventor. As to Dr. Kinneir's success with spts. 
 terebinth., which seems to have been remarkable, Baudelocque is 
 inclined to attribute it to the purgative quality of the drug in 
 the cases. Those successes, he states to have been witnessed by 
 too many Edinburgh physicians to leave any doubt as to the facts. 
 Yet after all, he looks upon it as one of the least "rational" of 
 the methods of treatment, and as chiefly applicable, if to any, to 
 those grave epidemic forms that resist other properly selected 
 means of treatment. 
 
 594. That eminent Philadelphia physician, the late Professor 
 Dewees, in his Treatise on the Diseases of Females, p. 453, acknow- 
 leges his little experimental acquaintance with the use of tur- 
 pentine in the cases, and is "sorry to say that so far, in our 
 hands, we have not had sufficient reason to rely solely upon it ; 
 though as an auxiliary in two or three recent instances we 
 thought it highly useful." He gives, in a foot-note, the case of 
 a Mrs. L., whom he visited in consultation, and considered her 
 hopelessly ill. The turpentine was administered ; and he was both 
 surprised and astonished to find, the next day, not only that 
 she was still alive, but much better. The patient recovered. 
 In another case it entirely failed. I called Professor Dewees to 
 assist me with advice in a very bad case, and he proposed the 
 remedy, both internally and externally ; but it was in vain that 
 we made use of it. The lady perished. 
 
 595. I find that Dr. Arneth, in his late published account of his 
 examinations concerning the state of midwifery in Dublin, makes 
 no allusion to the turpentine practice there. Dr. Blundell, Princ. 
 and Pract. of Ohstet. Med., 531, considers that "oil of turpentine 
 does not, in any obvious manner, aggravate the symptoms, and 
 I am not prepared to deny that it may, in some cases, be useful 
 in curing the disease; though it is my decided opinion that, in 
 London, this remedy is by no means so powerful in subduing the 
 fever as the Dublin practitioners have supposed." Dr. Blundell 
 gives four cases, in one only of which was the exhibition of the 
 oil followed by recovery. She had, however, been bled before 
 she took the medicine. 
 
 596. Jacquemier omits it w T holly in his account of the reme- 
 dies. 
 
TUEPENTINE-OIL. 321 
 
 597. You may find yourselves placed in circumstances that 
 shall induce you to resort to Brenan's method. I conceive there 
 will be little objection to your taking such a step, seeing that 
 the inconveniences of the practice are null, and that certain persons 
 do appear to have been rescued, by it, from dangerous extremity. 
 But, as I have taken the pains to open up this whole subject to 
 you, I venture to hope that, whenever you shall please to adopt 
 the turpentine as a remedy, you will do so understandingly, and 
 not, as commonly has happened, from a merely empirical notion, 
 or with a view to the shock. C. D. M. 
 
 21 
 
LET TEE XXV. 
 
 SUDOKIFICS. 
 
 598. I beg you, before you proceed to read this Letter, to turn 
 to sect. 502, and peruse the account you will there find of Mrs. 
 
 , for I wish you to observe that, after I had bled her, I gave 
 
 her a diaphoretic draught that made her "sweat like a squeezed 
 sponge," and which I concluded to have been a fortunate circum- 
 stance, that contributed materially to her happy escape from 
 danger. 
 
 599. Sudorific medicines are among the most reliable of the 
 articles of our materia medica, so that, we might say, we are in 
 possession of numerous specifics as to the sudoriferous glands: 
 many of them, too, are extremely simple and innocuous, which is 
 a thing to invite us to the often employment of them. In the ter- 
 rible constitutional disorders and perversions of function that 
 wait upon the progress of a childbed fever, the skin is not the 
 last of the organs to suffer; nor can man tolerate great departures 
 of it from its normal rate of function without much damage ; for 
 the skin is not only the general investment and shield, behind which 
 the rest of the organs are protected in the conflict with the external 
 world, but it is an important sense-organ, for no part of it is wholly 
 destitute of the sense of touch, which shows how vast as well as 
 how indispensable and delicate are its relations to the whole 
 economy. It is, moreover, an exhalant organ, carrying off a large 
 moiety of the watery elements of the body, and along with it 
 great volumes of carbonic acid and salts. The sebaceous follicles 
 of the skin are also charged with the function of eliminating a 
 quantity of the oily residue of the vital operations. See, then, 
 what must be the inconvenience and the mischiefs arising from 
 those modifications of the cutaneous organ that coincide with 
 violent fevers! The suppression of the aqueous exhalation; of the 
 outgoing of the carbonic acid; of the salts, and of the oil, could 
 
SUDOEIFICS. 323 
 
 not but increase the disorders of any fever, and medicines, there- 
 fore, calculated to maintain all those powers in a healthful state, 
 ought to win our confidence. 
 
 600.- The object usually aimed at in the exhibition of diaphoretic 
 and sudorific medicines is a very simple one — that of procuring or 
 maintaining an abundant discharge of fluid from the pores, and 
 a free evacuation of the materials furnished by the sebaceous 
 glands. Whenever this can be done, the suppleness of the skin 
 is preserved, the heat of the entire body lessened, and a freer 
 course given to the capillary circulation of the surface of the body. 
 It matters little what the agent is, by which these conditions are 
 obtained, except that, as a general rule, the simpler they are, the 
 better they are. Probably, among the diaphoretics, there is none 
 more easily managed, or more sure, than the tartar of antimony 
 and potash, as it is quite tasteless, and may be broken into frac- 
 tional doses in such a way as almost to insure one against any 
 distressing nausea in using it. Some physicians like to use it in 
 very positive doses, as the fourth, the sixth, or the eighth of a 
 grain. I am not of that way of thinking, and rarely exhibit it in 
 stronger than thirtieth of a grain doses. If you should dissolve 
 one grain of emetic tartar in thirty teaspoonfuls of water, and 
 give a teaspoonful once an hour, I am confident you would not 
 notice many such repetitions without hearing complaints of nau- 
 sea, and sometimes even of vomiting. I can scarcely ever meet 
 with a sick person taking such doses, who does not complain after 
 swallowing the third spoonful ; in which case I usually order ten 
 more teaspoonfuls of water to be added, and try it in fortieths, and 
 occasionally afterwards reduce it to fiftieths, or even seventieths 
 of a grain for each dose. 
 
 601. It is, perhaps, desirable, under the usual circumstances of 
 childbed fever, that the woman should be somewhat nauseated, 
 because the state of the nervous system, under nausea, is one to 
 favor a milder or gentler systole of the heart, that seems to me 
 to become, so to speak, always faintish or weak, when the sense of 
 nausea is very positive. This condition not only promotes the 
 diaphoresis, but it lessens the force of the vascular injection, and 
 so, powerfully favors any tendency to resolution of the inflamed 
 areas. Antimonials, then, are among our most precious resources; 
 they are truly deobstruent medicines. 
 
324 CHILDBED FEVER. 
 
 602. The golden sulphur of antimony is also an invaluable 
 medicine for the above-named ends, and this kermes, as it is 
 called, has long played an important part in the treatment. 
 
 603. With regard to kermes mineral, I perceive that Wood 
 and Bache, in the last edition of the Dispensatory, propose the de- 
 nomination of precip. sulph. of antimony, and say the Edinburgh 
 College name it, incorrectly, the golden sulphuret of antimony. 
 They look upon the precip. sulph. of antimony as "an uncertain 
 medicine, as well from the want of uniformity in its composition, 
 as from its liability to vary in its action, with the state of the 
 stomach." Nevertheless, it has been very largely employed in 
 practice, and still enjoys, perhaps, as much of the confidence of 
 the European part of the profession as any other antimonial — I 
 mean in the cure of inflammation. I myself have long habitually 
 relied upon it in pneumonic inflammations, and have many times 
 resorted to it in the treatment of the lying-in diseases. I have 
 not in my library a copy of Dr. Boer's work, Abhandlungen und 
 Versuche. Beobachtungen uber das Kindbettfieber, but I have here an 
 excerpt by Dr. Gooch, taken from Boer, who says : " I once lost, 
 in one day, two lying-in women from puerperal fever ; the one I 
 attended alone ; the other in consultation with the ordinary house 
 physician. At the same time, I had also in the practical school 
 (of Midwifery), two lying-in women ill with the same disease. 
 The next day one of them died, and in the other, death was ap- 
 proaching. It was the seventh or eighth day of her disease ; the 
 belly was very prominent, tense, and so painful that she could 
 hardly bear the bedclothes ; everything passed away from her 
 unconsciously. She had an excessively quick pulse, with start- 
 ing of the tendons, and wandered in her talk; her breathing 
 was difficult and broken, and her countenance fallen ; the milk in 
 the breasts had gradually disappeared, and almost from the be- 
 ginning of the disease no lochia were to be seen. With the death 
 of these three lying-in women, to which I already, in anticipation, 
 added the fourth, I was so depressed in spirits, that, in the even- 
 ing, I sought for consolation in the society of two intimate 
 friends ; but I could not divest myself of the fatality of these dis- 
 eases. Among other thoughts, it occurred to me to try a hitherto 
 unemployed preparation of antimony, which I was assured, in 
 many kinds of fever, had manifested an uncommon efficacy. In 
 
SUDOKIFICS — BOER. 325 
 
 this case, thought I, there is nothing to be lost in the attempt. I 
 went home, provided myself with a dose of it, and reached, about 
 ten o'clock in the evening, the chamber of the dying woman. I 
 found her worse than she was six or seven hours before; but as 
 one of the students and two of the female practitioners were 
 waiting at the bedside, I was obliged to take care not to be seen 
 giving a dying woman a remedy out of my pocket. I gave it, 
 therefore, unseen, to the midwife, who gave it to the patient in- 
 stead of one of the common camphor-powders, mixed with tea. 
 I then wished the poor creature an eternal good night. When I 
 went the next morning, my first question was, 'When did the pa- 
 tient die?' * Die !' answered the midwife. 'Early in the morning 
 she begged half a cup of coffee. She sat up in bed, and could 
 not rest till the nurse combed out her hair: I thought her de- 
 lirious.' When we came to the patient's bed we found her sitting 
 up. She seized me by the hand and thanked me. I knew not, at 
 the moment, whether what I saw was an improvement or only a 
 delusive lighting up from the insensibility of a fatal gangrene ; 
 but it was a real amendment." In short, the relation goes on to 
 show that the disease was " gone by magic." In eight or nine 
 days she left the hospital {vide Grooch, p. 19). Boer speaks of 
 " twelve or fourteen such desperate cases," cured in the same way ; 
 he placed especial confidence in the drug, and " from that time, in 
 our practice, the puerperal fever was never fatal ; it both obviated 
 the disease, and cured it if fully formed." Dr. Boer never told 
 what this divine remedy was, and it is asserted, by Gooch, that 
 he was said to refuse to give it to any medical man, with direc- 
 tions how to use it. Was this kermes, that he employed ? Was 
 it James's fever powder ? No one knows. If it was either the 
 one or the other, no person can believe either of them capable of 
 doing such wonders. If it was something else, which he alone 
 knew, what right had he to refuse to promulgate it, or what 
 reasonable ground to hope for an entrance into the Kingdom of 
 Heaven ? A physician who should die with such an undivulged 
 secret, ought to be burned by the hangman, and his ashes scattered 
 to the four winds, as unworthy to rest in the bosom of the earth. 
 604. Doulcet's method, as you have seen, was to use the kermes 
 after the exhibition of his ipecacuan doses; and I believe the 
 French and German practitioners and continental physicians in 
 
326 CHILDBED FEVER. 
 
 general, are much given to its employment, while in the United 
 States and England it is less used than it should be. If I am to 
 advise you as to this drug, I have to say that, whenever I can 
 feel in the beginning of a case that I have not only done my duty, 
 but satisfied my judgment and wishes as to the plenary operation 
 of my venesection, I shall, for the most part, rest content with 
 the tartar emetic, as above ; but, where I have not succeeded in 
 taking away a quantity of blood, to satisfy me that I have made 
 the requisite impression on the inflammatory power, I shall prefer 
 the kermes mineral, and prepare it in the following manner, viz : — 
 
 R. Kermes mineral, 12 grains. 
 Opium, 2 grains. 
 Nitrate of potash, 30 grains. 
 Camphor, 30 grains. 
 
 Mix, and make a powder to be divided in six doses. One of 
 these powders may be administered every second hour. On many 
 occasions it will be deemed proper to add half a grain or a grain 
 of calomel to each dose. I look upon it as an admirable diapho- 
 retic and resolvent, the sudorific operation of which can scarcely 
 fail, provided the patient should, in the intervals of the dosings, 
 take very liberal draughts, composed of balm, or weak sage, or 
 chamomile tea, or hot lemonade, or orangeade. In case of the 
 supervention of nausea, the doses may be lessened one-half at each 
 taking. Some persons will bear three grains of the kermes in 
 each dose. 
 
 605. In many years past, I have hardly failed to cause profuse 
 sweating whenever I have given to sick people the posset drink 
 I described in my sect. 502, which see. I so confidently expect 
 that effect, that I now advise you, as my Students, to resort to it 
 in case the kermes as above should fail to bring out the perspira- 
 tion. It is a composition not to be despised for its simplicity, as 
 I know full well, after a familiar multiplied experience with it for 
 forty years. 
 
 606. Haply, you may prefer to resort to the admirable Dover's 
 powder as a diaphoretic dose. This I conceive to be best calcu- 
 lated as a night medicine, on account of its combining the dia- 
 phoretic with its soporific power. Ten grains is a full quantity. 
 
SUD0R1FICS. 327 
 
 More than this is like to be rejected by vomiting ; but if the 
 anodyne and soporific force requires to be increased, you might 
 add a grain of powdered opium to the potion. 
 
 607. I invited you, at the beginning of this Letter, to read the 
 case at sect. 502, with a view to show you how I gave a posset- 
 drink, and in what manner it acted in the case ; and I now take 
 occasion to say that the physician is always most in the right 
 when he selects the easiest, cheapest, and most commodious means 
 of attaining his therapeutical objects. Pray, then, in some of your 
 future cases, after you shall have taken away the quantity of blood 
 that may seem to be just and right, invite the woman to swallow a 
 tumbler and a half of the plain posset-drink as warm as she can bear 
 it, and wait for six or ten minutes to see if she is not bathed in 
 floods of sweat. If this should be so, then take care to lighten 
 the bed-coverings, lest by excessive artificial warmth you obviate 
 the cooling and calming tendencies of the perspiration, which 
 should be, from time to time, kept up by abundant draughts of 
 hot lemonade, tea, or balm or sage infusion, or chamomile, or even 
 hot eau sucree, which is extremely convenient on all accounts. 
 
 608. As to demulcent drinks, as they are called, it is probable 
 that some of them may possess a soothing or calming property 
 depending on the mucilage they contain ; yet it is rather to be 
 believed that their supposed demulcent influences are fruits, 
 rather, of the mere dilution; for such liquids, entering speedily 
 into the circulation, must produce a minorative effect through the 
 more aqueous nature of the blood that follows copious imbibition. 
 It has even been proposed and practised to attempt the cure of 
 childbed fevers by enormous imbibition of fluids ; and it is sur- 
 prising to notice what an immense quantity has been drunk daily 
 by sick women. You are reminded by it of Hawthorne's treat- 
 ment of cholera by opium and toast-water. 
 
 609. I should think you would do well, as a general rule, to 
 prevail on the patient to take as large a quantity of liquid as pos- 
 sible ; and this means, as large a quantity as can be swallowed 
 without oppressing the primae vise. In many sick individuals, 
 the power of endosmose seems almost inexhaustible, while in 
 others, it appears to be suspended very early in the sickness. 
 "When the drink seems rapidly to disappear from the primse vise, 
 
328 CHILDBED FEVER. 
 
 leaving no sense of fulness and no gurgling there, the more the 
 patient takes the better ; on the other hand, if the absorptive or 
 endosmose faculty is, in a measure, weakened or lost, caution is 
 required on the subject, for any load or oppression of the epigas- 
 trium serves to promote the expansion of the local limits and 
 obstruct the resolution tendency of the topical inflammation. 
 
 C. D. M. . 
 
LETTER XXVI. 
 
 BLISTERS — SINAPISMS — STUPES— CATAPLASMS — TURPENTINE, USED 
 AS TOPICAL REMEDIES IN CHILDBED FEVERS. 
 
 610. Blisters, sinapisms, and stupes, or cataplasms, are resorted 
 to by many practitioners as among the most hopeful means of 
 counteracting the bad tendencies of a childbed fever, and it is an 
 important question how far you should trust to such means of 
 cure. I believe that, by common consent, the use of blisters in 
 pleurisy is admitted to be both prudent and salutary, and I know 
 not if society in general do not place a chief reliance upon them. 
 It is not, however, certain that blisters act as favorably in the 
 serous inflammations of the belly as they do in those of the chest ; 
 yet the fact that they do much good in the latter, prompts many 
 of our people to equally confide in them as the former. 
 
 611. As you may desire to know what my own opinion on 
 the subject of blisters in our cases is, I must state that I do not 
 think I have ever, of my own motion, used blisters to the abdo- 
 men in childbed fevers; and I will go further, and say that I in- 
 variably regret their application, having seen many of them used, 
 but few women to recover after them. 
 
 612. The object of applying the blister is, I presume, to get at 
 the counter-irritation, on the principle that as pars Mens trahit, 
 whatever of cutaneous inflammation may result from the blister, 
 will be so much subtracted from the internal serous area. But, 
 under all circumstances of this sort, there is certainly no man 
 who can do more than guess, or hope, or rather, wish that the 
 serous may wane as the cutaneous inflammation waxes in intensity. 
 The use of blisters here, is one of the clearest examples of the 
 shock-practice, that is, the making a violent or strong impression 
 somewhere, in order to see whether, haply, some new action, 
 
330 CHILDBED FEVER. 
 
 some new disposition, or tendency, may not follow in the economy 
 It is a sheer tentamen iherapeuticum. 
 
 613. A woman- attacked with a childbed fever, is one already 
 overburdened with an intolerable load of irritation, a load which 
 often serves, in eighteen or twenty-four hours, to crush her to the 
 earth. If, by applying a blistering plaster upon the whole abdo- 
 men, as I have seen it done, you could have any certainty, or even 
 any strong presumption that you would thereby wholly abolish, 
 or take away the internal causes of the constitutional distress and 
 perversion, I grant you that your blistering would prove a most 
 admirable therapia; but, I am quite convinced that, in twenty 
 cases, the blister will be followed by positive alleviation in not 
 more than two or three of them, and that it will not save, nor 
 help to save the life, in more than one. It is cruel to blister the 
 dying, and cruel to add to those pains which, when we can cure 
 them at all, we can much better control by means not painful and 
 disgusting like these. 
 
 614. It has often happened to me to verify, by observation, at 
 the bedside, the truth of Baglivi's assertions as to the mischief 
 from blisters. That elegant Italian scholar, Opera Omnia, p. 421, 
 has three chapters, De usu etAhusu Vesicantium. In Chap. II. p. 423, 
 he says: "Nihil tarn cito, post exhibita supervenit vessicantia, 
 quam sitis cum linguaB ariditate ;" and he assures us that this 
 thirst, notwithstanding continual rinsing of the mouth, continues 
 for at least three days, which I believe to be quite a true account. 
 In Section III. p. 424 : " Post applicationem vessicantium, obser- 
 vavi nonnunquam motus tendinum veluti subsultorios, et con- 
 vulsivos, non nullas sudoris expressiones, et quandoque copio- 
 sas, pulsus veluti obscurantur, &c, et haec tamdiu durant, quam- 
 diu. inherent sanguini acres cantharidum sales, qui bus mox 
 eliminatis, evanescunt," &c. &c. I am confident that few expe- 
 rienced practitioners can have failed to observe the symptoms, so 
 clearly pointed out in the above passages of Baglivi; for my own 
 part, however, I rest convinced that where, in an acute febrile 
 disorder, blisters, being early applied, are seen to be followed by 
 the subsultus, thirst, dry tongue, and copious sweat, instead of 
 finding the symptoms to disappear in about seventy hours, they 
 are far more likely to accompany the case until dissolution alone 
 
BLISTERS. 331 
 
 puts an end to them. De la Roche, that admirable author, con- 
 demns them, and says, p. 208 : " That, so far as he knows, no 
 physician has ever thought fit to apply a blister to the belly of a 
 woman in puerperal fever." I would it were so, in fact, but it is 
 not so, and a German writer, Eichelberg, treated his cases with a 
 blister as large as an octavo page, on the hypogastrium, and if 
 that would not cure the poor victim, another of equal size was 
 laid higher up. How many patients could this man rescue from 
 these horrible inflammations by a practice so very detestable? 
 De la Roche himself, on one occasion applied a blister, and had 
 no reason to be pleased with its effects ; it appears to me only to 
 have added a new burden to an already insupportable load that 
 destroyed the woman's life. (See his ninth case, p. 293.) . He 
 supposes that in cases long drawn out, the use of blisters may, 
 at times, be found useful to oppose certain distant engorgements 
 accidentally arising in the progress of the malady. 
 
 615. According to Baudelocque, they are mischievous and 
 inapplicable remedies : he quotes Manningham, at 389, to show 
 that a blister, applied within the first three days, always brings 
 danger, and ofttimes death ; also Baglivi's case, which that author 
 relates at p. 423 — his third case — in which the blisters did evident 
 mischief, and did not save the woman's life. Jno. Clark is also 
 one of his witnesses to show how they augment the frequency of 
 the pulse. Recamier also is brought up to show that they gene- 
 rally give rise to delirium, with other exasperations. 
 
 616. Baudelocque himself adds: "I participate entirely in the 
 opinion of those who reject the application of blisters to the belly 
 or lower extremities in the early periods of the disorder ;" but, at 
 a more advanced stage, there may be found motives to employ 
 them. It is quite proper, however, that you should be made aware 
 of the sentiments of Dr. Collins, who, op. eit. p. 397, states that 
 "blistering the entire abdomen after leeching had been pushed as 
 far as could be, was found serviceable. In some instances the 
 debility, from the very commencement, was so excessive as to 
 induce us to apply the blister at once, using calomel and stimulants 
 at the same time." 
 
 617. But I need neither to burden you nor oppress my book 
 with quotations from other authors, for all the authors that have 
 
332 CHILDBED FEVEK. 
 
 existed could not make, in this matter, the worse the better reason; 
 and I should think you could desire no stronger argument against 
 the practice than this; that when you have laid on the blister, you 
 have foreclosed and given up or resigned your privilege of making 
 any further diagnostications of the state of parts beneath the 
 blistered area. There is no malady in which it is more essential 
 frequently to diagnosticate the state and progress of the disorder^ 
 and your most precious resource to that end is in the palpation 
 of the regions affected. But, with a belly sore as a blister, what 
 fruit can you pluck from such an inquiry ? Neither you nor the 
 patient can possibly discriminate between the sensibility of the 
 blistered surface, and that connected with the disorders within. 
 Away, then, with every proposal to blister the abdomen in the 
 first days of a childbed fever, which I regard as both a cruel prac- 
 tice and one discreditable to the taste and humanity of the doctor. 
 While I object, then, to the use of blisters, I can lend no credence 
 to the power of the oil of turpentine poured over flannel laid on 
 the sick woman's abdomen, according to the method recommended 
 by Brenan, already detailed in Letter XXIY. 
 
 618. Fomentations, or stupes, as they are called, and cataplasms, 
 which give no pain, may be very advantageously prescribed. 
 Almost invariably the patient acknowledges a certain degree of 
 relief and comfort from them, and willingly suffers them to be 
 from time to time renewed, provided they be not too heavy, and 
 not so cool as to chill the skin. 
 
 619. I should think no better poultice can be made than one of 
 pure warm water imbibed in a large, soft, and well-doubled napkin 
 or square of flannel; to be spread over the sore region, and then 
 covered up with a square of oiled silk; which should be used both 
 to restrain evaporation, and to prevent the moisture from spreading 
 into the dress, or the bed-coverings. Those who, from prejudice or 
 other motives, prefer poultices, employ the light mixture of Indian 
 meal boiled in water to the consistency of mush. A teacupful 
 of hot mush laid betwixt folds of flannel, and spread out thin, may 
 be sprinkled with a tablespoonful of laudanum, and then laid on 
 the part ; or, hops soaked in boiling vinegar and water and laid 
 in a flannel bag might, by some, be preferred. Others will use 
 the powder of lintseed, &c. &c. It matters little what the stupe 
 
POULTICES — STUPES. 333 
 
 or cataplasm be made of, provided, always, it be only moist and 
 warm enough to fulfil the indication, which is to maintain the 
 humidity and suppleness of the parts lying above the diseased 
 areas. I cannot venture to advise you to employ the treatment 
 recommended by Brandis, of Hanover, in 1798, which was to cover 
 the belly with ice. Yet, what more probable topical remedy 
 could you apply than this ? I say, I cannot advise you to adopt 
 it, since, I believe, a single case so treated in this country, and 
 resulting fatally, would suffice to ruin the professional reputation 
 of whosoever might venture to put it in practice. Physicians, 
 unhappily, like other men, are too often compelled to bend to the 
 power of popular opinion, or rather of ignorant prejudice. I 
 regard the universal distrust of cool applications in our cases, as 
 one of the existing remaining influences of the doctrine of milk- 
 metastasis. You should be aware of the excessive cautions, 
 advised by Busch, as to the warmth of the sick chamber, the 
 avoiding of draughts of cool air, &c, for even the wisest physicians 
 are bound by the chains imposed, I verily believe, rather by 
 public sentiment than their own unbiassed feeling and judgment. 
 620. In my next Letter I shall lay before you certain opinions 
 that have been, in different quarters, maintained as to the tonic 
 medicines, and seize the occasion to speak of cases which, though 
 generally ranged under the class of childbed fevers, ought, unless 
 I am in error in such an opinion, to be collocated with other 
 classes of diseased action ; and I rest now, with the greatest re- 
 gard, &c. &c. , C. D. M. 
 
LETTER XXVII. 
 
 621. " The extreme difference of opinion, and the very opposite 
 measures recommended by practitioners, arise chiefly, I am satis- 
 fied, from their treating of every variety of puerperal fever as 
 one and the same disease ; whereas there is not, perhaps, any other 
 which exhibits a greater diversity of character in different situa- 
 tions, and even in the same situations at different periods. In 
 some, the fever is accompanied by symptoms indicative of the 
 most active inflammation, such as to forbid the least delay in the 
 free use of venesection, and the decided employment of antiphlo- 
 gistic medicines. This form of disease, which is by far the most 
 manageable, is generally met with in private practice. Puerperal 
 fever, when epidemic in hospitals, is directly the reverse; at least, 
 in four epidemics which I have witnessed, the symptoms were of 
 the lowest typhoid (typhous?) description, the pulse being so 
 feeble as to make you dread, in many, even the application of 
 leeches; the patients, in several instances of this form of the 
 disease, exhibiting somewhat the appearance of those laboring 
 under cholera." 
 
 622. I have here, my young friends, presented to you an excerpt 
 from Dr. Collins's Midwifery, which you may find at his 390th 
 page, and I now ask you to consider, whether or no these diverse 
 forms of childbed fevers can possibly be one and the same disease, 
 arising from the same causes, and governed by the same principles 
 of nervous impression and reflexion. I ask you to consider 
 whether there is not a probability, so great that it passes in to 
 certainty, that the principles of these diverse maladies must be 
 totally different from each other, and whether Dr. Collins has not 
 described as childbed fever cases, in his hospital, affections having 
 no claim to that title, but rather to those classed with true zymotic 
 typhus. 
 
335 
 
 623. Unless I am a man grossly deceived and misinformed by 
 my studies both of books and circumstances, it will be impossible 
 to make, out of these foudroyant forms noticed by Dr. Collins, as 
 well as by numerous other writers, anything but malignant 
 typhus, with which, as an accident there has come to complicate 
 the zymotic disorder a topical inflammation usually appertaining 
 to the whole group of childbed fever phlegmasias, and which, once 
 established upon this typhous basis, rim only the more rapidly 
 their career of devastation as the effusion, suppuration, or gangrene 
 of childbed fever. 
 
 624. All the writers, I think, insist that these typhous forms are 
 to be met with only in hospital practice, where, as you observe 
 by the excerpt from Dr. Collins, it reigns coincidently as to times 
 or seasons, with the inflammatory forms as they are called ; by 
 which, I conceive, you ought to understand is meant a childbed 
 fever inflammation and not a true typhus fever carrying along 
 with it a putrescentia uteri or a galloping inflammation of the peri- 
 toneum. The instances of this raging typhus complicated ' with 
 lying-in inflammations, are very numerous in our records, and 
 while I should not find it expedient to present here an endless 
 citation of them, yet I shall beg to say, that Dr. John C. Douglas, of 
 Dublin, who spent several years in the lying-in hospital there, and 
 was familiar with its incidents and transactions during many years, 
 gave us his Report on Puerperal Fever, in answer to queries 
 addressed to him. It is in Dublin Hospital Eeports, vol. iii., at 
 page 145 : Query 4. " Have you observed any connection between 
 puerperal and common epidemic fever?" Answer. "Although I 
 am satisfied that puerperal fever, in all its forms, may be generated 
 in a lying-in hospital by local causes, I have no doubt of its being 
 often excited by atmospherical influence, like common epidemic 
 fever ; and I am of opinion that the same exciting influ- 
 ence which would, at another period, produce 
 common fever in an individual, might, at the 
 time of lying-in, produce puerperal fever." This 
 seems to me to be a very clear admission that the zymotic cause 
 or causes of typhus, ought to be regarded as the real cause of 
 those fatal attacks by which lying-in institutions are scourged to 
 that degree that they are rather fitted to be qualified as slaughter- 
 houses for poor lying-in women, than as the beneficent asylums 
 
336 CHILDBED FEVER. 
 
 of the distressed. Should you concede that those mortal forms 
 of the lying-in disorder called hospital childbed fever, are really 
 based upon and governed by the pathological principles of true 
 malignant typhus, then I think you ought to banish them from 
 our category, and class them rather among the zymotic diseases, and 
 that no woman perishing under those forms should be numbered 
 among the victims of childbed fever, but rather cast among the 
 hecatombs of typhus victims. If your patients, lying in during 
 epidemic smallpox and yellow fever, should perish with either of 
 those disorders, but with childbed fever complications, would you 
 not report them as victims of smallpox or yellow fever ? Where- 
 fore, then, during the reign of equally malignant typhus, should 
 you report your cases as childbed fever, and not as cases of epi- 
 demic typhus ? 
 
 625. In the remarks I offered to you in a former Letter, I showed 
 you that women sometimes are observed to hasten through all 
 the phases of our disease with a surprisingly rapid pace, exhibit- 
 ing after death appearances of a complete ramollescence of the 
 womb, or putrescence of that viscus. We may well comprehend 
 that, in certain circumstances of the general health, an inflamma- 
 tion of the more delicate bloodvessels and capillaries of the womb 
 should be capable of suppurating as rapidly as an ordinary gum- 
 boil, and so, of reducing the whole viscus to a state of softening, 
 amounting to disintegration of the entire textures of it. That a 
 woman just delivered, and subjected to such frightfully rapid 
 inflammatory dissolution of the but now vacate^ womb, should 
 succumb, and with symptoms closely resembling those of ma- 
 lignant typhus, ought not to give rise to any wonderment ; and it 
 is perfectly conceivable that she should thus die with a pure and 
 simple phlebitis of the organ, without suspicion of typhus com- 
 plicity. ' 
 
 626. That a death so rapid as that just mentioned, though it 
 might exhibit phenomena precisely similar to those attendant on 
 typhus fevers, with uterine, or peritonitic, or phlebitic accidents, 
 depends upon a wholly different principle in pathology, ought not 
 to be questioned. Typhus fever is not a disease of the gastro- 
 enteric mucous membrane, nor of the liver, or the spleen, or 
 reproductive organs, or kidneys! Typhus is an affection de- 
 
TYPHUS, WITH CHILDBED FEVER. 337 
 
 pendent upon modifications primary in the nervous centres, or in 
 the nervous mass; one in which the powers of the nervous tissue, 
 a form of albumen, are so changed, or reduced so low, that the 
 organs and tissues over which it presides, and whose functions, 
 and indeed very life, are absolutely dependent upon its creating, 
 conserving, and governing forces, fall into a confusion and disorder 
 proportioned to the greater or less abandonment in which they 
 are left when thus bereft of the centro-peripheric force. Typhus 
 rules at the nerve-centres. Inflammations rule at the opposite 
 poles, among the organs and textures, of whatever name. The 
 brain, says Oken, is the sun — the centre of a system ; the organs 
 are planets revolving around this common centre, and drawing 
 thence their life and activity through nerves, that, like illuminant 
 and calorific rays, connect them with the sources of their life and 
 power. 
 
 627. Typhus is centro- peripheral; phlegmasias are periphero- 
 central maladies ; and the difference between them is as great as 
 that betwixt the positive and the negative poles of a galvanic 
 battery. 
 
 628. There are in our obstetric literature many records of epi- 
 demic childbed fevers, so called, in which all the patients perished. 
 I have already shown you that of thirty-two, Dr. Wm. Hunter, a 
 learned, dexterous, and bold practitioner, lost thirty-one women 
 with the disease in his hospital ; and in an epidemic in ^Normandy, 
 in 1767, D. Lepecy is reported by Eisenmann, p. 150, to state that 
 all the subjects perished. This same Dr. Eisenmann, of Munich, 
 has given us a work, Die Kindbettfieber, of the greatest learning 
 and research, one which no man can peruse without admiration 
 of his science, however one may hesitate to admit his therapy. 
 He devotes many pages of his second part, commencing at p. 149, 
 to the discussion of what he denominates Typhus Puerperarum, or 
 Puerpero-typhus. Dr. Eisenmann does not, however, conceive of 
 this puerpero-typhus as original typhus, but looks upon the cere- 
 brospinal symptoms as accidents or secondaries, rather than as 
 chiefs or primaries in the diseased processes. In maintaining this 
 opinion, Dr. Eisenmann must be classed among the believers in 
 childbed fever, a notion against which I have too often protested 
 in these Letters to make it proper for me to repeat any arguments 
 
 22 
 
338 CHILDBED FEVER. 
 
 in this one. The fact that epidemics have existed in which all the 
 patients perished, is a fact to prove that they could not have died 
 with inflammations, pure and simple; for inflammations can never, 
 in any epidemic, prevail with such invariably mortal power. 
 There are too many differences and varieties in human con- 
 stitutions to make such a universality of deaths possible in pure 
 phlegmasias. 
 
 629. On the other hand, I can discover no reason why the 
 epidemic cause of puerperal typhus, or puerpero-typhus, as Eisen- 
 mann hath it, should not cut down both strong and weak alike ; 
 for the causes of typhus, whether they be natural or substantive 
 contagions, are poisons for all manner of persons ; and those poi- 
 sons, when intense, either from condensation or from some natural 
 quality or power they possess, may be conceived of as capable of 
 destroying whatever persons they encounter. But this is surely 
 not possible as to inflammations. 
 
 630. Let me advise you to procure, at the first opportunity, a 
 copy of Schleiden's delicious book, called The Plant; a Biography, 
 printed at London in 1853, and to read in it the eighth Lecture, 
 and in reference to the subject now before us, particularly the 
 206th page relative to the Javanese " Valley of Death." After de- 
 scribing the intricate forests, the frightful steeps and volcanoes, 
 and strange poisonous vegetable productions of the place, he 
 proceeds : " Large tracts are desolated by the action of the great 
 volcanic phenomena. But new life springs up everywhere, side 
 by side with destruction, and once more clothes the naked earth. 
 Only particular regions make exceptions to this rule. Leaving 
 the thickets of the old forest, and climbing a moderate hill, sud- 
 denly, in a narrow flat valley, a horrible wilderness, a true palace 
 of death spreads itself out before the eyes of the shuddering wan- 
 derer. No trace of thriving vegetation screens the sun-scorched 
 earth. Skeletons of all kinds of animals bestrew the ground. 
 There is it often seen how the terrible tiger, in the moment when 
 he has seized his prey, is himself overtaken by destruction ; how 
 the bird of prey, hurrying, to feed upon the fresh carcass, falls 
 into the maw of death. Dead beetles, ants, and other insects, lie 
 in. heaps around, and testify still more, how apt is the name, 
 ' Valley of Death,' or ' Poison Valley,' as these places are called 
 
TYPHUS, WITH CHILDBED FEVEK. 339 
 
 by the natives. The formidable character of these localities arises 
 from the exhalations from the soil, consisting of carbonic acid gas, 
 which, on account of its weight, is a long time diffusing itself in 
 the air; exactly as in the celebrated Grotto del Cane at Naples, 
 or the vapor caves at Pyrmont. This gas causes inevitable death 
 by asphyxia, to all near the surface of the soil. Man alone, to 
 whom Grod has given it to walk erect, traverses usually uninjured 
 these deserted tracts, since the poisonous exhalations do not reach 
 up to his head." Can not you, young gentlemen, conceive of a 
 substantive though impalpable, invisible cause of typhus, spread- 
 ing itself abroad as an exhalation within the wards of a Hospital, 
 and .acting as mortally and undistinguishingly as M. Schleiden's 
 vapors of the Poison Valley ? 
 
 631. I expect here to be met by the question, What difference 
 does it make, whether your childbed-fever inflammation, or j^our 
 puerperal typhus, be the disease that cuts off so many women? 
 Are they not all childbed cases, or lying-in diseases? Such a 
 question, though nothing more nor less than a cavil, should be 
 ans wered according to the imagination or convictions of a man. 
 In an epidemic typhus fever, many lying-in women may perish; 
 and though they give manifest signs of the existence of the phleg- 
 masias I have so much spoken of in these Letters, they have no 
 claim, on that score, to be ranked among the childbed-fever cases. 
 They are only lying-in diseases engrafted upon a horrible basis 
 of typhus fever, which is an affection, primary in the cerebro- 
 spinal axis, or, if one would but speak the whole truth, in the 
 nervous mass, wherever it exists within the boundaries of 
 an animal economy. It would be quite as true to say, that in an 
 epidemy of Syrian plague, all the pregnant and lying-in women 
 dying of the disorder, do perish with childbed fever; and it is 
 probable, indeed, that they do so — but the phlegm asias are the 
 secondaries — the accidence falling out in the course of the plague 
 cases. The same is true of epidemic smallpox, and a multitude 
 of other disorders. But such accidents, such inter currences, are 
 far from nullifying the truth, that those women are victims to 
 smallpox, or plague, &c, and not to childbed fever. 
 
 632. Kiwisch, at p. 564, op. cit., protests against the gathering 
 together into the group of disorders called puerperal fever all the 
 
340 CHILDBED FEVEE. 
 
 febrile affections that may chance to lying-in women, and consi- 
 ders that they who would do so will render no service to the 
 cause of science. 
 
 633. Dr. Schleiden, in this relation of the Poison Yalley, seems 
 to me to foreshadow a future explanation, or rationale of epide 
 mics, which, in all the real, great, wide-spread instances of them 
 appear to me to depend upon exhalations, not merely from the soil 
 but from the far-under depths of the earth, below the lower strata 
 where the boiling, incandescent materials of the globe evolve prin 
 ciples, poisonous as those of the Valley of Death, and destroying 
 us, sometimes, by a force analogous to asphyxiation, and at others 
 by volatilized mineral substances and gases, of whose real nature 
 we have, as yet, no knowledge. A man must be very credulous 
 to believe, because the reagent and the eudiometer can detect no 
 foreign substances in the atmosphere, that none such can exist 
 there, and that chemists have already attained to a final term or 
 limit, in their daily lengthening catalogue of simple elementary 
 substances. 
 
 634. Is typhus a contagious disorder ? To this question I am 
 not prepared with knowledge that should warrant me to assume 
 the privilege of a judge, and to decide either affirmatively or nega- 
 tively. As far as my own private opinion goes, I am free to say 
 that I much doubt of the contagiousness of typhus. But as my 
 opinion is that of only one man out of the thousands of our Class, 
 who have as good a right as I to judge, it is a matter of the 
 greatest indifference what bias I may have taken on the question. 
 If I could know that it is, or is not contagious, it would be an- 
 other thing. I do not know ; I only believe that it is not con- 
 tagious, in the sense of a virus, effluvium, exhalation, or sub- 
 stance, generated within or upon the bodies of the sick, and 
 capable of producing a similar specific disorder in other persons. 
 
 635. As to the contagiousness of childbed fever I have not only 
 expressed my deep inward conviction, but have furnished you 
 with the arguments and facts that have resulted in that conviction 
 as to myself. I shall not, therefore, say anything further on the 
 subject. Can those arguments convince you ? Time alone can 
 show what it is that you shall admit or deny. 
 
 636. But at last, and always, the question must come up con- 
 
TYPHUS, WITH CHILDBED FEVER. 341 
 
 cerniug the treatment to be pursued in these instances of compli- 
 cation — complication of typhus fever with the various forms of 
 inflammation assumed in the group called childbed fevers. 
 
 637. It is melancholy to think that our art has so little power to 
 intervene beneficially in these unhappy instances ; and I am of the 
 same mind with De la Roche, who looks upon the lancet as the chief 
 resource of the physician, and, in a foot-note at p. 159, asks, "Mais 
 si les malades respirent dans une atmosphere souille'e d'exhalaisons 
 putrides, sans qu'a, cet egard on puisse rien changer aleur position, 
 comme cela se voit dans certains hopitaux, il est tres possible que 
 la methode de curation que j'expose ne soit point celle a laquelle 
 on doit alors donner la preference ; et surement il ne convien- 
 droit pas d'employer la saignee aussi hardiment que je le fais. 
 Mais quel est le traitement a, suivre dans de telles circonstances ? 
 Je rien sais Tien." 
 
 638. This answer of De la Roche ought to be in the mouth of 
 every man of us, to whom the question is addressed : Je rien. sais 
 rien. The hospital returns of deaths in lying-in women during the 
 prevalence of epidemic childbed fevers in them, all show that, as to 
 the cure, the answer of every great celebrity in Physic is, "Je 
 rien sais rien? 
 
 639. I have had hospital cases of childbed fever under my care, 
 and I bled them against all protests, and even with fear and trem- 
 bling sometimes; nor did my professional conduct on those occa- 
 sions leave in my mind any sting of remorse. I have had many 
 occasions to treat typhous forms of childbed fever in the city. I 
 bled the patients, and, though I have not cured all, I remain, in 
 a somewhat advanced stage of life and clinical experience, pro- 
 foundly impressed with the thought that it was the best remedy 
 in my power to offer ; and the whole result of my ministry in this 
 way, gives me to-day no heartache when I examine myself to 
 learn what it is I have done. 
 
 640. Will you cure these typhous forms with opium ? You 
 cannot. 
 
 Will they yield to the power of ipecacuanha? No. 
 Will you sustain them with cinchona and wine, meat-broths 
 and jellies ? Try them. 
 
342 CHILDBED FEVEE. 
 
 Will you treat them with camphor, with oil of turpentine, and 
 with blisters? What nonsense ! 
 
 Will you venture to attack the local malady with leeches and 
 cupping-glasses ? But, to do this is only to bleed ! You only 
 will cheat yourself, and, perhaps, do some good to others. 
 
 641. Is it true that all typhus is, invariably, aggravated by 
 venesection ? Why should it be so ! 
 
 What is the result of the treatment of the typhus fever, compli- 
 cated with childbed-fever inflammation, when conducted on the 
 principle of stimulation ? Is it not death ? 
 
 How else will you cure it ? Je rHen sais rien. 
 
 If you will not cure them by the lancet, what will you do? Je 
 n'en sais rien. 
 
 642. Suppose your case of typhus, with childbed fever engrafted 
 on it, breaks out in hospital, or in the country, will the patient 
 die for the abstraction by venesection of one ounce of blood ? 
 ISTo; two ounces? four ounces? six? eight? ten, 
 perhaps? De la Eoche says, p. 163, "In doubtful cases I think 
 one never risks much in drawing away a very small quantity of 
 blood by way of experiment. If, after this evacuation, the pulse 
 seems to be better developed, and the blood shows a degree of 
 siziness, one should not hesitate to take more. If, on the con- 
 trary, the pulsations are enfeebled by it, and grow unequal and 
 irregular, a new bleeding would be, at most, useless; and, do 
 whatsoever we would, it is probable the patient's life could not 
 be saved." De la Eoche was a very sensible, wise man. 
 
 643. I am not one of those to believe, because Moses, the law- 
 giver of ancient Israel, has said that the " blood thereof is the 
 life thereof," we must always do mischief by taking some of it 
 away. It does not make any difference, as to the life, whether a 
 person shall have twenty pounds of blood in the vessels, or only 
 nineteen pounds and a half; and if I can suppose that by taking 
 away half a pound out of the twenty, I shall cause the pulses to 
 beat in a way more favorable to the progress of the disease, and 
 even hopefully as to its cure, I shall certainly venture to abstract 
 it. Therefore, even when I am standing in presence of typhus, 
 complicated with one of those horrible childbed-fever inflam- 
 mations, I shall overlook the typhus, and attack the local disease 
 
DIET. 343 
 
 by the only valid measures that are left to me under such circum- 
 stances. I am not here speaking to you as if I should do this 
 with confident hope or belief in the power of the measure to cure ; 
 but I should do so, only because, as to all other hope, there is 
 not one, except perhaps that sort of chance-medley, wherein 
 people do recover, like Boer's woman, in section 603. 
 
 644. Such patieDts require nourishment. But it is a common 
 error, I believe, in our ministry, to inquire how much of this or 
 that food the patient has taken, and to infer that there is so much 
 nourishment, because so much deglutition. There is a wide 
 difference between swallowing the food and drinks, and profitably 
 employing them afterwards. We should reflect that in these 
 dreadful inflammations, with fever, the blood is rapidly losing its 
 healthy crasis, and that a few days of such fever may suffice 
 wholly to ruin it, for the haematosis is not only a power to deve- 
 lop blood, but to maintain that developed stage of it. In these 
 fevers, the hsematosis is as much deranged as the digestion, the 
 biliary function, the renal, and all the rest. Therefore, let us not 
 count upon the ounces of soup, or the pounds of barley-water 
 swallowed, as so much gained in the case. The very endosmose 
 itself appears to me, in bad cases, to be suspended, which is the 
 reason why we so often see the accumulated ingestions of many 
 hours suddenly discharged from the stomach by vomiting, or else 
 running off in the form of colliquative diarrhoea; whereas, the 
 discharge is, mainly, the unabsorbed portions of aliment or drinks. 
 I am very desirous that my Students should, in feeding very ill 
 people, make such reflections as those above, and not add to the 
 mischief and hopelessness, the still more abominable burdens of 
 beef-tea, wine-wheys, rice and barley-water, &c, that are so wrong- 
 fully forced upon the reluctant and revolting organs of the sick. 
 True it is, the patients do require to be sustained, but they cannot 
 digest beefsteaks, nor Liebig's maceration of beef in cold water. 
 Certainly, if Liebig's broth, or chicken soup, or oyster liquor, and 
 such like things, must be given, they ought to be given in very 
 small quantities indeed, while pure water, or water acidulated 
 with lemons or oranges should be allowed ad libitum, with the 
 sole oft-repeated protest — Don't drink too much, lest you add to 
 the distress and danger. 
 
344 CHILDBED FEVEE. 
 
 645. A woman lying ill with a childbed fever, should be in- 
 structed that it is dangerous to abandon the recumbent position, 
 one in which she should be carefully kept until the disease is abso- 
 lutely judged. A case might be, by one of you, happily conducted 
 to a stage in which resolution should be on the point of taking 
 place ; that is, it might be so situated as to make it almost certain 
 that this fortunate resolution should occur, and yet, all these bene- 
 fits be dashed aside by imprudently rising up or leaving the bed, 
 even for a moment. A very temporary rest in a sitting posture 
 might so change the sanguine determinations within the belly as 
 to insure a subsequent and speedy effusion. I advise you, there- 
 fore, invariably to direct that all the evacuations, whether by 
 stools or urine, should be with the use of the bed-pan. To rise 
 and sit for a few minutes by the bedside would be to expose the 
 surface, and more particularly the extremities to difference of 
 temperature that might have a fatal influence. 
 
 646. Any lying-in woman ought to be protected from shocks 
 and strong emotions of all kinds. The countenance of the phy- 
 sician, and the manners and words of the attendants should be 
 studiously of a kind to inspire confidence and hope; and, in order 
 to that end it is not necessary to be false to the woman, for no 
 one knows at the commencement what shall be the issue of the 
 illness. We may, therefore, feel authorized, however great are 
 our doubts and misgivings as to the success of our ministry, to 
 set in plain array all the motives to hope and even expect a happy 
 recovery. Such conduct may haply give important aid to a gene- 
 ral treatment ; whereas, a gloomy and anxious, timid look on the 
 part of the medical attendant, and his assistants, would but add 
 depressing influences to the exhausting perceptions that are 
 striving to sink her into the grave. 
 
 647. As to the ventilation of the apartment, I should think 
 there can be almost no disease in which a free circulation of air 
 in the sick chamber is more important — seeing that the respira- 
 tion soon becomes greatly troubled and embarrassed by the dis- 
 tending tympanitis; for, as I more fully explained in sect. 275, it 
 must always happen, when the tympanitis is very considerable, 
 that the woman shall either employ a smaller quantity of oxygen 
 than is compatible with a perfect aeration of the blood, or the 
 
HORIZONTAL REST. 345 
 
 breathing organs must exercise their power at a greatly increased 
 rate. Hence, I say an impure confined atmosphere must be to 
 the last degree unfriendly to the woman. It is, surely, a subject 
 quite worthy to engage a share of your attention, that of regu- 
 lating the chamber, as to the position of the sick woman's couch, 
 in such a way as to avoid draughts of air which would be un- 
 friendly in such disorders. C. D. M. 
 
LETTER XXVIII. 
 
 FEBRIS GRAVIDARUM ET PARTURIENTIUM. 
 
 648. Some of our writers have spoken of a febris gravidarum 
 et parturientium as an affection not very unfrequently to be 
 met with in practice ; and my own clinical experience has fur- 
 nished me with various occasions to observe its appearances. 
 
 Inasmuch as women, when recently confined, are extremely 
 liable to be attacked with different forms of the group of disorders 
 called childbed fevers, we might, & priori, suppose that the founda- 
 tions of those affections are, many times, laid before the birth of 
 the child. There is, therefore, a feverish condition which is met 
 with in many pregnant women advanced to near term time, and 
 which, previously to the attack of labor, is mistook for inter- 
 mittent, or interpreted as an hectical irritation dependent upon the 
 pregnancy, yet which, soon after confinement, bursts out fearfully 
 as childbed-fever inflammation, in some one of the forms of that 
 group of phlegmasias. 
 
 649. Dr. Meissner, op. cit. 218, treats of the fever and inflamma- 
 tions that attack pregnant women, and justly remarks upon the 
 complicating power of pregnancy over the rates and tendencies 
 of such affections ; and indeed I consider that the Student should 
 look upon all the maladive conditions of a pregnant woman as 
 cases of complex disorder ; since the presence of the ovum in 
 utero, the instant necessity for continuous acts of uterine evolu- 
 tion, the consumption of material in the uterine and foetal develop- 
 ment, are all circumstances that tend to be interrupted by, or that 
 tend to interrupt, bias, and modify any general feverish state, as 
 well as any topical inflammation. For the pregnant woman, the 
 first necessity is to complete the evolution-acts ; and in order to 
 that end the health ought not to be disturbed in any way, since 
 whatever disturbs the equable operation of the constitutional 
 
FEBRIS GRAVIDARUM. 347 
 
 powers acts directly upon that most delicate of the life-functions, 
 gestation. Either to lessen the progress or to augment the rate of 
 the uterine evolution beyond the normal ratio is, alone, sufficient 
 to endanger, not the process only, but the life of the woman herself. 
 Fevers and inflammations could not but have such a tendency. 
 The observations on these topics, that you may study with greatest 
 profit, are those of Prof. Jorg, in Handbuch der KranJcheiten des 
 Weibes, cap. 25, § 569, u. s. w. 
 
 650. It is clearly asserted that a woman may be seized with 
 putrescentia uteri so as to die within eight hours after the comple- 
 tion of the labor, or the abortion ; for it occurs even in very early 
 stages of pregnancy ; nor have we reason to doubt that, as pu- 
 trescence of the womb is found to affect, in some cases, only small 
 portions of the organ, the existence of the disorder during preg- 
 nancy might lead to a hasty evacuation of the womb ; nor that the 
 unaffected muscular portions should be able to exert so much 
 expulsive power as to complete the delivery, soon to be followed 
 by fatal aggravation of the lesions precedently established. 
 
 651. I consider you would scarcely err, should you assume it 
 to be probable that all those rapid dissolutions that I have men- 
 tioned in these Letters, sections 225, 230, 251, 273, and of which 
 you may find abundant records in the medical library, are really 
 cases in which the inflammation had gone far before the labor 
 began, and that exploded, so to speak, as soon as it was trans- 
 acted, being precipitated and driven to a mortal term by the vio- 
 lence of excitement through which the womb had just passed. 
 
 652. In the course of my own clinical experience, I have 
 observed several examples of slow febrile disorders that had 
 lasted many days before the labor came on, and in which, after 
 the birth of the child, I had to contend against what I regarded as 
 an inflammatory fever. In certain of the cases this inflammatory 
 fever developed itself as fatal childbed-fever inflammation, under 
 the form of uterine phlebitis with peritonitis. The signs, during 
 the progress of the attacks, were not to be misconstrued; since not 
 only was the pain, the ballooning of the belly, &c, to be observed, 
 but the pyaemic intoxication, and the death, at last, with black 
 vomit. I have already, in a former Letter, alluded to the unfor- 
 tunate case of a lady here, who perished, as I believe, from 
 
348 CHILDBED FEVER. 
 
 too rapid an evolution of the womb by dropsy of the ovum, that 
 gave rise to a sort of eruptive or bursting development of the 
 ovum. 
 
 This day, September 18, 1854, visited a young lady who was 
 delivered of her first child at 3 o'clock A. M. of the 17th inst. She 
 was at term. On the 16th, she sent me a message, late in the 
 evening, to say she was in labor and would call me in the night. 
 I was not called, however, until the next morning at about 10 
 o'clock, when I found her affected, every three or four minutes, 
 with the most violent pains and bearing down, as if in advanced 
 labor. She suffered very severely. I observed that the uterine 
 globe did not become very hard during these pains, and, upon 
 touching, discovered that she was not in labor, but affected with 
 rhumatismus uteri, which, it is true, might at length bring on the 
 contractions, ad partum. The pulse was very frequent— at 145. 
 I gave her directions to be bled at the arm, and left her. At 
 about 9 o'clock P. M. I was hastily recalled, being told she was 
 now much worse. I again touched, and found the os and cervix 
 wholly unaffected. Ordering the nurse to give an opiate enema 
 of forty-five drops of laudanum with starch-water, to be repeated 
 in an hour if unrelieved, I again left, and was recalled at 1 j- A.M., 
 when I found the child's head quite out of the circle of the os, and 
 pressing the perineum outwards. It was born at 3 o'clock, and 
 all was well except the pulse, which was 140. She was a good 
 deal fatigued, and, as she had been bled shortly before, I did not 
 open the vessel again. All day yesterday the pulse was flying; 
 the skin not very warm; the intelligence and temper perfectly 
 natural; and she had no hypogastric pain on pressure or move- 
 ment. I gave her a small portion of oil, which procured two 
 dejections, and to-day the pulse is normal, and my patient in every 
 respect as well as I could wish. What was the matter with this 
 young woman? What caused the pulse to fly at the rate of 145 
 beats to the minute ? She was not frightened, but, on the con- 
 trary, courageous. She had rhumatismus uteri, no doubt, before 
 the child was expelled, but not to a degree sufficient to account 
 for so extraordinary a circulation. There was nothing extraordi- 
 nary as to the brain, lungs, or alimentary organs. What was it? 
 I feared at the time it would prove to be febris gravidarum et 
 parturientium, to end, probably, in fatal phlebitis. Was there not 
 
FEBRIS GRAVIDARUM. 349 
 
 in the young lady a state of the membrana vasorum communis, 
 of greatly exalted life, that should account for those strange phe- 
 nomena ? 
 
 653. Afebris gravidarum ought, in my opinion, to be invariably 
 looked on as an endaogial inflammation. It is a real disorder of 
 the bloodvessels, and its seat is chiefly in the sanguiferous vessels 
 of the reproductive system of tissues. It is this that renders it 
 dangerous ; a danger not a little enhanced by the uncertainty and 
 even impossibility of making early diagnoses. The diagnosis is 
 an ex post facto determination in these maladies. As inflamma- 
 tion may attain to, and for a long series of days, maintain any 
 certain stage, it is reasonable to think that, in these vascular 
 phlegmasias, affecting the most delicate vessels, fever should arise 
 and continue with little augmentation for many consecutive days 
 during the last processes of a gestation ; and that the incidents 
 and the consequences of the labor should, in certain instances, 
 allow of their ready and perfect resolution, or in others, hasten 
 them on to a fatal termination. 
 
 654. The example we have in crural phlebitis, vulgarly known 
 as milk leg, is a case in point, to prove to you that a very great 
 and dangerous inflammation of important veins may arise and 
 come to a conclusion during pregnancy, which is not interrupted 
 by it. There are here two ladies, each of whom suffered from a most 
 violent crural phlebitis, that came on in each of them six weeks 
 previous to the accouchement. In both of them, the inflammation 
 was cured and the children afterwards safely born, both the 
 mothers recovering without the least lying-in accident. I saw a 
 lady here with a saphenitis, that came on a few days before the 
 birth of her child. I regarded her position as most perilous when 
 I first inspected the limb — for unhappily, the malady had already 
 reached the pyasmic stage when I took charge of the case. She 
 died a few days after delivery, with all the usual accompaniments 
 of purulent infection of the blood. This was the second fatal case 
 of phlebitis of the saphena system that I have met with. In the 
 first, the pysemic intoxication sometimes amounted to mania of 
 the greatest violence. 
 
 655. In treating the febrile diseases of the closing clays of 
 pregnancy, I have, then, to advise you to keep your eyes open to 
 
350 CHILDBED FEVER. 
 
 the signs that indicate phlebitic disturbance ; and I cannot give 
 you any more friendly counsel than this, viz : to ask you to reflect 
 upon my propositions as to the possibility and the existence of 
 that state which I have so repeatedly pointed out under the de- 
 nomination of endangitis, or inflammatory excitement of the true 
 bloodvessel ; i. e. the inner bloodvessel — the membrane commune 
 of Bichat — membrana vasorum communis of the authors. 
 
 656. Keep this thought before you in diagnosticating the late 
 fevers of pregnant women ; and instead Of drugging your sick 
 ladies with calomel, you will command them to lie in bed, to bathe 
 in warm water, to diet rigorously, to use camphor and kermes, 
 and nitrate of potash, or tartar emetic solution, or opium in some 
 of its numerous formulas ; and more than all that, you will attack 
 the enemy in his castle, and expel him at the point of the lancet. 
 Never be so foolish a doctor as to be afraid to bleed your patient, 
 when you think it safe and convenient and in her interest, to do 
 so, because you may be surrounded by chattering women or doc- 
 tors who are already half ruined by •Homoeopathic propensities. 
 Keep the bowels in a soluble state ; visit the patient often ; enjoin 
 strict, protracted recumbency, and bleed her so that she cannot 
 inflame. Such is the method I have to commend to your consid- 
 eration ; such is that I should pursue this hour if the case were 
 now under my care. 
 
 C. D. M. 
 
LETTEE XXIX. 
 
 CRURAL PHLEBITIS, COMMONLY CALLED MILK-LEG. 
 
 657. There is a disease for the full comprehension of which 
 we are indebted to that admirable gentleman, Dr. Eobert Lee, of 
 London, who has done so much to promote medical progress in 
 obstetricy for these many years past ; a man always on the side 
 of reason, truth, and moderation. You should all possess you of 
 his Lectures and his Treatise of the Diseases of Women, and his 
 little excellent duodecimo of Clinical Midwifery, &c. &c, books 
 that are replete with useful clinical instruction. In those works you 
 will find an excellent literary,- and critical, and clinical, and thera- 
 peutical history of the disorder called milk-leg, but which, thanks 
 to his worthy industry, is now clearly known by the title of crural 
 phlebitis ; for he it was who showed to the present age what physi- 
 cians never learned before, that phlegmasia alba, or phlegmasia alba 
 dolens puerperarum, or milk-leg, is not a disease of the areolar tis- 
 sue, or of the lymphatics of the leg, but a cruel and very dangerous 
 inflammation of the veins, sometimes the great crural, sometimes 
 the superficial or saphena system, and, in certain cases, of both 
 together, extending high upwards in the iliacs and cava. I should 
 not undertake to speak of it here, were it not that I cannot but 
 regard crural phlebitis as one of the forms of the puerperal phleg- 
 masia that constitute the burthen of these Letters. It is true that 
 a woman may suffer from crural phlebitis without hazarding the 
 integrity of the uterine veins; yet it not rarely happens that 
 whether the original areas of the phlogosis are laid in the mem- 
 bran a vasorum below Poupart's ligament, or even in the saphena, 
 or whether they commence in the external iliac or even the 
 vena cava, the phlegmasia spreads creepingly into the vessels of 
 the new-delivered womb itself, whereupon we soon detect the 
 existence of a metro-phlebitis. 
 
352 CHILDBED FEVER. 
 
 658. My own clinical observation of crural phlebitis induces 
 me to rely confidently on the curative power of proper treatment 
 early begun ; but that cannot be, except for a medical attendant 
 who is as vigilant and inquiring as he ought to be. 
 
 659. When a crural vein, or an external, an internal or pri- 
 mitive iliac, or a saphena, begins to inflame, no pain is felt, nor is 
 there any rigor or any speedy reaction of fever observed. I 
 say, when the endangium begins to inflame. Not so, however, 
 when the inflammation has begun to affect the basement tissue 
 which sustains the true vessel. Here, there is tension, pain, ob- 
 struction of the efferent function of the vessel, swelling, heat, and 
 rigors, with fever. 
 
 660. This I conceive to be a correct statement of the case, and 
 this it is that, seeing the early diagnosis is difficult if not impossi- 
 ble, leads to so many painful results; for it is to be believed that 
 an educated physician, could he know of the founding of the in- 
 cipient areas of inflammation, could and would cure them at a 
 blow. 
 
 661. Let me here repeat that vascular phlegmasias are the bane 
 of pregnant women, and that they constitute a large percentum of 
 the serious maladies to which they are subject. Hence, it seems 
 to follow that whenever you find a pregnant woman complaining 
 of febrile symptoms, pains, and inabilities, which you cannot 
 at once diagnosticate, and so, locate, if I may use the phraseology, 
 I think you ought to suspect some phlebitic malady, and on that 
 hint direct your investigations. 
 
 662. In my own case, whenever I am in this way embarrassed, 
 I can in general readily resolve all my doubts by pressing the 
 soleus and gastrocnemius muscles suddenly and strongly against 
 the bones of the leg. If the crural vein, either below Poupart's 
 ligament, or the external iliac above it, are in a somewhat advanced 
 stage of phlebitis, the pressure of the calf of the leg, as above ex- 
 plained, invariably draws forth a sudden cry or complaint, though 
 the woman never before suspected any ailment of the limb. This 
 is the first step in such a diagnosis. The next is to ask permis- 
 sion to explore the state of the crural vein, in doing which, the 
 woman should lie on the back, so as to enable you to trace the 
 course of the fasciculus of vessels coming out from the belly. In a 
 
CRURAL PHLEBITIS. 353 
 
 somewhat advanced stage, this tract is found to be sensitive and 
 somewhat enlarged, as if a cord were running in a spiral direction 
 from the semicircular edge of the fascia lata, inwards and down- 
 wards, along the thigh. The detection of such a swelling, coin- 
 ciding with tenderness of the calf of the leg, settles the ques- 
 tion ; it is a crural phlebitis ; and if you allow it to proceed to the 
 extent of what is called pyogenic inflammation, the woman, in 
 all human probability, will die with the disease. 
 
 663. Sometimes the phlebitis has not descended yet to the thigh. 
 You can detect the swollen and painful cord, where it runs along 
 the margin of the pelvis, by pressing the iliac region with the 
 hand, after directing the thigh to be somewhat flexed. 
 
 664. In my opinion, these cases will be detected at a period 
 when it is too late to bleed as a method of cure ; nevertheless, 
 provided you should judge it not already too late, and the state 
 of the constitution should warrant the act, I hope you will freely 
 bleed every and any such patient that may come into your hands. 
 But where you cannot resolve to do so, you ought to apply a row 
 of leeches along the course of the swollen vessel, not in the vain 
 hope by this alone, to cure the phlebitis, but as a means of moder- 
 ating the heat, pain, and tension of the areolar sheath, in which . 
 the inflamed vein runs. 
 
 665. As soon as the leech-bites have become dry, a narrow strip 
 of blistering plaster, say an inch and a half wide, by three and a 
 half to five and a half inches long, should be laid over the track 
 of the vein, and maintained by an adhesive strap until the blister 
 rises ; to be dressed with basilicon, kept in sitti by an adhesive 
 strip. 
 
 6Q6. The woman should be commanded not to quit the hori- 
 zontal posture until the disease is fully judged, nor, indeed, until 
 the resolution of the inflammation is completed. 
 
 667. The leg should be laid upon a long pillow or bolster, so 
 adjusted as to give the limb an inclination upwards of some 8°, 
 or at most 10°, and it should be kept so day and night. 
 
 668. An old petticoat of flannel should have its hem cut off, and 
 the gathers also, in order to make a stupe-cloth. This old flannel 
 being wrung as hard as possible out of a hot mixture of vinegar 
 and water, equal parts, should envelop the limb from the toes to a 
 
 23 
 
354 CHILDBED FEVEK. 
 
 point above the knee, and being next covered with a dry flannel, 
 should be kept in situ for six consecutive hours, after which it 
 ought to be removed. Next, let the whole leg and thigh be gently 
 rubbed with a hand dipped in a warm mixture of olive oil and 
 laudanum, for many minutes ; using, all the while, a gentle force of 
 pressure in the bathing, which being completed, every particle of 
 the oil should be carefully wiped away with a soft napkin, and the 
 limb allowed to rest, after being wrapped up in fine warm flannel 
 for the next four hours. These four hours being elapsed, the acid 
 fomentation is repeated for another six hours, to be followed by 
 the opiated-oil frictions ; and so on, alternating the treatment. 
 
 669. There are very few examples of milk-leg that remain unre- 
 solved for more than forty-eight hours, when treated as I have 
 above advised. I have pursued the plan for many years, and I 
 believe I am indebted for it to consultation I had with the late 
 Professor Dewees, many years ago. 
 
 670. I must now bring to a conclusion this work which I so 
 long ago undertook to produce, in conformity with an engagement 
 entered into while bidding you all farewell in our Class-room. I 
 know full well that you have been disappointed at the delay in 
 thus filling up a void in my course of winter Lectures, but I have 
 to hope that you will accept my excuses for it, seeing what very 
 constant and fatiguing professional avocations perpetually inter- 
 vened ; so that, after vainly waiting for and expecting some interval 
 of leisure that I might properly devote to my task, I was com- 
 pelled to commence and finish these Letters just as I send them 
 to you now. From what I have written in them, it is easy to per- 
 ceive how impossible a thing it must be for a Professor, in an 
 American College of Medicine, to enter into a full discussion of 
 childbed fever; and that whosoever he may be that gives a course 
 of lectures here, he must be content merely to skim the surface of 
 this important subject, and present, at most, only very general 
 views of it. An American Professor of Obstetrics has too many 
 other things to do, to rest long enough among these great con- 
 siderations. Indispensable details in regard to the special anato- 
 my and physiology of the woman; her diseases and accidents, 
 whether as single or married; the informations required on the 
 subject of embryogeny ; labors ; the lying-in state, and the cares 
 
CONCLUSION. 355 
 
 due to the new-born child, fill np to overflowing all the hours of 
 a winter curriculum. You will please to remember that I spoke 
 to you only two days on the subject with which I have here occu- 
 pied 356 pages. 
 
 Look at my section 481, to see what Br. Hulme says concerning 
 his own feelings whenever he suspected patients of his to be even 
 remotely threatened with an attack of childbed fever ; or, if haply, 
 since our last parting, you have yourselves been compelled to 
 strive with this deadly enemy of women, remember the keen and 
 searching anxiety with which your whole ministry in the cases 
 was fulfilled ; and I believe you will be ready to say that we all 
 want more information on the subject than we have as yet obtained. 
 I confess that, for myself, I should greatly rejoice could my own 
 knowledge of it become far more copious and precise than this 
 book shows it to be. 
 
 671. It is not for me, therefore, to judge whether, in fulfilling 
 my promise to the Class, I have executed the task in such a man- 
 ner as to meet and satisfy your reasonable expectations. Yet, 
 while I freely leave you to judge in this matter, I beg to claim 
 at your hands some kind consideration of the pains I have taken 
 to render these Letters as explanatory and instructive as I could. 
 To do this in a right way, an author ought to enjoy some" leisure, 
 and be, at least, free from the constant interruptions and fatigues, 
 and carking cares of a practitioner's life. There should be time 
 allowed him to collect and collate the numerous authorities that 
 he might desire to cite in the course of his expositions or argu- 
 ments. When such leisure is not attainable, one must either 
 consent to hold his peace, or to write hurriedly. In the present 
 case, I fear you may find reasons to suppose that I have had 
 many professional duties to perform, that have conflicted with 
 my wishes to make these Letters more worthy to be presented to 
 you than they are. 
 
 672. You, my dear young gentlemen, have been so uniformly 
 indulgent to my many faults as your teacher, that I cannot but 
 look, with a feeling of confidence, for a continuation of that 
 kindness, in at least, a friendly reception of these Letters of 
 mine. I hope you may find in them some good and useful hints 
 as to practice, if not also take out of them some fruitful sugges- 
 tions, that may lead to thoughts beneficial on collateral subjects. 
 
356 CHILDBED FEVEK. 
 
 673. Let me earnestly beseech you to consider your ways, in 
 the Medical life, and to take daily, higher and still higher views 
 of that mission in society with which you are invested. I would 
 it might please the Divine Author of the Universe to fill your 
 minds with wisdom, and your hearts with philanthropy, and so, 
 make you become worthy members of the great class of the phy- 
 sicians of America. May you never forget that you have a 
 country to which you owe allegiance, not as its defender and tax- 
 payer only, but as one of its Scholars, called on to contribute to 
 its glory and honor, by helping your whole class to become more 
 learned, more pure, more useful. The glory and renown of our 
 native land will hinge not so much upon her numerous and grow- 
 ing population, her wealth, and her power on land and at sea, as in 
 her educational pre-eminence, with the advances of which she con- 
 tinually rises in the estimation of mankind, and which alone can 
 cause her to live in future story. Never then, for a moment, 
 forget that your country expects from the hands of her Scholar- 
 classes all that they can do to assist in elevating the standard of 
 learning among our people, and that much is to be looked for 
 from American physicians. Whose is the name, among all of 
 you — that shall hereafter be pronounced by distant ages, along 
 with the names of Hippocrates, or Sydenham, or Schwann? 
 There is not a man of you incapable of either helping or hinder- 
 ing the great work of progress for our common calling, and so, 
 in augmenting the boundaries of science and the arts that wait 
 upon it, in all the various departments of knowledge. Be not 
 then hinderers, but, what is far better, be ye true helpers in this 
 great thing. 
 
 From your grateful friend and servant, 
 
 CHAELES D. MEIGS, 
 
 324 Walnut St., October, 1854. 
 
 To the Students of my Class of 1850-51. 
 
INDEX. 
 
 Abdominal relaxation causes the attack, 
 184 
 
 Absorbents, a sort of uteri, 72 
 
 Absorption through diaphragms, 74 
 
 Abulpharajius cited, 47 
 
 Accidental childbed fever, in G. S. B., 133 
 
 or unavoidable, 
 
 114 
 
 iEginetta, Paul of, 45 
 
 Aeration of the blood lessened by tym- 
 panitis, 154 
 
 Aetius, 44 
 
 After-pains, diagnosis of, 218 
 
 Alex. Trallianus, 45 
 
 Analogy of erysipelas with peritonitis, 209 
 
 Angulation of the bowel, 158 
 
 Antonius Guaynerius, 47 
 
 Ancients, views on childbed fever, 39 
 
 Areas of phlogosis, where laid, 123 
 
 rapid expansion of, 
 
 152 
 
 Aretaeus, 44 
 
 Armstrong on contagion, 107 
 
 Atmospheric causes of epidemics, 194 
 
 Author's apology, 37, 238 
 
 Avicenna's canons, 46 
 
 Avenzoar, 47 
 
 Averrhoes, 47 
 
 B 
 
 Baudelocque's book, 154 
 Baudelocque on contagion, 94 
 
 leeching, 278 
 
 Bichet, 58 
 
 his case of a saddler's wife, 69 
 
 Black vomit of puerperal fever, 158, 215 
 Bladder, as diagnostic, 223 
 Bleeding to prepare for labor, 228 
 
 and leeching compared, 276 
 
 Blood, depends on endangium, 76 
 quantity moved per minute, 248 
 
 Blood, in embryo, 73 
 
 membrane, 77 
 
 early affected in phlebitis, 170 
 
 Bloodvessel, what it truly is, 75 
 Bloodletting, a chief remedy, Letter on, 
 237 
 
 Deleurye commends, 245 
 
 disapproved by Walsh, 258 
 
 doubted by White, 258 
 
 Hulme's fears of, 259 
 
 to be carried to 24 ounces, 
 
 260 
 
 how to be performed, 261 
 
 subject to fashion, 234 
 
 in the typhous cases, 342 
 
 Bloody sheep-skin, anecdote of, 50 
 Blut-dissolution und cholaemie, 176 
 Boivin and Duges on putrescentia uteri, 
 
 165 
 Book-makers, Fichte's advice to, 36 
 Bowels inflamed in peritonitis, 146 
 
 of pregnant women, torpor of, 
 
 185,228 
 Bourgeois Louise, 57 
 Brain, heart, and lungs, 153 
 Breasts, power of the, Willis on, 55 
 state of the, 220 
 
 Burdach, passage from, 76 
 
 Busch, von, purifies his hospital by heat, 
 
 96 
 Byrthe of Mankinde, Raynalde's work, 49 
 
 Campbell's cases of contagion, 101 
 Canons of Avicenna, 46 
 Catheterism, to be remembered, 229 
 Case by Armstrong, 135, 242 
 
 by Author, 133, 137, 155, 162, 171, 
 
 186, 203, 213, 225, 229, 244, 
 264, 265, 266, 267, 268, 269, 
 272 
 
 by Baudelocque, 270 
 
 by Bichet, 69 
 
 23^ 
 
358 
 
 INDEX, 
 
 Case by Chevillard, 220 
 
 of childbed fever described at 
 
 length, 212 
 
 of cholera in labor, 203 
 
 by Dance, 126-130 
 
 of Dromeades's wife, 41 
 
 of febris gravidarum, 348 
 
 by Gordon, Elspet Robertson, 244 
 
 -- Mrs. Forbes, 262 
 
 by Kiwisch, of Blut-dissolution, 
 
 177-180 
 
 by Legouais, Augustine Lef — , 243 
 
 of mammary abscess, fatal, 203 
 
 of Pantimedes's servant, 42 
 
 of pyaemia by the Author, 225 
 
 by Dr. Rutter, 105 
 
 of typhus with childbed fever, 202 
 
 Celsus cited, 44 
 
 Cerise, Dr., on neurosity, 198 
 Cervix uteri, injuries of, a cause of child- 
 bed fever, 183 
 Childbed fever commences as topical in- 
 flammation, 87 
 
 complicates typhus, &c, 
 
 204 
 
 Dance on, 126 
 
 De la Roche on, 120 
 
 emetics, how used in, by 
 
 Doulcet, 282 
 emetics, how used in, by 
 
 De la Roche, 287 
 emetics, how used in, by 
 
 Ferguson, 285 
 emetics, how used in, by 
 
 Tonnelle, 285 
 emetics, how used in, by 
 
 Ch. White, 285 
 
 and erysipelas, 206 
 
 a group of various inflam- 
 mations, 1 22 i 
 
 is it a fever? 121 
 
 not contagious, 94, 97, 
 
 100-102 
 
 or milk fever, 222 
 
 sketch of a whole case, 
 
 149 
 Chevillard's case, 220 
 Chill of childbed fever, 219 
 Cholsemia and blood-dissolution, 176 
 Clarke on the fatal tendency, 257 
 
 emetics, 284 
 
 Climate, Humboldt on, 190 
 Cleanliness after confinement, 229 
 Collins, Dr., purifies his hospital, 99 
 
 advises leeching more than 
 
 bleeding, 279 
 a case by him, 202 
 
 Colles, Dr., cases of phlebitis from 
 
 wounds, 107 
 Concluding remarks, 354 
 Constipation from angulated bowel, 155 
 Constitutions of the air, 193 
 Contagion, Armstrong on, 107 
 
 Baudelocque on, 94 
 
 Busch's hospital, 91 
 
 Campbell's cases, 101 
 
 Churchill's remarks on, 111 
 
 conditions of the problem of, 
 
 91 
 
 definitions of, 86, 91, 191 
 
 Douglass on, 106 
 
 Dubois on, 97 
 
 Holmes on, 93 
 
 Jacquemier on, 94 
 
 Jorg on, 107 
 
 Kiwisch on, 94 
 
 Lee on, 93 
 
 Meigs's experience in, 102 
 
 Scanzoni on, 100 
 
 TonneUS on, 94 
 
 no respecter of persons, 85 
 
 specific and incubative nature 
 
 of, 88 
 Contusions in labor, a cause, 183 
 Courage, resolution, Venture — Gordon's 
 
 words, 250 
 Crural phlebitis, 351 
 
 how detected early, 164 
 
 Cure of childbed fever, general measures 
 
 in the, 231 
 Cyanosis of childbed fever explained, 153 
 
 Dance, M., his papers in Archiv. Gen., 126 
 -30 
 opinion on use of leeches, 279 
 
 on the use of leeches, 279 
 
 midwifery referred to, 201 
 
 on typhus with childbed 
 
 fever, 202 
 
 De la Roche on emetics in childbed fever, 
 287 
 
 Depots laiteux, letter on, 52 
 
 Diagnosis, difficult in early stage, 217 
 
 of phlebitis and metritis and 
 
 peritonitis, 171 
 
 Differential diagnosis, phlebitis, and peri- 
 tonitis, 171 
 
 Dionis, an anecdote from, 50 
 
 Dissection wounds may give phlebitis; 
 Colles, 101 
 
 Distension of the bladder, dangers of, 229 
 
 Dogma of milk -metastasis, 52 
 
 Doublet, Dr., 63 
 
 - on emetics in the disease, 284 
 
 Doulcet' s specific method, report on, 282 
 Douglass, 80 
 
 on contagion, 106 
 
 Dromeades's wife, case of, 40 
 
 Drugs, a list of, used in treatment, 232 
 
INDEX. 
 
 359 
 
 Drugs, futility of, -when unaided by vene- 
 section, 199 
 Dunglisou's definition of miasm, 191 
 
 E 
 
 Early diagnosis, difficulty of, 217 
 
 Eisenmann's work, 337 
 
 Effusion, suppuration, gangrene, the end 
 
 of the case, 172 
 Elspet Robertson's case, 244 
 Embryonal blood, how formed, 73 • 
 Embryotomy, fatal case, 272 
 Emetics in childbed fever, Doulcet's spe- 
 cific, 282 
 
 Doublet on, 
 
 284 
 
 Clarke on, 284 
 
 De la Roche 
 
 on, 287 
 
 Ferguson on, 
 
 285 
 
 Tonnelle on, 
 
 285 
 
 White on, 288 
 
 Endangitis or febris gravidarum, 349 
 Endangium, seat of haematosis, 75 
 Endosmose of corpuscles impossible, 74 
 Epidemics, table of, 116 
 
 Busch destroys one, 96 
 
 — Collins suppresses, 99 
 
 Roberton's account of Man- 
 chester, 108 
 — Rutter's experience in, 104 
 
 causes below the strata, 193 
 
 act on the nervous mass 
 
 first, 105 
 
 caused by filth ? 194 
 
 constitution of the air, influ- 
 ence of in bloodletting, 234 
 Errements de lait, letter on, 52 
 Erysipelas a membranous affection, 209 
 Eructations and vomitings, fatal import 
 
 of, 215 
 Erysipelas and childbed fever, 206 
 Excluding diagnosis, 178 
 Experiments cited by Ferguson, 175 
 
 Fainting upon venesection not always a 
 
 reason to stop, 260 
 Fallopian tube diseased, G. S. B., 133 
 F. A. J., case of, 162 
 Fashion, influence of as to venesection, 
 
 234 
 Febris gravidarum, 180 
 
 or endangitis, 346 
 
 Fermentation of the blood, Willis on, 53 
 
 Ferguson on vitiated blood, 81, 124, 175 
 
 —on emetics in childbed fever, 
 
 285 
 Fernelius, 92 
 
 Fevers from undischarged placental lo- 
 bules, 182 
 contusion in labor, 183 
 
 idea excited by the word, 121 
 
 zymotic, 198 
 
 from inflammation, 337 
 
 Fichte's advice, 36 
 
 Filth as cause of epidemics, 194 
 
 Foetal haematosis, 78 
 
 Foetus oxygenated by means of placenta, 
 
 74 
 Forbes, Mrs., case of, 262 
 Foreign entities in the blood, 83 
 Fothergill, Dr., on emetics in England,284 
 
 G 
 
 Galen's remarks on a case, 43 
 Gasc on the disease, 143 
 Gastric symptoms in childbed fever, 158 
 peritonitis, 146 
 
 Globules of blood, young and old, 73 
 
 Gooch on contagion, 106 
 
 various forms of childbed fever, 
 
 142 
 Goubelly, 65 
 
 Greek writers on childbed fevers, 39 
 Group of disorders, childbed fever in, 
 
 122, 147 
 Gordon, Alexander, his rule as to time for 
 venesection, 252 
 pupils, McRea and 
 
 Gordon, 262 
 Guillemeau, his epoch, 56 
 
 H 
 
 Haematosis of foetus, 75 
 
 Hemorrhage in women, little inconve- 
 nience from, 233 
 
 Haines, Dr., case of putrescentia uteri. 
 145 
 
 Halle and Vicq D'Azyr's report, 220 
 
 Halo of contagion, 86 
 
 Haze or nebula of contagion,' Willis on, 
 86 
 
 Harmony, want of, in medical theories, 33 
 
 Heart, brain, lungs, their united power, 
 153 
 
 Heat, a disinfecting agent, 96 
 
 Hey on contagion, 107 
 
 High stand-point to observe from, 253 
 
 Hippocrates, quotation from, 40 
 
 Hoffman, 60 
 
 Holmes, O. W., on contagion, 93 
 
360 
 
 INDEX. 
 
 Houdart's book mentioned, 40 
 Hotel Dieu, Tenon's account, 195 
 Humboldt on climate, 190 
 Hulme, Dr., fears of venesection, 259 
 
 , on the dangerous nature of 
 
 childbed fever, 253 
 Hunter loses many cases, 337 
 Hyperinosis and hydraemia contrasted, 77 
 Hypogastric pain at commencement, 217 
 Hysteroid signs of pyaemia, 169, 224 
 
 I 
 
 Idea, divine, of the world, 94 
 
 of the childbed fever, 38 
 
 Identity of childbed fever, as inflamma- 
 tion, 118 
 , with erysipe- 
 las, 206 
 Incubation of the contagion, 89 
 blood in its formation, 
 
 72 
 Infection, purulent, of the blood, 225 
 Inflammation negative, typhus positive, 
 
 337 
 Insidious attacks of phlebitis, 164 
 Intoxication from pyaemia, 170 
 Involution of the womb, 180, 188 
 Ipecacuanha, or Doulcet's specific, 282 
 Is contagion a truth? our duty then, 
 
 112 
 
 Jacquemier on contagion, 94 
 J org on putrescentia, 165 
 
 contagion, 107 
 
 Jugulare febrim, 256 i 
 
 Je rten sais rien, De la Roche's words, 341 
 
 E 
 
 Kiwisch, a notice of, 95 
 
 ■ on blood-dissolution, 177 
 
 febris gravidarum, 180 j 
 
 contagion, 95 
 
 Krauss defines contagion, 86 
 
 Labor, preparation for necessary, 227 
 La, Roche, Dr. R., quotation from his 
 
 work on pneumonia, 192 
 Lamotte, 54 
 
 Leclerc's History of Medicine, 40 
 Lee on contagion, 93 
 Lee's table of 160 cases, 247 
 
 Lee on crural phlebitis, 166 
 Leeching as chief remedy, 276-280 
 Legouais's work quoted, 257 
 
 on leeching, 280 
 
 Lepecy on peritonitis, 337 
 Liebaut on female complaints, 56 
 Lochia, milky nature of, Willis, 55 
 Lobules of placenta dangerous if left, 182 
 Louis de Mercado, 40 
 Louise Bourgeois, 57 
 Lungs, brain, and heart, their powers, 
 153 
 
 M 
 
 Manchester epidemic, Roberton on the, 
 108 
 
 Mary Anne Alii 's case, 244 
 
 Materies morbi, an idea of ontology, 209 
 Mauriceau on milk-leg, 59 
 Medical men, disagreements of, on child- 
 bed fever, 33 
 sciences, slow growth of the, 
 
 Medicines for childbed fevers, list of, 232 
 Meissner on febris gravidarum, 346 
 Membrana vasorum communis, a true 
 
 bloodvessel, 75 
 Mercatus Lusitanus, 48 
 Mercury, letter on, 289 
 , cases treated without it, 248 
 
 Messue, 46 
 
 Metastasis of milk, letter on, 52 
 Meteorism or tympanitis, 150 
 Metro-phlebitis, letter on, 159 
 
 less painful than perito- 
 
 nitis, 223 
 Miasm defined, 191 
 may issue far below the strata, 
 
 340 
 and contagion, specific nature of 
 
 them, 198 
 Milk-leg, Mauriceau on, 59 
 
 , Bichet's case, 69 
 
 , Puzos on, 60 
 
 , Lee on, 166 
 
 Milk, particles in the blood, 54 
 
 school account of the, 63 
 
 Milky tongue in childbed fever, 151 
 Mind, state of the, in peritonitis, 223 
 , metro-phlebitis, 
 
 224 
 
 M'Clintock and Hardy on contagion, 112 
 Morton defines species, 70 
 Motion and sensation depend on states of 
 
 the blood, 240 
 
 Nacquart defines contagion, 87 
 Name of the disease ? 120 
 
INDEX. 
 
 361 
 
 Nausea dangerous at close, 157 
 Nikeil, Elizabeth, and Dionis, 112 
 Nebula or haze of contagion, 86 
 Necroscopic researches of Tonnelle, 131 
 Nervous mass creates and controls its 
 
 organs, 196 
 New books, Fichte's advice, 36 
 Nourishment suitable for the sick, 343 
 Neurosity, how developed, Cerise, 198 
 
 Oken and Cuvier on the nervous system, 
 196 
 
 Opinions of medical men, unsettled state 
 of, 33 
 
 Oribasius, 44 
 
 Oxygen, sources of, for foetus, 74 
 
 , carried by the blood, 196 
 
 , indispensable element of neuro- 
 sity, 198 
 
 Ozanam on epidemics cited, 116 
 
 Pain and after-pain, 218 
 
 of childbed fever, 150 
 
 Pantimedes's servant, her case, 42 
 
 Paul of JEgina, 45 
 
 Peritonitis, extent of its complications, 
 
 146 
 pain of, greater than in 
 
 phlebitis, 150 
 Petit, Antoine, cited, 62 
 Plethora and hydrsemia contrasted, 77 
 Phlebitis, hy steroid signs of, 169, 224 
 
 is the phlegmonous nucleus of a 
 
 childbed fever, 209, 274 
 
 — Dance on, 126 
 
 — ratio of two other forms, Ton- 
 
 nelle on the, 131 
 Phlegmonous and membranous childbed 
 
 fever, 171, 209, 274 
 Physiognomical expression of a case, 
 
 214 
 Placento-uterine surface, its state, 181 
 compared to 
 
 stump of amputation, 209 
 Placental lobules undischarged, dangers 
 
 of, 182 
 Plant, the, by Schleiden, 338 
 Pneumonia attends pyaemia, 161 
 Poisoned blood, in the cases, 79 
 Poison of dissection wounds, causes phle- 
 bitis, Colles, 
 211 
 — — may affect a 
 
 pregnant or parturient woman, 211 
 Pouteau, 182 
 
 Pregnant and lying-in women alone sub- 
 ject to the contagion, 89 
 Pregnancy sometimes a disease, 174 
 Pressing calf of leg to detect crural phle- 
 bitis, 169 
 Private pestilences, 112 
 Psychical signs, in the cases, 169 
 Puerperal peritonitis, Baudelocque's 
 
 work, and Gasc's, 144 
 Pulse, in childbed fever, 151 
 not always best guide in venesec- 
 tion, 270 
 Purulent infection of the blood, 167, 225 
 Pus, not absorbable as such, 168 
 
 transported, 166 
 
 intoxication, 170 
 
 Putrescentia uteri, Boivin on, 165 
 
 Jorg on, 168 
 
 Kiwisch on, 90 
 
 Putridity of blood impossible during life, 
 80 
 compared with the 
 
 milk-dogma, 82 
 Putrid tendency of childbed fever, 7! 
 Puzos, 60 
 
 Quintilian, extract from, 240 
 
 R 
 
 Raciborsky on veins, 144 
 
 Ratio of metritis to the cases, by Ton- 
 nelle, 167 
 
 Raynalde's book, 44 
 
 Report on Doulcet's specific, 282 
 
 Respiration of childbed fever, 153, 224 
 
 Resolution, courage, venture, Gordon's 
 phrases, 250 
 
 of the inflammation to be ef- 
 fected, 235 
 
 Rigby believes in vitiated blood as cause, 
 80 
 
 Ritgen, Prof., on pneumonia in childbed 
 fever, 161 
 
 Riverius, quoted, 57 
 
 Roberton, Manchester epidemic, 108 
 
 Rokitansky quoted, 68 
 
 Rutter's cases, 104 
 
 Scanzoni's opinion on contagion, 100 
 Schleiden, D., his book, the plant, 338 
 Seasons, influence of, on mortality, 
 
 Tenon, 187 
 Semmelweiss's and Skoda's views on con- 
 tagion, noticed, 100 
 
362 
 
 INDEX. 
 
 Serres, M., his Anatomie Trancendente, 
 165 
 
 Ship or typhus fever complicated with 
 childbed fever, 204 
 
 Sieur de la Motte, 59 
 
 Simpson, Prof., on erysipelas and child- 
 bed fever, 207 
 
 Skoda and Semmelweiss on contagion, 100 
 
 Spach's collection, 48 
 
 Specific nature of contagions, 88, 148 
 
 each tissue, and of the 
 
 blood, 70 
 
 Sporadic or epidemic, 114 
 
 Stoll on emetics, 282 
 
 Stump compared to womb recently de- 
 livered, 204 
 
 Superficies affected in cases of peritonitis, 
 its extent, 156 
 
 Suppression of urine, cares necessary 
 concerning, 229 
 
 Sydenham on epidemic constitutions of 
 the atmosphere, 193 
 
 Synopses of Oribasius, 44 
 
 Table of epidemics 116 
 Tonnelle's results, 131 
 
 Tenon on the seasons of mor- 
 
 tality, 187 
 
 cases, 467 in number, by author, 
 
 103 
 
 160 cases by Dr. Lee, referred 
 
 to, 247 •* 
 
 Tenon's account of Hotel Dieu, 195 
 
 table of seasons, 187 
 
 Tetrabiblon of Aetius, 44 
 Tonnelle's paper in Archives, 285 
 
 on emetics, 285 i 
 
 case of Lori , 287 
 
 Marie M., 222 
 
 table of dissections, 131 
 
 Torpid bowels in pregnancy, 185 
 Tranquillity advised, 344 
 Trallianus, 48 
 
 Treatment, medicines used in, 232 
 Twelve hours after attack, bleed, 264 
 Twins, weight of, 184 
 Tympanitis, 150, 228 
 
 leads to cyanosis, 154 
 
 Typhous symptoms not pysemic, 168 
 Typhus, with childbed fever, 202 
 contagious, 205 
 
 Valley of Death, Javanese, 338 
 
 Veins of embryo, first receptacle of plas- 
 ma, 74 
 
 Ventilation of sick room, 344 
 
 Vessel, Burdach's idea of a, 76 
 
 Vienna epidemic, 100 
 
 Vigarous's work examined, 63 
 
 Virgil, lines from, 99, 103 
 
 Vigilance necessary, 252 
 
 Vital functions, three in number, brain, 
 heart, lungs, 153 
 
 Vitiation of the blood, as cause of child- 
 bed fever, 54 
 
 Ferguson on, 178 
 
 W 
 
 Walsh on erysipelas and childbed fever, 
 207 
 
 argues against venesection, 258 
 
 Womb compared with a stump, 204 
 
 White on emetics, 288 
 
 doubts of venesection, 258 
 
 Young and old globules of blood, 73, 
 
 Zymotic fevers, idea of, 198 
 
 THE END. 
 

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