the conflicting impressions and perceptions that attend upon such vast disorders of the tissues?

But what I just now said is not only true, but most important, viz., that the serous coat of an organ is part and parcel with the organ. Hence, when the intestine, stomach, liver, spleen, &c., are, as to their serous portion, inflamed, there is an inflammation of the bowels, a gastritis, a hepatitis, a splenitis, &c., superadded to the metritis or the metro-phlebitis. This cannot be denied; and if not, then where is the ground for that astonishment that is often expressed on contemplating the early sinking state of the woman?

This very tendency to sink appears to me one of the strongest arguments that can be brought forward, by those who contend that we have here no typhus or true adynamic disorder to deal with, but only a diffused and deadly inflammation to combat. In typhus, the patient sinks, not because the organs have given way primarily, but because the cause of typhus produces a state of the nervous mass that makes it give way primarily, and the organs secondarily. Typhus depends not on acute meningitis, nor on any inflammatory or catarrhal accident, but it is a primary degeneration or altered crasis of the molecules of the nervous mass, caused by epidemical or contagious poisons. In our sinking childbed phlegmasias, on the contrary, the outburst is with the organs, and so to the subsequent overthrow of the nervous mass; the cases are at opposite poles. The nervous centres are the positive, the organs are the negative poles of the functions or powers of animals. Typhus rules at the positive, phlegmasia at the negative poles. As to any difficulty in accounting for the weakness or sinking in the terrible forms of childbed fever, I cannot conceive of it, after the foregoing statement and contrast. Indeed, the daily observed cases of sinking, or nervous shock that follow dreadful railroad accidents, wherein limbs are torn or crushed, may well convince any man that the nervous mass, at once and directly, succumbs, and fails under such shock; but it might quite as readily be supposed to fail under the perception of those multiplied and innumerable morbid impressions that are produced by many superficial feet of peritonitis affecting the most important organs, that are dying because their peritoneal portion is at the same time dying.

I have perhaps already said as much as is necessary to show my opinions of the nature or pathology of the disorder, as a mere general statement of it. I have not as yet spoken at large of the purulent infection of the blood, or pyæmia, that arises under certain stages of metro-phlebitis, in which myriads of pus corpuscles are evolved from the inflamed endangium. I leave these last matters to be treated of

in a future page, and now proceed to speak of the causes of childbed fever, reserving to myself the privilege of entering into fuller explanations of the pathogenic process and pathological states of our disorder.

A woman advanced towards the full period of utero-gestation, or one who has recently passed through the conflict of labor, ought to be considered, ipso facto, as in a state of precarious health, and peculiarly liable to be attacked with inflammation. The tissues most likely to suffer such attacks are those that have been directly concerned in the acts of gestation and parturition. In the course of a labor, there is always to be supposed such an amount of distension, pressure, distortion of parts, and check of the circulation and innervation, as to leave no room for surprise that inflammation ensues. Indeed, we have more occasion to be surprised at the failure than at the occurrence of phlegmasiæ as sequelae of parturition.

In addition to these circumstances it ought not to be overlooked that the uterus, and the whole reproductive apparatus, indeed, are undergoing a rapid transition-stage-one in which they are to seek a state of organic rest or repose, which is only to be attained when they shall all have recovered their normal condition, as it exists in the non-gravid state of the woman. This very transition-state of the organs is one prompt to morbid deviation in its course, and inciting to attacks of phlegmasia.

Again: the blood of the woman during pregnancy, and in the lying. in is, for most individuals, highly charged with the fibrinous element; a state of the blood that is supposed to give a proneness to inflammatory seizure.

There is, also, in women recently confined, a marked diminution of the pressure which previously had acted upon all the parts contained within the abdomen. Such diminution of organic pressure acts in a way, somewhat like the lessening of atmospheric pressure upon a part, as in cupping, to allow the unsupported vessels to become over full. If a new-delivered woman should have the abdomen left without due support from the tonicity or muscular activity of the abdominal muscles, fasciæ, and skin, the circulation within could not but become more abundant; since the vessels of the mesentery and peritoneum must be fuller in relaxed than in well-condensed states of the abdominal integuments. Hence I say that relaxation of them, after labor, incites to inflammatory congestion.

Besides the above-mentioned incitements and provocations to inflam mation, there often happen contusions, wounds, and abrasions, greater or less, of parts concerned in the labor; and inasmuch as many orifices

of vessels connected with the venous system of the uterus remain patulous long after the discharge of the secundines; and, further, as these orifices are bathed with corrupt and even putrid juices, collected within the womb, we are rather surprised to find the woman recover without accident, than to see her fall a victim to inflammation of the parts.

The placental disk of the womb, or that part of it which, during the pregnancy, was occupied by the after-birth, is left, by its separation in a quasi-traumatic state; so that, instead of readily recovering or healing, it may as readily, under peculiar circumstances, pass into a dangerous state of inflammation.

While enumerating the above circumstances as likely to incite to the attack, I am not forgetful of other so-called causes of childbed fever, nor among them, the Epidemic cause. There is scarcely any disorder that is more frequently observed to become epidemical than this: and it is a singular thing that it may become so for a single house, used as a lying in hospital. Or, it may become epidemic in a town only, or in a certain district, a state or nation, or a continent. If this be true, then there is to be sought for, and, if possible, discovered, some cause that can either exist as to a single house or even ward of a lying-in hospital, or as to a town, city, or whole country.

The medical writers who have furnished to the profession learned disquisitions on epidemic causation, have signally failed to point out to us what that cause is. And we are to this day as much in the dark on the subject as were the ancients at the date of Hippocrates' treatises on epidemical disorders.

Dr. Sydenham candidly acknowledges our ignorance of the material essence or epidemic cause of such diseases. And while he teaches us that there are what he signalizes as epidemic constitutions of the air, he by no means presumes to show further than the fact that one epidemic constitution is accompanied with a general prevalence of sthenic disorders, while another one is marked by its train of adynamic affections; and, further that epidemic causes act to produce frequent attacks of one set of anatomic tissues, to the exclusion of other sets. Wholly unable to find, in the meteorological states of the air, a clear rationale of these influences, he fell back upon the only remaining resource of the judgment, and showed how probable it is that telluric poisons, coming up from below the geological strata, may render the air unwholesome and inquinate.

My own opinion has long been, that many true epidemial diseases do depend upon causes that are produced beneath the earth's rocky crust; and that volatile and perhaps imponderable essences in which

they consist, may forever escape the extortions of the chemist, or the observations of the eudiometrist. The atmospheric ocean, at the bot tom of which we live, to use the figure of Humboldt, cannot but have perpetual relations with the earth's more central and igneous mass. There may then be, and there are probably, many material essences or compounds, whose names are not yet, and perhaps never shall be placed upon the catalogue of simple substances. Such elements might inquinate the whole air of a place or a nation for months in succession, modifying the life-force of man in epidemic fevers, inflammation, &c, or they might even be supposed to rise like the material cause of cholera, in certain parallels and meridians, and even to make the cir cuit of the earth; as cholera has twice done, and as influenza has several times been known to do.

I believe it is correct to say that the meteorological documents have hitherto cast no real light upon the nature of epidemic causes; for those prevalent and wide-spread diseases that depend upon meteorological states are rather to be regarded as weatherly or climatic, than as true epidemial disorders. Hence, it appears to me that the word epidemic-disease, and the word epidemic-constitution, are declaratory and not explanatory words, and mean, indeed, little more than this, namely, that a disease is unusually prevalent, and that such unusual prevalence has some relation to a state of the atmosphere, of the precise nature of which all men are equally ignorant.

Now, although the Student may be unable to learn what it is that poisons the air, and makes us sick, he needs not to deny that the air is vitiated; for he cannot refuse to admit that the cause really exists, and that it must exist in the atmosphere, and not in the earth, or only in vegetable or animal substances upon the earth; inasmuch as if they were confined within the bowels of the earth, or unextricated from vegetable substances, or combined in the waters, they would prove innocuous. He can no more escape from the conviction of its exist ence than he can escape from the conviction that there is time, space, or force; of which, however, he can no more know what they are, than what epidemic-cause is. Inasmuch as he can reason upon time, space, and force, and make accurate computations of them though he knows them not; so can he, in like manner, reason upon epidemiccause, and compute its date, duration, and violence, by its effects and

results.

For example, let one inquire what it is within the animal economy that can be acted upon by such epidemic-causes. In the Hôtel-Dieu, at Paris, there have prevailed the most devastating epidemics of childbed fever, which, after disappearing for years, have recommenced their

ravages in the same establishment, again and again. The same is true of the Maison d'Accouchements or Maternity Hospital, of the Dublin Lying-in Hospital, of hospitals at Vienna, London, Berlin, Prague, Philadelphia, and, indeed, wherever there may have been established any large houses for the accommodation of numerous lying-in women. Such epidemic-cause has been in activity since the age of Hippocrates, twenty-three centuries ago. I made out from that elegant work of Dr. Meissner, Die Frauenzimmerkrankheiten, and from Ozanam's Histoire Médicale Générale et Particulière des Maladies Epidémiques, Contagieuses, et Epizootiques, a catalogue of dates and places in which epidemic childbed fever has prevailed from 1652 to 1845, with references to the authors who have mentioned or described them. I could easily have augmented this catalogue by additions from Churchill's account. in the vol. of Essays on Puerperal Fever, republished by the Sydenham Society, were it not inconsistent with the objects and limits of this volume to do so. I shall, therefore, subjoin only the data found in Meissner and Ozanam, notifying that the authorities from Meissner are indicated by the letter M., and in Ozanam by the letter O.

TABLE OF YEARS AND PLACES OF EPIDEMIC CHILDBED FEVER, WITH NAMES OF AUTHORITIES.