or against the sensitive areas of the phlegmasia, which can tolerate no great disturbance nor rude touching. Hence, she breathes with a short, quick, frequent respiration.

If, during the rigor, the pulse is counted, it will be found beating one hundred and twenty, or perhaps one hundred and forty times to the minute; the artery being small and wiry, with a quick and sudden stroke of the systole. As the chill goes off, the pulse increases in size, but lessens a little in frequency, as the hot stage begins to develop itself. The hot stage makes progress; the area or inflamed disk expands, and, as it does so, causes the woman to experience frequent slight, momentary rigors, that are insufficient, however, to arrest the progress of the hot stage. In proportion as the area of phlogosis enlarges, so does the constitutional reaction against it augment. The effort of the heart becomes more and more energetic; the systole is again more frequent and sudden; the temperature of the body increases in the same ratio, and a hot stage is soon fully established. During the excitement of the hot stage, the area of inflammation expands rapidly. Under the predisposing conditions arising out of the woman's puerperal state, this reaction spreads out the area of inflammation more and more until it transcends the boundaries of the pelvis, where it was first established; it migrates upwards on the peritoneum covering the iliac muscles; it inflames the serous coat lying behind the muscles of the belly; it creeps up along the meso-rectum, and the sigma of the colon; it burns like a raging fire in the loose and movable peritoneum of the omentum: the whole colic arch is inflamed; the meso-colon; the mesenteric and intestinal peritoneum are involved; it takes hold on the stomach, passes along the serous lining of the liver, and fastens itself on the vault of the diaphragm, and the abdomen becomes tympanitic almost to bursting. Under the overthrowing power of such a complication of inflammations, the nervous power is demolished. The belly has become tympanitic; the respiration and calorification are disturbed and lessened; and the blood becomes more and more venous in its character, as the neurosity grows less and less under the lessening aëration of the blood. The countenance and the skin undergo the remarkable changes so often signalized. The stomach gives way with eructations, regurgitation, vomiting of yellow, green, blackish fluids, and lastly black-vomit. The nails are bluish, and the lips also; all pain has ceased; the pulse grows small, thready, vermicular; it ceases at the wrists, elbows, and axillæ, and at last the heart lies still; the woman is dead, the child an orphan, the family altar is overthrown as the divinity that presided there takes its flight to the unseen. world.

This is a picture of the progress of a childbed fever assuming the form of puerperal peritonitis. The sketch I have presented is a rapid one; but it seems to me that many women have begun and matured the whole progress of the events I have related, in a little more time than I have employed to write these words. In common, however, the rate is not so rapid. As a general rule, my cases have begun a little later, as at the end of the third day; so that I suppose the seventieth hour is more likely to give rise to the first symptoms than the fortyeighth hour after delivery. Still, it is not to be denied that, in multitudes of women, the area of phlogosis is first laid during the labor, or even before the commencement of it.

I hope the Student will allow me now to remind him of what I have before said, namely, that the serous coat of an abdominal viscus is an essential part of such organ; and that inflammation of its serous coat is, virtually, inflammation of the organ itself. But in my statement of the progress of the disorder I have asserted that the original area of the peritonitis has become expanded, or that the inflammation bas migrated beyond the bounds of the pelvis, and has at last fastened itself upon each and every of the abdominal viscera and the diaphragm. This I regard as a true account of any one of the bad cases of peritonitis. The Student would expect, even were the area of inflammation confined to the limits of one broad ligament, a very hazardous constitutional reaction from it; what shall he expect when every viscus is become inflamed in the progressive expansion of the area!

When the whole peritoneum of the colon and small intestines becomes involved, the peristaltic muscles, lying underneath their serous coat, must lose their power, and the whole tractus of intestine become distended with gas, just as a paralyzed bladder suffers itself to be filled to bursting with urine upon which it cannot contract to expel it. In like manner, the inflamed bowel fills with gases extricated within them, so as to produce, first, a state of meteorism which soon becomes an enormous tympany. The woman's abdomen begins to expand, in a short time after the inflammation has ascended upon the bowels, and then speedily becomes larger than it was before the birth of the child. I have seen some women in whom the abdomen was tense as a drum-head, and perfectly sonorous under percussion.

The nervous system ought very soon to succumb under the torment of such a vast area of inflammation; but there is another influence that tends quite as rapidly to sink it under such circumstances; it is this: the diaphragm has not free play any longer, to descend, as the respiratory piston, to the proper point in the cylinder of the trunk; for whenever the woman would make a free aspiration of air, she is

prevented by the pain; for as the diaphragm goes down, carrying everything beneath it in a downward direction, its pressure upon the inflamed bowels gives rise to torturing pain, so that she will not, if she can, and cannot if she will, take a full and perfect breath. To breathe imperfectly, is to oxygenate the blood imperfectly; and hence, this great and painful tympany soon comes to interfere with the aëration of the blood, and consequently with the innervative power which depends upon it. The constitution thus sinks rapidly under the double influence of a commencing tendency to asphyxiation and an intolerable burden of perceived irritations. All the writers notice a peculiar expression of the face in women in childbed fever. The countenance has a peculiar leaden hue, which it acquires in consequence of the imperfect aëration of the blood just explained; and this it is that gives the peculiar childbed fever physiognomy, so much spoken of in the books.

Moreover, when the bowels become thus greatly distended, their superficies of inflamed serous membranes expands pari passû. There is little hope, therefore, to effect the cure of the serous inflammation by resolution; it can come to its term only by effusion and adhesion, or by gangrene. The latter result is not to be expected, since the woman must die with an irritation so terrible, even before it could reach the point of passing into gangrene.

In some women, as soon as the bowels have become thus greatly inflated, a total stoppage occurs by what I have called angulation of the gut. For example, if the colon should be greatly distended, its returns, instead of being effected by arcs, are effected by angles; but a hollow cylinder, suddenly bent at an acute, or even right angle, will shut its cavity at the angle, so as not to allow even gases to pass. If the Student would roll up a sheet of paper into the form of a hollow cylinder two inches in diameter, and bend it so as to make an acute angle at the return, he will find that he cannot even force his breath through it. This is what happens in some of these cases. The obstruction becomes absolute and complete, so that neither liquids nor gases can pass; and the case becomes an iliac passion to all intents and purposes, and the woman dies as surely as if a ligature were applied and strictly tied around the gut. I have met with such instances, and proved them by dissection. No medicine can operate. The largest doses of calomel, senna, jalap, salts, croton oil, or elatin, are alike unavailing, for such angulation of the gut is a mortal accident. I saw a woman, attacked at 4 o'clock A. M., who at 11 A. M. was dying, under these very circumstances. It was in vain that any efforts to rescue her were made.

While these consequences flow out of the serous inflammation of the intestines, what must be those resulting from the serous gastritis? Every person who has witnessed the cases must be familiar with those fatal signals that are early presented in the first gastric eructations of thin mucus mixed with ingesta; soon after which appears a yellowtinted fluid, that comes at last to be greenish, verditer, dark green, darker, black and granular, and at last black vomit. These are the signs and fruits of an inflamed and dying stomach and duodenum.

Why need I further cite the serous hepatitis and paraphrenitis? It is enough to say that we have allowed the area of phlogosis to expand, to mount above the plane of the superior strait, and invade, as a fire in a prairie, every tissue that can be a fitting prey to the flame!

The Student has here, as I hope, acquired a clearer view of the nature and progress of a case of childbed fever, under the most ordinary form of puerperal peritonitis; and what I most desire is, that he should solemnly reflect upon the idea of an area of inflammation beginning within the pelvis, of a small superficies at first, but allowed by him to transcend its original limits and at last pervade everything within its reach. I feel sure that he will not look with surprise upon the woman who, under such circumstances, seems to sink without a struggle for life, her functions perishing, one by one, until the medulla oblongata at last ceases to excite the motor cord of the vagus nerve, which is death.

In the progress of the various operations I have depicted, the woman reaches a stage of the inflammation in which nature attempts the cure by effusion. As soon as the serum and sero-pus, and copious albumen begin to exude from the serous surfaces, the pain is mitigated, becomes rapidly less and less, and is soon all gone. The belly still continues to be large. If angulation has taken place, it will never subside; but if not, then, when the effusion has occurred, the abdomen becomes softer and less resonant, but still continues much distended. The inflammation is at an end, and it has come to its term by means of the act of effusion. By percussing the abdomen, we can now discover that the peritoneal sac is filled with a fluctuating liquid, and we know that the signs of melioration, so joyfully hailed, are but the disguised harbingers of doom. If the Student should read Gordon's account of the case of John Low's wife, he will have a most touching picture of the treacherous nature of this enthanasial melioration. When the effusions began, her great pain ceased, and, upon the doctor's arrival, they "received him with transports of joy;" but he saw that his patient was dying.

The Student ought very carefully to obtain a correct diagnosis of

the condition of any woman recently delivered, who complains of indisposition. If he should make an early and correct diagnosis of the incipient areas of inflammation, which I have supposed to be the true beginnings of childbed fever, he could scarcely fail of success by a resort to the Gordon method, to be hereafter described. And I advise him to give his patients the benefit of any doubt that may be left after a due exploration of the signs; that is to say, if he remain in doubt whether the malady be inflammation or not, let him proceed with his method as if justly convinced of the existence of a veritable inflammation.

One of the most constant signs is a remarkable frequency and quickness of the pulse, with which, however, he cannot become familiar by mere book learning. One must feel the childbed fever pulse in a few cases in order to become familiar with the peculiar and informing impression it makes upon the sense of Touch and the mind. I shall no further attempt to describe it than by saying that it generally beats at least 120, and often 140, or even 160 strokes to the minute. The volume and resistance of the artery vary, even in the early stages, according to the constitution of the patient, the violence of the phlegmasia, its extent, and the force of the epidemic cause, or other

cause.

Let the diagnosis between milk-fever and childbed fever be made with care: milk-fever may be accompanied with after-pains, with rheumatism of the womb, or with pure neuralgia of the pelvic and abdominal viscera, strangely connected with a tenesmic condition; or with retention of urine, or with retained coagula, or costiveness. I have met with many cases of supposed child bed fever, for example, that were by no means childbed fever, but only pain and irritation in the pelvis and belly, and a quick pulse and hot skin, caused by a tenesmic descent of the late gravid womb. In such cases, the abdomen is as tender and sore as it is in the most violent peritonitis, but it is instantly relieved by pushing the uterus upwards with two fingers in the vagina. If there be doubts about it, let them be cleared up by raising the womb upwards in the pelvis, and then by striking upon the sore abdomen to learn that the operation has wholly taken away all the pain and soreness, which it could not do if they were the symptoms of a real phlegmasia, instead of a descent of the womb. But, as I cannot devote, in this volume, a space sufficient for a treatise in extenso upon our disorder, I shall rest content with having indicated the above-named subjects of diagnostic research.

What can we do in these cases of childbed fever? What is our duty? Who shall show us any good? The profession is utterly di