organs cease to perform their functions with sufficient activity, cannot, we think, be denied, inasmuch as the depuration of the blood, and the completion of hæmatosis, is dependent upon the action of these organs; nor do we believe it possible to doubt the resorption of the colouring matter, at least of the bile, in cases of jaundice.

Dr. Paine denies that any direct medication of the blood can take place; in other words, that, by any therapeutic agent, acting immediately upon the blood, a change can be effected in the condition of that fluid, so as to bring it back, when diseased, to its normal condition. This, he maintains, can be effected only by restoring to the solids their healthful condition and functions. In this, to a certain extent, we coincide with the author. We have always doubted the correctness of the chemical doctrines in therapeutics; at the same time, however, we think the fact can be very clearly established that the blood may be medicated, that is, that it may be so imbued with substances having remedial properties as to render it adapted to effect a salutary impression on those tissues and organs which are the seats of disease.

According to Dr. Paine, the whole philosophy of the operation of remedial and morbific agents rests upon physiological principles, whether as manifested through the medium of the nervous influence, or in their more independent action upon the organic constitution of parts with which they may come into contact, but differing from the natural stimuli of life not only in the greater manifestation of the nervous influence, but in the alterative effects which it

exerts.

Lying at the foundation of both remedial and morbific action is the mutability of the organic properties, which, in being designed for a variety of useful purposes, such as the progressive changes of organization from infancy to manhood-gestation, lactation, etc., is necessarily subject to deleterious influences, from numerous external and internal causes, while others of a different nature are, for the same reason, and through another great law-the increased susceptibility of morbid states to the action of the latter class, in such regular modes as shall not act profoundly-capable of substituting other pathological changes, which, through another great law-the inherent tendency of the organic properties to maintain the normal state-subside spontaneously into the natural physiological conditions.

That all remedial agents act as alteratives, if we understand by the term alterative an agent which modifies the vital condition or action of the tissues or organs, sustaining, exciting, or depressing it, we admit, but we cannot perceive the correctness of the position assumed by the author, that "remedies operate like morbific causes," and that, in the cure of diseases, they institute "a succession of pathological changes," which displace the morbid conditions present. The use of similar language has a tendency to rather mystify than to throw light upon the modus operandi of therapeutic agents.

Throughout the several divisions and sections of the treatise before us, amid much that is mystical, indefinite, and inconclusive, there are scattered views of a most interesting character, many bearing the character of truth, and having an important practical bearing. To point out all that the volume offers of interest or of value, or to present a running commentary upon those even of the author's teachings that we consider most worthy of notice, would extend the present article to an unreasonable length. This arises, in a great measure, from his having adopted a somewhat defective method in the development of his peculiar views upon the several subjects embraced within the circle of the institutes of medicine, in consequence of which a fair exposition of the leading points inculcated by Dr. Paine would require a somewhat extended analysis of the entire volume, or, at least, of a very considerable portion of it; a task, which, however much we might feel inclined to undertake, we have not the time properly to execute; nor could we with propriety occupy the space in this department of the Journal that would be necessary to present its results.

We consider the treatise to be one well worthy of an attentive study on the part of every advanced student and practitioner of medicine, to whose notice we earnestly recommend it. Although far from being inclined to indorse the

accuracy of every doctrine advanced by the author, nor the chain of reasoning by which he attempts its support, we are, nevertheless, convinced that his prelections, from the amount of truth set forth in them, and the vitality by which they are pervaded, if they do not actually convey sound views on everything that relates to the philosophy of medicine, cannot fail to lead, at least, to a correct basis for the establishment of such views. The strong conservative predilections of Dr. Paine, which induce him to subject every new observation and theory in medicine to the severest scrutiny, and to refuse its admission until positively established, can have no other than a favourable influence upon his readers, by teaching them to be progressive only in the road of positive truth. D. F. C.

ART. XXIV. Puerperal Fever; its Causes and Modes of Propagation. Read be fore the New York Academy of Medicine, at the opening of the Discussion on Puerperal Fever, on the 4th of April, 1857; and published by consent of that body. By JOSEPH M. SMITH, M. D., Professor of Materia Medica and Clinical Medicine in the New York College of Physicians, etc. 8vo. pp. 29. From the New York Journal of Medicine, for September 1, 1857. Remarks on Puerperal Fever, before the New York Academy of Medicine, October 7, 1857. By B. FORDYce Barker, M. D., Professor of Obstetrics and Diseases of Women and Children, in the New York Medical College, etc. etc. 8vo. pp. 23. From the American Medical Monthly for November, 1857.

THE etiology and general pathology of puerperal fever are subjects that press themselves with no little force upon the attention of every practitioner of medicine in this country. The disease is one of frequent occurrence; generally, as an epidemic, confined within comparatively narrow limits. It is always very rapid in its course, and, even in its mildest form, difficult to manage, while it often assumes a type of the utmost malignancy, destroying, with a frightful certainty and speed, the life of those in whom it is developed. Under all circumstances, puerperal fever must be ranked among the most formidable of the maladies which the physician is liable at any moment to be called upon to treat. In consequence of this, added to the very great discrepancy of opinion as to the true character and proper treatment of the disease prevailing among those who have undertaken its investigation, the young practitioner always comes to its treatment under circumstances the most painful and disadvantageous; doubtful as to its true nature, and uncertain as to the course of treatment it is his duty to pursue to arrest its fatal course.

The diversity of views that exists in respect to the pathology of puerperal fever can scarcely be ascribed to any actual obscurity or startling irregularity in its phenomena, or to any confusion or want of significance in its morbid anatomy, as revealed by the dissections of different observers. They have arisen rather, we apprehend, from an error in the logic of many of those who have furnished us with accounts of the disease, that has led them to form erroneous conclusions from unquestionable facts, but facts misinterpreted, or entirely detached from their legitimate relationship with other facts of equal prominence, and which exist in intimate connection with those adduced as constituting the true indices of the nature of the disease, and modifying essentially their pathological import and tendency.

Inflammation of the peritoneum, of the uterus, of the uterine veins, of the ovaries, or of several or all of these parts, being detected in almost every case of puerperal fever, it has been concluded, therefore, with great positiveness, that the disease was nothing more nor less than simply a local inflammation of the peritoneum, the uterus, or its appendages-a peritonitis, metritis, phlebitis, or ovaritis; that the local lesions are the primary effects of the cause that gives rise to puerperal fever, and that all the phenomena which characterize it are the direct result of the local lesions; no inquiry being instituted to ascertain whether, 1st, the lesions discovered in the abdominal serous membrane, and in

certain or all of the pelvic viscera of the female, are the only ones that ordinarily occur in cases of puerperal fever. 2d. Whether the indications of local disease that are usually met with are in truth the primary results of the action upon the organism of the producing cause of the disease, whatever this may be; or, 3d. Whether they are not, rather, secondary results, depending on a prior diseased condition of the blood.

"The more," as has been correctly remarked by W. Tyler Smith, "puerperal fever is investigated, and tracked, as it were, to its elements or origin, the less satisfactory does any partial or local explanation of its nature become. In the progress of such examination, it appears more and more evident that there is a puerperal poison to which the lying-in woman is liable, and which produces (by its morbific action on the blood) all the varied phenomena of puerperal fever met with in different epidemics, localities, seasons, and constitutions. In one time or person, peritonitis is produced; in another, metritis; in another, phlebitis; in another, mammary or other abscesses; in another, low fever; in another, intestinal irritation; in another, dissolution of the blood, without a trace of local inflammatory disorder; and so on throughout the list of local or special disorders which have been described by authors in puerperal fever. It may be questioned, even if phlebitis ever occurs without a poisoned condition of the blood, produced either as the result of contagion, epidemic influence, or the absorption of putrid matter from the uterus." Scarcely any heed has been given to draw a correct and accurate diagnosis between puerperal fever, properly so called, and cases of open, acute, uncomplicated peritonitis or metritis occurring during gestation or in the puerperal state. That the local phlegmasiæ just referred to do occasionally occur in the pregnant, but more frequently in the newly delivered, female is most certain; it is likewise certain that they have been, under such circumstances, almost invariably confounded with puerperal fever, adding to the confusion with which the pathology of the latter has been environed, and the uncertainty that has marked everything relative to its treatment. And yet the attentive observer will very readily discover an essential difference between the general pathological character of the simple phlegmasia of the abdominal and pelvic viscera as they present themselves during pregnancy and after parturition, as well as between their respective pathognomonic criteria; as much so, at least, as there is between the bronchial, pneumonic, and intestinal inflammations so common in the typhoid form of fever, and the simple acute form of bronchitis, pneumonia, or enteritis, occurring as a primary uncomplicated disease.

Another cause of the obscurity and contradiction which mark the commonly received opinions in respect to the pathology of puerperal fever is the assumption that it is an affection sui generis, nothing corresponding to it being ever met with in non-puerperal females or in the male subject. Had the so-called child-bed fever been carefully compared with certain febrile diseases occurring alike in individuals of both sexes, of nearly all ages, and under almost every circumstance and condition in which they may be placed, more correct views in relation to its nature would long ere this have been reached, and a more rational and successful plan of treatment and of prophylaxis discovered and confirmed.

That puerperal fever is not simply a peritonitis, metritis, or metro-phlebitis, is proved by the fact that the lesions met with after death are not only those of peritoneal, uterine, or venous inflammation, but, most generally, of all these combined, in connection, usually, with indications of a diseased condition, to a greater or less extent, of many of the other organs and tissues of the body, and invariably of the blood. The morbid anatomy of the disease thus very clearly indicates, that so far from the symptoms which characterize it being the result of a local inflammatory affection of the womb itself, or of its appendages or peritoneal coat, the local lesions that are present in any case are but part of a disease which, like continued fever, involves the entire organism, and which is the result of a contamination of the blood, as Dr. Ferguson has long ago clearly established; the contamination originating, it may be, in some cases, from causes existing within the patient's own body, but most generally from a contagion, infection, or poison coming from without.

Another fact in respect to puerperal fever has been most conclusively estab lished, and that is its intimate relationship to constitutional erysipelas-erysi pelatous fever. It has been shown by the histories furnished us of the epidemics of erysipelas which have prevailed in different parts of Europe and of this country, by physicians who had the best opportunities of studying them, that during such epidemics not only are a large proportion of recently deliv ered females liable to an attack of puerperal fever, but that unmarried and non-pregnant females are also liable to a disease having all the characteristic features of the fever reputed to be peculiar to the puerperal state, and exhibiting, in fatal cases, nearly all the lesions detected in the latter affection. Nay, further, that during these epidemics of erysipelas, males, also, are liable to the same inflammatory conditions of the serous and mucous tissues and of the veins, and to the same morbid state of the blood, that attend upon genuine puerperal fever. While, on the other hand, we have on record a number of well authenticated cases, whieh would seem to prove very conclusively that the contagion, infection, or poison, be it what it may, of puerperal fever is capable of producing erysipelas in both sexes. Thus, as Krämer has well remarked, we have ample evidence of the fact that so far as concerns their pathological constitutions and etiological relationship, puerperal fever and erysipelatous fever are identical; they differ only in certain non-essential pheno

mena.

The important bearing of the foregoing facts are beginning to attract the attention of the medical profession everywhere; and, while a few teachers, of unquestionable authority, still persist in viewing puerperal fever as simply an acute peritonitis or endo-metritis, or a metro-phlebitis with pyæmia, the major portion of our best educated practitioners are beginning to recognize the true pathological character of the disease, and, as a consequence, we find that its treatment has become more rational-or, at least, less exclusive-and, as we have reason to believe, more successful.

A very able and animated discussion on the subject of the disease in question -its etiology, pathology, prophylaxis, and treatment-took place in the early part of the past year, at the New York Academy of Medicine, and was continued at several of its sessions. The publications whose titles are prefixed to the present article are particularly interesting as setting forth the views advocated by two of the leading speakers on these occasions.

The first of them, by Dr. Joseph M. Smith, presents a very excellent and somewhat elaborate examination into the producing causes of puerperal fever. It will richly repay an attentive perusal. The views advanced in it are, in the main, sound, while the evidence adduced in their support is pertinent, and, as we believe, conclusive. Similar views, based upon the same class of facts, have for many years been advocated by us. Although the essay of Dr. Smith presents, confessedly, a very able outline of the true causes and mode of propagation of puerperal fever, it has by no means exhausted the subject. To the array of facts given by the author could be added, with very little research, a host of others, equally, if not more, striking and conclusive.

That our readers may know what are the views of Dr. Smith in reference to the nature of puerperal fever, we copy the following initiatory sentences of the pamphlet before us:

"In glancing over the literature of puerperal fever, it is seen that physicians have been divided in their views concerning the pathology of that disease; some holding the opinion that it is an idiopathic fever, sui generis; others regarding it as essentially a local inflammation, taking the form of peritonitis, metritis, metro-peritonitis, or uterine phlebitis. Of late, the former of these opinions, with the exception of so much of it as imputes to the disease a specific attribute, has received the support of numerous able contributors to obstetric pathology. In fact, so generally is this view of the disease entertained at present, that Professor Simpson remarks that the evidence on which it rests has induced, of late, most of our best pathologists to reject the idea that puerperal fever is an idiopathic fever, sui generis, or a disease originating in, or identical with, peritonitis, or any other local inflammation.' But, while it is generally admitted that puerperal fever is not a disease, sui generis, it is nevertheless

regarded as an idiopathic fever, assuming a peculiar malignant form, being one of a group of febrile affections which originate, for the most part, from similar local conditions, and which have for their primary and essential pathological element a poisoned state of the blood. The forms of disease associated with puerperal fever, and which mainly constitute the group of disorders referred to, are typhus, and its modification typhoid fever, erysipelas, and hospital gangrene. That these are congeric affections, and due to a common toxæmia, seems evident from the fact that they occur in situations in which a subtle poison, the ochletic miasm of Dr. Gregory, is generated and diffused in the air, and which, finding its way into and contaminating the blood, produces constitutional and local phenomena, varying in form and character, according to certain morbid predispositions of the system existing at the time of its reception into the circulating fluid."

The opinions of the author as to the etiology of the disease are thus summed up, in the conclusion of the essay:

"In reviewing the facts which have been stated, it appears that puerperal fever sometimes arises from the noxious air generated from the foul discharges of puerperal women in crowded and ill-ventilated lying-in hospitals; sometimes from the absorption of putrescent matters lodged in the uterus and vagina after parturition; sometimes from the exhalations of patients labouring under typhus fever, erysipelas, and gangrenous diseases; and sometimes from the emanations from the human body dissected after death.

"It further appears, that the miasms of typhus, erysipelas, and puerperal fever are severally capable of producing any one, or all of these diseases; and that they may attach themselves to the persons or clothing of midwives and physicians, and thus be transported from their sources to the chambers of lying-in women. It is also observable, that the more ordinary form of disease, induced by the febrile effluvia in question, is typhus and its modification, typhoid fever, whilst puerperal fever and hospital erysipelas are but varieties of that disease, taking their forms from the peculiar predisposing conditions of the system, and certain epidemic influences.

"Finally, in contemplating the results of our inquiries, there are two things which cannot fail to be specially suggested and to make durable impressions on the mind. The first is, the importance of preserving in absolute purity the persons, clothing, and bedding of the inmates, and also the floors, furniture, and atmosphere of lying-in hospitals; and in case puerperal fever manifests itself, of adopting the most prompt and efficient means of extinguishing itsuch as ablution, ventilation, fumigation, and, if necessary, dispersion of the patients. The second is, the imperative duty of physicians ever to bear in mind the danger of their becoming agents of disseminating the disease in epidemic puerperal fever seasons, and to observe every precaution against such accidents. If, indeed, there be any moral obligation resting on a medical man to his patients, paramount to every other, it is that of refraining from attending a female in labour, if there be the slightest chance of his conveying to her the germ of a mortal disease."

The remarks of Dr. Barker, as reported in the second pamphlet, bear more exclusively upon the pathology and treatment of puerperal fever. In reference to the first of these points, he observes that the disease is one which cannot be investigated by the study of a few sporadic cases, or of a single epidemic, or of different epidemics in the same locality.

"Neither is it a disease to be studied in the dead-house, for, valuable as are the researches which have been made into the minute anatomy of this affection, important as it is, for the complete elucidation of the subject, that everything should be known as to the autopsic lesions which are to be found; yet their variety in different epidemics, the absence of everything like constancy or uniformity in these autopsic lesions, the frequent want of everything like correspondence between the severity of the symptoms during life, and the amount of the morbid appearances found after death, prove, as I think, that these lesions should be regarded as results of the disease, but not as the disease. And it seems to me that there is some danger of our giving undue prominence to these autopsic lesions. We might as well seek to find out the cause of the fire, in a