of serious surgical operations, a considerable number die, however dexterously and well the operations may be performed. When the operation is severe, the proportion that thus die in consequence of it is much larger than is generally believed. For instance, among every 100 cases of amputation of the limbs—including amputation of the thigh, leg, arm, and forearm-about 30 terminate in death, and 70 in recovery. Dr. Fenwick, some time ago, published the results of 4937 cases of these amputations, collated from the practice of some of our best civil and military surgeons. Among these 4937 patients, 1565 died after the operations, or nearly 1 in every 3. The numerous deaths which thus follow operations in surgical cases are, in a small proportion of instances only, the more immediate and direct results of primary complications or accidents connected with the operation itself, such as hemorrhage, syncope, collapse, &c. In a large proportion of instances the death of the surgical patient is the result, on the contrary, of a combined febrile and inflammatory morbid state, which I believe to be generically, if not specifically, the same as puerperal fever in the childbed mother; and in accordance with the common principles of nosological nomenclature, this disease may as correctly be denominated "surgical fever," as the other is denominated "puerperal fever." A few years ago, Dr. Chevers published the apparent cause of death in 153 patients, whose bodies had been examined at Guy's Hospital,3 London, and who had died within that institution in consequence of surgical operations or injuries. Among these 153 surgical cases, in 1 the precise cause of death could not be discovered, and 18 of them had sunk under hemorrhage, tetanus, sloughing, suppuration, gangrene, erysipelas, diarrhoea, and the total deficiency of reparative action in the wound. Excepting, then, these 19 cases, Dr. Chevers found

1 See his excellent papers in the Monthly Journal for 1847, p. 238, &c.; and the corresponding evidence of the fatality of amputations and other operations, adduced by Malgaigne, Phillips, Lawrie, Inman, &c.

2 Puerperal fever has been often denominated in accordance with the special notions which the writer happened to entertain of its pathological nature. Hence we have it spoken of in some works as puerperal peritonitis, or metritis, or phlebitis, peritoneal fever, &c. &c. Any name thus drawn from pathology must ever change with the changes and advances of pathology itself; while a nosological name—such as puerperal fever-never requires to be varied, and is always fixed and intelligible. For example, all physicians know and recognize dysentery under that, its nosological name; but if we had had it described and denominated in different ages and works according to the ideas entertained of its nature, an inextricable amount of confusion would long ere this have resulted; and so with regard to most other diseases. Some surgical pathologists have described the consecutive fever and internal inflammations under which surgical patients sink, under the names of pyæmia, phlebitis, &c., each in accordance with his own pathological notions. The term "surgical" or "chirurgical fever" would enable us to avoid all the difficulties and perplexities connected with such a pathological nomenclature; it implies no pathological theory; and it is suffi ciently precise and distinctive as a simple nosological designation.

3 Guy's Hospital Reports for 1843, p. 89.

that in all of the remaining 134 cases, the post-mortem examination betrayed, as the more immediate cause of death, the existence of acute inflammation of one or more internal organs or structures ;1 and, no doubt, in all of them the usual symptoms of surgical fever were more or less perfectly marked during the last days of life. In most of these 134 cases, the recent internal inflammatory lesions discovered on the bodies of the patients were, as we shall see in the sequel, not confined to a single organ or structure, but several were frequently found affected at the same time in the same patient.

Medical literature does not yet possess a sufficient series of data to enable us to institute a full comparison between all the elements of puerperal and of surgical fever. But the consideration of a few points may prove enough to indicate at least a strong analogy, if not an identity, between these two forms of disease. With this view, I shall in the following notes attempt very briefly to show in what respects puerperal and surgical fevers are assimilated to each other: 1. In the anatomical conditions and constitutional peculiarities of those who are the subjects of them; 2. In the pathological nature of the attendant fever; 3. In the morbid lesions respectively left by either disease; and 4. In the symptoms which accompany each affection.

1. Analogy in the Anatomical, &c., Conditions of the Subjects of Puerperal and Surgical Fever.-The anatomical conditions of the puerperal patient after delivery, and of the surgical patient after an

1 It is proper to state, that, as Dr. Chevers remarks, in about 13 out of the above 134 cases the nature of the injuries was such that the patients had evidently from that cause alone no fair chance of recovery; but in the whole of the other 121 cases it appeared that there was nothing to render the patient's restoration impossible, had not severe inflammation or some other unfavorable change supervened.

2 Perhaps I may be pardoned for remarking, in vindication of obstetrical literature, that it possesses many separate essays and volumes on puerperal fever; and every text-book on midwifery contains a full chapter on the subject. But the reverse holds too true with regard to the literature of surgery. "Works," says Dr. Fenwick, " upon operative surgery are daily written, which detail with the greatest accuracy the formation of flaps, and lay down to a hair's-breadth the extent of incisions, without mentioning the secondary affections liable to occur after the operation. Huge dictionaries issue from the press, discussing the rival merits of ancient authorities to some trifling improvement in the method of amputating, but forgetting to lay down rules for the prevention or detection of the many dangerous diseases which so often follow its performance. How many hospital surgeons seem to imagine that the necessity for their personal attention to a case of amputation terminates at the door of the operating theatre, and leave the after treatment to be solely directed by a house-surgeon or ǝ dresser. How many content themselves with a hurried inspection of the pulse and tongue of the patient, after an amputation, instead of exploring the chest, or watching for the first indication of phlebitis; and how many young practitioners do we not find who speak of an amputation as though the interest connected with it ended with the operation, and as though success were certain if the patient surmounted the shock, or be unaffected with hemorrhage." Monthly Journal, vol. viii. p. 242.

operation, are in many respects the same. In the surgical patient, we have a wound or solution of continuity on the external part of the body, made by the knife of the surgeon; this wound has, opening upon its free surface, the mouths of numerous arteries and veins; and it comes to be repaired either by the direct adhesion of its opposed surfaces, or more slowly by exudation of organizable lymph upon its surface, and the ultimate formation or development of a new skin or new enveloping or connecting tissue. In the puerperal patient we have a wound or solution of continuity on the whole internal surface of the womb made by the separation of the placenta, and the exfoliation of the decidua or superficial layer of the mucous membrane of the fundus and body of the uterus; this wound has, opening upon its free surface at the former site of the placenta, the mouths of numerous arteries and veins; and it comes to be repaired under the usual accompanying exudation of organizable lymph upon its surface, and by the ultimate formation or development of a new layer or coating of mucous membrane. The obstetrical patient has the wound complicated with constitutional states of the same kind as those observed in the subjects of surgical operations. Both, at the first, are liable to present the symptoms of shock or collapse, particularly if the labor or the operation has been unusually severe; both have generally a subsequent limited degree of febrile reaction-the traumatic fever of the surgeon-the so-called milk fever of the obstetrician; and both the external surgical wound and the internal obstetrical wound are liable to deviate from the standard mode of reparation; for their secretions may alter

' Dr. Heschl, Demonstrator of Pathological Anatomy to the large Hospital of Vienna, has there enjoyed greater opportunities of studying the changes in the uterus after delivery, than perhaps any other living observer, and has lately published the results of his observations on the subject.

In speaking of the condition of the uterus immediately after delivery, he remarks, "The veins of the placental spot are filled with dark-red, or grayish-red, clots sticking to their parietes, and gape into the cavity of the uterus with their orifices plugged with these clots. This placental spot, which always occupies a third part of the inner surface of the contracted uterus, still retains a projecting, uneven, and considerably lacerated surface. The rest of the inner surface of the corpus uteri (from which the decidua had separated) is composed of the bare muscular substance, from which hang here and there shreds, the remains of the decidua vera."

Dr. Heschl repudiates entirely the idea of Robin and Kilian as to the formation of a new mucous membrane between the decidua and muscular structure of the human uterus during the period of pregnancy.

In studying the mode of reconstruction of the mucous membrane after delivery, Dr. Heschl finds that in two days after birth, the entire inner surface of the uterus appears covered with a soft pap-like, flaky substance, which gradually spreads over that surface in layers like very fine meshed-net. Vessels are not evident in it, however, till the third week; and the appearance of the mucous glands is still later.

For more lengthened details, see his Researches on the Conduct of the Human Uterus after Delivery, 1853.—(Ed.)

morbidly; or they may become the seat of an excess of inflammation or of ulceration; or of phlebitic suppuration and its consequences. In the internal obstetrical, as in the external surgical wound, immediately after their infliction, air occasionally enters by the mouths of the veins opening upon their free surface; from both forms of wound, dangerous hemorrhage, both primary and secondary, is liable to occur; both are occasionally, though very rarely, followed by delirium, tetanus, and other nervous complications; and, in like manner, but much more frequently, they are apt to be followed by that form of combined febrile and inflammatory action which we term surgical fever in the surgical patient, and puerperal fever in the puerperal patient. In short, the two species of wounds are subject to the same local pathological deviations, and liable to be attended with the same pathological constitutional effects and complications.

2. Analogy in the Pathological Nature of Puerperal and Surgical Fever.-Two opinions were formerly held with respect to the pathological nature of puerperal fever. One class of pathologists (as Puzos, Levret, Hamilton, White, &c.) regarded it as an idiopathic or putrid fever, sui generis; another class (Hey, Armstrong, Mackintosh, Campbell, &c.) still more earnestly maintained that the disease was essentially a local inflammation-that the fever was merely a consequence of, and attendant upon, this local inflammatory irritation—and that the malady was to be treated and cured by venesection and other active antiphlogistics. The first of these doctrines became generally abandoned with the advances of pathological anatomy, because local inflammatory lesions in the uterus, peritoneum, chest, &c., were, after death, found far too frequently, and of far too marked and intense a character to be explained upon the doctrine of a previously existing fever alone. But again, on the other hand, the idea that the disease was essentially a local inflammation, and that the fever was merely an effect symptomatic or sympathetic of that local inflammation, has been in turn gradually disproved also, as the pathological anatomy of the disease has been of late years more completely investigated. For it has been found that—1st, There is no general uniformity of relation and sequence between the degree and intensity of the supposed cause (the local inflammatory lesions), and the degree and intensity of their supposed effect (the attendant fever); 2d, Sometimes the supposed cause (in the form of simple peritonitis or metritis, &c.), may exist, without these inflammations exciting the usual phenomena of their supposed effect, namely, the symptoms of puerperal fever; and, 3d, We see occasionally cases of true and fatal puerperal fever, without discover

And

ing on the dead body any traces or evidence of the local inflammation which had been considered the origin of the disease. In other words, under this last class of cases we have the existence of the supposed effect without the existence of the supposed cause. this observation holds good with regard not only to the individual local inflammations, which have been illogically dogmatized into the alleged invariable origin of puerperal fever; but it holds good with regard to the whole class of local inflammatory causes. For instance, puerperal fever has been regarded as a form of fever produced by inflammation of the omentum, according to Hulme and Leake; by inflammation of the peritoneum, according to Gordon, Mackintosh, and many others; by inflammation of the uterus, according to Astruc and Denman; by inflammation of the uterine veins or lymphatics, according to Dance and Duplay, &c., &c. Now, in different epidemics, and sometimes in the course of the same epidemic, we see well-marked and fatal cases of puerperal fever, without being able to trace on the dead body any evidence of the one local inflammation theoretically fixed upon as the origin and essence of the whole disease. We thus see fatal cases without any proof whatever of omentitis, or any proof of peritonitis, or of metritis, or of uterine phlebitis or lymphatitis. In other words, in answer to those who maintain the identity of puerperal fever and peritonitis, for example, we can point to cases of genuine and fatal puerperal fever, in which the peritoneum was found perfectly healthy after death; and we can repeat this proof with regard to any other individual local inflammation that may be improperly adduced and considered as the cause and origin of the whole disease.

Some authors, while they maintain the disease to be a fever entirely symptomatic of some local inflammation, at the same time hold that this local inflammation may be seated in different parts in different cases, and different epidemics; and that the disease originates, in one case, in metritis; in another, in ovaritis; in a third, in peritonitis; and so on. Without remarking on the illogical nature of imagining that the same disease may have such varied origins, we may once more pointedly observe, that (as sometimes happens in continued fever) occasionally, though very rarely, no inflammatory lesions whatever can be traced upon the bodies of

1 For example, in 222 autopsies which he made of puerperal fever patients, Tonnellé found peritonitis in 193; and there was apparently no evidence of it in 39 of the dissections. "Inflammation of the peritoneum," he observes," is one of the most frequent alterations which we met with as a result of puerperal fever; but," he adds, "it would be a grave error to think that it existed always. Sometimes, in fact, this membrane preserved its natural aspect, and the most minute researches could not detect in it any appreciable change."-Archives Générales de Médecine, vol. xxii. p. 350.