hæmorrhage during labor cannot be controlled by remedies, the os not dilated, the tampon or Barnes' dilators should be used until turning or the forceps may hasten the labor.

Rest in the recumbent position, freedom from excitement of any kind, is very essential in case of hæmorrhage at any stage of gestation.

PUERPERAL MORTALITY: FEBRILE— PREVENTIVE.

BY C. G. HIGBEE, M.D.

It would scarcely be expected that the writer upon "The Prevention of Puerperal Fever," would enter upon the task without some statement of the causes of such fever, so that the means of prevention or prophylactics would be applicable. Let us then briefly notice the several conditions that the best authorities assign as the cause of this fever. Nearly all authors agree that "Puerperal Fever" is caused by a peculiar poison in the blood, and the opinion is quite as universally held that the nature of such poison is unknown. Why it should affect the patient only at the lying-in period is also imperfectly understood, and time and space forbids our discussion of it at the present time. That the disease is of a zymotic nature, and manifests itself more as a contagious epidemic when there are unfavorable conditions of ventilation, drainage, etc., the same as other zymotic diseases, is also settled.

That this peculiar disease may be caused by other forms when a lying-in patient becomes subject to their influence, is well proven and needs no discussion.

We must also notice that sporadic cases occur, and due precaution should be taken to avoid them.

Leishman says that "the general health, temperament and constitutional vigor of the patient have some influence in the manifestations of the disease. It has been repeatedly noticed that depressing mental emotions exercise a marked effect, so that women who have been seduced are more prone to the disease than others. 'Several of the worst cases that I have seen,' observes Dr. Churchill, 'were mainly attributable to this cause.' Any causes that have a tendency to produce peritonitis, acute tympanitis, metritis, uterine phlebitis, vaginitis or angioleucitis in a puerperal woman should be avoided, as these diseases when once developed may rapidly extend to true puerperal fever."

Is it not probable that as the base of all outward manifestations that we designate as so many different forms of disease leading to, and resulting in, puerperal fever, there is a diseased nervous system? That the germ, that from various causes develops into the different forms of the disease, is similar in all cases? That the objective symptoms are only such as arise from the different circumstances under which each case is developed? That there are no characteristic lesions discoverable after death in persons who die of puerperal fever any more than there are in those who die of nervous debility is, in our mind, a strong argument going to prove that the real cause of all cases of puerperal fever lies in the nervous centres.

We designate typhoid as a nervous fever. We certainly have many typhoid symptoms in any case of puerperal fever. Taking this view of the disease, the general course to pursue to prevent it will be obvious.

As the first step in the prophylaxis of puerperal mortality, we would urge every physician to have each case that he assumes the responsibility of under his professional observation during the whole course of gestation. See to it that her nervous and physical strength is sustained to the utmost. See that she has a nutritious, non-stimulating diet. That all gloomy forebodings as to her expected confinement are dispelled by reason and not by ridicule, as the former will carry conviction followed by hope and serenity, while the latter often only tends to confirm their suspicions and add fuel to the already overheated nervous fire. See that she sleeps in a well ventilated room, and with the head level with the body. Advise her to arrange her clothing so as to prevent undue pressure upon the abdominal organs or upon the breasts.

We firmly believe in the prophylactic power of homœopathic remedies administered previous to confinement. Hence it is necessary that we should see our patients frequently, and have their confidence, so that what to them might seem a very unimportant symptom, would be brought to our notice, and aid us in the selection of the proper remedy. It is of vital importance that the pregnant woman should sleep well, for in no cases is it more surely "kind nature's sweet restorer." In troubled sleep or in complete

insomnia, a few pellets of Ignatia, Coffea, Aconite, Belladonna, or Gelsemium, will usually quiet the nerves and secure the coveted sleep.

Regular and cheerful exercise in the open air by walking will greatly assist in keeping up a good circulation of blood in the legs and prevent the cramping that is the bane of so many women in the later months of gestation, and so excites the nerves, both from the dread and the actual suffering, that the effects are often visible even after confinement. Walking also promotes muscular development and strength, which women so much need during labor. It also aids digestion, and turns into natural channels the excess of nervous vitality.

We wish here to protest most decidedly against the practice of dieting to soften the muscles, or upon any other theory that will reduce the patient.

She needs a mixed diet. She needs meat to give tone and strength to her muscles. She needs fruit and vegetables to furnish food to the nervous system and to properly stimulate the digestive

organs.

We need only refer to the published proceedings of this Institute to prove how nearly approaching anæmia a woman is in the latter months of gestation, and that her imaginations and sensations are in a highly exalted state. Does not reason then urge us to do all in our power to overcome the anæmia and extinguish the spark that may end in puerperal fever? If the patient is so unfortunate as to be unable to walk, by all means have her ride, though this will give but minor benefits.

Another valuable adjunct to a safe and easy labor, and indirectly a prophylactic to "Puerperal Mortality," is the sitz bath, taken every day after the morning meal has digested and before the duties of the day have limited her power of reaction; the water to be of as low a temperature as will be borne by the patient without discomfort, and the time limited to ten or twenty minutes, according to her desire.

It is difficult to describe the prophylactics to be observed during labor, and yet they are of great importance to the future welfare and progress of the patient. She should have confidence that her medical attendant would do all that could be done for her safe

delivery under any circumstances that could arise. If false alarms and pains irritate her, do not be impatient, but ever maintain a quiet, cheerful self-possession, that should always characterize the obstetrician in the lying-in chamber. Do not deceive her. Inform her as near as can be of the probable course and duration of her labor. Do not assure her she will be through in a few moments, when you know it will be hours. Unless some peculiar circumstances call for your presence constantly, show your confidence in your prognosis of the progress by going about your business, if during business hours, or to sleep, if in the night. Give only such remedies as are needed to control the mental symptoms and the nerves, except in special cases.

To prevent repetition, and only bring to notice those points in the prevention of "Puerperal Mortality" not heretofore printed in the proceedings of this Institute, we have purposely omitted from this paper several material points, and would refer our members to those admirable papers printed in the Transactions for 1875. The recommendations there expressed we fully endorse.