Such then is Barker's standpoint to-day, and he holds this position firmly in face of the almost uniform belief of obstetricians throughout the world thut, as Lusk expresses it, surgical fever and puerperal fever are not only analogous, but are essentially one and the same process. Of all those who discussed Thomas's paper, Lusk, Chamberlain, Hanks and others, only one, Muncie, was inclined to agree in a measure with Barker. Mendes views are best expressed in a quotation from his recently pub lished appendix to Cazeaux and Tarnier's Treatise on Obstetrics: " I be lieve the majority of cases of so-called puerperal fever to be, in reality, eases of puerperal.septicamia, the septic infection coming usually from without, carried generally by the fingers, instruments, dressing, etc., and no doubt at times in the clothing or on the person of the attendant, but in exceptional cases transmitted through the medium of the atmosphere. I am impelled to the last admission by the fact that I have seen appar ently spontaneous cases of puerperal fever, in which all possibility of in fection by contact could be absolutely excluded. I have been unable to explain the occurrence of such cases except by transmission through the air by a so-called status epidemieus (I refer, of course, to cases in private practice), unless I join the small minority of obstetricians, at the head of whom, in this country, stands Fordyce Barker, who still firmly believe in the occurrence of puerperal fever as a zymotic disease tali generis, that is, a disease produced by a specific poison of its own. I must confess that I have not been able to entirely divest myself of the belief that such a disease may exist, though I also believe that it is one of the rarest of exceptions." For our part, we are unwilling to commit ourselves to the absolute statement that we are ever dealing with septicaemia, pure and simple, ex actly like unto surgical septicaemia. Every age has its craze, and this is essentially the age of microbes and of sepsis. The question, judicially considered, must still be left open. We have certainly seen cases where there was absolute certainty, as far as this can exist at all, of the absence of any and all possible causes of infection, and yet the patients have suffered from puerperal fever, a fever zymotic, essential. The future, we think, will testify to the truth of Barker's views in very exceptional in stances. that is to say, while septicemia will be the disease in nine hun dred and ninety-nine cases, in the thousandth the disease will be of ayinetic origin. The one, in the future, will be absolutely preventable, the other no more so than are the other so-called essential fev3rs.—Ed.] Max Boer, in his report at Berlin, 1877, declares in the name of the appointed committee, that puerperal accidents are due to the absorption by the lymphatics, and by the blood-vessels of septic materials engen dered in the uterus by putrid decomposition, and Boer's conclusions are weepttx1 by Schroeder, Fasbender, Martin, Ltihlein, Winckel and Spiegel berg.
In America, in Belgium, in Italy, Denmark, Switzerland, England, the same unanimity exists, and Johnston, Atthill, MacClintock, Macau. Priestley, admit that puerperal fever is only septicaemia the result of ioliorreinia. According to Playfair there exists identity between puer pond septicaemia and surgical septicaemia, and there may be either auto or hdero-infection; auto-infection resulting from any condition which MIN OS decomposition, whether of the maternal organs themselves, or of debris retained in the uterus or the vagina, or of putrefied portions of a dead foetus; hetero-infection, resulting from cadaveric poison, erysipelas, ay mode diseases, puerperal contagion through physician, nurse, or others.
I Hobert Barnes, in discussing the question as to the absolute identity or puerperal fever and so-called surgical fever thus expresses himself: "'flat there are many points of analogy is undoubted; but there are also points of difference which forbid us to accept the doctrine of identity. The subject of an amputation, and a woman after labor, both present Both may be considered as susceptible to invasion by poisons.
In both the poison may affect a lodgment on the wounds. But it is easy to carry the comparison too far. Amputation is presumably performed on account of disease. The condition of the patient is pathological to start with. There is no special provision in the system made for the express purpose of healing the wound. The wounds in the puerpera are phy siological. There is a distinct provision ad hoc for restoration to the ordinary state. It is in this provision, marked by extraordinary activity of absorption and excretion, that lies the peculiarity of the puerperal state. This condition has no parallel in the ordinary surgical patient. If we are asked, What is puerperal fever ? may it not be asked return, What is surgical fever? Is surgical fever one uniform, definite, pathological entity ? In neither case is the fever one constant thing. There are vari eties of surgical fevers, even as there are varieties of puerperal fevers. If it be contended that by surgical fever is meant septicaemia, and nothing else, this is simply begging the question; we must still ask, What is septi caemia? And again, if surgeons are prepared to give a precise definition of septicaemia in surgical patients, are they also prepared to show that septicaemia of the same character is produced in lying-in women ? Sep ticaemia is a compound term. There is the sepsis, the poison; there is the blood which receives the poison. Now, if it be possible to show that the sepsis in the two subjects is identical, it would still be necessary to show identity or near similarity in the recipient blood. The first term of the proposition is certainly not proved; the second is certainly not true. This theory, then, like that of the microbists, is too absolute and exclusive. It may account for a large number, perhaps the greater num. ber, of cases in lying-in hospitals; but it does not account for cases begin ning before there is a wound, nor for the propagation to non-puerperal women." Barnes, further, is inclined to grant that a fever may attack the nuerpera of zymotic origin, to which the specific term puerperal fever may be applied. These words, from one of the leading accoucheurs of the world, may well be pondered by those who, carried away by the prevalent doctrines of sepsis and of microbes, can see nothing outside of them.
Alfred Galabin, in his recent work on obstetrics, resumes the question of puerperal septicemia and of puerperal fever, sal generis, as follows: The chief arguments showing that puerperal fever is not a specific zymo tic disease are: 1. The symptoms and anatomical lesions of the disease have not a special and definite character like those of a specific zymotic disease, but are rather analogous to those of septicemia or of pyemia fol lowing surgical wounds. 2. A definite local cause, such as decomposition of retained placenta, may give rise to a disease undistinguishable from puerperal fever due to conveyed contagion, and having the same anatomi cal lesions. 3. Puerperal fever may be originated not merely by conta gion conveyed from other puerperal women, but by various kinds of septic material.