these calculations there are some obvious sources of error, since they include deaths from all causes within four weeks of delivery, some of which must have been independent of the puerperal state.

All

But it is not the deaths alone which should be considered. practitioners know how large a number of their patients suffer from morbid states which may be directly traced to the effects of childbearing. It is impossible to arrive at any statistical conclusion on this point, but it must have a very sensible and important influence on the health of childbearing women.

Alterations in the Blood after Delivery.-The state of the blood during pregnancy, already referred to (p. 145), has an important bearing on the puerperal state. There is hyperinosis, which is largely increased by the changes going on immediately after the birth of the child; for then the large supply of blood which has been going to the uterus is suddenly stopped, and the system must also get rid of a quantity of effete matter thrown into the circulation, in consequence of the degenerative changes occurring in the muscular fibres of the uterus. Hence all the depurative channels by which this can be eliminated are called on to act with great energy. If, in addition, the peculiar condition of the generative tract be borne in mind-viz., the large open vessels on its inner surface, the partially bared inner surface of the uterus, and the channels for absorption existing in consequence of slight lacerations in the cervix or vagina-it is not a matter of surprise that septic diseases should be so common.

It will be well to consider successively the various changes going on after delivery, and then we shall be in a better position for studying the rational management of the puerperal state.

Some degree of nervous shock or exhaustion is observable after most labors. In many cases it is entirely absent; in others it is well marked. Its amount is in proportion to the severity of the labor and the susceptibility of the patient; and it is, therefore, most likely to be excessive in women who have suffered greatly from pain, who have undergone much muscular exertion, or who have been weakened from undue loss of blood. It is evidenced by a feeling of exhaustion and fatigue, and not uncommonly there is some shivering, which soon passes off, and is generally followed by refreshing sleep. The extreme nervous susceptibility continues for a considerable time after delivery, and indicates the necessity of keeping the lying-in patient as free from all sources of excitement as possible.

Immediately after delivery the pulse falls, and the importance of this as indicating a favorable state of the patient has already been alluded to. The condition of the pulse has been carefully studied by Blot, who has shown that this diminution, which he believes to be connected with a diminished tension in the arteries due to the sudden arrest of the uterine circulation, continues, in a large proportion of cases, for a considerable number of days after delivery; and, as a matter of clinical import, as long as it does, the patient may be considered to be in a favorable state. In many instances the slowness of

1 Arch. gén. de Méd., 1864.

the pulse is remarkable, often sinking to fifty or even forty beats per minute. Any increase above the normal rate, especially if at all continuous, should always be carefully noted and looked on with suspicion. In connection with this subject, however, it must be remembered that in puerperal women the most trivial circumstances may cause a sudden rise of the pulse. This must be familar to every practical obstetrician, who has constant opportunities of observing this effect after any transient excitement or fatigue. In lying-in hospitals it has generally been observed that the occurrence of any particularly bad case will send up the pulse of all the other patients who may have

heard of it.

Temperature in the Puerperal State.-The temperature in the lying-in state affords much valuable information. During and for a short time after labor there is a slight elevation. It soon falls to, or even somewhat below, the normal level. Squire found that the fall occurred within twenty-four hours, sometimes within twelve hours after the termination of labor. For a few days there is often a slight increase of temperature, especially toward the evening, which is probably caused by the rapid oxidation of tissue in connection with the involution of the uterus. In about forty-eight hours there is a rise connected with the establishment of lactation, amounting to one or two degrees over the normal level; but this again subsides as soon as the milk is freely secreted. Credé has also shown that rapid, but transient, rises of temperature may occur at any period, connected with trivial causes, such as constipation, errors of diet, or mental disturbances. But if there be any rise of temperature which is at all continuous, especially to over 100° Fahr., and associated with rapidity of the pulse, there is reason to fear the existence of some complication.

2

The Secretions and Excretions.-The various secretions and excretions are carried on with increased activity after labor. The skin especially acts freely, the patient often sweating profusely. There is also an abundant secretion of urine, but not uncommonly a difficulty of voiding it, either on account of temporary paralysis of the neck of the bladder, resulting from the pressure to which it has been subjected, or from swelling and occlusion of the urethra. For the same reason the rectum is sluggish for a time, and constipation is not infrequent. The appetite is generally indifferent, and the patient is often thirsty.

Generally in about forty-eight hours the secretion of milk becomes established, and this is occasionally accompanied by a certain amount of constitutional irritation. The breasts often become turgid, hot, and painful. There may or may not be some general disturbance, quickening of pulse, elevation of temperature, possibly slight shivering and a general sense of oppression, which are quickly relieved as the milk is formed and the breasts emptied by suckling. Squire says that the most constant phenomenon connected with the temperature is a slight elevation as the milk is secreted, rapidly falling when lactation is established. Barker noted elevation, either of temperature or pulse, in only four out of fifty-two cases that were carefully watched. There

1 "Puerperal Temperatures." Obstetrical Transactions, 1868, vol. ix. p. 129.

2 Monats. f. Geburt., 1868, Bd. xxxii. S. 453.

can be little doubt that the importance of the so-called “milk fever” has been immensely exaggerated, and its existence, as a normal accompaniment of the puerperal state, is more than doubtful. It is certain, however, that in a small minority of cases there is an appreciable amount of disturbance about the time that the milk is formed. Out of 423 cases, Macan found that in 114, or about 27 per cent., there was no rise of temperature; in 226 the temperature did rise to 100° and over, and of these in 32, or a little over 7 cent., the only ascertainable cause was a painful or distended condition of the breast. Many modern writers, such as Winckel, Grünewaldt, and D'Espine, entirely deny the connection of this disturbance with lactation, and refer it to a slight and transient septicemia. Graily Hewitt remarks that it is most commonly met with when the patient is kept low and on deficient diet after delivery, especially when the system is below par from hemorrhage or any other cause. This observation will, no doubt, account for the comparative rarity of febrile disturbance in connection with lactation in these days, in which the starving of puerperal patients is not considered necessary. It is certain that anything deserving the name of milk fever is now altogether exceptional, and such feverishness as exists is generally quite transient. It is also a fact that it is most apt to occur in delicate and weakly women, especially in those who do not, or are unable to, nurse. There does not, however, seem to be any sufficient reason for referring it, even when tolerably well marked, to septicemia. The relief which attends the emptying of the breasts seems sufficient to prove its connection with lactation, and the discomfort which is necessarily associated with the swollen and turgid mammæ is, of itself, quite sufficient to explain it.

In the urine of women during lactation an appreciable amount of sugar may readily be detected. The amount varies according to the condition of the breasts. It increases when they are turgid and congested, and is, therefore, most abundant in women in whom the breasts are not emptied, as when the child is dead, or when lactation is not attempted.

Contraction of the Uterus after Delivery.-Immediately after delivery the uterus contracts firmly, and can be felt at the lower part of the abdomen as a hard, firm mass, about the size of a cricket-ball. (Plate V.) After a time it again relaxes somewhat, and alternate relaxations and contractions go on at intervals for a considerable time after the expulsion of the placenta. The more complete and permanent the contraction, the greater the safety and comfort of the patient; for when the organ remains in a state of partial relaxation, coagula are apt to be retained in its cavity, while, for the same reason, air enters more readily into it. Hence decomposition is favored, and the chances of septic absorption are much increased; while even when this does not occur, the muscular fibres are excited to contract, and severe afterpains are produced.

After the first few days the diminution in the size of the uterus progresses with great rapidity. By about the sixth day it is so much

1 Dublin Quarterly Journ. of Med. Science, 1878, vol. lxv. p. 435.

(To face page 578.)

Cellular tissue

Anus, upper part