London, and belong exclusively to families so poor as to be unable to find those comforts which are always provided for these occasions by the well-to-do artisan and better classes.

From such a source there must necessarily come a large proportion of patients with worn-out constitutions and incurable organic disease, yet such is the class which in these calculations has been contrasted with the remainder of the population of London, including that section which is unexceptionably fed, housed, and nursed.

The operations of that excellent institution the Royal Maternity Charity are carried out by a staff of intelligent, respectable women, furnished with routine instructions for conducting their cases, and with arrangements for calling in certain obstetric physicians in cases of difficulty and danger. Thus these women, so simply equipped, occupy towards their patients precisely the same relation as that of the general practitioner, who, in London, has similar facilities for occasionally resorting to an eminent obstetrician. What, then, is the cause of the comparative immunity from death which appears among that class which would appear to be in every way the least favourably circumstanced? It cannot be supposed that more knowledge or greater skill is possessed by these comparatively uneducated women than by the medical men. Some ascribe unfavourable results to the nervous derangement which upon these occasions is caused in susceptible women by the entrance of an attendant of the other sex, and there is something in this; but in my opinion the death-rate among patients attended by gentlemen in general practice arises from infection with various animal poisons. These gentlemen are necessarily exposed to personal contamination from attending other patients with infectious diseases, from dressing certain wounds, from making post mortem examinations, and other duties; and hence, however careful they may be, in the hurry and bustle of general practice febrile infection is frequently carried to the lying-in patients whom they may attend. This is the real source of many of those unaccountable deaths which occur to healthy women a week or so after an apparently safe and simple delivery. It is a never ceasing but unsuspected source of mortality, the infection takes with wonderful effect through all abraded surfaces, and it produces among lying-in women a form of blood poisoning known as "puerperal fever" which spreads itself to other women in the same susceptible condition.

Just as a veterinary surgeon may convey to an ox the present cattle plague, although the infection is not otherwise discoverable about him, so may the medical attendant convey this fearful fever; and so wonderfully penetrating is the influence, that the proximity of any possible medium of infection is almost certain death to the lying-in woman. In this way, a whole series of healthy women are often destroyed; yet, sometimes the doctor is so loath to believe that he himself has been

the origin and medium of infection, that he perseveres in practice until his track of destruction scares the entire public into refusing to employ him; generally, however, seeing the mischief in time, he abandons the neighbourhood, and, by taking proper precautions, may, subsequently, again resume practice with safety.

Upon this occasion, and before an audience chiefly non-medical, it may not be out of place to cite a few facts, illustrative of a subject not only of vital importance, but of wide and deep interest, because of its bearing upon a host of analogous pestilences which may be almost entirely eradicated by due attention to preventive measures.

Thus Dr. Gooch says

"A gentleman in large midwifery practice lost so many patients from puerperal fever, that he abandoned practice. For one month his partner acted in his place, and not a single case of the disease occurred. He then returned to the practice, and the first patient he attended was attacked with the disease and died."

Dr. West, of Philadelphia, says

"Seven patients were attended in rapid succession by Dr. S. Jackson; all were attacked with puerperal fever, and five died. These were the only cases that occurred in that district, for the women became alarmed and sent for other assistance."

In Sunderland forty cases occurred in the practice of one surgeon and his assistant, and the disease became almost epidemic in the town. Dr. Blundell says—

"However skilful and well educated a man may be, unfortunate cases will occur. Sir Richard Croft was shamefully used, though his shoes have never since been filled. After the Princess Charlotte's death, he attended a Mrs. Thackeray, who died, and he blew out his brains in her house. A medical man in Edinburgh wrote a book against him, but within three months afterwards he lost twenty or twenty-five women of rank from an epidemic, and none escaped who were in his hands. He lost besidę one case exactly like that of the Princess,"

Mr. Hey says

"For some time after the commencement of this malady it proved fatal in every case that came within my knowledge."

These statements are paralleled by innumerable narratives from various other observers of different outbreaks. In reference to its arising and spreading in the way which I have indicated, such men as Rokitansky, Semelweiss, Leibig, and others whom it would be superfluous to mention, both in this and other countries have given evidence which is practically unchallenged. I myself was for many years occupied with a large obstetric practice. I was one day alarmed by the appearance of a case of true puerperal fever. That poor lady was attended for me in an emergency by a gentleman who, I afterwards

learnt, had just previously been dissecting. She died; but owing to proper precautions, I avoided personal contamination and the disease went no further. Enough of these sad details. This dire malady springing from various kinds of blood-poisoning amounts as it were to a dissolution of the vital fluid while life still continues, and the resources of medical science are almost limited to preventing it.

Infections from erysipelas, from scarlet fever, from typhus, and from dissection-taint alike reappear in the lying-in room in this dread shape. Infection may occur as well from female as from male attendants, as well from the clothing as from the person, and the risk of infection is just in proportion to the length and frequency of contact with the contaminated medium. Infections of this kind will in other cases put on other shapes. Some three years since, after performing an anxious post mortem examination for judicial purposes, I happened, as I rode home, to touch a small pimple on my ear with hands carefully washed, but not thoroughly disinfected. Four days afterwards I was attacked with erysipelas, from which I narrowly escaped with my life, and which for a long time left me with shattered strength.

There is also a fever which stalks through the surgical wards of our London hospitals. Like the same agent in other places it assumes Protean shapes, and sometimes goes by one name and sometimes by another. "Hospital gangrene," "pyæmia," "phlebitis," "typhoid state," and other terms are used to designate or disguise an apparition which scares the surgeon. We will speak of it as "surgical fever." It kills the great majority of all who die after cutting operations within the walls of our hospitals. An enemy from which our hospitals are never free, it sometimes becomes so deadly that the surgeons shirk all operations, and sometimes are compelled to formally close and disinfect the wards of which it has taken too obtrusive possession. Yet this infection arises from the same causes as puerperal fever, and it might, by proper attention, be altogether prevented. Its continued existence is a reflection of the want of knowledge which exists among the responsible directors of our magnificent hospitals, and a singular mark of the apathy of the individual members of a most noble and learned profession.

Reference to a list of the appointments of our surgical teachers will show that the office of operator to a hospital is frequently combined with that of demonstrator in an adjoining dissecting room. Any day this week you may witness men who for hours have been handling halfputrid dissections, cast off their aprons and hasten to the operating theatre, there, with reeking hands, to manipulate the freshly incised surfaces of living, trusting, hoping fellow-creatures.

Observers stand by admiring the accuracy and rapidity of the incisions, and they feel proud of the minute attention and ample comfort

which our benevolent and affluent lavish upon our poor and suffering; but a few days afterwards they miss the patients from the wards. Others merely see the spectacle with idle curiosity, and never note the results of these magnificent operations. Some there are, however, who, in sight of the perhaps foppish paraphernalia of the operating table, ask themselves, with swelling hearts, how it can be that considerations of such importance are thus ignored; and, in the interests of medicine, they will afterwards sadly seek out the patient, and watch the symptoms with which he drifts into that "bourne whence no traveller returns." It is astounding that, in this day, it remains for anyone to point out that the dissecting room should be dissociated from the operating theatre as carefully as our cattle from the plague, and that men who undertake to demonstrate anatomy, should not be allowed to mix up the occupation with operations upon living men and women. Yet it is so, and the statement is now put forward in the conviction that life and money, suffering and bereavement, will be thereby saved. This may seem a digression, but the entire art of healing is one, and just as we now know that heat, light, electricity, and motion, are mutually convertible, so do we find that the same animal poison may assume the most various shapes—that the principles of saving and of healing are mutually interdependent and inseparable, and that you cannot rightly take a place in the practice of midwifery without surveying the length and breadth of medical science in general.

I have placed these important facts before you this day, feeling that in commencing your studies you should clearly recognise certain features of that territory which lies before you; which must to a certain extent sway your future career; which will suggest to you the importance of making yourselves thoroughly competent in obstetrics and its accessory branches of medicine; which will probably determine you to restrict yourself from certain medical and surgical duties, rather than incur the fearful risk which hangs upon an inadvertence in travelling between these different classes of patients; which will impress upon you the importance of habitual and minute precaution in respect to simplicity of attire, to the avoidance of all unnecessary contamination of yourself or your dress, and to the necessity of extreme care in the ablution and preservation of the hands. It is clear from the facts which I have narrated, that preventive measures are the means of protecting your patients-that, if once you acquire any contamination of your person or your dress, no ordinary habit of personal cleanliness will then make you safe, but that systematic means of disinfection must at once be adopted, before you venture near another patient.

I believe that much of our present mortality in connection with child-birth may be prevented. The practice of midwifery should be separated from the general practice of medicine and surgery, with which

it is now associated in the hands of the general medical practitioner. It is well known that the greatest advances in every science are produced by those who practically confine their energies to a single department. On this ground alone it would be an advantage to make the general practice of midwifery more of a specialty than it is at present. But when it is proved that the mixing up of these heterogeneous and often incompatible branches of practice, produces evils of such fatality, and risks of such magnitude, the proposed rearrangement is enforced by considerations no less than the conviction that human life may be directly saved and secured.

It will be evident that medical men in general practice cannot avoid exposure to the sources of infection which have been enumeratedwhereas it is also evident that properly educated female attendants need not be exposed to such influences at all, and may most properly and practicably restrict themselves to midwifery practice.

If midwifery be made an entirely separate branch of medical practice, its followers will, like those of all other professions, fall into two classes —those who attend to the general and routine work, and those who become recognised as consulting practitioners for cases of difficulty and danger. Precisely this division exists at the present time, and now it is only proposed that the routine superintendence of a natural event, should, as a rule, be left in the hands of properly educated women, and that thenceforth other questions as to women dealing with difficult cases, or practising medicine and surgery in general, be left to adjust themselves. The proportion of cases in which the midwives of the Royal Maternity Charity last year required the services of the physicians, was 88 to 2,782 deliveries, or about 3 per cent., and the following quotation from Dr. Blundell brings out nearly the same result.

"Till the time of Drs. Hunter and Denman it was thought disreputable in this country for men to practice midwifery. Parturition is a natural process often requiring no scientific interference, and when assistance is required it is often difficult to render it beneficially. Dr. Clarke, of Dublin, says-that of 10,000 cases which occurred in the lying-in hospital there, 9,400 were natural labours, and that most of the rest only required patience."

The existing body of highly educated obstetricians, who supply consulting skill to the present general practitioner, will, for a long time, be an ample resource in these exceptional cases, and the necessity of requiring to obtain such assistance upon isolated occasions would scarcely expose our women to an appreciable risk, even if these gentlemen were, as a rule, engaged in other hazardous branches of practice. I have no doubt that certain students whom I now see present, will, senior practitioners, hereafter acquire for themselves the confidence of their fellow students, and gradually rise into a position like that which eminent women have acquired and held for years in France and other

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