No. 260.

LONDON, SATURDAY, AUGUST 23. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY.

DELIVERED AT GUY’S HOSPITAL BY

DR. BLUNDELL.

LECTURE XXXVI.

Of the Piteipei-al Fever.

WOMEN, after their delivery in the gene-ral, do perfectly well, although no atten-tions are paid to them ; and where the con-stitution is good, and the circumstances arenot extraordinary, I believe the less theyare interfered with the better. Although,however, as every reflecting man knowsthis position holds good in the general, yetit is no less certain that, after parturition,women are sometimes affected with some ofthe most dreadful diseases to which thehuman frame is liable ; disorder of themental functions, for example, and that

puerperal fever which so speedily termi-nates in death. This being the case, then,it is well worth our while to give a littleattention to the management of the puer-peral state; and of this condition of thesystem after delivery, I propose to treat

under three different titles ; the diseases ofpuerperal women, I mean ; the diseases ofm:ants ; and the management of the puer-peral state in those cases in which thewoman, on the whole, is recovering in themost favourable manner.Of all the diseases to which the puer-

peral condition is liable, by far the mostformidable is the fever of which you musthave heard so much-the puerperal plague,a, it might be called, so sudden in its attack,1-3 rapid in its progress, so fatal in itsEffects, and so choice in its victims ; amongthe young and the beautiful, assailing thosewho are the most endeared to us-those

Young wives and mothers, the moulds of’e human species, who. in European so-

ciety at least, form not the least valuable,nor the least interesting part of the domesticcircle. On the second or third day it is,reckoning that of delivery as the first, thatthe puerperal fever usually makes its firstonset on a Tuesday or Wednesday for ex-ample, if the child was born on a Monday.

Death, however, I have known to occur,with all the symptoms of puerperal fever,within the first four-and-twenty hours afterparturition ; and Dr. Haighton used to re-late the case of a woman who perishedunder a puerperal fever, which commencedten or twelve days after delivery ; indeed, ifmy memory serve, after the patient had madeher appearance in the drawing- room. Thelater the attack, the less is the pertinacityof the symptoms ; and the fever, whichseizes the patient on the fifth day, is muchless likely to prove fatal than that whichcommences on the first.

It is with chills and heats that the puer-peral fever usually commences ; and thosechills, felt more especially along the back,arise, I suppose, from a peculiar conditionof the spinal marrow; in the lumbar regionthey are, I believe, rarely perceived, butfrequently about the shoulders and the neck.In the intensity of the chill, there is a gooddeal of variety ; for some women, whenattacked, will cliatter as in an ague fit ;while, in others, the refrigeration is so

slight, that unless you search them withthe accuracy of a sectarian catechist, you.

: may not be able to find out that there havebeen any chills at all ; it is said that thef fever may sometimes assail without chill ;and, it is not perhaps impossible, that half

asleep at the time, the patient may not per-ceive its occurrence. The intensity of the

chill is no measure of the subsequent vehe-mence of the fever ; fierce fever may followt mild chills, or the chill may be moderate,t and the fever may be violent ; indeed, I in-, chine to suspect that when the disease opens, in this mild manner, there is more cause3for fearing its future progress-ipsa silentiuterrent.

About the time of the rigor, the womancomplains of abdominal pains, very slightf sometimes, so that their detection has its

.difficulties and at others so severe, that

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the touch of the finger is regarded with ap- case. Besides these principal and patho-prehension, and the weight of the coverlet nomonic symptoms, however, we nui I-.;

is complained of as a distress and a bur- patient is affected with others of hoss .:-then. All over the abdomen these pains portance, and vomiting may G(.c’jr and

may be felt above, below, to the right, to purgings-and headachs-and increase the left, in the region of the diaphragm, and the animal temperature-and taiiuresof thein the lumbar region ; this diffusion, how- milk. Cephalalgia, in some epidemic. ever, is neither constant nor frequent, and, been a constant symptom ; and Loweryou will find, especially in the less malig- with others, was disposed to place it itnm;nant varieties of the disease that it is in the the pathognomonic symptoms ; but cases

region of the navel, and more especially have occurred within my own observaUM,below it, that the patient complains ; and in which no headachs at all have been ft,t,hence, whenever you suspect the puerperal or, at all events, where the attack has beenfever, you should immediately lay your so slight, that it could scarcely deserve at.hand upon the abdomen below the navel, in tention as a characteristic symptom.the region of the womb. In some varieties Like some other diseases, the puerperalof the epidemic, severe after-pain is not in- fever is in its duration somewhat unfixed;frequently felt; so that, as soon as you it may last, especially if we comprise theenter the chamber on your second visit, the cachexia which follows it, for many da%&;nurse addresses you by saying, " Sir, my or where no bleeding, or other activemistress has suffered a great deal from the remedy has been employed, it may destroyafter-pains." You approach the bed, and you the patient, which it has done, under mythen perceive the rising cloud. This pain, I own observation, within twenty-four hourssuspect, is felt most severely, where the from the commencement of the disease, theuterine peritoneum is the seat of inflamma- plague itself being scarcely more rapid, ortion, and where the inflammation has a more fatal in its progress. Three or fourtendency to spread down into the substance days, not to say five or six, may be theof the uterus. Mild fever may accompany average duration of this affection. I speakintense pain, and the reverse. A circum- here of the epidemic.scribed pain is always favourable, but much In different modes the disease may beis to be apprehended when the pain and brought to its close; and sometimes we havetenderness are diffused extensively over the great satisfaction of seeing it terminatethe surface of the abdomen, although the in a resolution of the inflammations underintensity of the pain be slight. which, after symptoms the most frightfulAn excellent characteristic of the puer- and alarming, danger gradually vailisbes;

.peral fever is derived from the number of and the pulse sinks steadily to 140, 130,the pulse, always frequent. In this dis- 120, or 110, in the minute ; and the otherease, it scarcely ever happens that you have symptoms give way in like manner, and thea pulse as low as 115 in a minute, unless the patient, a few hours before on the verge ofdisease be giving way to remedy ; and gene- dissolution, is now brought into a state of,rally it rises as high as 120,130, or 140, and comparative security. Too frequently, how-I have myself counted pulses 165 or 170 in ever, it happens, (and I regret to add, tuo,the minute. Those are mistaken, who tell under the best average treatment,) that theus that these frequent pulses cannot be disease terminates in a very different man-numbered. You may count, in the rabbit, ner ; the extremities become cool, the paiMwhen agitated, a pulse of 300, and, of course, in a great measure cease, the mind re-

there can be no difficulty of numeration mains tranquil, and hopes of recovery Oat-arising from mere number, while the pulse, ter, and the patient, perhaps, talks of thein the human subject, is below 200. little schemes in which she is to be engagedThe symptoms which I have here men- on her re-establishment, and every thing,

tioned I have purposely detached, and in short, is promising to our wishes, ex-separated from the rest, because I look cepting the pulse, and there you find tJ.e

upon them as constituting, in good mea- token of death. Whenever, in conjunctionsure, the character of the disease. If, upon with these insidious and adulatory symp-the second or third day of delivery, the pa- toms, you perceive a pulse of 150, or 100,tient is attacked with chills and heats, and in a minute, the worst consequences are,

abdominal pains and tenderness, and if, to- I conceive, to be apprehended. Now this

gether with these symptoms, you find the termination, under symptoms so fattering,pulse rising above the healthy level to 130, is by no means very uncommon; and I dwell140, or 150, or 160, in the minute, and more on it the more because I am anxious t!.at

especially if the puerperal fever is preva- it should not be forgotten; for it has nowlent at the time, provided you make those and then happened with physicians of emi-diagnostics which I shall hereafter expose uence, men who, whether they hare re-

to your consideration ; there can, then, be fleeted much or not, must certainly Lalelittle doubt respecting the nature of the seen much of practice ; that, nowithstand

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all their experience, they have beenreceived by these symptoms, and have pro-

the patient secure fro.n danger,though, perhaps, she has died in the courseone or two hours afterwards ; nor have

mp and ambition of manner always beenting to give magnificence to the error,

which, after all, may well be pardoned in- Me who have seen but little of this dread-

ful disease. It must be acknowledged, how-ever,that the lofty neglect of THE vocn-

may expose professional dignity to

rade assaults; and, on hearing some of thesetales narrated by my younger friends, Ihave now and then been forcibly remindedoi the fate of other arrogant personages ofMys gone by :

" Vellunt tibi barbamLascivi pueri magnorum maxime regum."There is yet a third mode in which the

puerperal fever may terminate, and that isby a sort of cachexia. In this termination,tue patient becomes liberated from hermore pressing symptoms, and the pulse getsdown to 130, or 120, or 115, in the minute,aad there is a disposition to vomitings topurgings, to colliquative sweatings, and toeiacerbation, and remissions of the feverishsymptoms. These symptoms continuing forseveral days, the patient recovers under aeradual cessation of them ; or the strength,notwithstanding some gleaming amend-ments, declines daily, and, at the end of aweek or two, the patient sinks. In thesecases, whether the patient sink or recoverunder cachexia, I always suspect that theinflammation of the peritoneum has given rise to disorganization, and adhesion of cer-tam folds of the intestines; and that thecause of the disease is the inflammationand irritation that is going on in those parts,the original parts also being slightly affect-ed, perhaps, but still not in the same violentmanner that they are, where the patientlabours under the dangerous and violentattack of the puerperal fever. And thusmuch, then, respecting the characteristicsor’this formidable disease, let us now con-sider its management.Under the best method of treatment, puer-

veral fever too often proves fatal. A varietyor means have been proposed and tried incùmbatwg this malady, but when we get tothe bed side, we too often find our master.lapuerperul fever, we have been advised tocommit the result to tonics-to purging-mercury-to turpentine-to emetics-todletting, conjoined with calomel, andthe more copious doses of opium. In themalignant form of the disease, I fear, yourent will die under the best known treat-x.:Lt, so that there seems to be but little.,4m for choice ; but, in the milder or in-

ammatory varieties of the epidemic, ]

think, on the whole,-for after all I haveseen, I speak with hesitation-on the

whole, I think, that your most effectualremedies will be venesection, calomel, andopium.

In using venesection, whether in themilder or severer forms of the disease, it isof the greatest importance to commence thebleeding as early as may be. 1 have laidit down as a sort of rule in my own practice,that if, in the less vehemeat attacks, thebleeding be commenced within six hoursafter the chill, your patient will be savedoften, and if within twelve hours, not in-frequently ; but that if you do not begin till24 hours are passed away, in epidemic casesthe patient will usually die. With regardto the quantity of blood you are to abstract,it must of necessity vary somewhat with thecondition of the patient, and the vehemenceof the disease ; yet it is well to have an

average, and this may, I think, range be-tween 25 and 35 ounces. In taking awaythis blood, you will sometimes find yourpatient becomes faint, even before manyounces have been drawn. Now if the faiut-ness is permanent, lasting for four or fivehours, (which in general it does not,) it

may be considered to be of great benefit tothe patient ; but if, on the other hand, itis merely temporary, I believe it has oftenoccasioned women to lose their lives, byintimidating the operator, and preventinghim, when bleeding, from abstracting thenecessary quantity. Be it remembered,then, in puerperal fever, that if venesectionbe begun, you must not act with irresolution.In cases like these, when syncope occurs,I would recommend you to remain with the

patient until you have ascertained whetherthe fainting be of short time only, or per-manent ; and if the circulation return aftera short interval, should the original sourcefail, you may open the vein afresh.From four to eight hours after you have

bled the patient, the first time you will, Ithink, generally be able to determine whe-ther the bleeding, in conjunction with theother practices, may or may not be sufficientto subdue the disease ; and, therefore, Ishould lay it down as a general rule in adisease which proceeds with such rapidity,that within six or seven hours after the firstvenesection, you ought to come to your de-termination whether you will have recourseto a second venesection ; and au anxiousand nice point it may be to decide. If youare placed in the midst of a large circle ofobstetric friends, endeavour, by all means,to have another opinion, as the decision maybe delicate, and a divided responsibilitymay not be undesirable ; but if your excel-

: lencies, or more pardonable defects, havemade that, circle small, you may find it

. necessary to decide on your own judgment

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only; and my own method of determining wards drawn has appeared inflammatory inthe point is the following : counting round high degree. It is better at each bleedingthe second circle, if I find that the pulse, to receive the blood in at least two or threewhich was sunk after the bleeding, perhaps, different cups.to 120 or 115, is mounted again to 130, 40, In about six or eight hours after the secondor 50 in the minute, perhaps to the same abstraction of blood, you must come to a de·number as before the operation-though termination whether you will or not bleed Inot alone decisive, yet, as far as it goes, third time-deciding the point sooner orthis symptom to me appears to indicate later, according to the symptoms and herethat further depletion will be required; let me observe, that your decision respectingand, on the other hand, if the pulse be sunk the third bleeding is more important andto 110, and be remaining there, I feel un- more difficult than the determination re-

willing to have recourse to the lancet-it is specting the second ; for where women sinkwise to let well alone. Again, after solici- under puerperal fever, it is commonly undertously counting the pulse, I should proceed the third bleeding that they appear to Mc-to a careful examination of the abdomen; cumb. Now if you are resolved on depte’and if I found that the abdomen was pain- tion in a case of puerperal fever, you oughtfiil and tender, even though the pain and not to wait for one minute for the advicethe tenderness were somewhat obscure, I of another respecting the first bleeding-mo-should look upon these symptoms as an ar- ments are precious; and, in the uncertaiatvofgument for the lancet ; on the other hand, medicine, there is not such risk from a firstrejecting the use of this instrument, if ten- bleeding, as may make it your duty to pause;derness and soreness of the abdomen were but in coming to a determination whetherwholly or in great measure subsided. If you shall or not bleed a third time, imleasyou have prudently refrained, during the first your experience is large, another opinion isfew hours, from the application of a blister, desirable ; provided an opinion of value maythe abdomen may be easily examined, by be obtained ; for if patients really sink fromlaying your hand above the symphysis pubis, over-bleeding, it is, I suspect, this thirdand pressing there ; and by directing the pa- venesection which destroys. Whether, as atient to draw her knees towards the bosom, general practice, it be wise to bleed a thirdor to attempt a turn in the bed, or to assume time at all, may, I think, be disputed; forthe sedentary posture, when, if tenderness if our two first bleedings fail, we may rea.exist, it may be easily detected, provided the sonably be discouraged, and doubt the ef-examination be conducted with patience and ficacy of a third. I think, however, that Iattention. Observe, that mere tenderness, have sometimes seen the third bleeding putor pain of the abdomen, without frequency a close to the inflammation ; and as 1 can.of the pulse, is no valid reason for the fur- not deny its occasional necessity, I proceedther abstraction of blood from the arm; and to prescribe rules for its management. Infurther, that mere frequency of the pulse, determining, then, whether we ought to

without the pain or tenderness of the ab- bleed a third time, we must be guided, indomen, is not a satisfactory warrant for this good measure, by the same indications asuse of the lancet. It is only where those in the determination respecting the secondtwo symptoms are met with in conjunction, bleeding; and if the pulse is not above 115,that I feel satisfied that inflammation is pro- or if the abdomen is not tender, or if symp’ceeding within the peritoneum, and that I toms of collapse are beginning to appear,am justified in acting; when, for example, you must abstain from the lancet; but ifthere is tenderness and pain of the abdo. there are no symptoms of collapse, and themen, and when, in conjunction with this, belly is tender, and the pulse is 120, 30,the pulse is at 125, 30, 35, or more in the 40, 50, or more in the minute, you mayminute. Perhaps you will ask me here, bleed ; though from the use of venesection Iwhether it will not be proper to inspect the fear much benefit is not to be expected.blood you have already taken away ? And Beware of bleeding, if collapse is begun,certainly this is proper; and should you and in epidemic cases this is not improba-find it cupped and buffy, like the specimen ble. Beware of rash bleeding, provided theI now show you, this is a collateral argu- two first bleedings have together exceededment in favour of further bleeding ; but re- fifty ounces or more. Before you take mere

member, that the absence of the inflamma- blood, pray pause, think, and act, coglitory appearance of the blood, if you have occhi aperti, with your eyes wide open.bled early, is no certain reason why you Tenderness of the abdomen alone, without ashould not bleed a second time, provided frequent pulse, perhaps frequent pulse alone,you find all the other inflammatory symp- without tenderness of tbe abdomen, will nottoms are present; for I have myself, in some justify bleeding : an average quantity for atwo or three cases, on bleeding early, de- third bleeding may be 10 or 12 ounces;tected no buffy or cupped appearance on 10 or 12 leeches may be substituted for ve-the first blood, although the blood after- nesection in the more doubtful cases. if

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6t pour and the contre, the arguments for ture to give opium in the larger quantityr:4 against bleeding a third time, are say five or ten grains of the extract ofad aetrlv to countervail each other, per- opium in the course of twenty-four hours.hrm it is better to decide against it. 1 have in divided doses; the remedy being admi-note than once seen patients apparently nistered not so much by weight as aecord-ing from the application of 20 or SO ing to the effect produced. There are twoches, after one or two great bleedings modes in which opium mav be employedhad been premised ; again, therefore, be- in this fever: you may begin the ad-ware. ministration of it directly after the first

To these special remarks, let me add one bleeding, so that the venesection and the

a two of a general kind. It is highly de- use of opium proceed hand in hand ; or,

siuble that the whole quantity of blood again, if you bleed a third time, you maydra",n in this disease should be abstracted wait till your third bleeding, which will bewithin the first twenty-four hours after the about sixteen hours from the chill, and thenchill; and as to the whole quantity which in commence with your anodyne. Of the

all the bleedings it may be necessary to with- opium practice I have not seen enough todraw, I think it may average between 40 and decide peremptorily for you, which of these50 ounces. Sixty or more ounces have been two methods is to be considered the best ;sometimes taken - with apparent benefit; but certainly, when trying the remedies

but,hearing of’these anomalous successes, myself, I should give the preference to thelam sometimes reminded of the sneer of first.

the Grecian sceptic, who, on being shownthe votive representation of an escape from With respect to calomel, I may re-

liupwreck, with a remark from the priest mark, that this also may be given in twoon’the efficacy of Pagan supplication, ex- ways. Guarded with opium, ten grains,elaimed, not without a scandalous and irre- or more, may be administered every six

iijious levity, 11 Who paints for those who hours, till the mouth be affected-a bold

sink." s, ’

practice, which I have myself seen triedwithout obvious ill consequences. In one

In puerperal fever we have been recom- case forty ounces of blood had been ab-mended to make trial of calomel and opium, stracted, and when forty grains of calomelin conjunction with venesection ; and I have had been administered, the mouth becamem’setf, in treating this disease, made use sore; the inflammation, however,continued,of opium in the larger doses, without ob- and ultimately destroyed the patient. But

serving any resulting ill consequences ; and a gentler, and perhaps safer practice, con-it seems not improbable, that it really does sists in the adrninistration of a grain ofpossess some efficacy in lowering the irrita- calomel every three or four hours, and in

bility of the vascular system, and in extin- conjunction with the opium, which mayguishing the inflammation. As opium, then, be conveniently taken at the same time.does no obvious injury, and may, perhaps, beof service, it deserves a fair trial; and it may Here, then, is one principal method ofbe better, when giving it, to administer the treating this most fatal disease, by vene-larger doses, say of five or ten grains in the section, calomel, and opium. While, how-course of the twenty-four hours, provided ever, you rely on these remedies as theyou carefully watchtlre patient occasionally. principal, there are others not to be forgot-I have given larger quantities than this, ten, which may be looked on as a sort ofand apparently without mischief; but it is auxiliaries in the contest. It may be pro-to be remembered, that there are idiosyn- per to purge the patient five or six times,crasies which may render these larger doses during the first day especially. It may, too,pecuharly dangerous. In large Booding be proper enough to give the digitalis. Incases, where opium is given, we find that one pressing case, within forty-eight hours;:e patients are not affected by given quan- from the chill, I brought a patient so com-

of this anodyne, in the same manner pletely under the operation of the digitalisas they would be if they were in a state of that 1 was alarmed for the consequences ;rid health, and in a full and lively con- yet, this notwithstanding, the fever ran its.Now it is, in a measure, to this course, and the patient sunk in the ordi-:’t.te of inanition patients are reduced by nary manner.-Leeches to the abdomen maybleeding, and this may be a reason why be proper, and more especially when yon’.- larger doses of opium may not so much dare not further bleed from the arm. Be-

them. Understand then, that where ware of applying too large a number of- case is highly dangerous, so as to justify leeches if you have bled twice from the armive remedy, and where you are watch- (this I have told you already) ; but if youyour patient sedulously, perhaps passing bleed but little from the arm, no dangerous-reat part of the day in the bed-room, or symptoms appearing, then you may applythe bed side, that you may ven- leeches with more freedom. The flow from

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the leech-bites maybe supported by spong-ing, or commodiously enough by three largesuccessive poultices, applied each of themfor two hours. There is one objection to ablister, which is, that it creates a difficultyin deciding that most important question, Imean, whether abdominal tenderness exist;but, after the second or third bleeding, thisobjection may be set aside. The milder va-rieties of the disease are best adapted forblisters, and those severer cases in whichthe abdominal tenderness is become, in

great measure, local, and where, perhaps,the pulse is not above 110 or 115. An ex-cellent rubefacient is the hot oil of turpen-tine, care being taken that you do not firethe house when you are heating the oil. Bymeans of tow, the oil may be applied to

the abdominal surface, and it may be keptthere till the skin become red.

To conclude ; I cannot dismiss the con-sideration of this method of treating the

puerperal fever, without candidly declaringthat, under the best management, and evenunder favourable circumstances, this treat-ment will sometimes, nay, perhaps not in-frequently, fail altogether, though with allits defects about it, it must, 1 presume, beconsidered, in the present state of know-

ledge, as one of the best methods of com-bating the disease of which we are at pre-sent in possession.

Let me add, moreover, another remark;it frequently happens, where depletion hasbeen employed, especially the large bleed-ings, that friends persuade themselves thatthe patient is sinking from the venesection,when, in reality, she collapses from theeffects of the disease. I once saw a robust

Irishwoman, who, in the commencement ofher attack, had been bled to eight or tenounces only, dying, a few hours afterwards,under the collapse of the fever, with symp-toms very like those to which a fatal flood-

ing might give rise. Making due allowance,however, for these deceptions, there can,I think, be no doubt, that women do oc-casionally sink, perhaps not very rarely, fromexcess in the best-interitioned bleedings;but, really, the collapse of the disease, andthe collapse from the depletion, may be sosimilar, that in any given case the wisestmay have their doubts. I fear there is a

disposition abroad to abstract blood fromthe arm too largely. In over-bleedings,however, I trust that transfusion may nowprove a remedy.

ON DISTORTIONS OF THE SPINE.

BY MR. SHELDRAKE.

To the Editor of THE LANCET.

SIR,-A s you have given publicity to the ecommunications that I have sent you, youwill, perhaps, do the same by that which 1send at present. My former were intendedto prove the efficacy of that mode of treat-ment which I have long tried, with success,to cure distortions and deformities in tMextremities, for which no adequate remedywas known ; the present is intenfied to

show how I have, with equal success, lora applied treatment, that is founded upon thesame principles, to cure spinal curvature,and those peculiarities of the human formthat are dependent upon it.

In your critique upon Dr. Harrison’s ob.servations upon spinal diseases, it is said," no very clear pathology, however, as ap’

plicable to cases of distortions in general,has yet been made out, at least by thewriters in question; although, since thedays of Pott, those varieties which are com-plicated with caries of the vertebra;, orulceration of their ligaments or carnlages,have been tolerably well understood." Yonproceed to say, " our readers are, perhaps,aware, that in the absence of organic diseasein the spine, Dr. Harrison supposes the seve-ral distortions to be occasioned by a yield-ing of the ligaments, which, giving wayirregularly, suffer the vertebra; to slide fromtheir proper positions on the column. Inshort, he supposes distortion to be a sublillalion

of the vertebral rinhs, frm a relased, loosened,or elongated condition of the luterat and pesteriurligaments of the spine." This, you say, wasAmbrose Paré’s opinion, and you quote apassage from him ; you then quote lliinto,who says, " if one or more vertebra are of

unequal thickness, on opposite sides, thespine must be inclined over to the thinnerside ; which, now sustaining the greatestshare of the weight, must still be more com-pressed, consequently hindered from ex-

tending itself in proportion to the other

side, which, being too much freed of itsburthen, has liberty to enjoy a luxuriant

growth." -

Having, by this quotation, exempted Dr.Harrison from all the guilt of originality, inthe opinions which he promulgates upon thecauses of spinal curvature, which, in mercyto your printer, I advise your readers toseek for in THE LANCET, No.197, p. 809.I shall, however, quote one passage from Hin this place, because it demands a verystrong observation. " This elasticity, how-ever, is lost by constant pressure; and, ofcourse, the muscles on the favoured side ofthe spine will have much to do in prevent-