and yet feels tolerably full and turgid, for a slight degree of circulation may go on nevertheless, sufficient to keep life enough in the fœtus, even for it to recover if the labour be hastened. We should especially examine the cord during the intervals of the pains, and after we have guided it into a more favourable part of the pelvis, where it will not be exposed to so much pressure, for then the pulsation will become more sensible to our touch, and prove that the child is still alive.

The following case by Dr. Evory Kennedy is an excellent illustration of what we have now stated:-"The midwife informed me that there was no pulsation in the funis, which had been protruding for an hour; on examination made during a pain, a fold of the funis was found protruding from the vagina, at its lateral part, and devoid of pulsation. As the pain subsided, I drew the funis backwards towards the sacro-iliac symphysis, and thought I could observe a very indistinct and irregular pulsation; I now applied the stethoscope, and distinguished a slight foetal pulsation over the pubes. Fortunately, on learning the nature of the case, I had brought the forceps, which were now instantly applied, and the patient delivered of a still-born child, which, with perseverance, was brought to breathe, and is now a living and healthy boy, four years of age. Had I not in this case ascertained, by the means mentioned, that the child still lived, I should not have felt justified in interfering; but, supposing the child dead, would have left the case to nature, and five minutes, in all likelihood, would have decided the child's fate." (Dr. Evory Kennedy, on Pregnancy and Auscultation, p. 241.)

CHAPTER XI.

PUERPERAL CONVULSIONS.

EPILEPTIC CONVULSIONS WITH CEREBRAL CONGESTION.-CAUSES.-SYMPTOMS.-TETANIC SPECIES.-DIAGNOSIS OF LABOUR DURING CONVULSIONS.-PROPHYLACTIC TREATMENT.-TREATMENT.-BLEEDING.-PURGATIVES.-APOPLECTIC SPECIES. ANÆMIC CONVULSIONS.-SYMPTOMS.-TREATMENT.-HYSTERICAL CONVULSIONS.-SYMPTOMS.

WOMEN are liable, both before, during, and after labour to attacks of convulsions, not only of variable intensity, but differing considerably in point of character. We shall consider them under three separate heads, viz. epileptic convulsions with cerebral congestion; epileptic convulsions from collapse or anæmia; and hysterical convulsions. Other species have been enumerated by authors, but they are either varieties of, or intimately connected with, those of the first species.

No author has more distinctly pointed out the fact that epilepsy may arise from diametrically opposite causes than Dr. Cullen; a circumstance which, in a practical point of view, is of the greatest importance. "The occasional causes," says he, "may, I think, be properly referred to two general heads; the first, being those which seem to act by directly stimulating and exciting the energies of the brain, and the second, of those which seem to act by weakening the same." "A certain fulness and tension of the vessels of the brain is necessary to the support of its ordinary and constant energy in the distribution of the nervous power (Practice of Physic;) and hence it may be inferred that, on the one hand, an over-distention, and, on the other, a collapsed state of these vessels, will be liable to be attended with so much cerebral disturbance as to produce epilepsy.

Epileptic convulsions with cerebral congestion. Epileptic convulsions connected with pregnancy or parturition, and which are preceded and attended with cerebral congestion, alone deserve, strictly speaking, the name of Eclampsia parturientium (which, in fact, signifies nothing more than the epilepsy of parturient females,) being peculiar to this condition; whereas, the anæmic and hysterical convulsions may occur at any other time quite independent of the pregnant or parturient state.

The term "puerperal convulsions" is employed in a much more vague and extended sense, and applies generally to every sort of convulsive affection which may occur at this period, and, as such, it therefore forms the title of the present chapter.

Causes. The exciting cause of eclampsia parturientium is the irritation arising from the presence of the child in the uterus or passages, or from a state of irritation, thus produced, continuing to exist after labour. The predisposing causes are, general plethora, the pressure of the gravid uterus upon

the abdominal aorta, the contractions of that organ during labour, by which a large quantity of the blood circulating in its spongy parietes is driven into the rest of the system, constipation, deranged bowels, retention of urine, previous injuries of the head or cerebral disease, and much mental excitement, early youth: also "in persons of hereditary predisposition, spare habit, irritable temperament, high mental refinement, and in whom the excitability of the nervous, and subsequently the sanguiferous system, is called forth by causes apparently trivial." (Facts and Cases in Obstetric Medicine, by I. T. Ingleby, p. 5.)

Symptoms. From the above mentioned list of causes it will be evident, that these convulsions will be invariably attended and preceded by symptoms of strong determination of blood to the head. Previous to the attack the patient has "drowsiness, a sense of weight in the head, especially in stooping; beating and pain in the head; redness of the conjunctiva; numbness of the hands; flushing of the face, and twitching of its muscles; irregular and slow pulse; ringing in the ears, heat in the scalp, transient but frequent attacks of vertigo, with muscæ volitantes, or temporary blindness; derangement of the auditory nerve; embarrassment of mind and speech; an unsteady gait; constipation and oedematous swelling." (Ingleby, op. cit. p. 12.)

As the attack approaches, the patient frequently complains of a peculiar dragging pain and sense of oppression about the præcordia, which comes on and again abates at short intervals, and is attended with much restlessness and anxiety: this is followed by intense pain, which usually attacks the back of the head, and upon the accession of which the præcordial affection apparently ceases; the pulse now becomes smaller and more contracted. If the convulsions do not make their appearance by this time, and the headach continues one or more hours, a slight degree of coma supervenes, the patient loses her consciousness more and more, and wanders now and then; after a time she becomes restless and evidently uneasy, the eye becomes fixed and staring, the countenance changes, and the outbreak of convulsive movements follows.

Sometimes the premonitory symptoms are much less marked; indeed, in some cases, there is scarcely a sign to warn us of the impending danger; in the midst of a conversation the patient becomes suddenly silent, and, on looking to see the cause, we find the expression altered, the muscles of the face are twitching, the features beginning to be distorted, and the next moment she falls down in general convulsions.

Wigand (Geburt des Menschen, vol. i. § 102,) considers that the two symptoms which usher in the attack are, the frightful staring, followed by rolling of the eyes, with sudden starts from right to left, and twisting of the head to the same side by the same sudden movements; as soon as the convulsions have commenced, the head generally returns to its former position, or rather is pulled more or less backwards; "The eyes are wide open, staring, and very prominent, the eyelids twitch violently, the iris is rapidly convulsed with alternate contractions and dilatations; the face begins to swell and grow purple, the mouth is open and distorted, through which the tongue is protruded, brown, and covered with froth; the lips swell, and become purple: in fact, it is the complete picture of one who is strangled." (Op. cit.)

These convulsions, as in common epilepsy under other circumstances, usually, if not always, commence about the head and face, gradually passing down to the chest and abdomen, and then attacking the extremities. After the above-mentioned changes, they pass into the throat and neck, by which a state of trismus is produced, and the protruded tongue is not unfrequently caught between the teeth and severely wounded. The neck is violently pulled on one side, and from the pressure to which the trachea is subjected, severe dyspnoea is produced. The respiration is nearly suspended, and from the violent rushing of the air as it is forced through the contracted rima glottidis, the breathing is performed with a peculiar hissing sound. The muscles of the chest now become affected, and the thorax is convulsively heaved and depressed with great vehemence; those of the abdomen succeed, and the convulsive efforts are here, if possible, still more violent: such are the contractions of the abdominal muscles, and so powerfully do they compress the contents of the abdomen, that a person who had not previously seen the patient would scarcely believe she was pregnant; the next moment the abdomen is as much protruded as it was before compressed. From the same cause, the contents of the rectum and bladder are expelled unconsciously, the extremities become violently convulsed, and the patient is bedewed with a cold clammy sweat. The duration of such a fit is variable; it seldom lasts more than five minutes, and frequently not more than two, and then a gradual subsidence of the convulsions and other symptoms follow; the swollen and livid face returns to its natural size and colour, the eyes become less prominent, the lips less turgid, the breathing is easier and more calm, the viscid saliva ceases to be blown into foam from the mouth, and the patient is left in a state of comatose insensibility or deep stertorous sleep, from which, in the course of a quarter of an hour, or twenty minutes, she suddenly awakes, quite unconscious of what has been the matter; she stares about with a vacant expression of surprise; she feels stiff and sore as if she were bruised: this will be especially the case if it has been attempted to hold her during the fit. The convulsive efforts of the muscles of the body and extremities are not easily resisted, and thus it is that we hear of a delicate woman under these circumstances requiring several strong men to hold her: the result of such treatment is, that her muscles and joints are severely strained, and continue painful for some time after. Patients, on recovering their senses, frequently complain of pain and soreness in the mouth, arising from the tongue having been bitten; in some cases, where the tongue has been much protruded, the injury is very severe, the tongue being bitten completely across, and hanging only by a small portion.

The woman may suffer but one attack, and have no return of the fit, or in half an hour, an hour, or longer, the convulsions again appear as at first. If this happens several times, she does not recover her consciousness during the intervals, but remains in a continued state of coma from one fit to another. Although it rarely happens that the patient dies during a fit, still, nevertheless, one fit will in some cases be sufficient to throw her into a state of coma from which she does not recover; in others, the patient may lie for even twenty-four hours in strong convulsions and yet recover.

The character of these attacks appears to vary a good deal with the

cause; thus, where plethora has been the predisposing cause, and the fits frequently repeated, they take on more or less of an apoplectic character, the coma is more profound, and of longer duration, and is frequently attended with paralysis; the cerebral affection is more severe, the patient does not recover her senses even where the intervals between the attacks have been of considerable duration; and when the fits have ceased, and the coma abated, she is occasionally left in a state of imbecility and blindness, which lasts for several hours or even days.

Where it is connected with constipation or deranged bowels, we think that we have seen it more frequently attended with delirium, or even temporary mania; the fits are as numerous, the convulsions as severe, but the cerebral congestion is not so intense, the coma less profound; instead of being left in a state of torpid stupor, the patient is very restless and at times unmanageable, and when we consider the identity of the causes which produce these convulsions, and one form of puerperal mania, it will be easily understood why the symptoms should assume this character. The degree also of determination to the head, will in no slight measure influence the character of the symptoms which attend these attacks. "One circumstance," says Dr. Parry, "of increased impetus deserves to be noticed. The delirium is preceded by a pain in the head, but as the delirium comes on, the pain ceases, though the impetus remains as before, or perhaps increases. Diminish in a slight degree the impetus, and you remove the delirium and renew the pain; diminish the impetus in a greater degree, and the frown on the forehead is relaxed, the features seem to open, and the pain entirely ceases." (Posthumous Medical Writings, vol. i. p. 263.)

By far the majority of cases of eclampsia parturientium occur in primiparæ thus in thirty cases which occurred to Dr. Collins, during his mastership at the Dublin Lying-in Hospital, "twenty-nine were in women with their first children, and the other single case was a second pregnancy, but in a woman who had suffered a similar attack with her first child." In two instances, under our own notice, where the disease occurred in multiparæ, the fits did not appear until after delivery; the patients were plethoric, and in one especially, the bowels were excessively deranged; in the other, the attack had much of the apoplectic character, and the coma did not once abate until the fatal termination.

Convulsions usually make their appearance towards evening; and if the pains are coming on, they return with every uterine contraction. The patient's danger will, in great measure, depend upon the severity, frequency, and duration of the fits; and although they must ever be looked upon as a disease of the most dangerous character, yet we are justified in saying that in the majority of instances the patient recovers: thus, of the forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of the thirty by Dr. Collins, only five died, "three of which were complicated with laceration of the vagina, one with twins, and one with peritoneal inflammation. It is thus evident that the fatal result in these cases, with the exception of the twin birth, was not immediately connected with the convulsions; and the danger in all twin deliveries, no matter what the attack may be, is in every instance greatly increased." (Practical Treatise, p. 210.)