Medical Society of Virginia--December Meeting. Dr. JAMES BEALE, First Vice-President, in the Chair. (Present Twenty-five Members.) After the minutes were read, the following gentlemen were elected members of the society: Dr. JOHN A CHILTON, of Fauquier. Dr. JETHRO M. HURT, of Nottoway, Dr. Wм. E. ANDERSON, of Richmond City. Several gentlemen were nominated for membership, and their nominations laid over as usual. The subject of the evening being called up, Dr. John P. LITTLE read the following paper on Puerperal Convulsions. As this disease is one of the most terrible in appearance and dangerous in reality that invades the parturient female, as it is one that primaparæ are especially liable to, as it is one in which, according to some authors, one-half of those seized with it, and one-fourth according to others, die in the attack, and as it demands the most prompt and decided treatment, it is worthy of our careful attention. Moreover, as there are several theories promulgated in regard to its origin, and as these theories if believed in and acted on, indicate different plans of treatment, it is the more necessary that we examine carefully the true character of the disease, and that, guided by correct indications, we arrive at just opinions, and propose a sound plan of treatment for the existing disease and a judicious prophylaxis. Let us first notice the varieties of this disease, the mode of attack, and the appearance of it or its symptoms. It has been divided into hysterical and epileptiform eclampsia, or convulsions with and without coma. I am not willing to dignify with the name of a disease, certainly not with the name of puerperal convulsions, that dread sound of horror, an hysterical fit occurring during the pains of labor. That is an affection in which the patient loses no consciousness, which is removed by the exhibition of antispasmodics or by a dash of cold water, and from whose presence the patient receives no injury except possibly a slight retardation of the labor. Tetanus or catalepsy may also occur during or after labor; I would class them with hysteria, not in point of danger, but as belonging to similar causes; they may all, I think, be traced to a greater or less degree of irritation of the spinal system of nerves. I consider none of them as belonging to the disease under consideration. We find puerperal convulsions most commonly occurring in strong young women pregnant with their first child; in these, from their very robustness, and from the muscular tissues of the abdomen being unaccustomed to yield, and also from the ignorance and alarm of the patient, the labor is generally difficult. Those who have been liable to epilepsy or to hysteria, who are easily affected by the emotions, or who have suffered from any disease of the brain or the nervous system, are more liable than others to this disease. The causes that produce abortion, terror, anxiety, bodily injury, mental depression, the use of stimulants, &c., are also causes of this affection. Unmarried women, who are compelled to retire with their shame from society, who brood over their wrongs and suffer the agonies of remorse, are especially those whom this disease invades. Although there is often no premonitory symptom, yet commonly the attack is preceded by signs of cerebral disturbance, headach, giddiness, &c. There is sometimes stiffness of the muscles of the neck, and some affection of the larynx, as shown by the voice, and this muscular stiffness impairs the circulation of the head. The symptoms of the disease are very much those of an attack of epilepsy. The woman becomes perfectly unconscious of everything around her, the eyes are turned up and roll rapidly about, the muscles of the eyes and the mouth twitch, the countenance is distorted and darkened; every muscle of the body is soon violently convulsed, and the patient is jerked and rolled about with violence; the tongue often protruded, is lacerated by the teeth, and foam flies from the lips in the hurried, gasping respiration; the action of the heart is impeded as in epilepsy, and as the attack subsides both respiration and pulse become slow. After the convulsion has lasted a longer or a shorter time it leaves the woman in deep stupor, and the exhausted patient lies still, breathing stertorously. Consciousness does not return until another and another fit comes on, similar to the first, and leaving the patient in the same condition. The woman may become more comatose after every fit and die appoplectic, or she may suddenly die in a convulsion; or after many fits, by judicious treatment or by the expulsion of the child, she may gradually recover consciousness and be restored to health. The contractions of the uterus sometimes come on and expel the child during the comatose condition of the mother; generally, however, they are diminished and made irregular. The stimulus of the child's presence and efforts to contract seem to pass into convulsions, and sometimes alternate with them. Convulsions not only complicate labor, they generally interrupt it, and we are compelled to look to other measures than the efforts of nature to produce parturition. In almost all cases of convulsions the child is born dead. Either the presence of a dead foetus has caused the attack, or more probably the disease has destroyed the foetus. In regard to the frequency of this disease we have no accurate data; it prevails among all classes and in all seasons. In 12,500 cases of labor occurring in Parisian hospitals the disease appeared only 10 times-one in 1,250. In Dublin, out of 1,600 cases 30 women had puerperal convulsions-one in 53. Dr. Lee of London, who has a most extensive practice, has met with this disease 54 times; these cases were chiefly seen in consultation. The affection is a rare one. It especially attacks primaparæ. Of 182 cases where this was noticed, 138 were cases of first labor, and in general, where the disease. appears in later pregnancies, it is in those who have been in convulsions during their first labor. This disease is considered by many authors fatal in onehalf of the cases that occur; by others more properly it is fixed at one-fourth. Dr. Lee reports 19 deaths out of 54 cases; several of these, however, died from uterine inflammations after recovery from the convulsions. Dr. Meigs places the mortality at 15 per cent. The disease is more apt to be fatal if convulsions come on early in the labor; convulsions occurring for the first time after the labor is completed are not so dangerous to the patient, and the reason is that she has been delivered. Of 276 cases of this disease that I have been able to collect, 81 died and 195 recovered. Of 22 cases where convulsions came on after delivery, 6 died and 16 recovered. My own opinion is that an average of one-third of the cases die, either from the disease itself or its consequences. As to the mode of death, it varies in different cases; patients sometimes die suddenly in a convulsion, the function of the heart being impeded and destroyed by the cerebro-spinal disturbance and by the impaired respiration; it is death by asthenia. Again, if there have been previous disease of the brain, effusion or rupture of a vessel may take place and death ensue, or from general congestion of brain coma may supervene and death result more slowly. Injury to the lungs from derangement of the circulation and respiration, or to some other organ of the body, may arise; the nervous system may receive a shock, or the uterus itself may have the cause of much mischief laid up in it, and the patient die from uterine affections or become maniacal. These are the modes of dying, and the post mortem appearances will be found to correspond with them. The most common death is by coma; the functions of the circulation and respiration are interrupted and slowly destroyed; this impairment of function arising from congestion of the cerebro-spinal centres, and this congestion generally leaving no more trace in the brain than is left there when death is produced slowly by the inhalation of noxious gases or by long continued anesthesia. We have during every attack an interruption to the function of lungs and heart, depending on an impaired innervation; the sensor and motor nerves, the hemispheres, and the cerebellum become exhausted by the repeated shocks and by the continued coma, until finally the medulla oblongata is also affected, and consequently the function of respiration over which it presides is destroyed. In consequence we generally find no lesion at all in this death by interruption of function; the congestion itself disappearing as life ceases or soon after its cessation. Sometimes effusion is found in the brain, or great congestion of its vessels; the heart may be remarkably placid, or the uterus in a state of inflammation. No one peculiar appearance should be expected, as none such is found to exist in all cases. The causes of this affection are many and various. There is no one distinct and definite cause, the presence of which always brings on the disease and in the absence of which it does not occur. The puerperal state itself, by producing so much disturbance of system and so much mental agitation-the plethoric state of the vascular system that naturally belongs to pregnancy-the irritation of the womb and vagina from the presence and passage of the child-the stimulus to the spinal system of nerves calling into action that reflex motive influence of which labor is one of the phenomena-sympathetic action of those organs presided over by the ganglionic nerves, as the heart, the stomach, &c.-irritation of bladder, rectum, mammæ and skin-pressure of the gravid uterus on the aorta and vena cava ascendens-pressure also of foetal head upon the sacral nerves, and the closure of the glottis during the violent expulsive efforts these are each and all considered causes of puerperal convulsions. Yet they all may and do occur without any such result being produced. The best writers on midwifery consider the brain as the seat of the disease. Tyler Smith, a late and able writer, makes the spinal system of nerves the seat of this affection, and allows the brain but a secondary place. In fact, in enumerating the causes of the disease he does not class cerebral congestion among them, but speaks of a possible effusion of serum within the cranium acting along with spinal congestion as one of the causes. My opinion is that the predisposing cause of this disease consists in that hyperamic condition of system which belongs to pregnancy. That this condition exists is admitted by all writers. During the earlier months this abundant blood is used in building up the child; at the later periods of pregnancy there is a greater abundance than at any former period, because the frame of the foetus is completed, the mother's system has acquired a habit of making much blood, the excretions that take place in vomiting, &c., have ceased, and costiveness has generally been induced. This fullness of blood is necessary to furnish material for the child, the enlarged substance of the womb, and also to supply the woman with strength to go through her labor. "The blood is the fluid body, and the body is the fixed and rigid blood." It is so much liquid nerve and muscle, and the woman, like an athlete who has been in training, has her system filled with blood, by whose stimulus her excitable nervous tissues are made to send forth immense influence, and her naturally placid muscles to undergo great labor. This abundant blood passes off from the system in the discharges of fluids, blood, sweat, &c., during labor, and in the lochia and secretion of milk afterwards. If from pressure of the womb, from resistance of muscular tissues in first pregnancy, from emotion of mind, or disease of brain, a sluggish circulation and congested condition be allowed to occur; if, morcover, from the pressure of the gravid womb on the kidneys, their function of eliminating urea from the blood be interrupted, and albumenurea ensue, we have toxæmia. Blood charged with urea produces convulsions in animals. If then we have this fullness of system, this tendency to congestions, and this poisoned condition of blood, any exciting cause-the pangs of labor, the alarm at its commencement, any emotion and almost any cause-may produce a convulsion. This is especially observed when the patient is not covered with those floods of perspiration with which the parturient female is commonly enveloped; by this sweating, urea is passed off from the system and the vascular fullness is relieved. The contractions of the womb force from its tissues blood into the circulation, the muscular contractions have the same effect; the pressure of the womb and the abdominal contractions prevent free expansion of the chest and interfere with the action of the heart and lungs, and these in their turn interfere with the circulation |