A System of Midwifery

by Edward Rigby

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 dyspnœa 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 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 purerperal 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 at once abate until the fatal termination.

Convulsions usually make their appearance towards evening; and if 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.)

Although puerperal convulsions usually occur at the commencement of labour, it not unfrequently happens that they do not come on until after the child is born; whereas, in other cases they occur several months before the full period: these varieties depend entirely upon the circumstances under which the attack has appeared. “With respect to their occurrence in the last month of gestation, although the paroxysm mostly appears during the actual dilatation of the os uteri, or on the first approach of labour, still when we recollect that in the last week or two of pregnancy the neck of the uterus is fully developed, the subsequent changes being confined to the os internum (the most sensitive part of the organ,) it cannot be surprising that, in very irritable persons, a serious impression should be made upon the brain at those periods.” (Ingleby, op. cit. p. 11.)

Dr. Merriman has called it dystocia epileptica: there is, in fact, no difference between this disease and common epilepsy, beyond that, under ordinary circumstances, epilepsy is a chronic affection, and, generally speaking, not attended with much danger, whereas, in the present case, it is an acute attack, and of a highly dangerous character.

Many phenomena connected with uterine irritation, both in the unimpregnated state and during pregnancy, prove the intimate nature of the consent existing between the brain and uterus. Thus it is well known that menstrual irritation is accompanied with a great variety of nervous and hysterical symptoms, which are merely a part of the same series of results to which epilepsy itself belongs: it is occasionally attended with delirium, spasms, and even coma, and preceded by the oppression at the pit of the stomach and pain of head, which we have already noticed among the immediate precursors of puerperal epilepsy; on the other hand, as Dr. Parry has well remarked, “the beginning and end of each epileptic fit, before total insensibility begins and after it ceases, is often delirium, screaming, false impressions, attempt to annoy others under these impressions,” &c. (Op. cit. vol. i. p. 396. &c.) Thus also during labour, either at the termination of the first stage, when the os uteri has attained its full degree of dilatation, or immediately after the birth of the child, the patient is frequently seized with a sudden convulsive rigour so violent as to make her teeth chatter and agitate the whole bed, and which is nothing more than a harmless modification of convulsive action arising from uterine irritation; the surface is perfectly warm, and the patient frequently expresses her surprise to find herself shivering thus violently and yet not feel cold.