68 PUERPERAL CONVULSIONS PUERPERAL FEVER become tonic, as it is called; that is, they become more persistent. The angles of the mouth are strongly drawn to one side, the mus- cles of the neck drawing the head in the same direction. After a few moments these parts will be drawn in the contrary direction. From the head the convulsive phenomena rapidly ex- tend to other parts of the body. The extensor muscles of the trunk contract, producing the condition called optithotonos, and the whole trunk becomes perfectly rigid. The neck swells, the jugular veins becoming prominent, and the carotid arteries beat violently. Contraction of the muscles of the larynx causes suspension of respiration, the capillary circulation becomes impeded, and the face assumes a livid hue. The tongue is often severely bitten between the convulsively closed jaws. In about half a minute these tonic convulsions are generally succeeded by those of a clonic character, and jerking movements of all the muscles succeed, the countenance becoming frightfully distort- ed. The pulse, strong and full at the com- mencement, is rapidly accelerated by the con- vulsions, but at the height of the paroxysm is very feeble. It is during the middle stage, that of tonic convulsions, that death is immediately imminent, when the respiration is suspended and the condition is that of profound asphyxia. When recovery from the attack takes place, the symptoms gradually abate; the convul- sive movements become less violent and then less frequent; the respiration becomes more regular but stertorous, and the circulation more active ; and the skin resumes its natural color. The patient does not immediately regain con- sciousness, but remains in a comatose condi- tion, the duration of which depends upon the intensity of the paroxysm ; sometimes only a few minutes elapse, at others several hours. But recovery from the tonic stage may not take place, or there may bo a succession of fits with intervals so brief that consciousness is not recovered between them, and the patient dies in a state of coma. In case of recovery, on regaining sensibility a confused feeling with headache is complained of, and she has no recollection of what has taken place. Some- times there is impairment of vision or of hear- ing, or both. As to the effects of these con- vulsions, they may, if occurring before the lying-in period, bring on premature labor and destroy the life of either the mother or the child, or both, or they may happily terminate in recovery. When the attack precedes de- livery, it frequently happens that the birth of a child removes the conditions upon which the convulsions depend, and the patient is im- mediately relieved. After delivery the attack may be followed by dangerous haemorrhage, from non-contraction of the uterus, due to exhausted nervous energy or to the impov- erished state of the blood. In some cases the recovery is surprising, and it often takes place contrary to the predictions of the most ex- perienced. The treatment is prophylactic or preventive, and curative. The prophylactic treatment consists in eliminating the urea from the system when present, by the use of diuretics and purgatives, and in relieving excessive ple- thora by bloodletting, which may sometimes be freely employed with advantage. PUERPERAL FEVER, or Childbed Fever, a disease which attacks lying-in women, generally at- tended by an inflammation of the peritoneum, or of the uterus and its appendages, of a dan- gerous character. The name puerperal fever was given by Strother in his work on fevers (1716). Hippocrates gives accounts of cases of death in lying-in women which resembled the puerperal fever of to-day, as do Celsus, Galen, Avicenna, and others down to near the 17th century. From observations extending through the last two centuries it has been gen- erally believed that the disease often prevails epidemically. It has been observed that lying- in women, attended by physicians coming from cases of erysipelas, gangrene, or sloughing sores of any kind, or from making post-mortem dis- sections, are very liable, sometimes almost certain, to be attacked with puerperal fever. These facts have caused several good authori- ties to regard the disease as due to the absorp- tion of septic matter by an abraded surface on the body of the patient. Denman, an English obstetrician, is said to have been the first to assert that puerperal fever is often propagated by the medical attendant ; and this view of the subject has been recently more particularly ex- amined, and, with others in regard to its prop- agation by septic contact, adopted in Germany. That absorption may occur, there must bo a fresh wound or abraded surface; if granula- tions have taken place, absorption is prevented. Now fresh wounds exist in every parturient woman in consequence of laceration or abra- sion during labor, and infection may take place by decomposition in the tissues of the patient, or it may have an external origin. The au- thorities who embrace those views do not therefore regard puerperal fever as contagious in the usual sense of the word, that is, spread by a specific contagion ; but admit that it is manually transferable, while the septic matter may be brought from an external source in which puerperal fever is not present. The viru- lence of cases which have been called puerperal fever has varied very greatly at different times and in the practice of different physicians, and the post-mortem appearances of the fatal cases have been unlike. Sometimes there would be found extensive lesions, not only in nearly all the pelvic viscera, but in other parts of the body. Sometimes there would be peritonitis alone, or with very few complications, and sometimes only the uterus would present much evidence of inflammation ; and in some of the most rapidly fatal cases no evidence of estab- lished inflammation would be found. More- over, the number of recoveries would be great in the practice of some physicians, and many of the cases would present symptoms indica-
