MIDWIFERY,

AND THE DISEASES OF WOMEN, ETC.

92.-NEW SPECULUM.

The engraving represents a self-holding Vaginal Fistula Speculum, which has been constructed by Mr. Foveaux, of the firm of Weiss and Son. That such an instrument is wanted can be attested by those who have had to hold the duckbill speculum in protracted and difficult operations. Several contrivances have been devised for this purpose, one of them a special and complicated operating table, but none of them have given satisfaction in this country. The instrument now under notice and depicted here, is applicable

in all the various positions for operation in vaginal fistula. It has now been twice used by Mr. Spencer Wells, no assistant being present on the last occasion, and it was found to answer its purpose most effectually. Its mode of action is very simple, the speculum blade or vaginal depressor, of which there are three sizes, being steadily held in the desired position by a counterpressure arm, which takes its bearing on each side of the spinal column. A screw adjustment approximates these two parts of the instrument in a parallel direction, while the angle of the apex of the speculum, as also that of the counter-pressure arm, can be regulated by small screws.

The instrument is, at the suggestion of Mr. Wells, made entirely of German silver, for the greater facility of cleaning it. One or two napkins serve as padding for the counter-pressure arm.-Lancet, Oct. 17, 1868, p. 513.

93.-THREE CASES OF PUERPERAL CONVULSIONS COMING ON AT THE COMMENCEMENT OF LABOUR.

By Dr. JAMES CAPPIE.

[The following paper was read before the Edinburgh Obstetrical Society.] Case 1.-On the morning of the 5th April, 1862, I was sent for to assist my friend, Mr. Gibb, in a case of puerperal convulsions. Mrs. C. had fallen on the floor in a fit at eight o'clock the previous evening, and since then severe convulsions had continued to come on every half-hour. When I saw her at two a. m., the point of the finger could hardly be introduced into the os uteri, and there did not appear to be any uterine contractions. I punctured the membranes with a common pencil, and tried to dilate the os with the finger, but with little success, on account of the want of expulsive efforts. Chloroform had been freely administered before my arrival, but the fits continued to recur regularly every half-hour. The condition of coma between them was so deep that she could not be made to swallow anything. A glance at the dirty pale, almost anæmic, countenance of the patient was sufficient to convince us that bleeding to any extent was not to be thought of. I left her, with instructions I should be sent for if pains appeared to commence. I was sent for at six a. m., and found the os slightly dilated, and the pains very slight. I again tried to dilate with the finger, and succeeded till it was about the size of a crown piece. The case now appeared very urgent. It was obvious that unless the patient was speedily delivered, she would soon sink from exhaustion. But the vagina was not relaxed, and the distinction between the internal and external lips of the os was not obliterated; that is to say, the parts were in the condition in which most eminent authorities insist that instrumental interference is not to be thought of. Still, such interference seemed to be the only chance left to the patient, and I determined to attempt delivery. In the manner to which I shall more particularly allude afterwards, I succeeded in applying the forceps; then, by making cautious and intermitting traction on the head, and at the same time supporting and pushing back the lips of the os, I got the latter gradually to dilate. After the head had passed into the vagina, the child (dead) was born in a few minutes. This was at eight a. m., and the patient had only two fits from that hour till four p. m., after which they did not return. In the forenoon she had a turpentine injection, which roused her sufficiently to enable her to swallow a little brandy and water, but the comatose condition continued the whole of the next day. Small quantities of stimulants and beef-tea continued to be administered to her, and after consciousness returned, her progress towards convalescence was steady. I may mention that this patient had convulsions in her first confinement; that, according to her husband's statement, she was then largely bled without the frequency of the fits being affected; and that, though they had continued a much longer period in her present confinement, her recovery this time was as satisfactory as in her first.

I was sent for to see this patient again a few months afterwards, as she had taken a convulsion fit. She was in the third month of pregnancy, and on examination I found the ovum in the vagina. After it was taken away there was no return of the convulsions.

Case 2.-On the morning of Sunday, 29th March, 1864, I was sent for to see Mrs. M'L., then in the beginning of the eighth month of her first pregnancy. I was informed that she had been obliged to rise about two o'clock on account of severe headache; that. to relieve this, she had allowed cold water to run from a cistern on her head for a few seconds, and that at four o'clock she was seized with a fit of convulsions. When I saw her, consciousness had returned, but as she was telling me how she had been feeling, another fit came on. After this, consciousness was not for the time recovered, and the fits recurred every half hour. I immediately ordered the hair to be cut off, and leeches to be applied to the temple. I returned at seven a. m., and found the patient as I had left her-unconsciousness persistent and.

deep. and the fits returning regularly. Drew off a small quantity of water, which I found to be albuminous. I then cupped over the loins, and took away more than a large soup-plateful of blood, and afterwards administered chloroform; but the frequency of the fits was not in the least affected by these means, I made occasional examination, but the os uteri showed no tendency to dilate till five o'clock in the afternoon, when I could introduce the finger within it. On account of its rigidity, and the unrelaxed state of the vagina, the efforts to dilate it were fatiguing for the fingers, and it was half-past seven before I could venture to apply the forceps. This, however, I accomplished before the os was half-dilated. I then set to work, and, in imitation of the natural pains, made intermitting traction on the head. and at the same time continued to dilate with the finger. The child (dead) was born at ten o'clock. From four in the morning till this time the convulsions had been wonderfully regular. Whenever the time was noted, the interval was never above a few minutes more or less than half an hour. After the second fit complete insensibility continued between the fits. From ten o'clock till half-past two next morning she had four seizures-scarcely one in each hour; then she had other four between 2.30 and 11 a. m.; after which they never returned. Altogether she would have forty distinct epileptiform seizures-the most of them severe. In the afternoon her breathing became quiet, and except that she could not be roused from it, her sleep appeared natural. In the evening she was able to swallow a little, and the next two days she readily took in whatever was given to her, but it was Thursday before she looked about her and attempted to speak. So speedy, however, was her convalescence after this, that on Saturday she was sitting up in bed to her meals and feeling quite well. Thirteen months afterwards, I again attended this patient, when she miscarried at the six months. During pregnancy she had frequent headaches, but no albuminuria. The kidneys were kept active with acetate of potass. There was no return of convulsions. She has been repeatedly pregnant, but miscarries at the sixth or seventh month from diseased placenta.

Case 3.-M. D., aged 30, was admitted to the City Poorhouse on Saturday, 11th April, 1868. She supposed herself to be near the end of the ninth month of her fourth pregnancy. On the Sunday forenoon she complained of headache, for which she kept her bed, and at mid-day she had a convulsive fit. The nurse, thinking she might be subject to epilepsy, did not send for medical assistance. The fit soon passed off, leaving the patient drowsy. She got a dose of castor oil, which operated freely, and during the two following days she was going about and feeling in her usual health. She stated that she never had suffered from convulsions before. On Tuesday evening she went to bed feeling well. At 1.30 on Wednesday morning she got out of bed, appearing stupid and not to know what she was about. Immediately on lying down again she was seized with a fit. When this went off, consciousness did not return before another seizure came on, twenty minutes after the first. When I was sent for, I happened unfortunately to be away at another confinement, and did not get the message till after four o'clock. The tenth fit was just passing off when I saw the patient. On examination, I found the os soft, and easily admitting the point of the finger. I separated the membranes as far as I could, and then ruptured them with a stocking-wire. There did not appear to be any uterine contractions. The question then came to be, should I bleed? The patient was a little woman, moderately well nourished, and with a very short neck. The breathing was hurried, the inspirations being short and quick, but without any approach to stertor, and the expirations more prolonged and noisy. In other respects she was perfectly quiet between the fits. All the muscles were flaccid, and the limbs motionless. Pulse 72, regular; the face rather pale; no flushing before the fits; no throbbing of the carotids; in short, nothing to indicate any unusual tension in the circulation. I therefore determined simply to attempt delivery as speedily as possible, and proceeded as I had done in the other two cases. I first dilated the os as far as the uterine inertia would permit. I drew off a small quantity of urine with the catheter, and it proved to be highly albuminous. Indeed,

the water in the tube appeared, on being heated, to become converted into a curd. Shortly after five o'clock I applied the forceps, made traction on the head, and continued to push back the os. This was pretty well dilated before any well-marked expulsive efforts were made on the part of the mother, and these efforts were only brought on when I made the initiative by moderate traction. The labour was completed at a quarter past six o'clock. The child, a fine healthy-looking girl, cried lustily as soon as it was born, and up to this time it has kept well. I now expected the severity of the fits to abate, but in this I was disappointed. They continued to recur every twenty minutes, and as strongly as before. When a seizure was about to come on the patient opened her eyes with an expression so placid that one could hardly help thinking she was about to become conscious. But this was only for a couple of seconds; immediately the head was turned to a side and thrown back; the eyes were rolled upwards towards a corner of the orbit and the mouth opened with a short cry, resembling a suppressed exclamation of dread; then the muscles of the face drew the features into ugly contortions; the arms were thrown out with rapid whirling and striking movements, as if passionately aiming blows at an imaginary antagonist; the body, too, wriggled with movement, and the legs were fairly lifted off the bed with a rapid pattering action. As the fit was going off, the limbs first became quiet, the arms fell with one or two spasmodic jerkings of the shoulders, and the working of the face-now livid from venous engorgement-disappeared with a few twitching movements. Abundant frothy mucus, occasionally tinged with blood, came from the mouth. Till another fit came on the most complete relaxation was present; neither head, hand, nor foot stirred, but lay in whatever position it was placed. The respiration continued hurried, but was never stertorous. Early in the morning her hair was cut off, and six leeches applied to the temple. A turpentine injection was also given, and acted freely. In the forenoon I tried the inhalation of chloroform. None of these ineans had any effect in moderating the fits; they continued regularly till midnight, by which time she must have had about seventy seizures. From 12 o'clock till 6 a. m., on Thursday she had one fit each hour. During the day she had only slight seizures on the right side, the arm being thrown up as far as it could be raised; pulse had become very quick and weak. She had a severe fit in the evening at 10.30, and others on Friday at 3 a. m. and 5.30 a. m. In the forenoon she kept very quiet, and was able to swallow a little spirits and water. I saw her at 11 a. m., and felt very sanguine she would rally. The respiration was tranquil; pulse 80; the kidneys were acting freely. An hour afterwards, however, the breathing suddenly stopped. The nurse thought she was about to become convulsed again, but no fit came on, and the breathing did not return. I may mention, that the mother of this patient also died from childbed convulsions.

Remarks. In detailing these cases, I have no intention to enter on the general pathology and treatment of puerperal convulsions; my special object has been to illustrate the safety of early instrumental interference when such seizures occur in the early stage of labour. As this is a point in practice on which authorities still differ, any facts bearing on it are not likely to be considered superfluous. Since I gave notice to your secretary that I would give an account of these cases here, a paper on Puerperal Convulsions has been published by Professor Dyce, of Aberdeen, in which occur the following remarks on this subject:-He says, "But there is another and very important part in the treatinent which remains to be considered. The patient is suffering from a disease dependent upon the state of the uterus; which state, it is believed, can only be got rid of by terminating the labour. What, then, are the principles that should guide us regarding delivery in these difficult cases? In short, will it be proper to interfere with the progress of gestation or parturition? As far as my own experience goes, I believe that generally interference is prejudicial, in whatever stage of the labour the convulsions may occur. Most assuredly during gestation, and before labour has commenced, it will be universally conceded, as admitting of no dispute, that until labour has commenced any interference on our part would be highly inju

rious, so that in convulsions during pregnancy we have, as Gooch says, nothing to do with the uterus, but solely to attend to the convulsions.' It will be also equally admitted, that in the first or early stage of labour, should convulsions come on, every attempt by the finger or other artificial means to dilate the os uteri ought to be avoided, as it will be found not only to bring on convulsions, but generally to increase them in violence. Denman assures us that he attempted gently during every pain to assist in the dilatation of the os, but he was soon convinced that the convulsions were not only brought on and continued, but increased in violence; he therefore desisted, and left the work of delivery to nature.' Thus, then, before labour comes on, and in the first stage of labour, I consider interference wholly inadmissible, and only tending to increase the danger." To these principles scarcely any practice could be more directly opposed than what I have detailed. I interfered in the first stage of labour, and that roughly, but I also think rightly. In the first place, the conviction on my mind is very strong, that if I had not so interfered, all the mothers I have spoken of would have died undelivered; and, in the second place, I submit that my interference did not at all aggravate the fits. All the cases had this characteristic in common, that the seizures came on at wonderfully regular intervals, and that for hours before the uterus was meddled with. In one case chloroform, and in another bleeding, did not affect the length of the interval. Then-and in connexion with the quotation I have just given-this is a point on which I must lay great stress,-in not one of the cases was either the frequency or severity of the fits in the east affected by the attempts to dilate the os with the finger, nor by the still more severe process of dragging the head against its inner surface, and at the same time pushing back its edges with some degree of force. The inference which such facts naturally suggest is, that the fear of aggravating the fits by interfering with the os is entirely visionary.

Another point in the treatment of puerperal convulsions, in regard to which difference in practice exists, and on which the above cases may provoke criticism, is blood-letting. I may possibly be asked, why this was not carried to a greater extent in their treatment. To this I have simply to answer, that none of the cases presented vascular or constitutional indications for the free use of the lancet. The first was a weakly, ill-nourished anæmic woman, who evidently had not a drop of blood to spare. The second case presented a very characteristic specimen of the lymphatic temperament-plump in appearance, but soft and spiritless. I bled her to a moderate extent without any effect on the seizures, and my conviction is that I would have lessened the chances of her recovery if I had bled her to the extent frequently recommended. The third case was that of a stouter woman, with a short neck; still there was no plethora, the circulation was quiet; there was certainly no determination of blood to the head; and the experience of the two previous cases had led me to put some faith in patient waiting.

There are a number of considerations which I think may be allowed to have weight with one before taking away from twenty to eighty ounces of blood in these cases. In the first place, it appears to me that the great danger to life lies in exhaustion; and my third case illustrates this in a marked manner. On the second day of her illness, I felt so hopeless in regard to her condition that I did not think of interfering, but I now regret very much that I did not make an effort to sustain her strength with nourishing enemata. From the marked improvement that took place on the third day, I feel convinced that a little more vitality, such as a moderate amount of nourishment might have imparted, would have enabled her constitution to tide over the danger. Certainly, if ever I have a case of the sort again, this is a point in practice I shall be inclined perseveringly to attend to.

Then, in regard to the pathology of epileptiform seizures, the opinion appears to be gaining ground, that during their continuance the brain is anæmic, and not congested; that the blood is watery, and not over-abounding in red corpuscles. If this view be correct, then bleeding can only exert a beneficial effect by diminishing the absolute amount of a supposed poison in the blood. But it is to be remembered that the most certain effect of blood-letting is to