4. Alterations in the Blood.—These changes play the leading role in producing endocarditis, acute or sub-aeute, and arterial thrombosis. Hemiplegia is thus only the epiphenomenon of a cardiac affection devel oped during pregnancy, or after numerous pregnancies, and reacting, in turn, on the central organ.
5. Allniminuria.—Ca,ses have been reported by Fleetwood Churchill, -Latham, Romberg, Simpson, Lever, Imbert Gourbeyre, Johnson, Braun, Fournier, etc.
6. Puerperal Seplicomnia.—Hervieux and Charpentier, have reported cases.
7. Antemitt.—Stork, Bataille, Ley, Churchill, Laurent.
8. Reflex. Aelton.—Whyt, Prochaska, Lever, Churchill, Imbert Gour beyre, Pellegrini, Crosse and Stokes, have reported cases.
The last two causes cannot be absolutely eliminated, but, in reality, two grand causes seem to us to dominate the pathogeny of puerperal hemiplegia. First, cerebral lesions, congestions, hemorrhages, thrombo ses of the sinuses, whether primary (Meniere) or secondary, lead to cardiac affections, i.e., to the acute puerperal endocarditis of Simpson and Decor niere, or to 011ivier's sub-acute progressive endoearditis, or to puerperal cardiac disturbances (Peter, Marty, Berthiot and Porak). These affec tions act, in turn, either rapidly or slowly, in determining the sudden or the slow development of hemiplegias. Second, we place albuminuria with or without eclampsia. We place last, as quite subordinate, and perhaps, doubtful, antemic hemiplegias, as well as those due to reflex action and to puerperal septicamia.
Frequeney.—Although not rare, puerperal paralyses are not very fre quent, but it is impossible to furnish reliable statistics, since many cases pass unobserved, owing to the coexistence of coma. The age of the patients does not seem to have a great influence, for, although there are more cases between twenty-five and thirty years, this is the age at which women generally become pregnant. Our outside figures were eighteen and forty-five years. Darcy gives twelve and forty-five years. Among thirty-five of our cases, twenty-four women were from eighteen to thirty years, and fourteen from thirty-two to forty-five years. Among thirty six of Darcy's cases, twenty-one were less than thirty years, and fifteen were from thirty to forty-three years. The same obtains as regards primiparte and multiparre. Our statistics are thug as follows: Thus, it is in the last two months of pregnancy that hemiplegins are the most frequent. After labor they appear, usually within ten days.
As regards the side on which the hemiplegia was located, Darcy has found: Right hemiplegia, 26; crossed hemiplegia, 2; left hemiplegia, 16; side not stated, 14.
Signs and Diagnosis. —There may be prodromata or these may be absent. Hemiplegias due to cerebral lesions commence, most frequently, suddenly, like an apoplectic attack. In women with albuminuria, how
ever, headache, disturbances of vision, or even convulsions, generally precede the attack by a few hours or days. The characters of the paralysis are as follows: Often it developes quickly, simultaneously invading the two limbs and even the face. Often, also, the upper and lower limbs are successively attacked. Sometimes the hemiplegia is incomplete, now affecting the upper extremity, and being accompanied by facial paralysis or amaurosis; now attacking the lower limb of the same or of the opposite side; now being limited to the face. It simultaneously involves motion and sensation, but is rarely attended by vesical or rectal difficulties. More rarely yet the intelligence is impaired. Generally it remains perfect after the patient has recovered consciousness. Speech is, indeed, affected, but that is due to impaired motility of the tongue, and, excepting in one case of our own, and in two of Tfmoin, in which delirium persisted several days, the intellect was unimpaired. Paralysis seems limited, in short, to motion and to sensation. The lesions of motility are the predominating features. Sometimes there is simply weakness or numbness, a,ccom panied, in some cases by tremors, formication, or more or less acute pains in the limbs involved. Sometimes the limbs are absolutely motionless and remain inactive in any position, without the patients being able to move them at all. Mobility may be progressively restored, or even rap idly, in a few hours or days. Sometimes the paralysis lasts several months before absolutely disappearing. In rare cases, death closes the scene, but patients generally recover, if not entirely, yet to such an extent as to re sume some of their occupations. Disturbances of sensibility present greater variety than those of motility, but exist habitually. In the major ity of cases, motility is notably impaired. There may be all kinds of an algesia and of ansesthesiEe, which may be the first symptoms of the pa ralysis. The patients notice that some part of their person first becomes insensible and then immobile. So the two symptoms, impairment of movement and diminution of sensibility, progress side by side, sensibility generally returning sooner in cases resulting in a cure. This change in sensibility, limited to the paralyzed side, or involving the other as well, is more or less profound, varies from the mildest analgesia to complete anaesthesia, and presents remissions and exacerbations accompanied by sensations of cold or heat, without these two' agents locally applied pro ducing appreciable phenomena. One may prick or pinch the patients without their knowledge. Again, there may be real hypertesthesia, always attended by sensations of cold or of heat.