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NEURITIS AND MYELITIS AND THE FORMS OF PAR- 
ALYSIS AND PSEUDO-PARALYSES FOLLOWING 
LABOR. 
By Charles K. Mills, M.D., 
Professor of Diseases of the Mind and Nervous System in the Philadelphia Polyclinic; Clinical 
Professor of Nervous Diseases in the Woman’s Medical College of Pennsylvania ; 
Lecturer on Mental and Nervous Diseases in the University of 
Pennsylvania ; and Neurologist to the Philadelphia 
Hospital. NEURITIS AND MYELITIS AND THE FORMS OF PAR- 
ALYSIS AND PSEUDO-PARALYSIS FOLLOWING 
LABOR.1 
By Charles K. Mills, M.D., 
Professor of Diseases of the Mind and Nervous System in the Philadelphia Polyclinic ; Clinical 
Professor of Nervous Diseases in the Woman’s Medical College of Penusylvania ; 
Lecturer on Mental and Nervous Diseases in the University of 
Pennsylvania ; and Neurologist to the Philadelphia 
Hospital. 
Neural and spinal affections of puerperal origin, although not 
entirely neglected, have received but little attention in the text-books 
and journals. Imbert-Gourbeyre2 refers briefly to the occurrence of 
paralyses from trauma during labor in a monograph on “ Puerperal 
Paralyses,” giving several cases. One of these, from Rademacher, was 
an incomplete and painful paraplegia coming on at the end of a long 
and difficult labor, and cured in eight days, chiefly by friction. Another 
patient, 36 years old, during her third labor was paralyzed in both 
extremities, and recovered in a few months. Salvat is recited as 
reporting the case of a woman treated by him for vesico-vaginal fistula, 
with paraplegia produced by the long stay of the head of the foetus in 
the inferior strait. Another patient, 32 years old, during her fourth 
labor, which was prolonged and the delivery by forceps, suffered great 
pain in the loins, accompanied by feebleness and swelling of the legs. 
The feebleness increased to paraplegia, and she had lancinating pains, 
paresthfsia and cramps in the limbs. I have cited these cases in a 
paper on “ Lesions of the Sacral and Lumbar Plexuses,” in which I 
1 Read before the College of Physicians, Philadelphia, March i, 1893. 
2 Imbert-Gourbeyre: M6m. de l’Acad. Imp. de M6d., tome xxv, 1861. 
3 Mills, Med. News, June 15, 1889. 2 
Charles K. Mills. 
have also reported two cases of sacral neuritis, kindly furnished me by 
Dr. Howard A. Kelly, of the Johns Hopkins Hospital. The first 
patient had passed through a difficult instrumental confinement some 
twelve years before coming under observation. She visited many 
prominent gynecologists and underwent a number of operations, the 
last being the removal of two large tubes and ovaries. She was 
relieved of menstrual exacerbations, but still suffered great pain in the 
pelvis, for which she was receiving galvanism, massage and antilithic 
remedies. A careful examination showed that the uterus and its sur- 
roundings were perfectly free from disease. On making a careful rectal 
examination, however, outlining the sacro-sciatic ligament and pyri- 
formis muscles, and carefully palpating the roots of the great sciatic 
nerve, upon touching one cord she gave a sudden scream, at the same 
time doubling up her leg and jerking her body in the bed. Here, 
directly over the roots of the left sciatic nerve—the left sacral plexus— 
was the only diseased area which could be detected in the pelvis. All 
subsequent treatment was directed to this condition. The second 
patient had constant pelvic pain, which she described as soreness, 
located at the “ back of the womb.” She had been for several years, 
since the birth of her last child, under the care of gynecologists, who 
had not been able to give her any relief whatever. It was found by 
exploration that the only point of tenderness in the pelvis was at the 
roots of the sciatic nerve, and here she at once located all her pain, 
when the doctor introduced his finger into the rectum and made press- 
ure on the nerve trunks. The case was one of neuritis. As Dr. Kelly 
remarks in the communication sending notes of these cases, they teach 
the value of exploration of the pelvis outside of the uterus and its 
annexes. 
Ramsbotham1 speaks of paralysis of both legs of varying degree 
occasionally happening after labor; more frequently when the process 
has been tedious and painful, but sometimes when it has been of 
ordinary duration, or even of unusual rapidity. He is evidently 
referring to the same classes of cases of wdiich we are treating in the 
present paper. “ It is not attended with cerebral affection,” he says, 
‘ ‘ but is dependent on pressure which the muscles and nerves have 
sustained during the passage of the child’s head through the pelvis. 
There is pain and numbness, both within the cavity and around the 
hip, and an inability to move the limb with freedom. It generally dis- 
appears by degrees wuthin a few days ; at other times it continues 
beyond the period the patient commonly remains in bed, and compels 
her when she rises from it to use a stick or a crutch. Fomentations in 
1 Ramsbotham : The Principles and Practice of Obstetric Medicine and Surgery. Am. ed., 
1865. Neuritis and Myelitis Following Labor. 
3 
the first instance, and afterward stimulating embrocations, a douche or 
shower bath, tonic medicines and gentle movement of the limb, will 
offer us the best chances of success. Hemiplegia, indeed, may appear 
after delivery as well as at other times ; but there will then be particular 
symptoms, independent of those connected with the local affection, 
which are too well known to require mention from us here.” 
Cazeaux and Tarnier,1 in the American edition of their treatise, 
translated by Hess, under ‘‘Lesions of Innervation,’’ direct attention 
to the various forms of paraplegia occurring during pregnancy or labor, 
most of which they attribute to reflex causes. Lloyd2 considers some 
aspects of the subject in a contribution to Hirst’s “ American System 
of Obstetrics.” 
Winckel3 introduces a brief chapter on the ‘ ‘ Neuralgias and 
Paralyses of the Lower Limbs,” with a paragraph which is compre- 
hensive in its presentation of the etiology of these affections: “The 
puerperal neuroses of the lowrer limbs are located chiefly in the nerve 
trunks, more rarely in the nerve centres, and generally owe their 
development to parturition. Injurious pressure is effected by a large, 
hard, child’s head, unfavorable in presentation in a small pelvis. 
Vigorous compression may result in complete interruption of conduc- 
tion at the compressed spot. This occurs in instrumental aid during 
labor, inasmuch as the rim of the blades of the forceps may produce 
severe contusion of the sacral plexus on forced closure as well as 
during extraction. The thick nerves are also compressed not infre- 
quently by a pelvic exudation, or small extravasations from the 
neighboring parts extend to the sheathes of the nerves, or hyperemia 
or edema of the neurilemma appear spontaneously. We have already 
mentioned that parametritis may give rise to such neuralgias. The 
location of the affection is in the external and middle cutaneous, 
obturator or sciatic nerves. The two latter nerves are especially apt 
to suffer during labor. Even the slight pelvic exudations, for example, 
one resulting from phlebitis, may make a nerve trunk incapable of 
conduction without compressing the entire trunk. (Leyden.) Injuries 
of the vagina, with subsequent severe cicatricial contraction, may 
also exercise traction and pressure on individual nerve trunks of the 
pelvis minor, and hyperesthesia and motor disturbances may thus be 
produced.” 
Brief references to this subject are also to be found in some of the 
neurological text-books, but it is not in these treated of systematically. 
To Dr. Anna M. Fullerton, of the Woman’s Hospital of Philadel- 
1 Cazeaux and Tarnier: Theory and Practice of Obstetrics. 8th Am. ed., edited and revised 
by R. J. Hess, M.D., 1887. 
2 Lloyd: Hirst’s System of Obstetrics by American Authors, Vol. 11. 
3 Winckel: A Text-Book of Obstetrics. Translated by J. Clilton Edgar, A.M., M.D., 1890. 4 
Charles K. Mills. 
phia, who, in her large obstetrical experience, has seen a number of 
instances of paralysis and pseudo-paralysis during the puerperium, I 
am indebted for the notes of some cases which will be given later. In 
a letter accompanying these notes she says that partial paralysis is in 
general short-lived, being limited generally to two or three days. . She 
has seen paralysis of the rectum and sphincter from long-continued 
pressure of the head upon the floor of the pelvis, which sometimes 
persisted for a week or ten days, and which was only overcome by 
faradism and time; also vesical paralysis, which has sometimes lasted 
up to the sixth, seventh, or twelfth day after delivery. According to 
Dr. Fullerton, cases of contracted pelvis, which, because of a narrow 
inlet, have resisted the engagement or descent of the head, and cases 
in which for any cause there has been impaction of the fetal head, 
have been those most commonly resulting in paralysis. 
The following are her notes of one of these somewhat serious but 
comparatively short-lived cases. Probably the case was one of pressure 
neuritis: 
“ M. M., married, a dwarf, aged 25 years; pubis generally con- 
tracted. The patient catne to the Woman’s Hospital maternity 
September, 1892, for her second confinement. The first stage of labor 
was very slow; descent of the fetal head very slow, with impaction in 
the pelvis before rotation; presentation, vertex, second posterior variety. 
There was threatened asphyxia of the child with exhaustion of the 
mother, which led to forceps delivery. The extraction was easy, and 
no laceration of the soft parts occurred. She complained, the night 
following delivery, of great pain in the right groin and entire right 
limb, and was unable to move the limb. Pressure on the anterior 
crural and obturator nerves caused her to cry out with pain. Flaxseed 
poultices were applied over the groin ; the limb was elevated and ban- 
daged with flannel. These symptoms lasted about ten days, and then 
entirely disappeared. She was out of bed by the third week, and able 
to return to her home the fourth week.” 
The most valable recent paper on puerperal paralysis of peripheral 
origin is that of Hiitiermann,1 assistant in the clinic of Gusserow, at 
Berlin, on “Paralysis in the Region of the Sciatic Nerve following 
Labor.” On examination of this paper, which I have obtained quite 
recently, I find that Hiinermann has reasoned with reference to the 
production of the most common type of these palsies in much the same 
manner as I had already presented the subject in the arena at the 
Philadelphia Hospital, and to my ward classes. He carefully traverses 
the literature of the subject, and his paper can be consulted with 
advantage for French and German references. Among the writers to 
1 Hunermann, Archiv. fur Gynakologie, Berlin, 1892, Vol. xlii, Part 3. Neuritis and Myelitis Following Labor. 
5 
whom he refers are von Renz, Koeppen, von Teyden, Kast, Mobius, 
von Basedow, Gerber, Breisky, Ritzmann, Kehrer, Dorion, Bianchi, 
Lefebre, Brivois, Guinon and Parmentier, and Handford, to .some of 
whom I shall have occasion to allude. 
The affections to which attention will be especially directed in the 
present paper can be conveniently discussed under five heads : 
(1) Traumatic paralysis of the peroneal type, usually associated 
with severe neuritis. 
(2) Sacral and sacro-distal neuritis, sometimes accompanied by a 
pseudo-paralysis, and often maintained or aggravated by disease and 
displacements of the pelvic organs and tissues. 
(3) Puerperal neuritis, local or multiple, and due to septic or other 
infection. 
(4) The neuritis, paralyses, and pseudo-paralyses of phlebitis, and 
phlegmasia alba dolens, which are often septic, but have special 
features. 
(5) Puerperal myelitis occurring under the same conditions as the 
forms of septic and infectious neuritis. 
Brief references will also be made to forms of hysterical and reflex 
paralysis which must be diagnosticated from the affection under con- 
sideration. Some cases illustrative of each of the classes mentioned 
will be presented, the first class, however, receiving the fullest discus- 
sion. The first three cases are interesting examples of this type of 
paralysis and neuritis. 
Paralysis of the Peroneal Type and Associated Neuritis 
AFTER IyABOR. 
Case I—Prolonged labor and forceps delivery; left peroneal paralysis, 
anesthesia, and neuritis; recovery from the neuritis and persistence of the 
paralysis; previous history of syphilis.—The notes of this case were pre- 
sented to the Philadelphia Neurological Society, and were published 
with the discussion.1 I shall give them here somewhat condensed. 
Mrs. W., aged 30 years, had been twice married, and believed that 
she had been infected writh syphilis by her first husband in 1884. In 
1889 she married again, and was in labor June 3, 1891. The labor was 
prolonged and painful; instruments and chloroform were used. On 
recovering from the anesthetic she felt a severe pain in the left hip, leg, 
and foot. The limb was paralyzed, and from this time she suffered 
with all the symptoms of a severe neuritis, which continued with little 
abatement for about three months, when it began to decrease. In 
October it had almost entirely disappeared, but the left leg was still in 
an extreme condition of motor paralysis. 
1 Journal of Nervous and Mental Diseases, February, 1892. 6 
Charles K. Mills. 
Five weeks before she was examined by me she was suddenly 
stricken, without unconciousness, with an attack of paresis in the left 
upper extremity, and some difficulty of speech, from which, however, 
she recovered. The attack was cerebral, and has no bearing upon the 
problems discussed in this paper, except in so far as syphilis was prob- 
ably the predisposing cause of both conditions. 
On examination, it was found that all the movements of the muscles 
below the knee supplied by the branches of the external popliteal or 
peroneal nerve were paralyzed and non-responsive to electric currents. 
The foot was swollen, purplish in color, and cold. No loss of sensation 
was found anywhere, but she still had great pain on pressure at the 
sciatic notch, and in such cords of the sacral plexus as could be reached 
by the rectum. The muscles above the knee, and also the gastrocne- 
mius, soleus, and posterior tibial, were not affected. Knee-jerk and 
muscle-jerk were normal on both sides. Bladder and rectum were not 
involved. 
In the discussion of this case,1 Dr. Wharton Sinkler spoke of a 
case which had fallen under his care. The patient was a small woman, 
a primipara, and the labor was instrumental and very difficult. On 
recovering from the anesthetic she complained of severe pains in the 
legs, and the pain and hyperesthesia continued for several weeks. He 
saw the patient in consultation about six weeks after labor. There was 
then contraction of the knees, and the muscles were considerably atro- 
phied. Extreme hyperesthesia was present, especially below the knee, 
but no special pain over the nerve trunks, no loss of reflexes, and no 
loss of response to the faradic current. The patient recovered entirely, 
and in two months was perfectly well. The neuritis was complete and 
equal in both legs. 
In the same discussion, Dr. F. X. Dercum reported a case which 
he saw some months after labor. Great violence had been used. 
Paralysis and wasting were both present. The type of the paralysis 
was not specified in either of these cases. 
Case: II—Left peroneal paralysis and, anesthesia ; neuritis after two 
weeks; recovery from the neuritis; persistence of some paralysis, but very 
great improvement.—Mrs. H., aged 33 years, was confined May 23, 
1892. She was in labor twenty-one hours, with severe, almost constant 
pain during the last ten hours. She was under the influence of chloro- 
form for nearly an hour, and was delivered by forceps. After delivery 
she found that her left leg was paralyzed and anesthetic, requiring to 
be lifted for all purposes. During the third week pain began in the 
hip, and rapidly became more and more severe, extending down the 
legs to the toes. Soon the other leg was attacked w'ith a similar but 
1 Ibid. Neuritis a?id Myelitis Following Labor. 
7 
less severe pain. Sometimes the pain was darting and burning, and 
the left foot was extremely sensitive to handling. Some loss of power 
was present in the right leg. She continued to have great pain, and 
was only able to stand or walk with the aid of a cane, and with much 
suffering on making the effort. Her treatment consisted of partial 
rest, the use of anodynes with liniments externally, and the internal 
use of morphine, atropine, and occasionally the bromides. Hypodermic 
injections of morphine and atropine were necessary for some time; but 
the morphine had unpleasant constitutional effects upon her, causing 
nausea and dizziness, so that it could not be continued. 
This patient was first examined by me early in September, 1892. 
Her left leg was extremely sensitive over both its anterior and posterior 
aspects, especially above the knee in the left popliteal space. On the 
right side similar hyperesthesia was present, but not nearly so marked. 
Lateral squeezing of the left foot caused considerable pain, which was 
absent in the right. Examination both by the rectum and vagina 
showed extreme sensitiveness of the nerves of the pelvis, particularly 
on the left side. Until a week or two before coming under observa- 
tion, moving about and sitting down with a slight jar would cause 
pain, which, she said, “ seemed to be in the bones on each side of the 
rectum.” No paralysis was present in the right lower extremity. The 
movements of this leg were almost perfect, showing only a little weak- 
ness. Below the left knee she was totally paralyzed for the movements 
of dorsal flexion at the tarsus, and of extension of the phalanges of the 
great toe and of the other toes. Movements controlled by the posterior 
muscles of the leg below the knee were present. 
Believing that she had suffered from a crushing of the lumbo- 
sacral cord and upper sacral nerves and a consequent neuritis, and that 
this neuritis was still present and active, although improved, she was 
placed in bed with sandbags to her limbs; and upon the use of hot 
douches, mercurial and atropine inunctions, salicin and other remedies 
internally, in accordance with a plan of treatment which will be dis- 
cussed later. After the neuritis had largely subsided, galvanism, 
massage and Swedish movements were systematically employed. The 
patient returned to her home cured of her neuritis, and with only 
partial paralysis of her anterior tibial remaining. She is still treated 
at her home with galvanism. 
Case III—Probable neuritis before labor; prolonged labor and 
forceps delivery; neuritis and right peroneal paralysis; recovery from 
neuritis, but persiste7ice of some paralysis.—Mrs. R., aged 24 years, had 
been healthy before her marriage. For a week before her first child 
was born she suffered severe pelvic pain. Labor was prolonged, and 
she was delivered with instruments. Before delivery she complained 8 
Charles K. Mills. 
of severe pain, commencing at the hip and extending to the toes of the 
right foot; and just at the time of the birth of the child she felt a very 
sharp pain, commencing at the hip and extending downward to the toes 
of the right foot. After delivery the pain and tenderness spread 
through the entire limb, every movement and jar of the leg causing 
suffering. On the ninth day she attempted to get on her feet,, but 
found that the right leg was nearly helpless, and the pain on move- 
ment was so great that she was forced to lie down. This condition 
continued for five weeks. She thought the pain had been most severe 
on the outside of the limb from the ankle to the hip. At the end of 
five weeks she was able to walk, but found that she had not the proper 
use of her foot. She was not aware of having had at any time loss of 
sensation. 
She came as an out-patient of the Polyclinic Hospital, remaining 
for a few weeks, and then disappearing from the service. She was 
sent for, however, and examined by me again January 28, 1893. In 
the meantime she had had another child, October 15, 1892. The con- 
dition of her leg was practically the same as at her first appearance at 
the Polyclinic service, although the woman herself claims that she had 
had better use of her limb since her last confinement. While having 
the second child she experienced pain similar to that from which she 
suffered during the birth of the first child, but of less severity. 
She has at present no sensory symptoms. The right leg below the 
knee is a little smaller by measurement than the left; circumference of 
the left calf is 13.5; of the right, 12 inches. The movements now com- 
pletely paralyzed are those of the tibialis anticus and peroneus tertius 
muscles. Dorsal flexion of the great toe and of the other toes can be 
performed, but flexion at the tarsus cannot. The extensor longus 
digitorum and extensor proprius pollicis muscles are, therefore, at 
present not paralyzed. Faradic and galvanic contractility are abolished 
in the anterior tibial and peroneus tertius—in fact, these muscles have 
largely disappeared. 
A summary of Hiinermann’s four cases will be of interest in con- 
nection with these reports: 
His first case was a primipara, aged 36 years. Labor began Jan- 
uary 22, 1892, in the morning. On the 23d she had severe pain and 
convulsive movements of the right leg. Forceps delivery under an 
anesthetic was unsuccessfully attempted, when she was transferred to 
Berlin, a few miles distant, arriving January 24th, at the Charity Hos- 
pital, after three and a half days’ labor. Details of her condition are 
given by Hiinermann. Perforation and extraction were performed. 
The child had evidently been dead for some time, but the puerperium 
passed favorably. On the morning after confinement Hiinermann dis- Neuritis and Myelitis Following Labor. 
9 
covered complete paralysis of the right peroneal nerve. The woman 
complained of severe pains in the course of the sciatic, also of a feeling 
of numbness on the outer side of the left calf, and of tingling and creep- 
ing sensations in the toes. She could not dorsal-flex the right foot or 
extend the toes, nor sink the inner border of the foot; but she could 
with considerable force bend the foot downward; she could also flex the 
toes and execute all the movements of the knee and hip joint without 
difficulty. There was not the slightest disturbance of sensation. Dur- 
ing the first three nights her sleep was completely interrupted by the 
pains in her legs. Wrapping the leg in cotton and bandaging it gave 
some relief. From the fourth day the patient was treated with the far- 
adic current; but when on the thirteenth day she got up the muscles 
supplied by the peroneal were completely paralyzed. On the sixteenth 
day she was carefully examined and depression of the electrical excita- 
bility of the paralyzed muscles was established. She received a daily 
bath and electricity. The impairment in motility was still noticeable 
at the end of the third week, when the patient left the hospital. Her 
walk wTas still greatly affected. 
Hiinermann’s second case was a primipara, aged 16 years, of frail, 
bony development, and childish in looks. Measurements were taken, 
which showed a contracted pelvis. The patient was at the end of her 
normal pregnancy. The child was in the first position on admission, 
January 22d. Details are given of the labor, w7hich was tedious and 
halting, the pains becoming stronger until the 25th. The head had 
entered the pelvis with a remarkably low position of the fontanelle. 
Toward evening the patient felt pain and a feeling of numbness and 
tingling in the right calf downward from the knee; and she could not 
step on the right foot when she got up to pass water. She was deliv- 
ered January 25, under an anesthetic, with the forceps, of a slightly 
asphyxiated girl, well developed, and showing a long line of pressure, 
which began about the right frontal eminence at the border of the hair, 
and reached diagonally to the left and backward. Hiinermann partic- 
ularly mentions this pressure line, which only disappeared on the tenth 
day, and was in his opinion not caused by the forceps, but by the linea 
innominata, which had resisted the progress of the child’s head. On 
the first day of the puerperium the mother was found to have a complete 
paralysis of the peroneal nerve. As in the previous case, the phenomena 
were the same during the first few days, being without disturbance of 
sensibility, but with complete loss of function of the groups of muscles 
supplied by the peroneal nerve. She complained of painful twitching 
and of numbness in the right calf. On the evening of the first day fever 
set in, lasting until the thirteenth day. The perineum was ruptured; 
involution of the uterus was faulty, and the lochia of bad odor until 10 
Charles K. Mills. 
corrected by the antiseptic douche. On the seventh day and later she 
developed great pain in the right trochanter, and other symptoms of a 
descending neuritis. She suffered from headache and insomnia. She 
left her bed on the fifteenth day. On the twentieth day examination 
showed unequal pupils, not reacting to light, and not contracting on 
convergence; knee jerk was missing on both sides. The ocular and 
knee phenomena are referred by the reporter to an attack of diphtheria 
which the girl had in her ninth year; or, perhaps, to congenital syph- 
ilis. She undoubtedly, however, had paralysis of the right peroneal 
nerve, which only developed in connection with or following the labor, 
although Hiinermann says that it must be admitted that a previous 
disturbance of her central nervous system had predisposed her to an 
affection of the peripheral nerves. Several weeks after labor only 
a slight improvement in the peroneal paralysis had been accom- 
plished. 
The third case of Hiinermann was a well-built woman wfith normal 
pelvis, aged 34 years, who had given birth to five living children with- 
out artificial aid. She was delivered in twelve hours, under chloroform, 
with forceps. The child was dead. Immediately after reaction from 
the anesthetic she felt strong, cramp-like pains in the left leg. She con- 
tinued constantly to complain of pain in this leg, but Hiinermann dis- 
covered a complete paralysis of the muscles supplied by the peroneal 
nerve of the left leg, while tactile sensibility was undisturbed. She 
had a hematoma in the left wall of the vagina, which disappeared in 
about two weeks. No pelvic exudate could be found. Paralysis with 
reactions of degeneration in the muscles supplied by the peroneal nerve 
continued. An examination made ten months after labor is given. 
The left leg was then somewhat atrophied on the anterior rnd outer 
side. The sciatic was not especially sensitive at the great seiat:c notch 
and trochanter major upon pressure; but distinct pain was present 
wrhen the head of the tibia was pressed. Knee-jerk was more marked 
on the left than on the right. Sensibility was not disturbed. This 
case of paralysis Hiinermann believes was due to the application of 
forceps, and as favorable to this view was the fact that the woman at 
once after the operation felt the pain in the left leg. A pressure of 
the roots of the sciatic nerve could easily take place; again, it was the 
lumbar roots which especially suffered, while the sacral nerves were 
very little affected. The case reminds him of one of the cases reported 
by Bernhart of left-sided peroneal paralysis after forceps delivery. In 
this case, also, forceps were applied in the high position, and the second 
position of the head. 
The fourth case, M. R., aged 37 years, had gone through four 
hard confinements, all the children being born dead; she had had three Neuritis and Myelitis Following Labor. 
11 
forceps deliveries. At the last confinement, after application and use 
of the forceps, she had a sudden tearing pain in the left side of the 
pelvis; at the same time she had strong jerking in the left leg. Since 
then she had been paralyzed in the same leg, and shortly after confine- 
ment she had wearing and jerking pains in this leg. She had no 
fever or parametritis after labor. Being disabled from walking, and 
the treatment at her home not being satisfactory, she came, six months 
after her confinement, to the medical clinic of Dr. Goldscheider, where 
Hiinermann had the opportunity of examining her. He found an 
otherwise healthy woman who showed no signs of disease of the inter- 
nal organs, with a marked paralysis in the region of the peroneal 
nerve, while the muscles of the tibial (internal popliteal) nerve were also 
affected. The paralyzed muscles were distinctly atrophied. Her walk, 
though awkward and clumsy, was quite possible without apparatus. 
Electrical examination showed complete reaction of degeneration in the 
left peroneal region; and in the region of the left internal popliteal a 
slight quantitative change to both currents was present. 
I have thought it worth while to summarize these cases of Hiiner- 
mann in connection with my own records, as the subject is one that 
has not been discussed in detail by writers; and in particular, the type 
of paralysis which so often results has not been pointed out, so far as I 
know, except by Hiinermann. 
In the cases described or referred to by Imbert-Gourbeyre, Rams- 
botham, Winckel, Lloyd, Kell)r, Fullerton, and others, no reference to 
any special form of paralysis has been made. 
This question of the particular type of paralysis which results is 
one of the most interesting connected with the subject in hand. It will 
be recalled that my three cases were left with persistent paralysis in all, 
or some of the muscles supplied by the branches of the external pop- 
liteal or peroneal nerve. The cases of Hiinermann were also of this 
type, and his paper is largely devoted to an exposition of the anatomi- 
cal reasons for the occurrence of this particular form of paralysis. I 
had arrived at almost identical conclusions with those of Hiinermann 
before I saw his paper, but I am indebted to him for interesting details 
and particular points in the anatomical explanation, of which I shall 
make use. 
The sciatic nerve arises from the apex of a triangle formed by the 
sacral plexus at the distal border of the pyriformis muscle. The 
plexus lies on the anterior surface of this muscle in such a manner that 
the first sacral lies above the proximal, and the third under its distal 
edge, the second sacral being between the two on the anterior surface 
of the muscle. While the plexus thus lies with its sacral roots on a 
soft layer of muscle, the lurnbo sacral nerve (lumbo-sacral cord), 
rising from fibres given off in part from the fourth and wholly from 12 
Charles K. Mills. 
the fifth lumbar nerve, glides almost immediately upon a bony base 
over the sharp linea innominata. This lumbo sacral nerve is mainly 
the root for the peroneal or external popliteal nerve. The superior 
gluteal nerve arises from the posterior part of this lumbo-sacral cord; 
and, therefore, we would expect to and do find it affected in some of 
these cases of puerperal paralysis. 
Lefebre, among others, has proved that the peroneal or external 
popliteal nerve is a continuation of the lumbo-sacral cord; and rare 
cases have been reported in which it could be traced as a separate 
nerve all the way from the pelvis. 
A study of this kind shows how anatomico-physiological investi- 
gation and practical medicine sometimes reciprocate their services. 
One of the important problems in spinal and peripheral localization is 
the determination of the relationship of particular segments of the spinal 
cord to certain nerve movements, reflexes and areas of sensation. M. 
Allan Starr1 has published a table of the localization of the segments 
of the spinal cord, which has been modified and added to by me in a 
paper on “ Spinal Localization.” 2 The results embodied in these tables 
were arrived at by physiological, clinical, clinico-pathological, anatomi- 
cal and histological investigations. In the present study practical 
obstetrics assist us to a decision as to the segmental origin, root and 
exact course of one of the most important nerves of the lower 
extremities. 
Below is given from this table that portion which relates to the 
localization of the representation of movements of the lower limb in 
the spinal cord from the fourth lumbar to the second sacral segment: 
Fourth Lumbar Segment : 
Muscles.—Abductors of thigh. 
Adductors of thigh. 
Flexors of knee. 
Tibialis anticus. 
Peroneus longus. 
Fifth Lumbar Segment : 
Muscles.—Outward rotators. 
Flexors of knee. 
Flexors of ankle. 
Peronei. 
Extensors of toes. 
First and Second Sacral Segments : 
Muscles.—Flexors of ankle. 
Extensors of ankle. 
Intrinsic foot muscles. 
1 Starr: Araer. Journ. Neurol, and Psych., 1884, and Amer. Journ. Med. Sci., 1888. 
2 Mills: Therapeutic Gazette, May 15 and June 15, 1889. Neuritis a?id Myelitis Following Labor. 
13 
The chief divisions of the peroneal are the anterior tibial and mus- 
culo-cutaneous nerves, the former supplying the tibialis anticus, exten- 
sor longus digitorum, peroneus tertius and extensor proprius pollicis 
muscles. One of the branches of the anterior tibial also supplies the 
extensor brevis digitorum ; and from the musculo cutaneous nerve are 
given out fibres to the peroneus longus and brevis. Any or all of the 
subdivisions of the peroneal may be affected in these traumatic puer- 
peral palsies, but the movements controlled by the anterior tibial are 
most likely to remain persistently paralyzed, as a brief reference to the 
movements effected by these muscles alone, or in groups, in connection 
with a study of the details of the cases, will serve to make clear. The 
tibialis anticus muscle elevates the inner front portion of the foot, flex- 
ing it at the ankle joint and adducting it. The extensor longus digi- 
torum, commonly working with the extensor proprius pollicis, extends 
the toes and, continuing, helps to flex and abduct the foot. The pero- 
neus tertius is really a part of the extensor longus digitorum, and 
works with the anterior tibial in the direct flexion of the tarsus upon 
the leg. The peroneus longus and the peroneus brevis, which are sup- 
plied by the musculo-cutaneous, evert and rotate the foot outward. 
A study of these facts of the table shows that the movements par- 
alyzed in these cases of puerperal traumatism are those of the muscles 
supplied by the peroneal or external popliteal nerve, and that these 
movements have their representation chiefly in the fourth and fifth lum- 
bar, and the first sacral segments of the spinal cord, where the lumbo- 
sacral cord and first sacral nerve evidently arise. 
It is a fair question whether the spinal cord does not become sec- 
ondarily diseased by extension of the inflammation backward along the 
great nerve cords assaulted. The paralytic-, trophic, and vasomotor 
phenomena presented by some of the cases are difficult to distinguish 
from the conditions due to a complete crushing of a large nerve root 
or cord. 
While a complete crushing ot the lumbo-sacral cord and of the 
upper sacral nerves would account for a long and persistent palsy of the 
muscles supplied by these nerves, it is not unlikely that the neuritis in 
some of these cases not only extended and diffused itself throughout 
the extremity, but has ascended and entered the cord, and attacked 
the ganglion cells of the cornua, giving us, in a word, a neuro- 
myelitis. 
In connection with this point the method of the extension of the 
inflammation from one limb to the other is of interest. This occurs 
after a longer or shorter time ; the two limbs are not coincidently 
affected with the inflammation. It is probable that the inflammation 
extends not in the pelvis nor by way of the cord proper, but rather by 
the cauda equina, spreading sidewise from one closely apposed nerve or 
nerve-sheath to another. 14 
Charles K. Mills. 
Although these peroneal palsies usually occur in cases of instru- 
mental delivery, the traumatism which produces them is not commonly 
inflicted by the forceps. The labor is instrumental because, owing to 
a contracted pelvis, it is greatly prolonged. The injury to the nerve 
cords is usually inflicted by the skull of the child, although nerve 
injuries are doubtless sometimes inflicted by instruments. Hiinermann 
speaks of this being the case sometimes when pendulum, side to side, 
and rotating movements are made. One practical point in the diag- 
nosis of nerve injuries made by the forceps from those caused by the 
head of the child is that in the former the second and third, and even 
lower sacral nerves are most likely to be injured, and in the latter the 
lumbo-sacral cord and first sacral nerve. Cases have been reported in 
which, from instruments, the posterior calf muscles—those supplied by 
the internal popliteal—have been paralyzed instead of those supplied by 
the external popliteal or peroneal. In one case which has come to my 
knowledge, a sharp pain came on immediately after the application of 
the forceps, and the patient said that this pain was much greater than 
any endured during the prolonged labor. She was at the time partially 
under the influence of ether, but cried aloud with the pain in her leg 
when the forceps were applied. The pain, she said, was different from 
the ordinary labor pain, although in her case this was extreme. After- 
ward she had some neuritis, which continued for six weeks, and when 
she was up and walking about she was quite lame for at least two weeks. 
This was probably an instance in which some portion of a nerve has 
been pinched—one of the cords of the plexus, and probably the second 
or third. 
From several points of view prophylaxis is of great importance in 
these traumatic cases. Certain obstetrical questions need to be more 
fully considered than can be done by one who, like myself, is not an 
obstetrician. The reports of the cases by Hiinermann have a value not 
possessed by the records of my own cases, in that he gives certain 
important obstetrical details, such as the positions of the head and pel- 
vic measurements. These measurements, according to him, in some of 
the cases showed a generally contracted pelvis. Certainly these cases 
emphasize the importance of taking pelvic measurements. Instrumen- 
tal delivery should, if possible, be effected comparatively early ; or 
even the propriety of resorting to perforation or Caesarean section should 
sometimes be taken into consideration. The delay in using forceps, 
rather than the forceps, is sometimes responsible for the nerve crushing, 
neuritis, and paralysis. 
According to Hiinermann, these accidents should not occur in nor- 
mal pelves, except in face and brow presentations. He quotes two Neuritis a?id Myelitis Following Labor. 
15 
cases from Gerber, in one of which the presentation was of the face, the 
brow forward and to the right. 
It is a striking fact that two sisters of one of my patients died in 
labor within two months of her own delivery. The three sisters may 
all have had generally contracted pelves. In the simple flat pelvis and 
the rachitic flat pelvis, according to Hiinermann, if instruments are not 
used, paralysis is not likely to occur, the oblique diameters of the pelvis 
being rather above than below the average in these cases. 
Sacral and Sacro-Distal Neuritis without True Paralysis, 
Although Sometimes Accompanied by Partial or 
by Pseudo Paralysis. 
During labor, especially when prolonged, and sometimes even 
during the last stages of pregnancy, as the result of friction and press- 
ure, a lumbo sacral neuritis of varying intensity arises, and may 
continue for a longer or shorter time, according to the constitution of 
the patient, the state of the uterus and other pelvic organs, and the 
course which is pursued in the management of the patient. Some of 
the cases which are alluded to by Dr. Fullerton, as instances of short- 
lived partial paralysis, are doubtless of this class, as, for instance, the 
one of which brief notes have been given in the introductory portion 
of this paper. This woman suffered great pain in the groin and limb, 
and was unable to move the latter, and pressure on several nerve 
trunks caused much suffering. In three weeks, however, she was 
practically well, the pain and paresis having disappeared in ten days. 
Every general practitioner will have in mind some case of this char- 
acter, which has recovered under rest, and which rest has been com- 
pelled by the patient’s suffering as much as by the advice of the doctor ; 
or has recovered without rest or treatment through the robust recupera- 
tive powers of the individual; but not a few patients of this class are 
practically neglected, all the conditions present not being fully recog- 
nized, and the treatment, as a rule, not being sufficiently painstaking 
and thorough. 
Altogether similar in their symptomatology are some cases, which 
appear to have no immediate connection with the processes of preg- 
nancy or labor, but are due to the irritation which is maintained by 
the nagging of an enlarged or displaced uterus, or by disease and 
enlargement of the ovaries and tubes, or by inflammatory processes in 
the pelvis, no matter how they may have originated. I wish, however, 
especially to direct attention to a set of cases which seem to date 
back to a particular labor, although they have evidently been aggra- 
vated and perhaps continued by conditions which may or may not be 
associated with the puerperium. I could give notes of many minor, 
although sufficiently troublesome, cases of this description, but I shall 16 
Charles K. Mills. 
content myself with presenting the details of one case in which the 
symptoms were severe and striking. This history will be presented 
without special comments, as the details speak clearly for them- 
selves. 
Case IV—Sacral neuritis; pseudo-paralysis; anemia and neuras- 
the7iia.—W., aged 33 years, had never been very strong, and 
when a child had been subject to precordial and other neuralgic attacks. 
Her mother had been subject to headaches and neuralgic attacks, and 
her only sister had had chorea when a child. Menstruation started when 
she was 12 years old, and had always been free, lasting usually 
from five to seven days. She was almost continuously pale and 
anemic-looking. She had had three children. Six years before 
coming under observation, while carrying her first child, she began to 
suffer with pain from the heel to the hip of the left leg ; this never 
entirely left her, and with each child she had become worse. After 
the birth of the third child, about one year before she was first seen, it 
became more severe, and she was compelled to use crutches for a month, 
chiefly because of the suffering it caused her in attempting to walk. 
At frequent intervals, also, she had exacerbations of pain in the left 
leg, and paroxysms of pain in the back, usually compelling her to go 
to bed. Her suffering was so great, and at times the limb was so 
helpless, that she could not move it. 
Careful examination showed great sensitiveness, particularly over 
the sciatic distribution, although not confined to it. The right lower 
extremity was also sensitive to pressure and handling, but not nearly 
to so marked a degree. Examinations were made both by the rectum 
and the vagina, and revealed extreme sensitiveness over the left sciatic 
plexus, less marked on the right side. The uterus was found to be 
prolapsed, enlarged, and completely retro verted, with pelvic exudations 
and adhesions. The os was patulous, and slight cervical and perineal 
lacerations were present. The ovary and tube on the left side were 
tender and somewhat enlarged ; the same conditions, but much less in 
degree, were present on the right. The uterus ajid surrounding tissues 
were all extremely sensitive. In brief, the nerves and the other organs 
and tissues in the pelvic cavity were in an inflammatory state, much 
more decided on the left. Treatment was instituted with the threefold 
purpose of improving the general health, of relieving the neuritis, and 
of restoring the uteru$ and its appendages as nearly as possible to a 
healthy state. She was placed in bed with sand bags to her limbs ; 
mercurial inunction, with atropine, were used twice daily ; strychnine, 
salicin and iron were given internally, with at times other tonics and 
nutrients and anti-neuritic remedies ; hot douches were used to the 
limb twice daily, and she was placed upon a nourishing and digestible Neuritis and Myelitis Following Labor. 
17 
diet. Phenacetin and sulphonal were occasionally used for pain and 
sleeplessness. 
The gynecological treatment was carried out by Dr. M. I. Bassette. 
Douches of hot water with opium and glycerin were used nightly; 
every other day for a time vaginal tampons, medicated with belladonna 
and boro-glyceride, and later with a io per cent, solution of ichthyol, 
were introduced. Gradually the exudate diminished, and the uterus 
became smaller and movable, when it was replaced daily, and the 
patient was made to assume the knee-chest position twice a day. The 
sensitiveness, both internal and external, steadily improved, and the 
attacks of paroxysmal pain become less and less frequent. 
After six weeks of treatment a consultation was held with Dr. 
B. F. Baer. The uterus was still enlarged, with a tendency to retro 
version, unless held in position with tampons. It was decided to 
curette with a view to decrease its size, and lessen the tendency to 
engorgement. After the operation the uterus was thoroughly washed 
out and injected with carbolic acid at intervals of a few days. She was 
also subsequently treated for three weeks with carbolic acid and iodine, 
at intervals of a few days. She was also given ergot and nux vomica, 
and under this treatment the uterus became smaller and less vascular, 
and remained in position longer without support. 
After three months the patient returned home, the neuritis having 
disappeared, and the uterus and its appendages in such condition as to 
require only occasional treatment. 
In all cases of this kind, and even in cases in which the symptoms 
are much less striking, careful examination should be made by the 
vagina and the rectum. The finger, guided by certain well-known 
landmarks, can reach some of the cords of the sacral plexus. Press- 
ure upon, or even a gentle touch of the inflamed nerves will cause 
excruciating pain. Any nerve pressed or rolled on a hard substance 
like bone, will of course be a source of pain, but the suffering which is 
experienced in cases of true neuritis is of scarcely endurable character. 
With a little practice we become more and more skillful in reaching 
the nerves, and in distinguishing between the pain of inflammation and 
an ordinary hurt of the nerves. 
The large nerve cords of the sacral plexus are not alone inflamed 
in these cases, but the inflammation may spread to the nerves dis- 
tributed everywhere in the pelvis, and to the nervous plexus to the 
uterus, which, Rein1 has shown, lies mainly in the cellular tissue 
surrounding the vagina, at the point where the hypogastric plexus 
1 Societe de Biologie, quoted in American Journal of Obstetrics, vol. xvi, 1888. 18 
Charles K. Mills. 
anastomoses with the filaments of the sacro-uterine nerves. All the 
fibres which go to the uterus, either from the hypogastric plexus or 
from the sacral nerves, pass through this plexus. This accounts for 
the extreme sensitiveness of such patients, even to careful vaginal 
examination. 
One mode in which the post-puerperal paralysis may develop is 
through inflammatory processes originating anywhere or anyhow in 
the pelvis. Hiinermann refers to this cause and cites a few cases. 
Intra- pelvic exudation may be of such size as to cause pressure, or the 
exudate may involve the lumbo sacral cord or sacral nerves. To such 
cases I have also called attention in my former paper on sacral and 
lumbar lesions. Hiinermann refers to three cases reported by Von 
Ueyden, of severe sacral neuralgia, all having high fever. In one of 
these cases an autopsy was had and showed peritonitis, pleuritis and 
numerous thrombotic veins in the pelvis, one of which ran close to the 
sciatic, and was bound to it by infiltrations. Microscopic examination 
showed both peri-neuritis and neuritis. Von Dorion has described a 
case with abscess in the left pelvis and peroneal paralysis after labor. 
Puerperal Neuritis Due to Septic or Other Infection. 
In a third class of cases, puerperal neuritis, isolated, diffused, or 
multiple, and probably infectious in origin, is present. A few writers 
have reported cases of multiple neuritis shortly after normal labor. 
Auto-infection has been suggested as the best explanation. Some of 
these cases occur during pregnancy, thus indicating their non-traumatic 
origin. In some the neuritis and consequent paralysis has been in part 
or chiefly in the upper extremities, as in cases reported by Mobius and 
Kast. The symptoms present need not be detailed : they are in brief 
those of neuritis, local, diffused or multiple ; pain, hyperesthesia, par- 
esthesia, paralysis or pseudo-paralysis; sometimes anesthesia; often 
changes of the reflexes ; cramps and contractures, and occasional atro- 
phies and reactions of degeneration. Usually these cases occur in the 
first, second or third weeks after labor, but they may follow immedi- 
ately or at a later period than three weeks. Theoretically no good rea- 
son exists why, as the result of infection either from without, or perhaps 
from within, any form of puerperal neuritis may not occur, and it is of 
some practical importance to separate traumatic cases from those which 
have a septic or infectious etiology. 
Mobius1 has reported the case of a woman, aged 29 years, who, 
two days after arising from bed, and three weeks after the birth of her 
child, had a sense of painful cramp in the left calf, which kept her in 
Mobius : Miinchener medicin. Wochenschr., 1892, No. 45, p. 799. Neuritis and Myelitis Following Labor. 
19 
bed for three weeks, at the end of which time some enfeeblement of 
movement of the forearms manifested itself. A few days later there was 
complaint of pain in the scapular regions, which lasted for a week. Then, 
in the ninth week, peculiar sensations in the right forearm were per: 
ceived ; and the act of writing could not be performed, because the thumb 
failed to firmly grasp the pen. The flexor longus pollicis was wasted and 
presented reactions of degeneration. Electrical treatment was followed 
by little improvement. In a second case a woman, 55 years old, com- 
plained of pain at the right elbow, which readily yielded to ordinary 
measures. Examination, however, disclosed the fact that atrophy of 
the ulnar and thenar muscles had been present for thirteen years, first 
showing itself shortly after labor. Motility was not materially impaired, 
and electric reactions were presented. Both cases were considered to 
be instances of neuritis of puerperal origin. Mobius1 also records the 
case of a patient who had had perfectly normal labor; the puerpe- 
rium was free from fever. She first complained of pain and paresthesia 
in the upper extremities, with diminution of motor power; two weeks 
later the same symptoms were present in the legs, no anesthesia, 
reflexes normal, as were also the responses of the muscles to mechani- 
cal irritation ; the muscles were somewhat atrophied in the upper 
extremities, but not in the lower. Recovery occurred under treatment 
by iodide of potassium. Eater she had a mild form of neurasthenia, 
but without any of the above symptoms of neuritis, except tenderness 
on pressure over the brachial plexus. Mobius considers the initial 
localization of the illness as characteristic, for in the later course all 
forms of neuritis may become general and give us the same picture. 
Handford,2 in a brief communication on the puerperium as a factor 
in the origin of multiple neuritis, has reported three interesting cases. 
Two of these bear out his diagnosis of multiple neuritis. In both, 
alcohol was a predisposing factor. As the notes of these cases are 
brief I will give them. 
K. M., aged 43 years, married seven years, three children; has 
always been a stout, florid, healthy woman. Her husband kept a 
public house, but evidence of drinking habits in the patient could not 
be obtained. Three days after her confinement she lost power in the 
legs, and at the same time felt strange sensations like pins and needles 
in the arms. This was soon followed by paralysis. She had been able 
to walk about up to the date of her confinement. The general course 
and character of the paralysis was typical of an alcoholic multiple 
neuritis. There was loss of muscular sense, impsired cutaneous sensi- 
1 Referred to by Hiinermann. Abstracted in Journal of Mental and Nervous Diseases, Jan- 
uary, 1891, Vol. xvi, No. 1, p. 45. 
2 Handford, British Medical Journal, November 28, 1891, Vol. ir, p. 1144. 20 
Charles K. Mills. 
bility, but greatly increased deep sensibility, great muscular wasting, 
loss of knee-jerks, and the presence of the reactions of degeneration in 
the muscles of the legs and arms. The condition of the eyes was 
normal. She was able to walk a little in six months, and in twelve 
months was comparatively well. 
The second case was a stout, well-nourished woman, aged 34 years, 
also the wife of a public-house keeper. She suffered with complete 
paralysis of the extensors of the toes and the flexors of the ankle, with 
weakness of most of the other muscles of the leg, coming on immedi- 
ately after confinement. The ankle-joints were habitually extended 
and the toes pointed. There was much hyperesthesia, but superficial 
and deep, and a little edematous swelling. No contraction could be 
elicited in the muscles below the knee by as strong a faradic current as 
the patient could bear. A voltaic current from twenty-six cells, 
registering thirty milliamperes, caused much pain and some contraction 
of the rectus femoris, deficient in quantity and normal in quality. No 
response could be obtained from the muscles below the knee. Some 
weeks later considerable muscular wasting was present, extending as 
high as the right gluteal muscles. In six months she could walk 
without a stick, and eventually recovered, Except that the affected 
muscles remained rather stiff. 
In a system predisposed by the effects of previous disease or 
excesses, and reduced by the exhaustion, excitement and strain of 
labor, septic or other infection attacks the nerve centres or fibres, and 
as a result, according to the degree and extent of the onslaught, 
neuritis with or without palsy, or myelitis, or intracranial inflamma- 
tions with convulsions, or psychical affections, or other brain symptoms, 
may occur. 
A woman, recently a patient at the Polyclinic, a few days after 
labor, and after an effort to stop the flow of milk, was attacked for the 
first time with frontal headache, which has persisted with a few 
intervals of relief for twelve years, during which time she has passed 
through five other labors, losing two of the children in early infancy. 
This ache, probably initiated by a mild infectious neuritis, has never 
left her. 
Recently, in the post-mortem room of the Philadelphia Hospital, 
I was present at an autopsy on a patient from the wards of Dr. E. P. 
Davis, this case illustrating the other extreme. This woman, three 
hours before she was brought to the hospital by the police patrol, had 
been delivered of a child without proper attention, and with wretched 
surroundings. She was suffering with hemorrhage until after admis- 
sion to the hospital, and was in a state of acute mania. In addition, 
her limbs, particularly the upper ones, were extremely hyperesthetic. Neuritis and Myelitis Following Labor. 
21 
Her head was drawn backward somewhat to one side, and active con- 
tractures were present in the upper limbs, and possibly also in the 
lower, but these were not closely examined. She had a scattered 
petechial eruption. She died about thirty-six hours after admission. 
The symptoms were such as to suggest cerebro-spinal meningitis. 
The autopsy showed clearly that no meningitis was present. Sections 
of the brain and cord showed them to be blanched and dry. Doubtless 
this was a case of profound toxemia, asssociated with anemia caused 
by the great loss of blood. The patient’s blood was in the puerperal 
condition, the surroundings of her labor were depressing, and she was 
of the class of those who so often suffer from the ravages of alcoholism 
or syphilis. 
Neuritis and Paresis Associated with Phlegmasia Alba 
Dolens. 
Neuritis, and the partial paralyses of phlebitis, and phlegmasia 
alba dolens, can be conveniently discussed as a separate class, although 
perhaps they might be included under other heads given. 
Patients suffering from phlegmasia alba dolens are, of course, more 
or less helpless and paretic during the progress of the affection; but, 
in addition, it sometimes leaves forms of paralysis and pseudo-paralysis. 
Doubtless a true neuritis is often present in phlegmasia, either as a 
result of the spread of inflammation by contiguity, or because of 
pressure and interference with the nerve trunks. A form of atheroma- 
tous neuritis is now recognized, and has been described by Gowers as 
a variety of the senile form of multiple neuritis; and it is held that in 
this disease the nerves of the limbs have been extensively damaged 
through the obliterating arteritis, necrotic inflammatory processes going 
on in the parts of the nerves supplied by the affected vessels, either 
arteries or veins. These processes may or may not result in occlusions, 
and are frequently accompanied by a true neuritis, which is the origin 
of most of the pain. In phlegmasia, likewise, a true neuritis may set 
up; and this may in part persist after other symptoms and conditions 
have subsided, or nerve degeneration may take place as the result of 
the neuritis, or of the pressure exercised on the nerves by the swollen 
and indurated tissues. Even the gangrene, in which phlegmasia some- 
times terminates, has been regarded as in part at least neuro-trophic 
rather than altogether due to interference with the circulation. 
Finally, a patient suffering from phlegmasia may at the same time, or 
as a sequel of the affection, develop a septic, pyemic, or infectious 
myelitis of the transverse or some other variety, which will give rise 
to marked and, it may be, incurable paraplegia. Winckel quotes 22 
Charles K. Mills. 
Mauriceau, Boer, Casper and Gittermann as reporting a greater or less 
degree of paralysis of the affected limb as left over by phlegmasia. 
Dr. Anna M. Fullerton has furnished me with some notes of several 
cases of this character, patients who have been confined at their homes 
without proper antiseptic surroundings and attendants, and have come 
to the hospital for treatment. She believes that inflammatory and 
septic complications are responsible for this class of cases; in them 
she has found extensive lesions, often of the soft parts, due to injuries 
occurring during birth, which have left open surfaces for the absorption 
of the poison. The following are notes from cases furnished by Dr. 
Fullerton: 
Case V—Pyemia, phlebitis, anesthesia and pseudo-paralysis.— 
A. H., married, aged 27 years, pelvis generally contracted, was 
delivered of her second child six weeks before admission to the 
Woman’s Hospital. The labor was said to have been easy. The 
condition of the patient during her pregnancy had been poor. The 
drainage of the house and the vicinity was poor, and she thought she 
had chronic malaria. She had suffered some time previous to her 
marriage with uterine trouble, and during her pregnancy had been 
under the constant care of physicians to ward off threatened abortion. 
Her second labor was followed by an attack of sepsis. When able to 
be moved she was brought to the hospital. Upon examination an 
abscess was found over the right sacro-sciatic foramen, and a bedsore 
on the buttock of the same side. A left crural phlebitis existed, with 
stiffness of the knee, and an edematous and anesthetic condition of the 
leg. The uterus was enlarged and tender, and found imbedded in a 
mass of pelvic exudate. She was placed upon supporting treatment. 
The limb was first treated by elevation and application of belladonna 
and iodine ointment. The pelvic condition was treated by douches 
and hot packs. The abscesses were evacuated and washed out with 
antiseptic solutions. Later the limb was treated with massage and 
electricity. She returned to her home much better six weeks after 
admission. She was able to walk, but the limb was still weak and 
continues so up to the present time, January, 1893. The pelvic 
exudate has been absorbed. The uterus is movable, but a left salpin- 
gitis exists with distention of the tube, for which laparotomy has been 
advised. 
Case VI—Phlegmasia and neuritis.—D. R., single, aged 22 years, 
was confined in the Woman’s Homeopathic Hospital early in October, 
1892, with her first child. Labor was said to have been long, but not 
instrumental, and was followed by phlegmasia dolens affecting both 
limbs, the left being first affected, and greatly swollen. She was 
admitted to the Woman’s Hospital January 8, 1893, for severe pain in Neuritis and Myelitis Following Labor. 
23 
the foot, affecting especially the great toe and the two next to it, and 
extending into the ball of the foot; some pain was in the entire limb, 
with imperfect use of it. She had enlarged inguinal, axillary and cer- 
vical glands; she was and still is pale and anemic, remaining under 
treatment, which has been supporting, with elevation and rest of the 
limb, and application of belladonna ointment. Considerable improve- 
ment has taken place in two weeks. Pelvic examination showed a 
laceration of the cervix, extending to the vault of the left side of the 
uterus, which is movable and larger than usual. 
Case VII—Pyemia with anchylosis, atrophy and pseudo-paralysis.— 
M. T., aged 27 years, married, entered the hospital October 30, 1891, 
threatened with premature labor at seven months. It was discovered 
that she had made attempts to induce labor for some time by means of 
vaginal injections. Her general condition on admission was very poor; 
she was pale, anemic and apparently half-starved, with albumin in the 
urine. Notwithstanding the efforts made to arrest the threatened mis- 
carriage, labor occurred on November 5, being preceded by a chill and 
rise in temperature. After the delivery her condition remained fair up 
to about the eleventh day, when again there was a chill and rise in 
temperature. She had complained of some paiu in the right limb since 
delivery. A synovitis of the right knee, with considerable swelling 
and complaint of pain and stiffness in the limb, developed. Later, sup- 
puration of the knee occurred, necessitating evacuation and drainage. 
Other metastatic abscesses occurred. The knee became anchylosed ; the 
muscles of the limb wasted greatly. After a long course of supporting 
treatment, with massage and electricity applied to the limb, she recov- 
ered so she was able to walk without pain, but with a slight limp. She 
was discharged March 21, 1892. 
Case VIII—Pyemia with paralysis, atrophy and anesthesia.—M. F., 
aged 26 years, married, flat pelvis, was confined to her home with her 
first child. The labor was long and difficult, requiring instrumental 
delivery. The child was still-born. There was extensive lacerations of 
the soft parts. The patient was kept to her bed for sixteen weeks with 
septic fever. The physician who attended her spoke of the position as 
having been a posterior variety of the occiput. The patient was 
admitted to the Woman’s Hospital February 1, 1890, with the left 
limb paralyzed, wasting of the muscles and some loss of sensation. 
Pelvic examination showed the existence of bilateral laceration of the 
cervix uteri to the vaginal vault. The pelvis was filled with an inflam- 
matory exudate, fixing the uterus, which was large and tender. She 
was placed under treatment, with douches and hot packs for the pelvic 
condition, and daily faradization of the paralyzed limb, with general 
restorative treatment. She was discharged March 16, greatly improved, 24 
Charles K. Mills. 
but with locomotion still imperfect. She returned to the hospital Sep- 
tember 22, 1891, for second delivery, although she had been advised, 
in a similar condition, to have premature labor induced. The os was 
found to be fully dilated ; the fetal head showed no attempt at fixation 
Version was performed, and delivery was effected without any injury 
to the mother. The fetus was born in the second stage of asphyxia, 
and could not be resuscitated. The puerperium was perfectly normal. 
The patient had entirely recovered from her paralysis. 
Puerperal Myelitis Due to Septic or other Infection. 
No reason exists why myelitis, or even meningitis or cerebritis, as 
well as neuritis, may not occur as a result of infection during the puer- 
perium. My own notes only include one case of myelitis. In this case 
the occurrence of two attacks at intervals of several years, and evidently 
myelitic in character, is interesting in connection not only with the 
history of alcoholism, but also with the view that disseminated mye- 
litic foci, in the great majority of cases, are septic and infectious. The 
following are the notes of this case : 
Cask IX— Transverse myelitis with persistent paraplegia; four 
years later, bulbar myelitis; history of alcoholism.—H. L,., aged 41 years, 
white, a patient in the nervous wards of the Philadelphia Hospital, was 
married when twenty-two years of age and had seven children. One 
of her sisters died of phthisis. She denied specific history, but admitted 
using alcohol to excess. Her menstruation had been painful up to her 
last labor, and since then had not occurred. At the time of, or just 
after her first labor, nearly five years before the time she was studied, 
she became paralyzed in both legs, but suffered no pain. From this 
time, also, she was unable to see distinctly as before, and she thinks 
that her eyeballs began to be a little more prominent. Her condition 
remained without much change for nearly four years. In a short time 
she was able to sit up, but never, since the attack, has she been able 
to walk. A few months since, while sitting in her chair, her speech 
suddenly became thick, and she lost power in both arms, the par- 
alysis of her legs, which had improved somewhat, at the same time 
becoming worse. 
At present she is unable to stand ; she can flex and extend her legs 
in a feeble manner while sitting or lying down, but has no control over 
the movements of her feet. Her legs are lean, but not atrophied. Her 
arms have nearly regained their usual power. She has no loss or per- 
version of sensation, although she says that at one time her limbs were 
completely anesthetic. No pain or hyperesthesia is present. Bladder 
and bowels are not paralyzed. Toe-jerk, ankle clonus, front tap, with 
exaggerated knee-jerks and muscle-jerks, are all present. In short, Neuritis and Myelitis Following Labor. 
25 
the paralysis and other phenomena in the lower limbs are such as we 
would expect from a transverse lesion of the dorsal cord. As results of 
her last attack, lips and tongue are paretic, she has slight palatal par- 
alysis, and is unable to phonate well. She also, apparently, has some 
exophthalmus, which she believes has been present several years. 
The best explanation of this case would seem to be that by infec- 
tion, or in some unknown way, an attack of myelitis was set up during 
or after labor, this spending its chief force upon the dorsal cord, although 
at first, as in other cases, the whole or a large portion of the cord may 
have been involved in the inflammation. Her recent attack was prob- 
ably pathologically of a similar character—a central bulbar myelitis. 
The alcoholic history is of interest, as chronic alcoholism, like syphilis 
or tuberculosis, would predispose a puerperal woman to such an attack. 
Neuritis, either diffused or multiple, was not present. The blindness of 
one eye and the protrusion of the eyeballs may be explained on the 
theory of the occurrence of foci of inflammation in some of the centres 
at the base of the brain, or in the ganglia of the sympathetic. 
Handford, in the paper cited, reports a third case of which he 
expresses doubt as to its neuritic character, or at least of its being one 
of simple neuritis. Its onset after confinement, however, was clear, 
and the case has some symptoms pointing toward neuritis. The fol- 
lowing are Handford’s notes : 
“ In this case the diagnosis is difficult, but it lies between tabes 
dorsalis, sclerosis with patches in the crura and in the lumbar enlarge- 
ment of the cord, and multiple neuritis. There certainly is ataxy; 
but against the affection being tabes are the facts that she has never suf- 
fered from lightning pains or gastric crises ; the pupils are dilated, 
there is no atrophy of the optic disc; the arms were affected as early 
and as severely as the legs; there is distinct loss of power, and now 
distinct muscular wasting. There was no evidence of syphilis, and her 
children are very healthy looking. E. S., aged 31 years ; married six 
years, three children. She suckled the last a year and a half. Diffi- 
culty in walking and a weakness in the arms came on after her confine- 
ment, two years ago. In the house she used to have to assist herself by 
the furniture, and in the street walk along by the wall. On admission, 
in July, 1888, she could not stand, and could only feed herself with one 
hand, with a spoon. The legs were very feeble, and occasionally jumped 
and became drawn up without the patient’s knowledge. The knee- 
jerks were totally absent, as were also all the superficial reflexes. 
Cutaneous sensibility was much diminished in the arms and legs. 
There was double ptosis and divergent strabismus, with widely dilated 
pupils, moving to neither light nor accommodation—a complete par- 
alysis of both nerves. Sight was good in each eye, and the discs were 26 
Charles K. Mills. 
normal. There was incoordination and loss of muscular sense. She 
soon went home, and I have been able to keep her under observation up 
to March, 1891. The duration of the illness is, therefore, five years. 
There is no appreciable alteration, except that the voluntary move- 
ments of the arms are more irregular, and the left is much weaker than 
the right. There is no rigidity of the legs. The thighs are well nour- 
ished, but there is considerable wasting of the muscles below the knee 
on the left side. She cannot stand, but spends her time entirely in bed, 
eats, sleeps well, and is free from pain.” 
A close reading of this case would seem to indicate that in all 
probability the patient suffered from a form of diffused myelitis, the 
inflammation attacking, beside the cord proper, the basal nuclei. The 
active sensory symptoms of neuritis were absent in the case, although 
diminished sensibility was present. 
To hysterical and reflex paralyses I shall only refer, as the chief 
purpose of the paper is to direct attention to the organic forms of post- 
puerperal affections, peripheral and spinal. Any form of hysterical 
paralysis may occur, in one predisposed, under any sufficient exciting 
cause, and certainly pregnancy or the puerperium is sufficient for the 
production of any functional nervous affection. A few cases with 
hemi-anesthesia, evidently hysterical, have been put on record as occur- 
ring during gestation or in the puerperal period, as, for instance, by 
Churchill,1 who is quoted by L,loyd. 
The reflex theory has been used for these as for other cases to 
escape difficulties which the industry or the ability of the physician 
has not been able to overcome. Instead of paralysis being due to some 
vague form of reflex action dependent upon an abnormal excitement 
exhausting the spinal centres, it is more reasonable to assume that, at 
least, in not a few of these cases, actual transmission of the inflamma- 
tory process by ascent to the cord occurs; or that a septic or infectious 
agent in the blood poisons the centres and nerve tracts, and gives rise 
to a true toxic palsy; although in extreme instances a puerperal excite- 
ment may be so sudden and so great as to overwhelm the centres to 
which it is transmitted, and to produce by exhaustion temporary 
paralysis. Cazeaux and Tarnier quote Jaccoud in explanation of the 
reflex origin of the paralysis of gestation and childbed as of other 
paralyses. Many such paralyses are said to be occasioned by exhaus- 
tion of the nerve centres. A long-continued excitement transmitted 
to the spinal cord by the uterine nerves, exhausts the excitability of the 
spinal centres, and these exhausted centres are no longer able to trans- 
mit the motor impulses to the brain, hence paralysis results. 
As many of the cases are of septic or infectious origin, and as this 
1 Churchill: Dublin Quart. Journ. Med. Sci., Vol. xvii, and op. cit. Neuritis and Myelitis Following Labor. 
27 
infection may in some instances be introduced from without, the 
importance of extreme cleanliness and antiseptic measures is empha- 
sized by these as well as by other accidents and consequences of labor. 
Occasionally, as in times of epidemics, influences from without, and 
not in any way connected with the labor, may be efficient to cause a 
multiple neuritis or myelitis, and these cannot be guarded against, 
except by attention to the general health of the patient. 
In treatment, as well as in diagnosis, it is of the utmost importance 
to consider the neuritis, intra-pelvic or extra-pelvic, which is present 
in these cases. When sure that neuritis is present, even if it is only 
of a moderate degree, but particularly when severe, the patient should 
be kept in bed, or, if on her feet, should be put back to bed. Rest 
alone will do much for these cases. Even where a persistent and perhaps 
permanent peroneal paralysis has been left, it is not necessary that the 
patient should suffer indefinitely with nerve inflammation, and the 
degree of improvement of the paralysis which will take place cannot 
be determined until the neuritis has been subdued; nor can thorough 
local treatment with electricity, massage, and Swedish movements be 
carried out while the limb is in a painful state. In cases of the second 
class which have been here discussed—those of neuritis with pseudo- 
palsy and affections of the intra-pelvic viscera—treatment of the 
neuritis by rest and other measures should go hand-in-hand with the 
gynecological and general measures. These patients will not be firm 
on their limbs as long as their pelvic nerves are in an inflamed condi- 
tion, and as long as these inflamed nerves are nagged and worried by 
exudates or by enlarged and displaced organs. 
By means of sand-bags between, and to each side of the legs and 
to the feet, the limbs may be kept in a state of quietude as nearly 
absolute as is possible. Hot douches, or douches of hot and cold 
water rapidly alternated, can be applied for a few minutes at a time, 
twice or three times daily. If necessary, opiates may be used, but 
when possible they should be avoided. Even in the absence of syphi- 
litic history, I commonly resort to inunctions of mercury until a slight 
constitutional effect is produced. A good ointment is one containing 
a mixture of mercurial ointment and lanolin, to which a measured 
amount of sulphate of atropine can be added. An ounce of the oint- 
ment may be divided into thirty-two parts, so that each part will con- 
tain about to of a grain of atropine; then each of these parts 
of ointment can be wrapped in paraffine paper, and one to four can be 
used daily. A good time to use the inunction is immediately after the 
douches. Between the times of these applications it is desirable, if 
possible, to keep the limbs in a mild perspiration, which may be accom- 
plished with strips of rubber dam, such as is used by dentists and sur- 28 
Charles K. Mills. 
geons; wrapping the limbs loosely with strips or layers of this fastened 
with tapes. 
Internally, in the acute and subacute stages, salicylate of sodium, 
salicin or salol, in full or fair doses, will sometimes be found very 
efficient; and phenacetin or antipyrin can sometimes be advantageously 
combined with these remedies. When the affection has become more 
chronic, iodide of sodium or potassium, or hydriodic acid, can be 
added, or can be substituted for the earlier treatment. 
It may be necessary -to use moderate doses of tonics, such as 
strychnine or quinine, from the first. Weak galvanic currents can be 
used before the pain has entirely left, as can also massage and Swedish 
movements; but the active electrical and manipulative treatment is 
rather for the paralysis which results from the nerve-crushing and 
neuritis than for the neuritis itself. Appropriate gynecological treat- 
ment should be thoroughly pursued.