PUERPERAL CONVULSIONS.
_Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.--
Tetanic species.--Diagnosis of labour during convulsions.--
Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.--
Apoplectic species.--Anæmic convulsions.--Symptoms.--Treatment.--
Hysterical convulsions.--Symptoms._
Women are liable, both before, during, and after labour to attacks of
convulsions, not only of variable intensity, but differing considerably in
point of character. We shall consider them under three separate heads,
viz. epileptic convulsions with cerebral congestion; epileptic convulsions
from collapse or anæmia; and hysterical convulsions. Other species have
been enumerated by authors, but they are either varieties of, or
intimately connected with, those of the first species.
No author has more distinctly pointed out the fact that epilepsy may arise
from diametrically opposite causes than Dr. Cullen; a circumstance which,
in a practical point of view, is of the greatest importance. "The
occasional causes," says he, "may, I think, be properly referred to two
general heads; the first, being those which seem to act by directly
stimulating and exciting the energies of the brain, and the second, of
those which seem to act by weakening the same." "A certain fulness and
tension of the vessels of the brain is necessary to the support of its
ordinary and constant energy in the distribution of the nervous power"
(_Practice of Physic_;) and hence it may be inferred that, on the one
hand, an over-distention, and, on the other, a collapsed state of these
vessels, will be liable to be attended with so much cerebral disturbance
as to produce epilepsy.
_Epileptic convulsions with cerebral congestion._ Epileptic convulsions
connected with pregnancy or parturition, and which are preceded and
attended with cerebral congestion, alone deserve, strictly speaking, the
name of _Eclampsia parturientium_ (which, in fact, signifies nothing more
than the epilepsy of parturient females,) being peculiar to this
condition; whereas, the anæmic and hysterical convulsions may occur at any
other time quite independent of the pregnant or parturient state.
The term "puerperal convulsions" is employed in a much more vague and
extended sense, and applies generally to every sort of convulsive
affection which may occur at this period, and as such, it therefore, forms
the title of the present chapter.
_Causes._ The exciting cause of eclampsia parturientium is the irritation
arising from the presence of the child in the uterus or passages, or from
a state of irritation thus produced, continuing to exist after labour. The
predisposing causes are, general plethora, the pressure of the gravid
uterus upon the abdominal aorta, the contractions of that organ during
labour, by which a large quantity of the blood circulating in its spongy
parietes is driven into the rest of the system, constipation, deranged
bowels, retention of urine, previous injuries of the head or cerebral
disease, and much mental excitement, early youth: also "in persons of
hereditary predisposition, spare habit, irritable temperament, high mental
refinement, and in whom the excitability of the nervous, and subsequently
the sanguiferous system is called forth by causes apparently trivial."
(_Facts and cases in Obstetric Medicine_, by I. T. Ingleby, p. 5.)
_Symptoms._ From the above-mentioned list of causes it will be evident,
that these convulsions will be invariably attended and preceded by
symptoms of strong determination of blood to the head. Previous to the
attack the patient has "drowsiness, a sense of weight in the head,
especially in stooping; beating and pain in the head; redness of the
conjunctiva; numbness of the hands; flushing of the face, and twitching of
its muscles; irregular and slow pulse; ringing in the ears, heat in the
scalp, transient but frequent attacks of vertigo, with muscæ volitantes,
or temporary blindness; derangement of the auditory nerve; embarrassment
of mind and speech; an unsteady gait; constipation and oedematous
swellings." (Ingleby, _op. cit._ p. 12.)
As the attack approaches, the patient frequently complains of a peculiar
dragging pain and sense of oppression about the præcordia, which comes on
and again abates at short intervals, and is attended with much
restlessness and anxiety: this is followed by intense pain, which usually
attacks the back of the head, and upon the accession of which the
præcordial affection apparently ceases; the pulse now becomes smaller and
more contracted. If the convulsions do not make their appearance by this
time, and the headach continues one or more hours, a slight degree of coma
supervenes, the patient loses her consciousness more and more, and wanders
now and then; after a time she becomes restless and evidently uneasy, the
eye becomes fixed and staring, the countenance changes, and the outbreak
of convulsive movements follows.
Sometimes the premonitory symptoms are much less marked; indeed, in some
cases, there is scarcely a sign to warn us of the impending danger; in the
midst of a conversation the patient becomes suddenly silent, and, on
looking to see the cause, we find the expression altered, the muscles of
the face are twitching, the features beginning to be distorted, and the
next moment she falls down in general convulsions.
Wigand (_Geburt des Menschen_, vol. i. § 102,) considers that the two
symptoms which usher in the attack are, the frightful staring followed by
rolling of the eyes, with sudden starts from right to left, and twisting
of the head to the same side by the same sudden movements; as soon as the
convulsions have commenced, the head generally returns to its former
position, or rather is pulled more or less backwards; "the eyes are wide
open, staring, and very prominent, the eyelids twitch violently, the iris
is rapidly convulsed with alternate contractions and dilatations; the face
begins to swell and grow purple, the mouth is open and distorted, through
which the tongue is protruded, brown, and covered with froth; the lips
swell and become purple: in fact, it is the complete picture of one who is
strangled." (_Op. cit._)
These convulsions, as in common epilepsy under other circumstances,
usually if not always commence about the head and face, gradually passing
down to the chest and abdomen, and then attacking the extremities. After
the above-mentioned changes, they pass into the throat and neck, by which
a state of trismus is produced, and the protruded tongue is not
unfrequently caught between the teeth and severely wounded. The neck is
violently pulled on one side, and from the pressure to which the trachea
is subjected, severe dyspnoea is produced. The respiration is nearly
suspended, and from the violent rushing of the air as it is forced through
the contracted rima glottidis, the breathing is performed with a peculiar
hissing sound. The muscles of the chest now become affected, and the
thorax is convulsively heaved and depressed with great vehemence; those of
the abdomen succeed, and the convulsive efforts are here, if possible,
still more violent: such are the contractions of the abdominal muscles,
and so powerfully do they compress the contents of the abdomen, that a
person who had not previously seen the patient would scarcely believe she
was pregnant; the next moment the abdomen is as much protruded as it was
before compressed. From the same cause, the contents of the rectum and
bladder are expelled unconsciously, the extremities become violently
convulsed, and the patient is bedewed with a cold clammy sweat. The
duration of such a fit is variable; it seldom lasts more than five
minutes, and frequently not more than two, and then a gradual subsidence
of the convulsions and other symptoms follow; the swollen and livid face
returns to its natural size and colour, the eyes become less prominent,
the lips less turgid, the breathing is easier and more calm, the viscid
saliva ceases to be blown into foam from the mouth, and the patient is
left in a state of comatose insensibility or deep stertorous sleep, from
which, in the course of a quarter of an hour or twenty minutes, she
suddenly awakes, quite unconscious of what has been the matter; she stares
about with a vacant expression of surprise; she feels stiff and sore as if
she were bruised: this will be especially the case if it has been
attempted to hold her during the fit. The convulsive efforts of the
muscles of the body and extremities are not easily resisted, and thus it
is that we hear of a delicate woman under these circumstances requiring
several strong men to hold her: the result of such treatment is, that her
muscles and joints are severely strained, and continue painful for some
time after. Patients, on recovering their senses, frequently complain of
pain and soreness in the mouth, arising from the tongue having been
bitten; in some cases where the tongue has been much protruded, the injury
is very severe, the tongue being bitten completely across, and hanging
only by a small portion.
The woman may suffer but one attack, and have no return of the fit, or in
half an hour, an hour, or longer, the convulsions again appear as at
first. If this happens several times, she does not recover her
consciousness during the intervals, but remains in a continued state of
coma from one fit to another. Although it rarely happens, that the patient
dies during a fit, still nevertheless, one fit will in some cases be
sufficient to throw her into a state of coma from which she does not
recover; in others, the patient may lie for even twenty-four hours in
strong convulsions and yet recover.
The character of these attacks appears to vary a good deal with the cause;
thus, where plethora has been the predisposing cause, and the fits
frequently repeated, they take on more or less of an apoplectic character,
the coma is more profound and of longer duration, and is frequently
attended with paralysis; the cerebral affection is more severe, the
patient does not recover her senses even where the intervals between the
attacks have been of considerable duration; and when the fits have ceased
and the coma abated, she is occasionally left in a state of imbecility and
blindness, which lasts for several hours or even days.
Where it is connected with constipation or deranged bowels, we think that
we have seen it more frequently attended with delirium or even temporary
mania; the fits are numerous, the convulsions as severe, but the cerebral
congestion is not so intense, the coma less profound; instead of being
left in a state of torpid stupor, the patient is very restless and at
times unmanageable, and when we consider the identity of the causes which
produce these convulsions and one form of purerperal mania, it will be
easily understood why the symptoms should assume this character. The
degree also of determination to the head, will in no slight measure
influence the character of the symptoms which attend these attacks. "One
circumstance," says Dr. Parry, "of increased impetus deserves to be
noticed. The delirium is preceded by a pain in the head, but as the
delirium comes on, the pain ceases, though the impetus remains as before,
or perhaps increases. Diminish in a slight degree the impetus, and you
remove the delirium and renew the pain; diminish the impetus in a greater
degree, and the frown on the forehead is relaxed, the features seem to
open, and the pain entirely ceases." (_Posthumous Medical Writings_, vol.
i. p. 263.)
By far the majority of cases of eclampsia parturientium occur in
primiparæ: thus in thirty cases which occurred to Dr. Collins, during his
mastership at the Dublin Lying-in Hospital, "twenty-nine were in women
with their first children, and the other single case was a second
pregnancy, but in a woman who had suffered a similar attack with her first
child." In two instances, under our own notice, where the disease occurred
in multiparæ, the fits did not appear until _after_ delivery; the patients
were plethoric, and in one especially, the bowels were excessively
deranged; in the other, the attack had much of the apoplectic character,
and the coma did not at once abate until the fatal termination.
Convulsions usually make their appearance towards evening; and if pains
are coming on, they return with every uterine contraction. The patient's
danger will, in great measure, depend upon the severity, frequency, and
duration of the fits; and although they must ever be looked upon as a
disease of the most dangerous character, yet we are justified in saying
that in the majority of instances the patient recovers: thus, of the
forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of
the thirty by Dr. Collins, only five died, "three of which were
complicated with laceration of the vagina, one with twins, and one with
peritoneal inflammation. It is thus evident that the fatal result in these
cases, with the exception of the twin birth, was not immediately connected
with the convulsions; and the danger in all twin deliveries, _no matter
what the attack may be_, is in every instance greatly increased."
(_Practical Treatise_, p. 210.)
Although puerperal convulsions usually occur at the commencement of
labour, it not unfrequently happens that they do not come on until after
the child is born; whereas, in other cases they occur several months
before the full period: these varieties depend entirely upon the
circumstances under which the attack has appeared. "With respect to their
occurrence in the last month of gestation, although the paroxysm mostly
appears during the actual dilatation of the os uteri, or on the first
approach of labour, still when we recollect that in the last week or two
of pregnancy the neck of the uterus is fully developed, the subsequent
changes being confined to the os internum (the most sensitive part of the
organ,) it cannot be surprising that, in very irritable persons, a
serious impression should be made upon the brain at those periods."
(Ingleby, _op. cit._ p. 11.)
Dr. Merriman has called it _dystocia epileptica_: there is, in fact, no
difference between this disease and common epilepsy, beyond that, under
ordinary circumstances, epilepsy is a chronic affection, and, generally
speaking, not attended with much danger, whereas, in the present case, it
is an acute attack, and of a highly dangerous character.
Many phenomena connected with uterine irritation, both in the
unimpregnated state and during pregnancy, prove the intimate nature of the
consent existing between the brain and uterus. Thus it is well known that
menstrual irritation is accompanied with a great variety of nervous and
hysterical symptoms, which are merely a part of the same series of results
to which epilepsy itself belongs: it is occasionally attended with
delirium, spasms, and even coma, and preceded by the oppression at the pit
of the stomach and pain of head, which we have already noticed among the
immediate precursors of puerperal epilepsy; on the other hand, as Dr.
Parry has well remarked, "the beginning and end of each epileptic fit,
before total insensibility begins and after it ceases, is often delirium,
screaming, false impressions, attempt to annoy others under these
impressions," &c. (_Op. cit._ vol. i. p. 396. &c.) Thus also during
labour, either at the termination of the first stage, when the os uteri
has attained its full degree of dilatation, or immediately after the birth
of the child, the patient is frequently seized with a sudden convulsive
rigour so violent as to make her teeth chatter and agitate the whole bed,
and which is nothing more than a harmless modification of convulsive
action arising from uterine irritation; the surface is perfectly warm, and
the patient frequently expresses her surprise to find herself shivering
thus violently and yet not feel cold.
It has been a common opinion that epileptic puerperal convulsions are
almost certainly fatal to the child, especially if they continue for any
length of time: experience, however, proves the contrary, as cases
continually occur where the mother has laid for many hours in a constant
succession of severe convulsions, and yet has been ultimately delivered of
a living child. Still, however, it must be owned, that barely an equal
number of the children are born alive under these circumstances. Thus, in
Dr. Merriman's 48 cases, as already mentioned, only 17 children were born
alive (including the 6 born before the mothers were attacked with
convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32
children (two of the women having had twins) were born dead; of these,
however, it must be observed, that 8 were delivered with the perforator,
and two were born putrid.
_Tetanic species._ There is one modification of eclampsia parturientium,
which, from the spastic rigidity of the uterus which accompanies it, is
peculiarly dangerous to the child's life: it has been called the tetanic
form: the convulsions are incessant, without any apparent interval, and
the uterus actively participates in the state of general spasms: under
such circumstances, the pressure which it exerts upon the body of the
foetus will seriously obstruct the abdominal circulation, and produce the
same effects as pressure on the cord.
In most cases, however, the convulsions have no effect upon the process of
labour, which continues its course uninterrupted; so that, where there has
been no return of consciousness during the intervals between the fits, and
the patient has laid in a continued state of coma for some time, the child
may actually be born before there has even been a suspicion that labour
was present. It is, therefore, of great importance that the practitioner
should be on the watch to detect any symptoms of its coming on, not only
for the purpose of giving her the necessary support at the moment of
expulsion, but also such assistance as may tend to shorten that process.
"By attentively observing what passes in cases of convulsions, we remark
that they do not always interrupt the course of the labour pains, whether
they had excited those pains, or the pains had preceded them. All authors
relate examples of women who have been delivered without help after
several fits of strong convulsions; and others while they were actually
convulsed, whether there were lucid intervals between, or that the loss of
understanding was permanent. The progress of labour in most of these cases
seems even more rapid than in others, since we have often found the child
between its mother's thighs, though an instant before we could discover no
disposition for delivery." (_Baudelocque_, trans. by Heath, § 1109.)
_Diagnosis of labour during convulsions._ Where the patient is in a state
of insensibility, we may infer the presence of labour by a variety of
symptoms; every now and then, from a state of torpor, she becomes
restless, and evidently uneasy; she pushes the bed-clothes from the
abdomen, and gropes about it as if trying to remove something that is
heavy or uncomfortable; she writhes her body, and moans as if in pain;
after awhile, she again relapses into her former state of coma. A little
attention will soon show us that these exacerbations of restlessness are
periodical; and if we examine the abdomen at the moment, we feel the
uterus evidently contracting; the os uteri also will be found tense and
more or less dilated: if the head has already advanced into the vagina,
these contractions will be accompanied by a distinct effort to strain.
It is rare to find convulsions complicated with malposition of the child;
indeed, so uncommon is the occurrence of it under these circumstances,
that we may feel almost certain, on being summoned to a case of
convulsions, that there will be little chance of this additional
difficulty being superadded. "There was but one case," says Dr. Collins,
"of convulsions during my residence in the hospital, where the child
presented preternaturally; there was not one case with a preternatural
presentation during Dr. Clarke's residence; and Dr. Labatt has stated the
same fact in his lectures while master of the hospital. In these three
different periods there were 48,379 women delivered, so that from this we
may infer, where the presentation is preternatural, there is little cause
to dread the attack." (_Practical Treatise_, p. 200.)
_Prophylactic treatment._ Under no circumstances is the old saying of
"Prevention is better than the cure," so well illustrated as in the
prophylactic treatment of puerperal epilepsy: it is only by carefully
watching for and recognising those symptoms which we have already
enumerated as threatening an attack, that we are able to adopt such
measures as shall either keep it off entirely, or at any rate considerably
diminish its violence.
The treatment which we have recommended during the last weeks of
pregnancy, is particularly valuable in keeping off any disposition to
these attacks: regular, and for her condition even tolerably active,
exercise and strict attention to the bowels, should be required,
especially in primiparæ. If any distinct symptoms of cerebral congestion
make their appearance, such as flushed face, headach, or slight wandering;
if, moreover, the pulse be slow and labouring, we must at once relieve the
circulation by bleeding; and by an active dose of calomel and James's
powder at night with a warm pediluvium, and a brisk laxative the next
morning, endeavour to ward off the dreaded attack. Not unfrequently,
however, we have no warning of the danger until the fits burst out, and
are thus debarred the opportunity of preparing against them.
_Treatment._ During the fit itself little can be done beyond placing the
patient in such a situation that she should not injure herself by her
exertions. If she happens to be upon a chair when the attack begins, it
will be as well to let her sink gently upon the floor, and lie there until
the fit is over; if she is in bed when it comes on, we have merely to
watch that she does not roll off during her struggles; her movements
should be restrained as little as possible, and by so doing we shall spare
her the suffering after the fit from strained muscles and half-wrenched
joints, which is so severe where the assistants, from mistaken kindness,
have endeavoured to hold her.
It has been recommended by Dr. Denman to have the patient's face
frequently dashed with cold water during the fit, a remedy which, as Dr.
Merriman observes, is very effectual in ordinary hysterical paroxysms, and
which possibly may have a slight effect in moderating the violence of the
epileptic convulsions; but from what we have seen we are not inclined to
consider it of much use.
_Bleeding._ As soon as the fit is sufficiently over to render the
operation possible, the patient ought to be placed in a half-sitting
posture, and bled from a large orifice in the arm; the quantity of blood
abstracted must be determined by the appearance of the patient, the
severity of the cerebral symptoms, and the condition of the pulse; this
latter will usually be found labouring, and even small, but will rise
considerably in fulness and volume as we gradually relieve the
circulation. Syncope is an effect which, under these circumstances, it
would neither be easy nor safe to produce; but at the same time it will be
highly desirable to produce a powerful effect upon the circulation by so
large and speedy an abstraction of blood as shall be certain of
alleviating the cerebral congestion: this is not often attained until
after a loss of twenty, or five and twenty ounces. She should be supported
in the half-sitting posture by means of a chair turned against the head of
the bed, so that its back forms an inclined plane, which should be covered
with pillows for her to lean upon.
_Purgatives._ An active dose of purgative medicine should be given the
moment the patient is able to swallow; for in case of the fit returning,
it will be sometimes very difficult to make her take any thing. Eight or
ten grains of calomel, with fifteen or twenty of jalap, should be mixed
into a paste with a little thin gruel and laid upon the back of the
tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If
this cannot be taken, a few drops of croton oil will seldom fail to
produce the necessary effect.
It is of the greatest importance to do this as early as possible, not only
for the reason we have just assigned, but also because we find that
purgative medicines frequently take a longer time to operate in these
cases than they do under ordinary circumstances, and require the
repetition of even a powerful dose before the bowels can be made to act.
Where the convulsions appear to depend in great measure upon the deranged
state of the bowels, the indications for the immediate employment of
purgatives become still more urgent, for although we may control the
cerebral congestion by means of the lancet, we shall not remove the source
of irritation; but when once the bowels have been freely evacuated, the
chain of morbid actions is broken, and the disease ceases: hence, in some
cases, we observe much more striking relief produced by purgatives than
even by bleeding. In order, therefore, to ensure a certain and speedy
effect upon the bowels, she should take, about two hours after the powder,
repeated doses of salts and senna, and if necessary, have their action
still farther assisted by a purgative injection.
In the mean time, the hair must be closely shaven from the crown and back
of the head, leaving the front bands, that she may be disfigured as little
as possible, and a large bullock's bladder half filled with pounded ice,
applied to the bare scalp; in lieu of which, an evaporating lotion of
vinegar spirit and water, may be applied until the ice is procured.
Sinapisms to the calves of the legs and soles of the feet will also be
required, so that, on coming into a room where a patient is lying in
puerperal convulsions, the practitioner may quickly find employment for
the numerous friends or assistants, who generally crowd round her on such
occasions, and convert their officiousness into real utility. The air of
the room must be kept as fresh as possible, and no more people allowed to
remain in it than are absolutely necessary.
If she be tolerably conscious during the interval, a hot foot bath,
rendered still more stimulating by some mustard flour, will be of great
service; flannels wrung out of a hot decoction of mustard, and wrapped
round the feet and legs, are also useful, and tend still farther to
diminish the cerebral congestion.
In all cases of convulsions, especially if the patient be near her full
time, it will be necessary to ascertain the state of the bladder; for the
pressure of the head frequently produces much difficulty in evacuating it,
and sometimes causes so much distention and irritation as to be itself
quite capable of exciting the convulsions. Lamotte has given two instances
where the fits had been evidently brought on by retention of urine, and
where relief was immediately given by evacuating the bladder.
Where the patient has still some time to go, and no appearance of uterine
action has been excited, the probability is, that the above-mentioned
treatment, will be sufficient to prevent a return of the attack; and, if
we have succeeded in calming the circulation, we may combine a little
henbane with her medicine to allay irritability. But if she be near her
full time, and labour has distinctly commenced, there will be little
chance of the convulsions permanently ceasing until she is delivered, as
the contractions of the uterus frequently appear to excite a return of
them.
The practice in former times of dilating the os uteri, introducing the
hand and turning the child, has been long since justly discarded, for the
irritation produced by such improper violence would run great risk of
aggravating the convulsions to a fatal degree.
"No cases require more prudence, attention, and sagacity, than the
accident of convulsions in women, with their first children especially.
The state of the os uteri is of immense importance, and when it will admit
of your delivering the woman without violence, trouble, or irritation, no
doubt it ought to be performed with all prudent expedition, as you never
can be sure of her being restored without delivery." (M'Kenzie's
_Lectures_, MS. 1764, quoted by Dr. Merriman.)
Where we are called to a patient, who has been some little time in
convulsions, and where bleeding and other necessary measures have been
already had recourse to, we may, with a tolerable degree of certainty,
expect to find the os uteri fully dilated, and the head in a favourable
state for the application of the forceps. The practitioner should be able
to apply the forceps whether the patient be lying upon her back or her
side, as it is not always possible to choose her position; the former,
will generally be the safest, as she will not only lie more quietly upon
her back, but can be kept with most facility in this posture. Generally
speaking the fits subside immediately after the child is delivered,
although not unfrequently they recur during the first twelve or sixteen
hours after labour, coming on at increasing intervals.
If, however, the state of the os uteri forbids our interfering with art,
we must be content to follow out that plan of antiphlogistic treatment
which has been just laid down, bearing in mind, that in proportion as we
reduce the power of the circulation we increase the disposition of the os
uteri to dilate, and, as Baudelocque justly observes, "while we wait the
favourable moment for operating, we should only employ those means which
we could use after delivery, if the convulsions should continue." (_Op.
cit._ § 1110.)
By the time that the medicine has begun to operate, a considerable change
will usually be observed in all the symptoms--the violence of the
convulsions abates, the coma is less profound, and if the child be not yet
born, the process of labour much more speedy and favourable; but if we
find that the convulsions assume a tetanic character, and that the uterus
actively participates in this state of spasmodic rigidity, we must not
expect any very favourable change until delivery is effected; and there
will be little chance for the child of its being born alive for reasons
already mentioned. Under such circumstances, which are fortunately of rare
occurrence, it will be our duty to perforate rather than run the risk of
losing the mother as well as her child; but before proceeding to this
extremity we must satisfy our minds that the state of the os uteri forbids
the forceps, and that, from the tetanic action of the uterus, there is
little chance of its farther dilatation.
"It does not always happen that the convulsions cease upon the termination
of the labour; on the contrary, they often continue after the birth of the
child, and sometimes increase in violence, and at length produce death.
If, however, the intervals between the fits become longer, a more
favourable prognosis may be formed, but it will be expedient to continue
our exertions in relieving the symptoms." (Merriman's _Synopsis_.)
The after treatment will be little more than a continuation of that which
has been described during the attack, only in a much milder form: the head
must be kept cool by a proper lotion, and the bowels sufficiently open by
gentle laxatives; a little gruel, with or without milk, may be given
occasionally; and if the child be alive, it should by all means be applied
early to the breast, in order to establish a flow of milk as soon as
possible. Where the breasts have been very flaccid, and there were little
or no signs of milk, we have now and then applied a sinapism over them
with very good effect, for the mammary excitement thus produced has been
attended with a copious lochial discharge, which has evidently produced
much relief.
_Apoplectic species._ Dr. Dewees has described a species of convulsions by
the term "apoplectic," but it is perhaps questionable how far he is
correct in calling them "puerperal convulsions;" for, from the cases which
have come under our own notice, the disease has been nothing else than
genuine apoplexy occurring in the pregnant, parturient, or puerperal
state: he justly observes, that "it may be brought on by causes
independent of pregnancy, though this process may with propriety be
regarded as an exciting cause; for it sometimes takes place when this
process is at its height, but is no otherwise accessary to this end, than
increasing by its efforts the determination of blood to the head." (_Op.
cit._ § 1238.)
The treatment will in no respect differ from that of the genuine puerperal
convulsions, except that, as the danger is still greater, so, if possible,
must the treatment be more prompt; indeed, it can scarcely be said that
there is a convulsion, for there is merely loss of motion with
insensibility. It is fortunately of rare occurrence, as the patient seldom
recovers.
_Anæmic convulsions._ The next form of epiplectic puerperal convulsions is
the anæmic form, where, in consequence of serious loss of blood or
debility otherwise induced, the due balance of the nervous system has been
disturbed, and irregular and convulsive actions have been the result.
We have already shown that cerebral congestion is favourable to that state
of irritability, which, by the help of any exciting cause, may easily pass
into a state of epilepsy; an opposite condition, viz. that of exhaustion,
is capable of acting in a similar way, and thus confirms Dr. Cullen's
assertion, "that there are certain powers of collapse, which, in effect,
prove stimulants and produce epilepsy."
"That there are such powers which may be termed indirect stimulants, I
conclude from hence, that several of the causes of epilepsy are such as
frequently produce syncope, which, we suppose, always to depend upon
causes weakening the energy of the brain." "The first to be mentioned,
which I suppose to be of this kind, is hæmorrhage, whether spontaneous or
artificial. That the same hæmorrhage which produces syncope, often at the
same time produces epilepsy, is well known; and from many experiments and
observations it appears, that hæmorrhages occurring to such a degree as
to prove mortal, seldom do so without first producing epilepsy." (_Op.
cit._) It is a well-known fact, that when once a state of exhaustion or
collapse has been carried beyond a certain point, the irritability of the
nervous system increases in proportion: the due balance of its various
actions becomes more and more unsteady; their equilibrium is disturbed by
the slightest impressions, and losing the state of well-adjusted repose
which belongs to health, they continually vibrate between the extremes of
excitement or collapse, which seldom fail to produce some serious
derangement.
"The symptoms of reaction from loss of blood," says Dr. Marshall Hall,
"accurately resemble those of power in the system, and of morbidly
increased action of the encephalon; and, from these causes, the case is
very apt to be mistaken and mistreated by the farther abstraction of
blood. The result of this treatment is, in itself, again apt farther to
mislead us; for all the previous symptoms are promptly and completely
relieved, and this relief, in its turn, again suggests the renewed use of
the lancet. In this manner the last blood-letting may prove suddenly and
unexpectedly fatal."
_Symptoms._ A very little attention, however, will discover the real
features of the disease; the pale face, the glazy eye, the shrunken
features and colourless lip, the cold moist skin, the heaving chest, the
quick, weak, small, and irritable pulse, all betoken a condition of
exhaustion and collapse. The history of the case will also show that the
patient has suffered from profuse hæmorrhage, or some other debilitating
evacuation; and the intense pain on the summit of the head, verging into
actual delirium, the rambling thoughts and confused mental associations,
the restlessness or absolute insomnia, the tinnitus aurium, disposition to
strabismus or other derangements of vision, indicate the defective
condition of the cerebral circulation.
We have already mentioned, in the congestive form of epilepsy, that where
the irritation from gastric derangement is conjoined to a state of body
already predisposed to the disease, that this is frequently sufficient to
excite it into action; still more will this be the case where the system
is rendered irritable by exhaustion; and it will occur under more
formidable circumstances, from our means of treatment being confined
within still narrower limits. Dr. M. Hall justly observes, that
"exhaustion is sooner induced under circumstances of intestinal
irritation:" and again, "paralysis has occurred in a state of exhaustion
from other causes, as undue lactation; and in various circumstances of
debility, as in cases of disorder of the general health, with sallowness
and pallor, and a loaded tongue and breath."
_Treatment._ Our treatment of these cases will not vary essentially from
that of exhaustion from hæmorrhage under the ordinary circumstances; the
patient must be placed with her head low, and as soon as she is able to
swallow, a little hot brandy and water, or ammonia, should be given to
rouse the circulation to a sufficient degree of activity. If the uterus be
still flaccid and disinclined to contract effectively, a dose of ergot
will be advisable, and the abdomen should be tightly bandaged with a broad
towel. When the powers of the circulation have rallied somewhat, a little
plain beef-tea will frequently prove very grateful and appear to revive
her more powerfully than even the stimulants above-mentioned; and now, as
it is of the greatest importance to calm the irritability of the brain and
nervous system, we must proceed to the use of sedatives. Of these, opium
and hyoscyamus have the preference, the latter especially so, from its not
being liable, like opium, to derange the stomach, or contract the bowels.
Moreover, where the exhaustion is very alarming, it is not always easy to
control the sedative action of opium within due bounds; and in such cases
we are sometimes apt to produce so much sopor, as to render it even
difficult to rouse the patient. For this reason, the combination with a
diffusible stimulant is always desirable: five grains of camphor and of
extr. hyosc. in two pills, form, perhaps, the best and safest sedative
which can be given; these may be repeated every hour, and then at longer
intervals of two or more hours, until sleep has been produced. Sleep, in
cases of this kind, is of the greatest importance, and produces the most
favourable change in the patient's condition; the intense headach and
irritability of the mind, of the sight, and of the hearing, all abate; the
circulation becomes calmer, the pulse more full and soft, the heat of the
body more equable; in short, the whole nervous system is returning to a
more natural and regular state of action, the stomach is more capable of
receiving and digesting its food, the bowels are more manageable, and we
may now venture to remove a state of constipation, if present, or any
morbid intestinal contents without running the risk of bringing on
diarrhoea and increasing the debility.
We rarely find that the convulsions return when once the patient has
enjoyed the calm of a sound and refreshing sleep, and consider the victory
as more than half gained when this favourable state has been produced. The
laxative should be of the mildest form, such as will merely excite the
peristaltic action of the intestines without increasing their secretions;
for this purpose a warm draught of rhubarb manna with hyoscyamus, or
castor oil guarded by a little liq. opii. sed., will be the safest. Food
of the blandest and most nutritious quality should be given in small and
frequently repeated doses; it is important not to load the stomach much or
suddenly, for vomiting is easily produced, and when once excited, the
stomach becomes so irritable as to be scarcely capable of retaining any
food whatever.
Where, on the other hand, several hours have passed, not only without
sleep but without even a temporary state of quiet; where the headach
alternates with restless delirium; where the medicines and nourishment
have produced little or no effect, or have been rejected by vomiting;
where the pulse becomes quicker, and the debility increases, we have not
only to dread a return of the fits, but that the stage of actual sinking
is at hand.
"It would perhaps," says Dr. Marshall Hall, "be difficult to offer any
observations on the nature and cause of excessive reaction; but it is
plain that the state of sinking involves a greatly impaired state of the
functions of all the vital organs, and especially of the brain from
defective stimulus. The tendency to dozing, the snoring and stertor, the
imperfect respiration, the impaired action of the sphincters, the
defective action of the lungs, and the accumulation of the secretions of
the bronchia, the feeble and hurried beat of the heart and pulse, the
disordered state of the secretions of the stomach and bowels, and the
evolution of flatus, all denote an impaired condition of the nervous
energy." (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.)
_Hysterical convulsions_ scarcely deserve the name of puerperal
convulsions, being liable to occur under circumstances quite independent
of the puerperal state; they rarely occur during the process of labour
itself, but are chiefly observed during the last few weeks of pregnancy,
and the first week or so after labour, especially when the milk is coming
on.
_Symptoms._ The patient is of a nervous hysterical habit; "she is either
still very young, or is of a slim and delicate make; the face is pale and
interesting; she has full blue eyes and light hair, and was always of a
highly sensitive constitution; the pulse is quick, small, and contracted;
the temperature of the skin is rather cool than otherwise; her spirits are
variable, fretful, and anxious; she starts at the slightest noise, cannot
bear much or loud talking, and misunderstands or takes every thing amiss.
During her slumbers, which are short, there are slight twitchings of the
eyes and mouth, and in her sleep the eyes are in constant restless motion,
and she frequently starts. She complains of sickness, and has frequent
calls to pass water, which is very pale; slight rigours alternate every
now and then with flushing, and she is easily tired, even by trifling
pains, and dozes a good deal during the intervals. She is excessively
sensitive, even to the most gentle and cautious examination; the os uteri
remains thin, hard, tense, and painful to the touch longer than is usually
the case. The ordinary tension and stretching of the os uteri at the
termination of a regular contraction is attended with much more pain, and
with a peculiar feeling of lassitude, although uncomplicated with any
rheumatic affection. The pains follow no regular course, being sometimes
stronger, at others weaker, and frequently cease entirely for
considerable periods. The uterus has a great disposition from the
slightest irritation, to partial and spasmodic contractions." (Wigand,
_Geburt des Menschen_, vol. i. p. 164.)
Before the fit the patient usually passes a large quantity of colourless
and limpid urine; she has oppression at the stomach, anxiety, difficulty
of breathing and palpitation, with globus, sobbing, and other hysterical
symptoms. There are not those precursory symptoms of cerebral congestion
as mark genuine epileptic puerperal convulsions; the headach is neither so
severe, nor is it in the same place, being usually at the temples and
across the forehead; the face is rather pale than flushed, and when the
fit begins, we see little or none of the convulsive twitching among the
small muscles, as is the case with an epileptic attack; the face is less
distorted, but the large muscles of the trunk and extremities are much
more violently affected; the patient struggles furiously, and in severe
cases has more or less of opisthotonos; she screams, and never appears to
lose her senses so entirely as in the epileptic form; her raving may
generally be controlled to a certain extent by suddenly dashing cold water
in her face, and speaking loudly and sharply to her; at any rate it
instantly produces a deep and sudden inspiration, which is frequently
attended with a prolonged hooping sound; this is followed by sobbing,
gasping, choking, and the ordinary phenomena of an hysteric fit, but the
convulsions themselves are usually arrested more or less by this
application: we hold the effects of cold water to be one of the best
diagnostics of the disease from epilepsy, in which the patient is entirely
insensible to such impressions.
A similar fact is observed during vaginal examination; the patient seems
aware of our intention, and resists in every possible way.
"The patient, after the fit, can for the most part be roused to attention
or will frequently become coherent so soon as she recovers from the
fatigue or exhaustion occasioned by her violent struggles; and though she
may lie apparently stupid, she will nevertheless sometimes talk or
indistinctly mutter. After the convulsion has passed over, she will often
open her eyes and vacantly look about, and then, as if suddenly seized by
a sense of shame, will sink lower in the bed, and attempt to hide her head
in the clothes." (Dewees's _Compend. Syst. of Midwifery_, § 1240.)
When sufficiently recovered to be capable of swallowing, she should sip
some cold water, or what is still better, take a dose of spiritus ammoniæ
foetidus in water; this soon produces copious eructations from the
stomach, which are followed with much relief. Where there is a disposition
to vomiting, and other evidences of a deranged stomach, it should be
encouraged by some warm water, chamomile tea, &c. The bowels are almost
always in an unhealthy state, which frequently produces much irritation,
and in plethoric habits so much tendency to cerebral congestion as to
endanger even an attack of the epileptic convulsions. One or two doses of
a pretty brisk purgative should, therefore, be given, and if there be
still heat or pain of head, a bleeding may be required.
Under ordinary circumstances hysterical convulsions are by no means
dangerous, and beyond a little fatigue and exhaustion, the patient
recovers from them almost immediately.