Part 28 (2/2)
It is of the greatest importance to do this as early as possible, not only for the reason we have just a.s.signed, but also because we find that purgative medicines frequently take a longer time to operate in these cases than they do under ordinary circ.u.mstances, and require the repet.i.tion 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 a.s.sisted 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 pract.i.tioner may quickly find employment for the numerous friends or a.s.sistants, 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 pract.i.tioner 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 a.s.sume a tetanic character, and that the uterus actively partic.i.p.ates 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 circ.u.mstances, 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 b.r.e.a.s.t.s 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.
_Anaemic convulsions._ The next form of epiplectic puerperal convulsions is the anaemic 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 pa.s.s 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 a.s.sertion, ”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 haemorrhage, whether spontaneous or artificial. That the same haemorrhage which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and observations it appears, that haemorrhages 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 haemorrhage, 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 a.s.sociations, 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 circ.u.mstances, from our means of treatment being confined within still narrower limits. Dr. M. Hall justly observes, that ”exhaustion is sooner induced under circ.u.mstances of intestinal irritation:” and again, ”paralysis has occurred in a state of exhaustion from other causes, as undue lactation; and in various circ.u.mstances of debility, as in cases of disorder of the general health, with sallowness and pallor, and a loaded tongue and breath.”
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