Part 35 (1/2)
On examination, instead of the os tincae and cervix uteri, a large irregular ulcerated excavation was found at the posterior end of the v.a.g.i.n.a. Shortly afterwards, increased uneasiness was experienced in the lower part of the abdomen, the right lower extremity swelled in its whole extent, with pain in the course of the femoral and iliac vessels, and all the other symptoms of phlegmatia dolens. The disease was treated by leeches and other antiphlogistic means, and the pain abated considerably; it, however, returned, and in about three weeks after, she died from a violent attack of uterine haemorrhage. On dissection, the fundus uteri was found somewhat enlarged and firm, the cervix had been destroyed by that kind of phagedenic ulceration, which is commonly called cancer of the uterus. The hypogastric vein was closed in consequence of previous inflammation of its coats, and the same change had taken place in the internal iliac, the common iliac, the external iliac, the femoral and profunda veins, as well as in the internal saphena, all of which were completely impervious. The affection terminated above at the junction of the common iliac with that of the opposite side, the latter vessel being quite natural. The saphena vein was closed for a length of about four or five inches, beyond which it was natural. The right spermatic vein was closed in its lower half. The coats of the affected vessels, and the surrounding cellular substance were a little thickened, and their cavities were plugged by a closely adherent and tolerably firm substance of a light brown colour; at some parts, the vessels and their contents were of a dark livid hue. (_Med. Chir. Trans._)[147]
CHAPTER XV.
PUERPERAL MANIA.
_Inflammatory or phrenitic form.--Treatment.--Gastro-enteric form.--Treatment.--Adynamic form.--Causes and symptoms.--Treatment._
There are many points of similarity between puerperal convulsions, and the disease which we are now about to consider, so that an acquaintance with the nature of the one, will greatly a.s.sist the reader in his study of the other: the same causes which induce the one, will, with trifling modification, induce the other; the different species of puerperal mania, will, therefore, resemble more or less those of puerperal convulsions.
Disorder of the mind, which comes under the head of puerperal mania, is rarely met with before labour; for when it occurs during pregnancy it is usually referrible to causes unconnected with that state, as to hysteria; or is, a form of ordinary mania arising from hereditary predisposition, cerebral diseases, &c. It is true these are conditions which will render the patient exceedingly liable to an attack of derangement during labour, and especially during the puerperal state; but the ident.i.ty of the affections cannot well be carried farther.
According to our own experience puerperal mania may occur under one of the three following conditions, viz.--
1. Where it is attended with, and probably depends upon, cerebral congestion or inflammation.
2. Where it arises from gastro-enteric irritation.
3. Where it is the result of general debility and anaemia.
The last two rather deserve the t.i.tle of melancholia.
_Inflammatory or phrenitic form._ We shall divide the inflammatory form into two species: first, where it is wild and furious delirium with phrenitis; secondly, where it is connected with, and is the result of, puerperal fever. The first, usually comes on during labour: the patient is attacked with violent pain, heat, and throbbing of the head, which are greatly increased by her efforts during the throes; the pulse becomes quick and hard; the face flushed and crimson; the eyes wild, and the manner more and more unnatural: if this state be not promptly checked, the cerebral excitement becomes more intense, furious delirium follows, which in its turn is succeeded by coma, effusion and paralysis.
On examination after death the ordinary appearances of fatal phrenitis manifest themselves, viz. preternatural fulness of the cerebral vessels, thickening and opacity of the different membranes, softening or even suppuration of the substance of the brain, extravasation of blood, or effusion of serum into the cavities or substance of the brain, or between its membranes.
The other form of inflammatory puerperal mania, is only seen _after_ labour, and is invariably connected with, and preceded by, symptoms of puerperal fever. These are the cases of puerperal mania, where the disease comes on with a rigour, a quick pulse, violent headach, and abdominal pain. In some, the attack has appeared from the very commencement to concentrate itself upon the brain; but in others, it more frequently appears in a day or two afterwards, when, from the subsidence of the abdominal pain, we are beginning to hope that the disease has been more or less controlled. The patient is suddenly seized with intense headach, and other symptoms of cerebral congestion, accompanied by disordered mind; but there is not that degree of furious delirium which is seen in the acute phrenitis; there is less excitement, but there is also, less strength; the powers of the system are rapidly giving away, not so much under the effects of the local disease, as under those of the general affection by which the local disease has been produced. The patient is frequently both violent and obstreperous; but we seldom see that state of wild and furious raving which is observed in acute phrenitis. The former of these two species is of very rare occurrence, but from not being complicated with puerperal fever, it is perhaps not so dangerous, if promptly treated, as the other. Dr. Ferguson, has correctly observed, in puerperal fever, that ”any cerebral disturbance diminishes the chances of recovery,” and that ”the presence of delirium in any case is almost always followed by a fatal result.” (_Op. cit._ p. 49, 50.)
The patient in whom we have chiefly observed phrenitic symptoms during labour were stout, robust, short-necked women, with black oily hair, and a swarthy complexion: from an early stage they had exerted themselves during the pain in a most violent and unnecessary degree, and had gradually worked themselves into that state of excitement, which was followed by the symptoms above-mentioned: in two instances, it was ascertained that the patient had received a violent blow on the head, either during pregnancy, or on some previous occasion. In similar habits the same symptoms have been observed occasionally to accompany the first appearance of the milk, or to follow its sudden suppression when established, or a similar state of the lochia.
_Treatment._ The treatment differs but little from that of the congestive epileptic convulsions, already described: she must be bled to fainting, leeches must be applied to the temples, the head shaved and cold applied to it, the feet should be put into hot water, and the bowels opened by an active purge of calomel. If the child be not delivered, and the pa.s.sages are sufficiently dilated, the forceps should be applied to shorten the labour.
In the other case, which is accompanied with puerperal fever, the propriety of bleeding to any considerable extent will be more questionable; it has probably been already employed in the early part of the original disease, and her powers more or less reduced by it: we must here rather trust to leeches and cold to the head, and bringing the system as soon as possible under the influence of calomel and opium. Whether or not the improvement which follows in some cases of puerperal fever has resulted from the use of saline medicines, we will not pretend to determine; but as, on more than one occasion, we have seen calm and refres.h.i.+ng sleep succeed their exhibition, it is not improbable that they might prove useful in this form of the disease.
We presume that these are the cases to which Dr. Gooch has referred, when he described them as being ”attended by fever, or at least, the most important part of it--a rapid pulse;” and that the majority of them prove fatal: their unfavourable result, however, is not so much from the local affection, as from the puerperal fever under which the patient sinks.
Pure phrenitis, which is a rare disease during labour or the puerperal state, is by no means difficult to control by active antiphlogistic treatment, if taken in sufficient time, before the brain has suffered any serious injury; nor is there much danger of her continuing deranged even after the inflammatory symptoms have been reduced. This appears to be also the case in that form which attends puerperal fever; but here the danger to life is so much greater, that we rarely have an opportunity of ascertaining the duration of the mental disorder after the symptoms of cerebral inflammation have been subdued, since most of these cases terminate fatally.
_Gastro-enteric form._ In the gastro-enteric form, the cerebral symptoms are of a much milder character: the head is perhaps warmer than natural, and it aches a good deal across the forehead and eyes; the face is seldom flushed, but it is sallow, the eye is yellow, the tongue is foul, the breath offensive, and if any evacuations have been pa.s.sed, they are excessively unhealthy; the abdomen feels full and loaded, the pulse is irritable, but devoid of strength; the patient is seldom violent, and if so, can usually be restrained by the mildest measures. Her previous history will also a.s.sist us in our diagnosis; we shall, probably, find that she has for some time suffered from constipation and deranged bowels, or is known to have greatly neglected them before her confinement.