A System of Midwifery Part 35

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 refreshing 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.

Puerperal mania from this cause is a result of cerebral irritation, not inflammation, and is a state which will generally cease the moment the cause is removed. As is the case with puerperal convulsions from gastro-enteric irritation, so here the moment we break the chain of morbid sympathies, upon which the disease depends, the symptoms disappear, and are instantly followed by a clearing up of the mental disorder. It usually comes on during the first few days after labour, before the patient has taken the laxative medicine which is customary at this time, and seems to be excited to an outbreak by any little source of mental annoyance or irritation. At first, it appears to be little else than giving way to caprice and temper, but by degrees her manner becomes more changed; and ultimately she grows violent and unmanageable. The state of mind, however, is very different to that of the inflammatory form of puerperal mania; there is no raving delirium, and but a slight degree of incoherence; she understands what is said to her, but reasons erroneously under the influence of a false impression. This state rarely proves dangerous either to her life or her reason, if the proper treatment has been promptly had recourse to; but where it has been allowed to run on for some time, or she has been reduced by antiphlogistic treatment under an erroneous fear of cerebral congestion or inflammation, there may be reason to fear that she will ultimately sink, or at any rate, that the derangement will become permanent.

_Treatment._ As the pulse scarcely ever betrays a febrile or inflammatory condition of the system, for although quick, it is seldom observed to be full and hard, bleeding is rarely required in this form of puerperal mania, leeches and cold applications being almost sufficient to control any symptoms of determination to the head which may be present: it is upon purgatives that we must place our chief hope in this disease, for until the bowels have been thoroughly and effectively cleared, there will be little chance of the symptoms being alleviated. In some cases it is scarcely credible to what an extent this may be carried; day after day sees the patient relieved of copious, dark, and offensive evacuations, which are evidently not merely the result of enormous acc.u.mulations in the bowels, but of excrement.i.tious matters, which are thrown off by the secreting vessels of the liver and alimentary ca.n.a.l. So far from producing debility, the pulse rises with each relief and becomes fuller and slower, the face resumes a healthier aspect, the tongue becomes cleaner, the headach subsides, reason regains its ascendancy, and this favourable change is followed by calm and refreshing sleep. We could quote several cases of our own, in ill.u.s.tration of this form of puerperal mania and its treatment, where the symptoms have quickly yielded, as soon as the source of irritation had been removed from the system; the patient has recovered favourably, although in most instances she has retained a sufficient recollection of what had pa.s.sed to feel much vexed and even shocked at, what she was aware had been, very strange and unruly conduct; but we prefer selecting Dr. Gooch's thirteenth case, of which the details are given so graphically, as not a little to enhance the value of it.

"A lady, twenty-two years of age, clever, susceptible, and given to books, was confined with her first child at ----, -- miles from town: she was anxious to nurse it; but several days pa.s.sing with little appearance of milk, doubts began to be entertained whether she would be able: _she_ thought she would, her nurse and surgeon thought she would not: this led to irritating discussions; her manner became sharp, quick, and unnatural; and at the end of a few days she was decidedly maniacal. I and another physician were now sent for; we found her in a straight waistcoat, incessantly talking and reciting poetry; her skin was hot, her pulse full, and much above 100; her tongue covered with a dark thick fur; her bowels were confined, and her stools excessively dark and offensive; she took a dose of calomel and jalap, followed by small doses of sulphate of magnesia; these produced a few evacuations, but they were followed by no relief; she talked almost incessantly, scarcely ever slept, and was so violent that it was impossible to keep her in bed without the straight waistcoat. Thus three days pa.s.sed from our first consultation. The physician who attended with me, thinking the case would be protracted, withdrew, and I was directed to take Dr. Sutherland down with me. As the purgative had operated very moderately, and the tongue and stools were as unnatural as at first, he proposed a more active purge. The next morning, therefore, she took a strong dose of senna and salts, made still more active by the addition of tincture of jalap; after this had been taken about three hours, it procured a very large evacuation, nearly black, and horribly offensive; this was as usual discharged into the bed without any notice on the part of the patient; it acted again an hour or two afterwards; but now the nurse, who was sitting by her bed-side, was surprised to see her turn round, and in a calm and natural manner request to be taken up, as her medicine was going to operate; her waistcoat was immediately loosened, and she was taken out of bed, when she voided a stool of prodigous size, as dark and offensive as the first, and then walked back to her bed calm and collected. We saw her not many hours afterwards; her waistcoat was off, she was lying on her sofa perfectly tranquil, answered questions correctly, manifested no vestige of her complaint, excepting some strangeness in the expression of her countenance, and a timidity and abstinence from conversation which was not natural to her: she recovered rapidly and uninterruptedly." (_Account of some of the most important Diseases peculiar to Women_, by Robert Gooch, M. D. p. 156.)

The chances of recovery in puerperal mania, from, gastro-enteric irritation are as great as they are small in the inflammatory form connected with puerperal fever: the danger is more from erroneous practice on the part of the medical attendant, who either prostrates the powers of life by active depletion, under the supposition that he is treating a case of cerebral congestion, or aggravates the disorder of the mind into wild delirium, by the exhibition of opium, to procure sleep. It is in these cases that we occasionally see so much relief procured by the action of emetics, as at one time to have been considered nearly specific in this disease, by some of the French pract.i.tioners. If the powers be good, we cannot agree with Dr. Gooch, in objecting to the use of antimony; when in a sufficient dose, and combined with ipecacuanha, it is too speedy in its operation to depress the patient much by nausea, and has the additional advantage of acting as a rapid and effectual purge: when its action is over, she usually falls into a sound sleep, perspires freely, and wakes greatly refreshed.

The indiscriminate use of emetics in puerperal mania, is not less mischievous than that of bleeding; they are chiefly indicated in those cases, where, in addition to the symptoms above-mentioned, there are signs of a foul and oppressed stomach, and where the patient either complains of nausea, or has already made several attempts to vomit. As soon as the offending cause is removed, the bowels should be kept open by mild alterative and laxative medicine, as equal parts of blue pill, compound extract of colocynth, and extract of henbane, in two pills at night, and a mineral acid in some bitter infusion during the day. The food should be bland but nutritious, the mind quietly but agreeably occupied, and all excitement carefully avoided. In this form of puerperal mania, it is not only a rare occurrence to find that the disordered state of the mind continues, when the cause which had produced it no longer exists, but it is scarcely ever known to return in the patient's subsequent confinements.

In the case which has been so ably recorded by Dr. Gooch, the patient has since had a very large family, her labours have all been perfectly favourable, and without the slightest symptom of her former disease.

The _adynamic form of puerperal mania_ is by far the most common species of the disease, and like the adynamic puerperal convulsions, arises from causes which produce exhaustion and collapse in the general powers of the system. It is to Dr. Gooch that we are indebted for a masterly exposition of this disease, and for having been one of the first to point out its real character.

_Causes and symptoms._ This form of disordered mind is a disease of true debility, and is closely allied to delirium tremens, and convulsions produced by anaemia. It can scarcely be said to deserve either the terms "puerperal," or "mania," for we frequently see a very near approach to it in females who are much weakened by haemorrhage, either from menorrhagia, malignant disease of the uterus, or abortion; and from being a disease which arises from great exhaustion, it rather deserves the name of melancholia, than of mania. In lying-in women, "there are two periods at which this is chiefly liable to occur; the one soon after delivery, when the body is sustaining the effects of labour, the other several months afterwards, when the body is sustaining the effects of nursing." (Gooch, _op. cit._ p. 109.) In the one case, it is usually the result of profuse haemorrhage, in the other, it is produced by suckling her child when she is not strong enough for this purpose. "I have repeatedly seen the commencement of mental derangement in women who had recovered from their confinement and had been suckling several months. Nearly all these cases were instances, not of mania but of melancholia. They occurred in women who had been debilitated by nursing. The disease at this period has been attributed to weaning; but, in all cases, I have seen, the disease has begun before the weaning, and this measure has been resorted to, because the patient had neither milk nor strength to fit her for a nurse. There was a peculiarity about the commencement of the disease which I have seldom or never noticed at the commencement of mania; there was an incipient stage in which the mind was wrong, yet right enough to recognise that it was wrong." (Gooch, _op. cit._ p. 114.)

This half-way state of mind between reason and derangement is frequently seen in women who have been exhausted by menorrhagia, leucorrhoea, &c., or who have been drained by nursing. We confess that we can see but little difference in the effects of anaemia upon the brain and nervous system, whether it be in the unimpregnated or puerperal state, beyond that, on account of the great changes which have taken place in the system by the process of labour, by the secretion of milk, &c., the system is probably more irritable, and susceptible than it would otherwise be. Nothing is more common than to see, in cases of menorrhagia, the mind becoming enfeebled, the memory impaired; the patient begins to find that she can no longer control her thoughts in the ordinary manner, but that strange trains of ideas will pa.s.s through her mind, the source of which she cannot explain, and frequently so unaccountably, as to cause her serious uneasiness: "If this goes on so, I shall lose my senses," is almost a never failing observation; and the dread that this will be the case, tends to depress the system still more. The sleep is disturbed by frightful dreams, or she pa.s.ses night after night in wakeful restlessness; she worries herself about trifles, her manner changes, and the mind at length is quite disordered. The same train of symptoms is a frequent result of over-suckling, and as Dr. Gooch has justly observed, is not the result of weaning. "In all the cases which I have seen, months after delivery, the weaning has been the consequence of the disease, not the disease the consequence of the weaning. The patients had been reduced in health by nursing, their memories had become enfeebled, their spirits depressed, and their minds ultimately disordered; they were directed to wean their children, because they had neither milk nor strength to enable them to nurse." (_Op. cit._ p. 130.)

A similar state of mind may be induced at an earlier period and more suddenly, by the effects of a profuse haemorrhage, by serious discharges, which occasionally take place shortly after labour, or even by mental depression; in fact, by whatever lowers the vital powers to a considerable extent. In these cases, the very history and appearance of the patient are sufficient to explain the nature of the disease: her hollow eyes, pale face, and blanched lip, show distinctly how her strength has been reduced.

The source and extent of her debilitated state will in great measure determine the degree of danger, and the chances of her recovery. In ordinary cases of this form there is not much to fear, as far as the life of the patient is concerned; and the cases which have come under our own notice confirm the excellent remark of Dr. Gooch, "that mania is a less durable disease than melancholia; it is more dangerous to life, but less dangerous to reason." But if the disordered mind has come on shortly after labour, in consequence of profuse flooding; if the powers of the system have rallied but imperfectly, and from the tinnitus aurium, strabismus, half vision, &c., it is evident that the cerebral functions are greatly impaired; if the nights are pa.s.sed without sleep, and the days in continued and exhausting excitement; if the pulse be feeble and rapid, the skin cold and clammy, the face covered with perspiration, and there is a disposition to colliquative diarrhoea, we shall have but too much reason to fear an unfavourable issue; every symptom denotes that the powers of the system have received a fatal blow, and she either sinks exhausted, or dies in a state of coma, probably from serous effusion upon the brain. On the contrary, if in addition to a general improvement, she has enjoyed some hours of refreshing sleep, there is every prospect, not only of returning health, but also of reason. A mere gleam of returning reason without a corresponding improvement of health, will afford but little satisfaction to the mind of a discerning pract.i.tioner, for it gives no a.s.surance that the danger of fatal sinking is at all diminished.

Disordered mind coming on some weeks after delivery from the effects of over-nursing, when the patient has been unable to afford the necessary supply to her child, is seldom attended with so much danger to life, as where suddenly induced immediately after labour by haemorrhage: the intermediate stage between reason and derangement is more distinctly marked, and is of considerable duration; and the gradually increasing affection of the mind frequently warns even the patient herself to seek medical advice before the symptoms become more serious.

We believe that the proportion of patients in whom the mind continues deranged after their health has been restored, is very small, and feel convinced that the results afforded by the practice of lunatic hospitals are far from giving a correct estimate. A large majority of the cases of derangement in lying-in women are of such short duration that they never come even under the notice of those members of the profession whose attention is particularly devoted to this branch of medical practice, still less do they require to be removed into asylums for lunatics. "The records of hospitals contain an account of cases which have been admitted only because they were unusually permanent; they are the picked obstinate cases, and can afford no notion of the average duration of all kinds; the cases of short duration, which last only a few days or a few weeks, which form a large proportion, are totally lost in the estimate of a lunatic hospital." (Gooch, _op. cit._ p. 125.) The results of Dr. Gooch's practice, which is known to have been very extensive, and especially in consultation, shows that out of a considerable number of cases only two of his patients remained disordered in mind, "and of these, one had already been so before her marriage." There are two cla.s.ses of patients in whom disordered mind is not only much to be apprehended during their lying-in, but in whom there will be some reason to fear that it may become permanent; first, in those who have already been deranged, independent of the puerperal state, or who inherit a strong predisposition to mental disease; and secondly, in those where hysteria has existed in an unusual degree during the latter part of pregnancy. These circ.u.mstances justify us in using every precaution in their lying-in to avoid any thing which may excite the disease; but, as already stated, not only is the disorder of the mind rarely of any duration, but it is seldom known to recur on any subsequent occasion.

_Treatment._ Our indications of treatment are two-fold, viz., to rouse and support the powers of the patient, and to allay as far as possible the irritability of the brain and nervous system.

If the patient has been prostrated by haemorrhage, not only a nutritious, but even a cordial and stimulant diet will be necessary: the emulsion of egg and brandy, which we have before recommended in anaemic puerperal convulsions, will here prove very useful; and it must be given in small but frequently repeated doses, until an improvement is observed in the pulse and in her general appearance. Under all circ.u.mstances, it will scarcely ever be proper or even safe to confine her to low diet: beaf-tea, veal-broth, &c. should be given in considerable quant.i.ties during the twenty-four hours; and it is surprising what improvement will even take place merely from the administration of this bland nutriment. If the face be pale and the pulse low, wine may be given according to the circ.u.mstances of the case.

To calm the cerebral excitement and procure sleep, sedatives will prove of the greatest value, and require to be repeated until the nervous system is fairly under their influence. The intense pain at the vertex, which of itself is sometimes quite sufficient to produce delirium, the tinnitus aurium, &c., all cease; the pulse becomes softer, fuller, and slower; and, even if sleep be not immediately induced, a state of calm tranquillity follows, in which the mind becomes more composed. The Liquor Opii Sedativus may be given in a dose of twenty-five minims, and repeated in an hour or so according to circ.u.mstances. The combination of camphor with morphia, or extract of henbane, is an excellent form, and may be given with perfect safety to a considerable extent.

The bowels should be opened by the mildest laxatives, such as castor oil, rhubarb and manna, &c., medicines which will neither act violently, nor weaken by producing watery evacuations; and, once in every few days, it will be desirable to rouse the action of the liver by Hydrarg. c. Creta, with extract of hop or gentian. To a.s.sist still farther in restoring her health and strength, she should take an infusion of a vegetable bitter with a mineral acid. As soon as her strength will permit, a change of residence may be recommended, and she should remove to some quiet watering-place, where invigorating air and agreeable scenery and occupations will a.s.sist in completing her recovery.

"The constant attendants on the patient ought to be those who will control her effectually but mildly, who will not irritate her, and will protect her from self-injury. These tasks are seldom well performed by her own servants and relatives.

"If the disease lasts more than a few days, and threatens to be of considerable duration, her monthly nurse and own servants ought to be removed, and a nurse accustomed to the care of deranged persons placed in their stead. Such an attendant will have more control over the patient, and be more likely to protect her from self-injury." "With regard to the removal of her husband and relations, this also will be a question; if the disease threatens to be lasting, it is generally right. Interviews with relations and friends are commonly pa.s.sed in increased emotion, remonstrance, altercation, and obviously do harm: large experience also is decidedly favourable to separation as a general rule; yet there may be exceptions, which the intelligent pract.i.tioner will detect by observing the effect of intercourse." (Gooch, _op. cit._ p. 158.)