POST-PARTUM PARALYSIS—MILK FEVER—MAMMARY TOXÆMIA—PARTURIENT APOPLEXY—DROPPING AFTER CALVING.
For a great part of the following short account we are indebted to an excellent report by J. J. Repp, V.M.D., in the Journal of Comp. Medicine and Veterinary Archives, September, 1901:—
The word “fever” in connection with the terminology of this disease is not very appropriate, because in the majority of cases fever is not present, but the animal has a subnormal temperature. The term milk fever is very misleading and indefinite, as it is also used by the laity to designate other diseases, such as parturient septicæmia and the various forms of mammitis. Parturient paralysis must be clearly differentiated from parturient septicæmia, which is a disease of an entirely different character and which may occur in any of the domestic species, whereas parturient paralysis occurs only in the cow.
Distribution. Parturient paralysis occurs wherever milch cows are kept. It is more prevalent in dairy districts, because it is the heavy milking strains of cows that are most subject to the disease.
Cause. No definite cause can be assigned for this disease. Schmidt’s theory is that parturient paralysis is caused by the evolution in the mammary gland of a poisonous substance through the over-activity of the epithelial cells of this gland excited by the determination to the udder after birth of large quantities of blood which was supplied to the uterus and the fœtus before birth, but which now goes to the udder because of the natural demand for milk secretion. This poisonous substance being carried in the circulation to various parts of the body, brings on the symptoms which characterise the disease. It is well recognised that living cells may, under certain circumstances, produce poisonous substances. Schmidt’s theory, therefore, is in accord with an established principle.
Pathogenesis, or generation, of the disease. Parturient paralysis, as a rule, occurs in cows which give a heavy flow of milk and which are in a high state of nutrition. It may develop at any age, but is extremely rare in cows before they have reached adult age and have given birth to several calves. It is also rare in old cows. It occurs, then, in cows which are of middle age and in the full height of their activity as milk producers. The disease attacks the cow after she has given birth to a calf, usually within twenty-four hours thereafter, but in some cases not until a week or even a month after parturition. In a few cases the disease has its inception a short time before parturition. Cows which are stabled and deprived of exercise are said to be more prone to the disease than those which are permitted to exercise at will. There are many exceptions to this statement, although it is the usual teaching. Further observation may show that it is not correct. In Iowa more cows take this disease while at pasture than in any other circumstance. This doubtless arises from the fact that in Iowa cows are given more freedom than is customary in older dairy States. The disease may arise at any time in the year, but, on account of the fact that spring-time is pre-eminently the calving season, most cases originate at this season.
Morbid anatomy. The morbid alterations are limited and variable, and offer nothing characteristic. The blood is irregularly distributed, a condition which probably indicates marked vaso-motor disturbance resulting from the profound interference with the nervous functions which accompanies the disease. The abdominal organs are usually filled with blood. The brain may be anæmic, œdematous, easily torn, and yellowish in colour. In other cases it shows hyperæmia of the meninges and of the brain substance.
Symptoms. The disease usually appears within twenty-four to forty-eight hours after parturition. In extreme cases it may not occur until two months or even six months after parturition. It may rarely occur before birth. It usually follows an easy birth. At the onset of the disease the cow manifests some uneasiness; it moves about in a restless manner, stamps, strikes the abdomen with its hind legs, perhaps bellows, grinds the teeth, and may have spasms of groups of muscles or even a general convulsion. After this period, which may be unnoticed, the symptoms of paralysis come on. The cow shows weakness, staggers, and at last falls. As the paralysis advances it stretches on the ground, lying on its side usually with the neck bent to one side so as to bring the nose into the flank or the costal region. This is the characteristic position in parturient paralysis. If the head is brought into the normal position, it at once returns to the unnatural position in which it was found. The animal is in a state of partial or complete unconsciousness, does not respond to blows or calls, and takes no note of its surroundings. The eye is dull and not sensitive to the finger touch, sunken, pupil dilated, and the upper lid is drooping; the tongue is paralysed, saliva runs from the mouth, the pharynx and œsophagus have lost the power of motion, so that the animal is unable to swallow; the peristalsis of the stomachs and intestines is in abeyance, and as a result digestion is arrested, fermentation sets in, and the animal becomes tympanitic; the contents of the rectum and colon are hard and dry, and may be covered with mucus or blood, urination is suspended; the os uteri is almost invariably dilated if the disease occurs within a day of parturition; pulse small, often imperceptible, 60 to 120 per minute; temperature, usually normal or below normal, may be as low as 95° Fahr., in some cases may be as high as 105° Fahr. Such a high temperature probably does not occur in a case of pure parturient paralysis, but only when there is a complication of parturient septicæmia. The extremities are cold. The after-birth is sometimes retained. There may be accompanying prolapse of the uterus.
Course. Without treatment, and, indeed, with most kinds of treatment which have been applied in the past, the disease usually runs rapidly to a fatal issue. It lasts two to three days, and in some cases longer, the condition gradually becoming more and more aggravated. Death results from sudden failure of the heart or brain, and is often preceded by profuse diarrhœa. In milder cases the cow may linger as long as two to four weeks and then die of pneumonia, which results from the inhalation, or introduction through attempts at medication, of foreign substances into the lungs during the period of paralysis of the pharynx and œsophagus. If recovery occurs, the animal is entirely well in two to five days. In rare cases paralysis of the hind parts may persist for a long while.
Diagnosis. This is made by a study of the history and symptoms. It is comparatively easy.
Differential diagnosis. It must be distinguished from ante-partum paralysis, broken-back, parturient septicæmia; but one familiar with the character of these diseases will find no difficulty in making this differentiation.
Treatment. This may be considered under two distinct subdivisions, viz., preventive treatment and curative treatment.
(a) Preventive treatment.—By considering what has been said under the head of “generation of the disease,” one can easily infer what measures should be adopted to prevent the disease. Cows in the later stage of gestation should be fed moderately, grain especially being given sparingly or entirely withheld; the animals should be given an opportunity to take plenty of exercise; the bowels should be kept in good condition by the administration of such salines as magnesium sulphate, sodium chloride, and sodium bicarbonate. The after-birth should be removed soon after parturition and several uterine douches administered.
(b) Curative treatment.—The older methods of treatment comprised: warmth and friction to the mammary gland; the administration of sedatives, such as opium, chloral and bromide of potassium; stimulants, including ammonia, ether, turpentine and alcohol; washing out the uterus with water or disinfectant solutions; the relief of tympany by the use of the trocar and canula (by which instrument medicines may also be injected directly into the rumen); the removal of fæces from the rectum; warm clothing of the body and general attention to the animal’s comfort, and to the teachings of hygiene. For all these widely diversified methods good results have been claimed, and, we may add, bad ones at times recorded. F. T. Harvey (Cornwall) estimates the average mortality at from 40 to 66 per cent., though he claims for his more recent practice a lessened mortality of only 20 per cent.
Schmidt does not claim that his method of treatment disposes bodily of the morbid condition, but that it does measurably assist Nature in her efforts to restore the animal to the normal physiological state. It is well known that after the beginning of the attack the animal, if left to itself, rapidly grows worse until the crisis of the disease is reached, at which time death occurs or convalescence begins, usually the former. It has been observed, however, that if the treatment is applied within a few hours after the inception of the disease its progress is modified in such a way that convalescence at once begins, as a rule, and the animal hastily recovers its health, usually within twelve hours, although in extreme cases it may be as late as forty-eight hours. The following is an outline of the plan of treatment of parturient paralysis suggested by Schmidt. The operator should disinfect his hands and the udder and teats of the cow by washing with a 5 per cent. solution of carbolic acid or creolin, or a 1½ per cent. solution of lysol or trikresol. The apparatus needed for the treatment consists of a small glass funnel, a rubber hose three feet long and one-eighth inch in calibre into which the funnel fits, and an ordinary milking tube over which the rubber hose fits. This apparatus should be sterilised immediately before it is used by boiling or soaking in such a solution as recommended for washing the udder. Dissolve from 2 to 2½ drachms of potassium iodide—the size of the dose depending upon the size of the cow and the character of the attack—in about one quart of clean water previously boiled to sterilise it, and allow the solution to cool to a little above body temperature, or 40° C. or 104° Fahr. The temperature may be determined with the clinical thermometer. Withdraw all the colostrum or milk from the udder. Then insert the milking tube, with hose and funnel attached, into one of the teats, elevate the funnel about two feet above the teat and slowly pour in one-fourth of the solution, allowing the funnel and hose to become empty several times during the process in order to permit the entrance of a liberal quantity of air. Repeat this infusion with the other three quarters of the udder. After all is introduced, knead the udder carefully so as to cause the solution to permeate the ducts and acini as much as possible.
As the condition of the cow is usually such as to call for additional treatment, the veterinarian should not be content with injecting the potassium iodide solution, but should resort to any and all other measures which promise assistance.
As the cow is usually unable to urinate, the bladder will be found filled with urine. This should be removed with the catheter, and its removal accomplished at intervals until the recovery of the cow renders this procedure no longer needful.
It may be advisable that catharsis be brought about. As the cow is usually unable to swallow, it is dangerous to attempt to give medicines by the mouth. This may be done if assurance that the cow can swallow is obtained. Some have given medicines successfully through a probang inserted into the stomach. The plan is feasible. Schmidt says that he usually resorted to an aloe powder. If this is done 1 ounce to 1½ ounces of aloes may be given. It would seem preferable to give the aloes in a bolus, capsule, or drench. Some have given linseed oil or Epsom salts. If the animal cannot swallow and a probang is not at hand, one may administer 1½ to 2 grains of physostigmine salicylate subcutaneously, repeating the dose in about three hours if purgation is not produced. Rectal injections should be given at short intervals in order to get rid of the accumulation of hard, dry fæces in the rectum. These injections may be of linseed oil, cotton-seed oil, or warm soap solution. Schmidt recommends, also, enemata of sodium chloride solution. Meanwhile the cow should be kept propped up on the sternum by means of bags of straw or pieces of wood. If the temperature is below normal, as it usually is, the cow should be thickly clothed with blankets and straw heaped up about it. Schmidt used powdered digitalis given by the mouth when the heart was rapid and weak. It would seem much better in every way to give the tincture of digitalis subcutaneously. He has also resorted to subcutaneous injections of camphor and caffeine. This is good treatment. If the cow does not show marked improvement within eight hours the potassium iodide infusion may be repeated. Schmidt has found that as much as 6 drachms may be injected into the udder without harm to the cow. Schmidt, in his first report, made in 1898, recorded 50 cases treated for parturient paralysis by this method with but two deaths from the disease. There were, however, only 46 recoveries, as two cows were slaughtered for beef during the first day of convalescence. A short time later a report was made by Jensen showing that in Denmark up to that time sixty-five veterinarians of that country had treated 412 cases by the Schmidt method, 90 per cent. of which recovered. Such results seem to indicate this as the treatment par excellence for parturient paralysis. It still remained to secure the introduction of this treatment into the United States and to determine what results could be obtained. In all 166 cases were reported; of these 166, 119 resulted in recovery, while 47 were fatal. Of the fatal cases, in eight of the cows death may be traced to some complication, such as prolapse of the uterus, foreign-body pneumonia, etc. In these cases the Schmidt treatment cannot be said to have failed, for it is not in any way intended that it shall be able to overcome such accidental conditions. If the cow has recovered from its condition of paralysis as a result of the Schmidt treatment far enough to be out of danger from that source and to promise recovery, but later falls a victim to some complication that is in no measure a part of parturient paralysis, but only a result of that disease, it may with justice be said that the Schmidt treatment was a success so far as the malady against which it was directed is concerned. Looking at the reports from this generous point of view, in 127 cases out of 166, or 76·5 per cent., the Schmidt treatment was successful so far as the parturient paralysis was concerned.
In a paper published in the Berliner Thierärztliche Wochenschrift in August, 1902, Schmidt reviews the results of his treatment as evinced by 914 patients treated by thirty-one different practitioners: 884, or 96·7 per cent., recovered, twelve died and six were slaughtered during the course of the disease. Twelve others were slaughtered at a later period in consequence of complications. Jensen reported the results of 1,744 cases.
Schmidt also found that the simple injection of air was in many cases sufficient to produce recovery, and subsequent observation tends to show that the fluid injected is of less importance than was first anticipated. A large number of unirritating solutions may be employed. Schmidt, however, still counsels the use of a quart of 1 per cent. solution of iodide of potassium, in which can be dissolved 5 grammes of caffein sodio-salicylate if the heart’s action is weak. About 10 ounces of this solution are injected into each quarter, and are followed by a liberal injection of air. The parts should afterwards be freely massaged.