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.