A System of Midwifery

by Edward Rigby

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 anæmia.

The last two rather deserve the title 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 passages 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.