If the woman is to die the eclamptic attacks usually increase in frequency and violence; the temperature runs up very high, or it sinks; the pulse becomes weak and running, edema of the lungs comes on, with rattling and cyanosis, and the urine ceases to flow. The woman may die in a convulsion from apoplexy or heart paralysis. At times the child is delivered, but the coma deepens and the woman dies. In other cases there are coma and death without convulsions. Rarely there is a condition akin to acute yellow atrophy of the liver, with delirium, twitchings, coma, and death.
Women who have chronic nephritis seldom have convulsions in pregnancy unless there happens to be cerebral hemorrhage as an effect, but they suffer the other results of chronic Bright's disease—dropsy, uremia, edema of the lungs, paralysis of the heart, and albuminuric retinitis; they also are inclined to premature labor, and to hemorrhages that loosen the placenta. When acute nephritis happens in pregnancy convulsions are quite common, and when there are convulsions as a result of either chronic or acute nephritis it is very difficult to differentiate between these convulsions and genuine eclampsia.
The real cause of eclampsia is unknown, but the most plausible explanation of this "disease of theories," as Zweifel of Leipsic called it, is that it is a toxemia which attacks the liver, and directly or indirectly the kidneys, and brings on convulsions by toxic action on the anterior cerebral cortex. The great difficulty is to explain how these toxins originate. One authority suggests that the poison comes from the liver; another, from the fetus; a third, from the placenta, the intestines, the general metabolism, disturbed glandular balance, bacteria, and so on, but nothing is certain as to the etiology except that it is an intoxication.
On an average, 20 per cent. of the women who have eclampsia die,—but statistics vary from 5.31 per cent. to 45.7 for the mother and from 30 to 42 per cent. for the child. Eclampsia occurring ante-partum has the worst mortality; intra-partum, less; post-partum, least. About half the children die from prematurity, toxemia, asphyxiation, narcotics administered to the mother, or injuries at birth.
If the patient's pulse remains full and hard and below 120, there is no immediate danger of death; but if faster, weaker, and running, the prognosis is bad. High fever is not necessarily fatal to the mother, but it is very dangerous to the fetus. Edema of the lungs is a very grave symptom, but recovery is possible. When the convulsions have gone beyond twenty the prognosis is bad, but there have been recoveries. Deep cyanosis, marked restlessness, anuria, and intense albuminuria are all bad symptoms. Apoplexy is nearly always fatal. After delivery the recovery of the woman is by no means certain. She may get pneumonia, sepsis, or another eclamptic attack. Hirst finds that if the diastolic pressure does not rise above a ratio of 1 to 3 times the pulse pressure (i. e., the difference between the systolic and diastolic pressures), the prognosis is good.
Every pregnant woman should be watched to prevent eclampsia, if possible, because all are liable to this outcome. The hygienic methods mentioned in the chapter on Abortion are most important here. The family history is of weight—if the women of the patient's family have been eclamptic, if her parents were alcoholic or insane, these facts increase her liability to the disease. If she has had eclampsia before, if her kidneys are acutely diseased,—especially if injured by infections,—if she is inclined to digestive disturbance, she is disposed to eclampsia. Albuminuria, diminishing amounts in the daily excretion of urine, and decrease in the total solids of the urine, casts or blood in the urine, are serious symptoms. If albumin increases and urea decreases, this is a grave sign.
The blood should be examined for the various anemias. If the thyroid gland is deficient or altered in activity, thyroid extract may be indicated—this acts also as a diuretic. Uterine malpositions should be corrected. Treatment should be given where there is any evidence of toxemia, as headache, altered secretion and excretion, neuralgia, mental eccentricity, increased vasomotor stimulation, high tension, disturbance in the sensory apparatus, obstinate constipation and jaundice. Toxemia is not necessarily renal in origin.
In any of these conditions the proteids should be kept low in the diet, so that the kidneys may not be overtaxed. To throw off toxins, the emunctories should be stimulated by laxatives, water for diuresis, tepid bathing. If the symptoms grow threatening, and the kidneys are involved, the woman should be put to bed, on water alone. After three days an absolute milk diet should be begun. As she improves, starches are added, then the vegetables containing proteid, vegetable oils, and butter. As the improvement goes on, the diet may be vegetables, fruit easy of digestion, and one egg a day. Later fish and chicken are used, but never a full meat diet. Beef, mutton, veal, and similar heavy meats are not to be eaten. The drink is to be water, buttermilk, or koumiss.
When the eclampsia is inevitable the question of inducing labor arises. If the child is not viable, abortion is out of the question, as has been proved in the chapter on Abortion and the general chapter on Homicide. If the child is viable, there are three opinions: one, that the premature delivery should be effected as soon as possible; a second, that this delivery should be delayed as long as possible; and a third, that it should not be attempted at all. Those who hold that the uterus should be emptied as soon as possible, induce labor at the first convulsion, rapidly and under deep narcosis. Chloroform is dangerous to the heart in such cases for full anesthesia; ether is better. Braun first observed that the convulsions cease or are lessened after delivery. Dührssen found these results in 93.72 per cent., Olshausen in 85 per cent., Zweifel in 66 per cent. Peterson said that in 615 cases of early delivery—as soon as possible after the first convulsion—the maternal mortality was 15.9 per cent., but 28.9 per cent. in the same maternities under the expectant method.
Olshausen was not in favor of forced delivery. Charpentier[122] held that forced delivery is dangerous and should be absolutely proscribed. His statistics of mortality are: after spontaneous labor, 18.96; after artificial labor, 30.04; after forced delivery, 40.74.