Eclampsia. Pre-eclamptic toxemia, as the name suggests, is a condition that frequently precedes eclampsia, and the importance of the prevention, early recognition and prompt treatment of this forerunner is due to the seriousness of eclampsia which threatens to ensue. This disease, which may be defined as a toxemia occurring before, during or after labor, is one of the gravest complications which arise in obstetrics. It is usually associated with both tonic and clonic convulsions, unconsciousness and coma.
Patients who have a tendency to kidney trouble and to digestive disturbances, such as so-called “biliousness,” are evidently likely to have eclampsia; and in eclampsia there is a peripheral necrosis of the liver which occurs in no other condition. These facts suggest that possibly when metabolism is proceeding normally, the liver converts certain material, whose retention within the body is inimical to health, into a form which the kidneys can excrete without great effort; that if the liver fails in this function, the kidneys are unable to stand the increased strain put upon them, as is evidenced by casts and albumen which appear in the urine, and the retained material gives rise to toxemia. It is possible that disturbed functions of other glandular organs, such as the thyroid, may play a part in causing eclampsia, but this, too, is only conjecture.
The frequency with which the disease occurs has been variously estimated at from one in 500 to one in 100 cases, apparently being more common in first pregnancies than subsequent ones, but more serious when occurring among women who have had children before. One attack is believed to confer an immunity, or, as Dr. Chipman puts it, “the woman with eclampsia vaccinates herself.” The average death rate from eclampsia is from 20 to 35 per cent. of the mothers and about 50 per cent. of the babies, except where the desired care can be given, either at home or in a hospital, when the mortality is greatly reduced. These figures vary, somewhat, according to the time of the onset, as the disease is usually more fatal if the convulsions occur before or during labor, than afterward.
Some authorities feel, however, that eclampsia is quite as fatal after, as before, labor.
Symptoms. The symptoms, as a rule, are those of pre-eclamptic toxemia which have persisted and grown more severe, accompanied by convulsions and coma. The blood pressure may be from 150 to 250 millimetres and the urine, in addition to showing many and varied casts, contains albumen, which varies in amount from a few grams per litre to more than a hundred in severe cases. In those cases which prove fatal and come to autopsy, there is always found a characteristic, peripheral necrosis of the liver, and since it is found in no other disease it definitely establishes the diagnosis. It is true that this is of no help to the poor woman who died, but it is of help to those investigators who are so earnestly studying the disease with the hope of finding its cause and cure.
Although there are frequently pre-eclamptic symptoms which have grown worse, with or without treatment, it sometimes happens that the patient has no warning discomfort and the first sign of the disease is a convulsion; or a patient who has been treated for pre-eclamptic toxemia may apparently recover, even to the extent of having the albumen disappear from her urine, and suddenly have a convulsion.
Convulsions, which are both tonic and clonic in character, occur in about 99.5 per cent. of all eclamptic cases and are very distressing to watch. They are sometimes preceded by an aura, but often are so unheralded that they may even occur while the patient is asleep. They ordinarily begin with a twitching of the eyelids; the eyes are wide open and staring and the pupils are first contracted and then dilated. The twitching extends to the muscles about the nose and mouth, then to the neck and arms, and so on until the entire body is convulsive. The patient’s face is usually cyanotic and badly distorted, the mouth being drawn to one side; she clenches her fists, rolls her head from side to side and tosses violently about the bed. She is totally unconscious and insensible to light, and during the seizure may not breathe beyond giving one or two struggling gasps. Her head is frequently bent backward, her neck forming a continuous curve with her stiffened, arched back. Another distressing feature is the protruding tongue and the frothy saliva, which is blood stained if the patient is not prevented from biting her tongue by the introduction of some sort of a mouth gag between her teeth.
Such is the typical eclamptic convulsion.
The attacks vary greatly in their intensity and duration. There may be only a few twitches, lasting ten or fifteen seconds or violent convulsions lasting as long as two minutes, their number and severity increasing with the seriousness of the patient’s condition. In mild cases there may be but one or two convulsions, particularly if the onset is either late in labor or postpartum. But as a rule, there are several convulsions; ten, twenty or thirty, and sometimes, though rarely, as many as a hundred.
The patient always goes into a coma after a convulsion and this also varies in length and profundity, her condition during the intervals being very suggestive of the probable outcome of the disease. If the attacks recur frequently, as they usually do in extreme cases, the patient is likely to remain unconscious during the entire interval; but she will usually awaken between attacks that are far apart, and this is regarded as a hopeful sign. The respirations are labored and noisy as a rule, and the pulse full and bounding, in which case the outlook is good. The temperature is often normal, but may go as high as 104° F. or 105° F., dropping rapidly as the attacks subside. But a weak, rapid pulse together with a high temperature, and above all, a persistently high blood pressure, no matter what the other symptoms may be, are always unfavorable.