It has been a common opinion that epileptic puerperal convulsions are almost certainly fatal to the child, especially if they continue for any length of time: experience, however, proves the contrary, as cases continually occur where the mother has laid for many hours in a constant succession of severe convulsions, and yet has been ultimately delivered of a living child. Still, however, it must be owned, that barely an equal number of the children are born alive under these circumstances. Thus, in Dr. Merriman’s 48 cases, as already mentioned, only 17 children were born alive (including the 6 born before the mothers were attacked with convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32 children (two of the women having had twins) were born dead; of these, however, it must be observed, that 8 were delivered with the perforator, and two were born putrid.
Tetanic species. There is one modification of eclampsia parturientium, which, from the spastic rigidity of the uterus which accompanies it, is peculiarly dangerous to the child’s life: it has been called the tetanic form: the convulsions are incessant, without any apparent interval, and the uterus actively participates in the state of general spasms: under such circumstances, the pressure which it exerts upon the body of the fœtus will seriously obstruct the abdominal circulation, and produce the same effects as pressure on the cord.
In most cases, however, the convulsions have no effect upon the process of labour, which continues its course uninterrupted; so that, where there has been no return of consciousness during the intervals between the fits, and the patient has laid in a continued state of coma for some time, the child may actually be born before there has even been a suspicion that labour was present. It is, therefore, of great importance that the practitioner should be on the watch to detect any symptoms of its coming on, not only for the purpose of giving her the necessary support at the moment of expulsion, but also such assistance as may tend to shorten that process.
“By attentively observing what passes in cases of convulsions, we remark that they do not always interrupt the course of the labour pains, whether they had excited those pains, or the pains had preceded them. All authors relate examples of women who have been delivered without help after several fits of strong convulsions; and others while they were actually convulsed, whether there were lucid intervals between, or that the loss of understanding was permanent. The progress of labour in most of these cases seems even more rapid than in others, since we have often found the child between its mother’s thighs, though an instant before we could discover no disposition for delivery.” (Baudelocque, trans. by Heath, § 1109.)
Diagnosis of labour during convulsions. Where the patient is in a state of insensibility, we may infer the presence of labour by a variety of symptoms; every now and then, from a state of torpor, she becomes restless, and evidently uneasy; she pushes the bed-clothes from the abdomen, and gropes about it as if trying to remove something that is heavy or uncomfortable; she writhes her body, and moans as if in pain; after awhile, she again relapses into her former state of coma. A little attention will soon show us that these exacerbations of restlessness are periodical; and if we examine the abdomen at the moment, we feel the uterus evidently contracting; the os uteri also will be found tense and more or less dilated: if the head has already advanced into the vagina, these contractions will be accompanied by a distinct effort to strain.
It is rare to find convulsions complicated with malposition of the child; indeed, so uncommon is the occurrence of it under these circumstances, that we may feel almost certain, on being summoned to a case of convulsions, that there will be little chance of this additional difficulty being superadded. “There was but one case,” says Dr. Collins, “of convulsions during my residence in the hospital, where the child presented preternaturally; there was not one case with a preternatural presentation during Dr. Clarke’s residence; and Dr. Labatt has stated the same fact in his lectures while master of the hospital. In these three different periods there were 48,379 women delivered, so that from this we may infer, where the presentation is preternatural, there is little cause to dread the attack.” (Practical Treatise, p. 200.)
Prophylactic treatment. Under no circumstances is the old saying of “Prevention is better than the cure,” so well illustrated as in the prophylactic treatment of puerperal epilepsy: it is only by carefully watching for and recognising those symptoms which we have already enumerated as threatening an attack, that we are able to adopt such measures as shall either keep it off entirely, or at any rate considerably diminish its violence.
The treatment which we have recommended during the last weeks of pregnancy, is particularly valuable in keeping off any disposition to these attacks: regular, and for her condition even tolerably active, exercise and strict attention to the bowels, should be required, especially in primiparæ. If any distinct symptoms of cerebral congestion make their appearance, such as flushed face, headach, or slight wandering; if, moreover, the pulse be slow and labouring, we must at once relieve the circulation by bleeding; and by an active dose of calomel and James’s powder at night with a warm pediluvium, and a brisk laxative the next morning, endeavour to ward off the dreaded attack. Not unfrequently, however, we have no warning of the danger until the fits burst out, and are thus debarred the opportunity of preparing against them.
Treatment. During the fit itself little can be done beyond placing the patient in such a situation that she should not injure herself by her exertions. If she happens to be upon a chair when the attack begins, it will be as well to let her sink gently upon the floor, and lie there until the fit is over; if she is in bed when it comes on, we have merely to watch that she does not roll off during her struggles; her movements should be restrained as little as possible, and by so doing we shall spare her the suffering after the fit from strained muscles and half-wrenched joints, which is so severe where the assistants, from mistaken kindness, have endeavoured to hold her.
It has been recommended by Dr. Denman to have the patient’s face frequently dashed with cold water during the fit, a remedy which, as Dr. Merriman observes, is very effectual in ordinary hysterical paroxysms, and which possibly may have a slight effect in moderating the violence of the epileptic convulsions; but from what we have seen we are not inclined to consider it of much use.