Without speaking of the cases in which eclampsia comes on during labor, it is undoubted that in most eases, when eclampsia comes on dar ing pregnancy, before term or at term, labor is induced, and almost always, when labor does not come on immediately, the child dies. It is delivered later, with alterations proportionate to the length of time which it has passed in the uterus after its death. The further from term eclarnpsia declares itself, the more clanger there will be for the child; on the con trary, the more advanced pregnancy happens to be, the more chance there will be for the child to survive, and these chances will be increased the more as the eclamptic att,acks supervene in the few days preceding full term, and the more rapid the labor has been, or has allowed active inter vention nearer to term. • As to the cause of the death of the child, must we look, as most authors do, to the convulsions, to disturbances in the blood, i.e., to as phyxia, to an altered state of the blood? All these causes may a,ct, be cause a certain number of children born alive die soon afterward, some because they were born prematurely, others because the asphyxia wa.s so pronounced that they could not be revived. Others, finally, only die at the end of some days, and then, a.s Depaul says, the death must be attri buted to congenital weakness or to convulsioirs, which seem to resemble somewhat the eclampsia of the mother, although we are not able to say that the two conditions are identical.
Van der Dolickt admits that the death of the fcetus may result: 1st, from asphyxia; 2d, apoplexy in the brain or cord. According to Grenser, Litzmann found in the bodies of twins born of an eclamptic mother, a great many blood extravasations between the dura mater and the inner surface of the skull. The pleura and the entire surface of the lung pre sented others, about the size of the head of a pin, and the pericardium contained bloody serum. Grenser has found pin-head ecchymoses and blood extravasations of tile size of a lentil seed on the pleura, pericardium, and peritoneum, in a case where there was a slight effusion of blood in the meninges; 3d, to blood poisoning; 4th, to non-albuminuric convulsions, coming on in utero or after birth (Cazeaux, Depaul); 5th, finally to peri tonitis. (Grenser.) Kiwisch attributes the death of the child in part to an arrest of the circulation in the placental vessels, during the attack of eclampsia and the resulting asphyxia, but he does not think that death of the ketus re sults from asphyxia.
Braiin, on the contrary, thinks that urremia is the cause of the death of the fcetus. After the first or second attack, the fcetus is already af fected, and dies almost always after a certain number of attacks. If the mother dies, the child, which is delivered by the Cwsarean section, is al ways dead. If the child is born alive, we find considerable urea in the
blood which flows from the cord. If it is dead, carbonate of ammonia is found m the blood immediately after delivery. If the labor is premature, the child dies in two or three days. Urcemia alone can kill the child without eclampsia having developed at all. The children of eclamptic mothers are often themselves albuminuric.
Now we have seen that the thermometer shows that the eclamptic at tack is not urtemic, and also that the temperature reaches in eclampsia 104°, 105°, and 106°, and it hanks from Runge's researches that the fcetus (lies whenever the maternal temperature reaches 104.2°. It is more than probable that, in the majority of cases, the death of the fcetus is due to the high temperature of the mothers. In the cases where the maternal temperature does not reach so high a point, death may be attributed either to the frequency of the attacks, to blood changes which result from it, or to blood poisoning.
These figures confirm the propositions which we made above.
The prognosis of eclampsia is also aggravated by the fact that it leads to puerperal complications, metritis, peritonitis etc. But along with these serious complications, there are two which, if they do not lead to the death of the patient, merit none the less serious attention. We refer to puerperal mania and paralysis.
In the following chapters we will treat in detail of these two condi. tions, and at present we will limit ourselves with what concerns the di rect relations between puerperal mania and eclampsia, be.fore entering more carefully into details in the chapter on puerperal insanity.
It was Simpson who first noted the relation which exists between eclampsia, albuminuria and puerperal mania. Scanzoni has seen 4 cases; Wieger has seen 10 cases in 100 eclamptic 'women; Grenser 4 times in 19 women; Braun 5 times in 44 women; and it has also been observed by Gooch, Merriman, Esquirol, Sanchez Frias, Selade, Billod, Muck and all alienists.
In cases of this nature, sometimes, the maniacal state immediately succeeds the coma which follows the convulsion. Sometimes the delirium does not break out for twenty-four or thirty-six hours after the cessation of the convulsions, when everything seems to indicate the end of.all cere bral complications. As a rule, cure follows at the expimtion of more or less time, but it is not always so, and mania may be incurable or even end in death. But we must be careful not to confound these cases of true mania with the cases of puerperal meningitis with delirium, which Cazeaux has mentioned among the terminations of eclatupsia. These may occur without albuminuria or eclampsia, and, although they are gen erally fatal, there are exceptional cures, as we observed in consultation, several years ago, in a single case.