ECLAMPSIA GRAVIDARUM ET PARTURIENTIUM. 
BY 
J. LINDSAY PORTEOUS, M.D., F.R.C.S. Ed., 
OF YONKERS, N. Y. 
EROM 
THE MEDICAL NEWS, 
February n, 1893. [Reprinted from The Medical News, February 11, 1893.] 
ECLAMPSIA GRAVIDARUM ET PARTURI- 
ENT! UM. 
By J. LINDSAY PORTEOUS, M.D., F.R.C.S. Ed., 
OF VUNIiERS. N. Y. 
The word " Eclampsia" is said by some authori- 
ties to be derived from ek and %-d/nrv, I shine-be- 
cause, in some forms of convulsions, flashes of light 
appear before the eyes, but the derivation that seems 
to us the best to describe the disease is ek and to/fiavv, 
I seize hold of, as in every form of this malady the 
patient clutches at something, real or imaginary. 
Anyone who has had experience in obstetrics 
must have noticed that there are several varieties of 
this dreaded disease. Some, to those conversant 
with such cases, give little alarm ; but unless the 
physician can promptly diagnosticate one form from 
another, much mental worry is occasioned both to 
himself and the friends of his patients. The object 
of this paper is to give some hints, the outcome of 
years of practice, to those of less experience. 
There are at least five varieties, viz. : (i) hysteric, 
(2) epileptic, (3) uremic, (4) apoplectic, (5) mi- 
crobic. 
1. The first form (Hysteric) need give little cause 
for alarm. It is, as a rule, confined to the period of 
gestation, but may continue throughout the period, 2 
at intervals, until labor sets in. When, however, 
the throes of labor begin and there is something of 
a realistic nature to occupy the mind, it vanishes. 
As the symptoms of hysteria are so well known to 
every physician, we will only take a cursory glance 
at them. Beginning with a tightness about the 
throat and the "globus hystericus," the attack 
is attended with sobbing and frequent attempts 
to swallow. Then the patient may become still or 
roll about. The hands clutch something or are car- 
ried to the breast or some other part of the body. 
The face is sometimes pale, though not always. 
There is no froth issuing from the mouth, no tongue- 
biting, no falling in a dangerous place. A very 
prominent feature is the quivering of the eyelids. 
The fit terminates, after a longer or shorter period, 
with a scream and the shedding of tears, and a 
quantity of limpid urine is often involuntarily dis- 
charged. As a rule, this form of eclampsia causes 
no interference with gestation, although premature 
labor is said to have been caused by it. The treat- 
ment, being so well known, need not be gone into at 
the present time. 
2. Epileptic.-For the sake of a more correct and 
sytematic diagnosis, we will adopt the Brown- Sequard 
method of dividing the symptoms into three distinct 
heads: (a) the premonitory, (b) the paroxysmal, 
(c) the inter-paroxysmal. 
a. The premonitory are in many cases well 
marked ; although the classic or Galenic aura is not 
often a prominent premonitory feature of this form, 
there are many others almost always present. To 
economize space, we will summarize the more impor- 3 
tant symptoms : A vague, indescribable sensation is 
sometimes complained of. Irascibility of temper; 
a vascular contraction in feet and hands, producing 
a falling in temperature; a spasmodic state of some 
muscle, or an optical illusion or hallucination, 
are almost always present, singly or collectively. 
Numerous other symptoms which have been noticed 
by different observers we need not refer to. 
b. The paroxysmal. In this stage the symptoms 
vary according to whether the attack is one of epilep- 
sia mitior {petit mal} or epilepsia gravior {haut maP). 
In the former there may only be the unconscious 
state, with a fixed condition of the muscles of the eye 
or contraction of one or more muscles of the face, or 
a movement of the lips, tongue, and throat as in 
the act of swallowing; or, according to D. Russell 
Reynolds, the patient may be only unconscious, 
i. e., have simple loss of perception and volition. 
In such case the duration of unconsciousness is so 
short (from one to four seconds) that the casual 
and inexperienced observer does not notice it. Epi- 
lepsia gravior,on the other hand, presents a very com- 
plex state of affairs. There is contraction of the 
bloodvessels of the brain and face, with consequent 
face-pallor, loss of consciousness, congestion at the 
base of the brain and of the spinal cord, tonic con- 
traction of the laryngeal, cervical, and some of the 
respiratory muscles (laryngismus and trachelismus), 
the peculiar cry, and falling backward or forward. 
There is also tonic contraction of the muscles of 
the limbs. The difficult breathing prevents the en- 
trance of the blood into the chpst and its issue from 
the cranio-spinal cavity. Asphyxia, contraction of 4 
bowels, bladder and womb, are present, with coma, 
fatigue, headache, and sleep. The urine has often 
been observed to contain albumin, although there 
was no evidence of renal disease. 
c. Inter-paroxysmal. The general health of 
epileptics is usually poor. They are excitable. 
Their memory is bad and they are subject to fits of 
depression. Their digestion and circulation are 
often affected. These do not take a form which is 
peculiar to this disease; neither does their morbid 
condition of mind have any peculiarity, nor are they 
necessary concomitants of epilepsy. The frequency 
of attacks varies greatly-some may have them daily 
for years, others may have a period of many years 
between the attacks. The more violent the convul- 
sion the less seldom the attack. 
Prognosis. Inherited epilepsy is seldom cured. 
Brown-Sequard says positively that some cases may 
be cured. A chance of cure is greater when some 
curable or amendable organic alteration exists as 
the cause, than if such were not the case. 
If the cause can be traced to syphilitic brain-dis- 
ease, the chances of cure are most favorable. If 
tumor of the brain be the cause, modern cerebral 
sugery may often be employed with certain success. 
There seems to be no necessary complication, but 
chronic nephritis, disease of the womb or other 
viscus may favor these convulsions. In the pregnant 
woman, death of the fetus or premature expulsion is 
to be dreaded more than the immediate danger to 
the mother. We do not consider that the mother 
runs more risk from -this form of convulsion because 
she is pregnant. 5 
Treatment. Our chief object in treating this 
disease in the pregnant or parturient woman should 
be to curtail the duration, frequency, and severity of 
the attack, in order that she should go safely through 
her full term of pregnancy and have sufficient 
strength for the final efforts of parturition. The 
means we adopt to accomplish this end may, for 
the of covenience, be divided into three heads : 
(1) What to do at the outset of a paroxysm; 
(2) What to do during a paroxysm; (3) What to 
do between the paroxysms. 
In case of the existence of a real aura, several 
means for the prevention of the development may 
be employed. Galen advised a treatment which 
is often successful, but the reason he gave has by 
Brown-Sequard been proved to be entirely wrong. 
The Galenic reason was that, by tying a ligature 
round a limb, it barred something from going to the 
brain. On the other hand, Brown-Sequard has 
proved that the preventive effect was caused "by 
sending an irritation toward or rather to the ner- 
vous centers." We have tried this with much success. 
The best way is not to apply the ligature and leave 
it, but to apply and to remove it repeatedly. It is not 
necessary, according to the same authority, to apply 
it to the limb when the aura is felt. If a premonitory 
symptom is disturbance of respiration, the adminis- 
tration of chloroform may give instant and some- 
times permanent relief. Immersion of the hands in 
warm water, giving stimulants, applying ice to the 
nape of the neck, may each or all be applied suc- 
cessfully. If we can find a part of the body which, 
by irritation, gives rise to an attack, we should apply 6 
counter-irritants to that part. If this part be the 
central organ of the nervous system, the spinal 
marrow, which is acted upon by an excited condi- 
tion of those nerves passing from the uterine organ 
to the spinal center, depending upon the puerperal 
state or upon actual labor, counter-irritants will be 
of little service. While these stimuli continue to 
influence the spinal marrow, epileptic convulsions 
may be caused in either of two ways: those acting 
permanently on the spinal marrow, or centric causes, 
and those affecting the extremities of its incidental 
nerves, which are causes of excentric or peripheral 
origin. According to Tyler Smith, those acting 
immediately on the central organ are: (x) Pressure 
on the medulla oblongata by congestion-coagula, 
nervous effusion within the cranium; (2) Loss of 
blood ; (3) Morbid elements in the blood, the in- 
fluence of emotion. 
Of causes acting on the extremities of the excitor 
nerves we have : (1) Irritation of the incident spinal 
nerves of the uterus and uterine passages; (2) Irrita- 
tion of the excitor nerves within the cranium; (3) 
Irritation of the incident spinal nerves of the rectum ; 
(4) Irritation of the ovarian nerves ; (5) Irritation 
of the gastric and intestinal branches of the pneumo- 
gastric nerves ; (6) Irritation of the incidental spinal 
nerves of the bladder; (7) As probable causes may 
be enumerated: irritation of the cutaneous nerves 
of the mammae and hepatic and renal branches ot 
the pneumogastric. Of course, the centric and 
excentric causes may act together. Over many of 
the conditions named we have no control. At all 7 
times, however, we should attend to the condition 
of the alimentary canal and kidneys. 
Treatment during the paroxysm. Lay the patient 
in the supine position ; loosen the clothes. Use only 
sufficient force to prevent the patient from injuring 
herself. Careful administration of chloroform is 
often useful when a status convulsivus occurs. If, 
however, the attacks are so frequent that they 
threaten death by exhaustion, or a miscarriage is 
imminent, or the period of gestation is within two 
months or even longer of completion, the most 
rational and best treatment in our experience is to 
hasten on labor and deliver as quickly as possible. 
The safest mode of performing this is by digital 
dilatation, which may be accomplished in from one 
hour and a quarter to two hours. This is simple 
enough, with an assistant, to dilate by turns. 
In the inter-paroxysmal stage, if the convulsions 
are not of a serious nature, we must search for a cause 
and treat it. 
There may be albumin in the urine, but not neces- 
sarily so, as we maintain that with this form of 
eclampsia the kidneys have little to do. About 9 
percent, of pregnant women have albumin in the 
urine some time during gestation, but convulsions do 
not occur in 9 per cent, of pregnant women. 
3. Uremic Convulsions.-Whatever may be the 
primary cause of this form of convulsion, whether 
mechanical or chemical, most authorities agree that 
it is a strike on the part of the eliminative organs. 
The symptoms may in many points resemble those 
of epilepsy. 
In some,cases there may be no loss of consciousness, 8 
but in all cases there is an abundance of an albumi- 
nous body in the urine, and a great diminution in 
quantity, sometimes total suppression. The attacks 
may resemble tetanus. There may only be one, 
coming on without warning or preceded by head- 
ache, giddiness, and drowsiness, or numerous con- 
vulsions may take place in rapid succession. Death 
has occurred during the attack, but not frequently 
during the puerperal state (if there is no true renal 
disease), because their origin in this state is a com- 
bination of circumstances which does not long per- 
sist, as either nature or art comes to the rescue. 
As there is no structural change in the kidney, there 
is no serum-albumin. 
Treatment. Reestablish as quickly as possible 
the action of the eliminative organs. Apply poul- 
tices over the loins ; use the hot pack ; give hydra- 
gogue cathartics and digitalis ; perform venesection 
up to 8 or io ounces; give diaphoretics, as pilo- 
carpine, etc. If all this treatment is of no avail, we 
must consider the advisability of bringing on labor 
as in the previous case. 
4. Apoplectic Convulsions.-Although this form, 
strictly speaking, should not be put under the head 
of eclampsia, it does sometimes happen that a pa- 
tient is so seized during gestation or parturition, 
and we ought to be prepared to diagnosticate the 
condition when present. It may be defined as loss 
of consciousness, of sensation, and of voluntary 
motion, coming on more or less suddenly, and due 
to a morbid state of the brain (Gowers). 
Symptoms. The onset is often sudden. The face 
is generally, but not always, flushed. The heart and 9 
arteries beat more forcibly than normal, but less fre- 
quently. Respiration is labored and stertorous. In 
profound coma, pupils are dilated, and sluggish in 
their reaction to light. The sphincters become re- 
laxed. There is often paralysis of one side. The 
temperature is at first always lowered, but rises in 
from twelve to twenty-four hours. 
The condition may be mistaken for syncope due to 
cardiac inaction, but we trust that the mistake is not 
frequently made. In cardiac syncope the heart's ac- 
tion fails, the pulse is weak and almost imperceptible, 
the face is pale, respiration is sighing and irregular, 
and the sphincters are rarely relaxed. Albumin is 
often present in the urine in cases of cerebral hemor- 
rhage. If the patient is young, and there is general 
edema, the case is more likely one of uremia than 
apoplexy. The coma is more profound in cerebral 
mischief than in uremia, although the patient may 
be roused in many cases. Convulsions may come on 
at the onset, but they are generally unilateral. In 
uremic poisoning there are general convulsions at the 
onset. Coma in apoplexy comes on suddenly; in 
uremia, slowly. 
Treatment. Remove all constrictions around the 
neck. Apply sinapisms to the back of the neck 
and to the extremities. Carefully administer stimu- 
lants when embolism or thrombosis is suspected. 
Strong purgatives, such as croton oil, lessen the 
serum in the blood, and remove it from the brain. 
Apply cold to the head. Little else can be done ; 
much interference may cause baneful results. 
5. Microbic Convulsions.-We are not aware that 
any notice of this form of convulsion has been given 10 
in text-books, and we are aware that not until the 25 th 
of March of this year, had a microbe been discovered 
On that day two French physicians announced that 
they had found the microbe of puerperal eclampsia. 
The symptoms can be best given by describing a 
recent typical case observed by the writer. 
On a Tuesday in the month of April last, we called 
on a lady who expected to be confined the follow- 
ing month. She looked the picture of health ; was 
cheerful and hopeful; had no drowsiness or feeling 
of fatigue. She was walking about her house, and, 
in fact, felt perfectly well. She had no anasarca, 
and both kidney, and bowels were performing their 
functions thoroughly. The urine contained no albu- 
min ; it had specific gravity of 1022, and was slightly 
acid. At 1 a.m., Wednesday, we were notified that 
the membranes had ruptured without pain. At 7 
a.m. we visited her and found that she had slight 
labor-pains, which continued at long intervals till 
noon, when suddenly, without warning, she had a 
convulsion which lasted about ten minutes. The 
twitching was only slight; there was no quivering 
of the eyelids, no frothing at the mouth, no press- 
ing of the thumb on the palm. The face was at 
first pale, then graduady became of a purplish 
hue. The pupils were normal in size, but did not 
respond to light. The pulse rose to 98. The 
woman recovered consciousness almost at once, and 
vomited. There was a slight feeling of exhaustion, 
but nothing else to indicate her late condition. At 
1 p.m. there was another very slight convulsion. 
Dreading more, we determined to hurry on labor 
and deliver. With the aid of D. E. Hermance, we 
anesthetized her deeply, and by persistent digital 
dilatation delivered her with forceps in one hour 
and twenty minutes of a dead child. When the 11 
effects of the anesthetic had passed away she fetl 
comparatively comfortable. This condition re- 
mained till 7.30 p.m., when she had in rapid suc- 
cession three slight convulsions. During the night 
she voided quite a quantity of urine, and slept well. 
All Thursday her condition seemed quite favorable. 
At night she had, on the suggestion of a physician, a 
small hypodermatic of morphine. At 7 a.m., Friday, 
we were told that she could not be awakened. The 
nurse had noticed during the night her twitching 
frequently. We immediately tried to restore con- 
sciousness, which, to the extent of an attempt to 
speak, we did. Steaming her, hypodermatics of 
pilocarpine, enemata, were tried without effect. A 
pint of urine was removed by catheter and found 
perfectly free from albumin. After numerous slight 
convulsions she died at about 4 p. m. 
We noticed no symptoms which might be said to 
be peculiar to this form, but there was the absence 
of the prominent symptoms in the previous four 
forms of eclampsia. There were no premonitory 
symptoms whatever which might give us a clew to 
the cause. The treatment pursued, we maintain, 
was quite justifiable. Until we know of a positive de- 
stroyer of this puerperal microbe, we can only try 
to drive it out of the system by exciting all the 
eliminative organs to do their utmost, and thus lessen 
their power of destruction, and at the same time get 
the patient out of the parturient condition as soon 
as possible. 
The question may arise, Is there a microbe pres- 
ent in all pregnant women, which some are able to 
throw off and others are not, which in some increase 
so much as to endanger life ? 12 
We firmly believe that this form of eclampsia, 
with our present knowledge of treatment, is always 
fatal; that the four previously mentioned are sel- 
dom fatal if the treatment we have suggested is faith- 
fully carried out. The Medical News. 
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