THE PROPHYLAXIS AND TREATMENT 
OF 
ECLAMPSIA 
Read before the American Gynecological Society, Baltimore, 
May 29, 1895. 
BY 
EDWARD P. DAVIS, A.M, M.D., 
Professor of Obstetrics and Diseases of Infancy in the Philadelphia Polyclinic; Clinical 
Professor of Obstetrics in the Jefferson Medical College; Visiting 
Obstetrician to the Philadelphia Hospital, etc. 
REPRINTED FROM THE THERAPEUTIC GAZETTE, JULY 15, 1895. 
DETROIT, MICH. : 
GEORGE S. DAVIS, PUBLISHER. 
1895. THE PROPHYLAXIS AND TREAT- 
MENT OE ECLAMPSIA. 
IN the American Journal of the Medical 
Sciences, February, 1894, in a paper enti- 
tled "The Toxaemia of Pregnancy," I drew 
attention to what seemed to me the salient 
features of the diagnosis of threatened eclamp- 
sia. Further experience has confirmed my be- 
lief that eclampsia is the result of a complex ir- 
ritant poison, which is produced not only by 
failure of excretion by the kidneys, but also by 
failure in the action of the liver, the skin, the 
lungs, and the intestines. It is my purpose in 
this paper to illustrate this fact by reference to 
clinical data. 
If a toxaemic condition is the cause of eclamp- 
sia, it is reasonable to expect in eclamptic pa- 
tients that symptoms of toxaemia, and especially 
those connected with the nervous system, should 
play a prominent part. One of the most striking 
of these is mania, and its occurrence as a pre- 
cursor of eclampsia is well illustrated in the 
following case : 
Mrs. A. S., aged thirty-eight years, had 
borne two children, and had one miscarriage. 
Her children are living and healthy. The 
labors were normal, and the mother made a 
good recovery after them. Her third -confine- 2 
ment was expected about the 20th of January, 
1895. The patient was the wife of a skilled 
workman, living in plain but comfortable cir- 
cumstances. With the exception of a slight 
cough, she had been in ordinary health until 
January 8, when she suffered with intense 
headache and disturbance of vision. On the 
following morning she prepared her husband's 
breakfast as usual and also the noonday meal 
for her children. About 1 p.m. she suddenly 
became maniacal, rushed up two flights of stairs 
hastily, and attacked her sister-in-law. She was 
finally placed upon a bed, when convulsions 
supervened, lasting for some time. She re- 
gained consciousness, but at 4 p.m. became 
comatose, and was taken in this condition to 
the Jefferson Maternity at 7.30 p.m. Upon ad- 
mission, she was entirely unconscious, the os 
uteri completely dilated, no uterine contractions 
being present. The pupils were equal and con- 
tracted, the eyes slightly turned towards the 
right, loud rales heard over both lungs. The 
pulse was rapid. As soon as I saw the patient 
I delivered her of twins, the first by version, 
the second by forceps. Neither child could 
be resuscitated. One had been dead several 
hours, the other but a short time. Both chil- 
dren were at term, one weighing five pounds 
thirteen ounces, the other six pounds five 
ounces. After three hours of vigorous treat- 
ment, consisting of hot packs, copious ene- 
mata, the administration of calomel, and, 
hypodermically, digitalis and atropine, the 
mother's urine, drawn by catheter, showed 
but slight traces of albfimin ; specific gravity, 
1020; reaction acid; percentage of urea, 1.3. 
The patient died four hours after admission. 3 
The post-mortem examination was made on the 
following day, when the body was found fairly 
nourished. It was noticed that the serous mem- 
branes were very dry. The right heart was dis- 
tended and flabby; the left empty. The lungs 
were markedly congested. The cortex of the 
kidneys showed fatty change, upon which had 
been grafted an acute process. The surface of 
the kidneys was granular. Considerable hem- 
orrhage in the retroperitoneal connective tissue 
had occurred. The uterine and ovarian veins 
of the right side were enormously dilated 
and varicose. The uterine muscle was firm, 
the cavity of the womb being clean and dry. 
Slight hemorrhagic extravasations were found 
in the stomach. The liver was soft, and its 
surface mottled and dark in color. It was 
somewhat enlarged. Post-mortem examination 
of the bodies of the children showed that no 
efforts at respiration had been made, the chil- 
dren perishing from asphyxia in utero. The 
placentae showed areas of infarction and a 
friable condition of the vessels. 
A review of this case with its post-mortem 
findings furnishes a clinical picture of death 
from irritant poison. The legs and feet of the 
patient were not oedematous, the symptoms of 
Bright's disease or acute kidney failure were 
lacking, while the sudden mania, followed by 
convulsions, coma, and death, resembled far 
more a case of ptomaine-poisoning than death 
by uraemia. The intense pulmonary conges- 
tion, dry, serous membranes, enlarged, mottled, 
and softened liver, injected and granular kid- 
neys, distended right heart, and diseased pla- 
centae complete a suggestive and instructive 
picture. 4 
That such a condition is not invariably fatal 
is illustrated by the case of J. S., a colored 
woman of uncertain habits, who gave a history 
of having previously suffered from enteric fever, 
grip, pleurisy, and pneumonia at various times. 
She had borne one child previously. During 
the present pregnancy she had suffered from 
epistaxis, swollen legs, less painful at night, 
and disturbance of vision, with headache. She 
sought relief at the Jefferson Maternity, where, 
upon examination, it was found that liver dul- 
ness extended three fingers'-breadth below the 
ribs. The tongue was furred and coated. The 
pulse was wiry, its tension being greatly in- 
creased. Dulness was found beneath the clavi- 
cles, with prolonged expiration. The patient 
suffered from chronic constipation, with ano- 
rexia. The urine was highly albuminous, the 
percentage of urea was below i, and epithelial 
and granular casts were present. The patient 
was treated by hot packs, with purges with 
calomel and salines, rest in bed, and milk 
diet. She improved and became insubordinate, 
and was discharged. She shortly afterwards 
came under my care at the Philadelphia Hos- 
pital, in the same condition in which I first 
saw her. Labor was induced, a very guarded 
prognosis being given, with a fatal prognosis 
as regards the child. After the first bougie 
was inserted in the uterus, the percentage of 
urea fell to .76, followed by two convulsions. 
Labor, however, supervened, and the patient 
was delivered spontaneously of a still-born 
foetus. The percentage of urea shortly after- 
wards rose to 1.5. The placenta showed mul- 
tiple infarcts. The patient was treated by the 
hot pack with free purgation and the plentiful 5 
use of water, and made a gradual recovery. 
The liver dulness diminished slightly, the con- 
dition of the urine became better, and she was 
able shortly afterwards to leave the hospital. 
It is interesting to observe that, following labor, 
the amount of urine increased from thirty-three 
to forty-two ounces, in the next twenty-four 
hours dropping to forty ounces. This was 
under the influence of calomel and the use of 
the hot pack. 
In this patient's case the enlarged liver, 
sluggish intestine, severe headache, and ano- 
rexia, with great irritability of the nervous sys- 
tem, illustrated well the presence in the body 
of an irritant poison. 
While the cases described illustrate the effects 
of profound toxaemia in pregnant women, in 
patients in comfortable circumstances and 
under intelligent care the physician will find 
that much of the suffering which pregnant 
patients complain of, referred to the nervous 
system, may be traced to a toxaemic condition 
more or less pronounced. In women of sensi- 
tive nervous system, premature labor is not an 
uncommon result of partial toxaemia. As an 
illustration of this, the following case is cited : 
Mrs. L. J., multigravida, third pregnancy, 
suffered from habitual constipation following 
an operation for hemorrhoids. When first ex- 
amined she was between seven and eight 
months advanced in pregnancy, in excellent 
general health, the excretory functions being 
well performed. She was accustomed to habit- 
ual overexertion, and early in the ninth month 
of pregnancy she complained of fatigue, rest- 
lessness, and severe uterine contractions, which 
led her to fear that labor was at hand. Exam- 
* 6 
ination of the size of the uterus and the posi- 
tion of the child showed that pregnancy lacked 
between four and five weeks of its normal dura- 
tion. The patient, however, was uncertain re- 
garding the time of the last menstruation, and 
believed her confinement to be due. A careful 
examination of the patient showed, however, 
that her processes of excretion were performed 
less perfectly than had been the case. The 
specific gravity of the urine was 1018, its re- 
action acid, it contained no albumin, but the 
percentage of urea was .8 of one per cent. 
Digestion was poorly performed, and the 
action of the intestine was sluggish. She was 
confined to her bed, given a carefully selected 
diet, the action of the liver stimulated, and the 
bowels freely moved. One week after this 
treatment was instituted the specific gravity 
of the urine was 1030; it contained an abun- 
dance of urates, the percentage of urea being 
2.5. Although the symptoms of labor were so 
pronounced as to cause the patient to summon 
her nurse on one occasion, uterine contractions 
gradually ceased, and the patient went four 
weeks longer in pregnancy, being subsequently 
delivered in normal labor. During the last 
four weeks overexertion was strictly avoided, 
her diet was carefully regulated, and a close 
watch kept of the excretory processes. 
(Edema and a trace of albumin and also of 
sugar, while pathological during pregnancy, 
may yet be present without threatening eclamp- 
sia. These phenomena are of distinctly minor 
importance if the percentage of solids in the 
urine indicates that excretion is proceeding 
properly. 
Mrs. L. E., aged thirty years, primigravida, 7 
had taken little exercise during her pregnancy, 
had suffered from constipation, and was ex- 
cessively fond of sweets. She is a stout, heavy 
woman, with justo-major pelvis. Her feet and 
legs were greatly swollen, the oedema extend- 
ing up the thighs to the groins and labia. 
General anasarca was present, the lower ex- 
tremities being more swollen than other por- 
tions of the body. The patient, however, while 
complaining of salivation and an abnormal 
taste in the mouth, did not suffer from head- 
ache, slept well, and had good appetite. The 
examination of the urine showed the specific 
gravity, 1020 ; sugar and albumin present, with 
an abundant secretion of urea, 2.7 per cent. 
This patient went to term and was delivered by 
forceps, her labor being complicated by oedema 
and haematoma of one of the labia. She is 
now convalescent and has never had symptoms 
of eclampsia. 
Toxaemia is occasionally associated with 
faecal impaction in a very plain and instructive 
relationship. The symptoms of this condition 
are characteristic headache and malaise and 
also a rapid and feeble pulse. By physical ex- 
amination the large intestine is found distended 
with masses of hardened faeces through either a 
portion or all of its extent. This condition is 
well illustrated by the following case : 
Mrs. F., aged twenty-eight, multigravida, 
was admitted to the Jefferson Maternity in the 
ninth month of pregnancy, seeking relief for 
headache, nausea, and prostration. Upon ex- 
amination, an impacted colon was plainly dis- 
cernible, the patient stating that she had had 
no free bowel movements for more than a 
week. Her temperature was 100.5° F.; her 8 
pulse, 124. She could not sleep, had little 
appetite, and complained of headache, im- 
paired vision, and general prostration. An 
examination of the urine showed its specific 
gravity 1006, albumin and sugar being absent, 
the percentage of urea present being .5 of one 
per cent. The patient stated that she had suf- 
fered in a similar manner in former pregnan- 
cies, but never so severely. She was at once 
put to bed and treated actively by hot packs, 
purgatives, and restricted diet. Under this 
treatment she experienced marked relief; her 
headache gradually ceased; she was able to 
sleep. Her appetite partially returned, and her 
improvement was so pronounced that she left 
the Maternity and returned to her home. The 
specific gravity of her urine increased steadily 
under the treatment pursued, while the per- 
centage of urea rose from .5 of 1 per cent, to 
1.1 per cent. By high enemata it was possible 
to partially empty the impacted colon, but as 
the patient would remain but four days in the 
Maternity, a thorough emptying of the bowel 
was impossible. This patient had been treated 
at her home by sedatives addressed to the ner- 
vous system, the physician in attendance sup- 
posing that her headache was a purely nervous 
phenomenon. 
In my first series of eighty-four cases, in 
which five hundred and sixty-four examina- 
tions of the urine were made, I found the 
average percentage of urea present before labor 
to be 1.4 per cent. After labor, in healthy 
women, an increased excretion of urea is ob- 
served for several days following parturition. 
In a second series of sixty five cases, in which 
one hundred and ninety-six examinations of 9 
the urine were made before labor, the same re- 
sults have been observed as in the previous 
series. The most pronounced cases showing 
the effects of toxaemia upon the nervous system 
without the occurrence of eclampsia are ob- 
served in women of highly nervous tempera- 
ment, and often highly educated and intelli- 
gent women. In these patients the gradual 
development of malaise, headache, sleepless- 
ness, nervous irritability, melancholia, appre- 
hension of approaching confinement, with 
gradually diminished excretion from the intes- 
tines and kidneys, form a clinical picture which 
should not be neglected by the practising ob- 
stetrician. If such a case is patiently studied, 
it will be found that the symptoms associated 
with the nervous system result from diminished 
excretion and the irritant effect of retained 
toxins. No greater mistake can be made than 
to treat these patients by the administration of 
bromides, as is often done. Rest and in- 
creased excretion have invariably, in my expe- 
rience, resulted in the disappearance of the 
symptoms. 
So far as the study of the urine is concerned, 
we yet lack for practical purposes a clinical 
index of the amount of solid matter excreted. 
It has been my custom to use the percentage of 
urea in a given specimen, whose specific gravity 
and quantity are known, as an index of excre- 
tion. I have found latterly the simple appa- 
ratus furnished by Squibb most convenient and 
efficient. His apparatus, familiar to all, does 
not require the use of bromine, which is so 
disagreeable to the investigator. Some prefer 
to take the coefficient 2.33, and obtain the 
amount of solid matter in a given specimen by 10 
multiplying the last two figures of its specific 
gravity by this coefficient. It is urged by 
those who prefer this method of study that 
urea in itself is not a dangerous ingredient of 
the urine, and that under a vegetable diet it 
may sink to a very low percentage, which 
would not fairly indicate the condition of the 
patient. Undoubtedly a more thorough way 
of studying the patient's excretory processes is 
by using both methods, and, in addition, put- 
ting the patient upon a fixed diet-list, so that 
an accurate idea of the ingesta may be ob- 
tained, as well as a knowledge of the excreta. 
Such a diet-list for pregnant patients should 
consist of the lighter sorts of meat, fish, 
oysters, birds, lamb, and mutton, to be taken 
in moderation, with an abundant supply of 
fresh fruit, fresh vegetables, stale bread, and 
water taken freely between meals. For restless 
patients who excrete badly, the warm bath at 
night will often assist greatly in procuring 
sleep. Light flannel next the skin, entire ab- 
sence from constriction about the waist, the 
prolonged use, if necessary, of gentle laxatives, 
such as cascara, with plenty of fresh air, and 
avoidance of overexertion usually suffice to 
keep these patients in comfortable condition. 
As with puerperal sepsis, so with toxaemia and 
eclampsia, they are best treated by preventing 
them and recognizing the conditions which 
favor their development. This requires, how- 
ever, a careful and intelligent supervision of 
pregnant patients, and the profession will find 
it necessary to educate many of their pa- 
tients in the belief that such medical care is 
necessary and deserving of adequate compen- 
sation. 11 
In the presence of eclampsia two indications 
are paramount. The first is to cause prompt, 
thorough, and copious elimination by every 
possible means. The hot pack, free purgation, 
and saline transfusion are of the greatest im- 
portance. To be avoided are sedatives, which 
hinder excretion and depress the cardiac and 
respiratory centres. In cases where apoplexy 
is threatened and a heavy, full pulse indicates 
bleeding, such a procedure is justifiable. 
It is rarely the case that a patient suffers 
from profound toxaemia and eclampsia without 
the beginning of labor, as a direct result from 
the stimulation of the uterine nerves which re- 
tained toxins furnish. Taking advantage of 
this conservative process, rapid delivery is indi- 
cated so soon as it can be accomplished with- 
out positive and severe injury to the mother. 
The interests of the foetus will be best served 
by rapid delivery, when the familiar fact is 
taken into consideration that the same poi- 
sons which threaten the mother often kill the 
child. 
It is not my purpose to weary you with a re- 
view of recent literature upon this subject. 
Recent studies in medicine, notably those of 
Hughes and Carter, with the familiar investi- 
gations of Bouchard, call attention to the fact 
that the first symptoms of toxaemia are often 
associated with the nervous system. The re- 
cent studies of Thomson and Herman, of Lon- 
don, call attention to the two different forms 
of visceral disease present in these cases. 
Woyer's interesting report of eclampsia in 
mother and child, with post-mortem examina- 
tion in the child and examination of its urine, 
illustrates in a most interesting manner the 12 
fact that toxsemia is fatal in the same way to 
mother and child. It has been my purpose in 
thus addressing this Society to urge as strongly 
as possible the necessity of a thorough study of 
pregnant patients, and to draw attention to the 
fallacy of the belief that a pregnant patient is 
not in danger unless the urine is highly al- 
buminous and oedema is pronounced. While 
in physiological patients pregnancy is a physi- 
ological process, yet so few of our patients are 
in perfect health before pregnancy or during 
this time, that the period of pregnancy re- 
quires watchful care, while the study of the 
condition of the mother during gestation affords 
a most interesting and instructive field of path- 
ological research. 
250 South Twenty-first Street. jSi*1 MAY 15. 1895. 
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