[Reprinted from the American Gynaecological and Obstetrical Journal 
for December, 1895.] 
TREATMENT OF ECLAMPSIA.* 
By John O. Polak, M. D., 
Instructor in Clinical Obstetrics at the New York Post-graduate and the Long Island Col- 
lege Hospitals ; Gynaecologist to the Eastern District Hospital. 
The few clinical notes which I have to present for your discussion 
this evening can hardly be dignified by the title of a paper ; further- 
more, my statements must be largely dogmatic, as the conclusions are 
drawn entirely from a personal experience in nine cases of eclampsia. 
Vinay, in referring to the pathogeny of eclampsia, states that the 
aetiological problem does not lie in the more or less normal condition 
of the urine, in the presence or absence of albuminuria, nor even in 
the integrity or alteration of the kidney, but in internal intoxication 
and the sufficiency or insufficiency of the emunctories. My own ob- 
servations lead me to agree with Vinay's statement, for many women 
have these attacks with no albumin in the urine, while others with a 
marked albuminuria have passed through an uneventful pregnancy. 
In my experience a diminution in the amount of urea eliminated has 
borne a more constant relation to the occurrence of the convulsion 
than the presence of albuminuria. 
Davis emphasizes the fact that eclampsia is the result of toxaemia 
produced by failure of excretion not only of the kidneys, but also of 
the liver, skin, lungs, and intestines. Whether this material retained 
is urea, creatin, creatinin, bacteria, or their ptomaines, acting singly 
or combined, has not been accurately determined. He also draws 
particular attention to the relation between constipation and toxaemia. 
Other observers, as Rapin and Monnier, claim to have isolated a. 
special bacillus, which when inoculated into animals causes symptoms 
similar to those of eclampsia. Cerdes insists that the eclamptic bacil- 
lus is the only cause, since it is not found in other diseases, and since 
the convulsion does not occur without it. 
While there is such a wide difference of opinion as to the origin 
of the puerperal convulsion and the exact relation which a pregnancy 
nephritis bears to it, two important facts must not be lost sight of- 
* Read before the Kings County Medical Association, October 8, 1895. 
Copyright, 1895, by J. D. Emmet, M. D. John O. Polak, M. D. 
2 
i. e., that the eclamptic attacks are due to a toxaemia the nature of 
which is not known; secondly, that the ultimate cause of the trouble 
is the child in utero. The treatment naturally divides itself into the 
prophylactic and the management of the attack, which latter, because 
of the time of occurrence, will differ as to whether the convulsion ap- 
pears during pregnancy, labor, or childbed. 
Admitting that the convulsion is generally coincident with a preg- 
nancy nephritis of greater or less severity-as was so in eight of the cases 
making the basis of this paper-and, further, granting that a nephritis 
during pregnancy once established, the kidneys never regain their nor- 
mal condition while the gestation continues, as the extra tax upon the 
already crippled kidney increases as pregnancy advances, hence the 
woman is ever open to the possibility of a sudden explosion of uraemic 
symptoms. After delivery, on the other hand, the renal symptoms 
subside and prompt recovery is the rule ; therefore, in the presence 
of expected eclampsia, two indications are paramount. The first is 
to cause prompt, thorough, copious elimination by every means pos- 
sible-i. e., purgation, diaphoresis, and diuresis. This last is accom- 
plished by the employment of copious normal saline infusions. 
The second indication is the rapid and immediate termination of 
pregnancy ; this is especially urgent in the last month of gestation, 
when the child has little to gain and the mother frequently much to 
lose by delay. In looking over my histories I find twelve cases (not 
included in this paper) in which a nephritis of greater or less severity 
complicated the pregnancy. In seven labor was induced between the 
fifth and eighth months; the other five went to term and were deliv- 
ered without accident, the child being dead in three instances and 
nephritic infarcts found in the placenta. These gestations were per- 
mitted to continue, owing to the improved urinary condition follow- 
ing the copious exhibition of water and the employment of tonics, 
baths, and a restricted diet, or the patient refused to consent to any 
interference whatsoever. 
With increased experience in this dreaded accident, the necessity 
for repeated chemical and microscopic examinations of the urine dur- 
ing the latter months becomes more apparent; the quantity passed in 
twenty-four hours and the amount of urea eliminated should be a 
matter of special inquiry. 
(Sufficient importance has not been attached to the total amount 
of solids eliminated.) 
In the prophylaxis we may secure elimination through any or all 
of the emunctories; the activity of the skin is obtained by wearing Treatment of Eclampsia. 
3 
warm flannels and the employment of daily hot baths. The patient 
being placed in a full bath of 8o° F., the temperature is then gradually 
raised to the highest point of tolerance, and hot drinks are adminis- 
tered, after which she is wrapped in a blanket, placed in bed, and the 
sweating continued ; the patient must be carefully guarded from ex- 
posure. 
The relation of constipation to toxsemia is so intimate that too 
much care can not be employed in emptying the intestinal tract. The 
bowels should be moved each day by colocynth, senna, or licorice, 
with occasional doses of calomel, which performs the double function 
of catharsis and diuresis. Although salines have been very generally 
condemned, I believe that a well-diluted drachm of Rochelle or Carls- 
bad salts taken each morning upon an empty stomach will prove of 
benefit to the patient. Diuretics which act upon the renal cells, 
thereby increasing the work put upon the tubules, have been utter 
failures in my hands. Pure water, or water containing lithia, accom- 
plishes more with the patient, who should be directed to drink two or 
three quarts daily, and kept on a diet restricted to milk, eggs, and a 
small quantity of the white meat of fowl. From two to four quarts 
of a normal saline solution injected into the colon daily has markedly 
increased the amount of water passed in twenty-four hours. By this 
forced ingestion of pure water diuresis is obtained by a process of 
filtration in the glomeruli without putting extra work upon a diseased 
organ. 
Veratrum viride in small doses is useful as a prophylactic when 
the pulse is full, hard, and rapid, as is often the condition preceding 
eclampsia. 
Now be it understood that while dietetic, diaphoretic, and cathar- 
tic measures are of great value as temporary expedients, they do not 
cure a pregnancy nephritis once established while the foetus is in 
utero. 
A brief analysis of my cases may serve to illustrate the necessity 
for radical treatment. Of the nine cases referred to, eight were pri- 
miparse between the ages of twenty-five and forty-one ; in six labor 
had begun before the convulsion appeared ; the number of convul- 
sions varied from three to twelve. Accouchement force with manual 
dilatation was employed seven times; Duhrssen's deep cervical in- 
cision once. 
Three children were born dead, and seven women made uninter- 
rupted recoveries after delivery. 
Two patients died, one being an ambulance case, admitted to the John O. Polak, M. D. 
4 
hospital in coma with an arm and cord presenting, after unsuccessful 
treatment by a midwife for twenty hours ; she subsequently died 
of sepsis on the fifth day. In the other instance an expectant plan 
was followed, using a bougie, with bromides, chloral, and veratrum. 
The patient died in the eleventh convulsion. In no instance did the 
convulsive seizures continue after the evacuation of the uterine con- 
tents. From the foregoing facts it would seem that the expectant 
plan of management should be relegated to the past-to be spoken of 
only as a matter of avoidance in practice. As my experience differs 
in nowise from that of other observers, it may be well to formulate 
certain indications for induction, and briefly to detail the most surgical 
methods. 
Before Viability.-A pregnancy nephritis progressing unfavorably 
under proper diaphoretic, cathartic, and dietetic measures is a posi- 
tive indication for the induction of abortion. Persistent frontal head- 
ache, nausea, epigastric pain, general oedema, diminution in the 
amount of urea, and of the quantity of water passed in twenty-four 
hours, together with partial or complete amaurosis and an albumi- 
nuric retinitis, aie among the chief symptoms to be watched. 
After Viability.-With the existence of a nephritis of pregnancy, 
each day's delay subjects the woman to an increased danger of 
eclampsia, while the child, as I have already stated, has little or 
nothing to gain by waiting. Hence premature labor is indicated. 
In the presence of the convulsion, we are all agreed that imme- 
diate delivery is the one thing necessary, but we differ as to the meth- 
ods of obtaining this end. 
When operative pro edure is decided upon, the period of gestation 
determines the method of operation. In the early months, after proper 
counsel, the patient should be placed in the Sims position, the vulva 
and vagina thoroughly scrubbed, then irrigated with an antiseptic so- 
lution, after which the anterior lip of the cervix is firmly grasped with 
a tenaculum forceps and the cervical canal cauterized with strong 
tincture of iodine, and then the canal is carefully, slowly, and sym- 
metrically divulsed to a diameter of an inch or an inch and a half. A 
Goodell-Ellinger dilator is best for this purpose. When the os has 
been thoroughly stretched, the finger is introduced into the uterus 
and the membranes are peeled up as high as can be reached. The 
lower segment and cervical canal is now firmly packed with iodoform 
gauze (strip gauze two and a half inches wide by five feet long is pref- 
erable for packing), the fornices are filled, and finally a vaginal plug 
inserted. Treatment of Eclampsia. 
5 
This tamponade is removed in from ten to twelve hours, when 
usually the ovum will be found separated and in the vagina. Should 
the delivery not have taken place, the dilatation will be sufficient to 
deliver manually. In the latter months induction by the bougie is 
the safest and most reliable method ; an aseptic technique is absolutely 
imperative to success. To induce labor by the intra-uterine injection 
of sterilized glycerin, as has been recommended by Pelzer and Edgar 
and practiced by the writer, is but to subject the patient to added 
dangers. This method should never be employed with an existing 
nephritis. 
In the presence of the convulsion nothing but the most radical 
treatment will save the life of the patient-i. e., accouchement force 
either following manual dilatation or the dee]) cervical incision of 
Duhrssen. When either of these rapid methods is employed, the 
patient is necessarily subjected to increased danger from shock and 
sepsis. The convulsions may recur in such rapid succession, the in- 
tervals so brief, that the patient passes directly from coma to convul- 
sion, without even a moment of partial consciousness intervening. 
The coma deepens with each succeeding convulsion, and death may 
occur at any moment from asphyxia. There is intense cerebral con- 
gestion from arrested respiration and pressure on the jugular veins. 
An increase in the body temperature is a constant characteristic of 
eclampsia and influences the prognosis adversely. Hence our first 
effort is to control the convulsion by the administration of chloroform 
or morphine and the use of veratrum viride hypodermically in an in- 
itial dose of fifteen drops of the fluid extract, thus reducing the pulse- 
rate and blood tension, with consequent diaphoresis. 
With the pulse reduced and held between sixty and seventy, a 
convulsion is not likely to occur, and evacuation of the uterus may 
be immediately proceeded with. In employing manual dilatation, the 
patient is chloroformed and placed in the lithotomy position across 
the bed (or, better, on a table). The vulva and vagina are then thor- 
oughly scrubbed and disinfected, after which the whole aseptic hand 
is passed into the vagina and one or two fingers through the cervix, 
carefully and slowly dilating it until three fingers are admitted, and 
so on, until the coned hand can be introduced into the os. At this 
point in the operation, unless great care be taken, deep lacerations 
are apt to occur, occasionally producing serious haemorrhage. From 
twenty minutes to an hour should be spent in this dilatation. When 
the canalization is complete, delivery may be accomplished by either 
forceps or version : the latter is preferable in all cases when the head 6 
John O. Polak, M. D. 
has not firmly engaged. Rapid dilatation in one of my cases was 
obtained by deep cervical incisions, as suggested and practiced by 
Duhrssen. 
The incision is made with the knife or scissors, the preference be- 
ing given to the latter. These artificial lacerations extend to the utero- 
vaginal junction, and are made to the right and left of the median 
line, both anteriorly and posteriorly; in this way the bladder, rectum, 
and deep tears into the broad ligaments are avoided. The portio 
vaginalis must be effaced before resorting to this method. These 
tears need not be repaired unless the patient's condition justifies the 
extra time and shock necessitated. An intra-uterine and vaginal 
tampon of iodoform gauze may be needed to control the haemor- 
rhage subsequent to delivery. 
An intra-uterine douche should be given after employing either of 
ihe above methods. 
Even after the uterus is empty and the convulsions have ceased, 
suppression of urine may persist, and our patient dies of uraemia. It 
is to this class of cases to which I desire to direct your attention. 
The activity of the skin may be preserved by hot baths, as already 
described, veratrum continued in five-drop doses for its diaphoretic 
and diuretic effect, and active catharsis established with elaterium or 
croton oil. 
The ordinary diuretics, as the potassium salts, digitalis, diuretin, 
etc., are practically worthless to increase the amount of water passed 
in such an emergency, and do harm by stimulating the renal cells, or 
by increasing the blood pressure in the diseased organ. The forced 
ingestion of pure water-employing a normal salt solution of ioo° F., 
which is thrown into the colon through a fountain syringe at slight 
elevation, the patient lying on the left side with the hips slightly 
elevated-will rapidly increase the urinary secretion. These injections 
of sterilized water may, also, be made directly into the circulation, as 
suggested by Dawbarn in acute anaemia. 
By way of recapitulation I present for your discussion the follow- 
ing conclusions : 
i. That eclampsia is due to a toxaemia in which the entire ex- 
cretory system plays a part. 
2. That constipation bears an intimate relation to this toxaemia. 
3. That a pregnancy nephritis is frequently coincident with the 
occurrence of convulsions, and that an albuminuria is of much less 
importance than a diminution in urea and total solids eliminated, or 
a decrease in the amount of water passed in twenty-four hours. Treatment of Eclampsia. 
7 
And, finally, that while diaphoretic, cathartic, and dietetic meas- 
ures often improve a nephritis of pregnancy, the woman is never safe 
with the foetus in utero ; therefore the gestation should be terminated 
in the most surgical manner.