Reprinted from 
Annals of Gynecology and Pediatry, 
June, 1892. 
The Use of Morphia in Eclampsia, with a Report 
of Two Cases. 
BY W. REYNOLDS WILSON, M.D. The Use of Morphia in Eclampsia, with a Report 
of Two Cases.1 
w. REYNOLDS WILSON, M.D. 
I desire in reporting the following 
cases to bring to the attention of the 
Society a form of treatment which 
deserves a more careful study than 
has hitherto been devoted to it. Mor- 
phia should not be relied upon as a 
safe means of treating every case of 
eclampsia, but there are cases in 
which its use can be replaced by that 
of no other form of treatment. The 
first of the two cases which follow, 
although not an absolute proof of 
this latter proposition, shows a result 
which compares more than favorably 
with that obtained by the more ac- 
cepted plans of treatment. The 
second case affords an instance in 
which the indications for treatment 
were met exactly by the use of mor- 
phia. 
Case I. - The patient, a prima- 
gravida, aged 21, was admitted to the 
hospital, without history, at 9 p.m., 
March 10, 1890. She was delirious 
and restless. Her countenance was 
oedematous, corresponding to the 
general oedema which was present. 
The os admitted one finger. There 
were no labor pains. The foetal heart 
sounds were detected on the right 
side below the umbilicus. The first 
convulsion after admission occurred 
at 9.25, the next at 10.5, the next at 
11 and the last at 6 a.m., March 11. 
At 2 a.m. the patient was in a state 
of narcosis from the effects of mor- 
phia, which was given after each con- 
vulsion in the following doses: .01 
gramme, .01 gramme, .02 grammes, 
.02 grammes, amounting to .06 
grammes, or gr. i| in eight hours 
and a half. Chloroform was adminis- 
tered at the time of each convulsion. 
At 8 a.m. the patient showed great 
restlessness, probably due to labor 
pains. The labor was terminated 
naturally at 2 p.m., the second stage 
lasting only a half hour. The child, 
which was born at the end of the 
eighth month, was living. The urine, 
upon boiling, after the addition of 
acetic acid, showed albumin equal to 
one-third the volume. The secretion 
in twenty-four hours amounted to 
1 Read before the Obstetrical Society of Philadel- 
phia, April 7, 1892. 2 
W. REYNOLDS WILSON. 
twenty-one ounces. The patient was 
discharged on the sixteenth day; the 
oedema had almost disappeared, and 
an examination of the urine showed a 
small amount of albumin and granular 
casts. 
Case II.-A Pole, aged 20, also a 
primagravida, was admitted to the 
Lying-in Charity, October 16, 1891. 
In the eleven hours preceding her 
entrance to the hospital she had had 
thirteen convulsions. She was coma- 
tose in the interval between the at- 
tacks, but the approach of each con- 
vulsion was marked by restless de- 
lirium. Morphia was administered 
hypodermically as follows: 
5-3o p-m gr., y2 
9.00 p.m gr., % 
2-30 a.m gr., % 
5-3o a.m gr., % 
During the afternoon of the day 
succeeding that of her admission she 
was given gr. %, making gr. 1% in 
twenty-four hours. Between the hour 
of admission (5.30 p.m.) and 11 p.m., 
in which time gr. had been given, 
there were but three convulsions, 
each less severe and of shorter dura- 
tion than the preceding. The patient 
was bled at 11 p.m., on account of the 
vascular tension, shown in the con- 
gestion of the face and throbbing of 
the arteries. Fifteen ounces were 
abstracted. The convulsions ceased 
after this, but the morphia was con- 
tinued, as noted above, to control the 
restlessness. During the next twelve 
hours sufficient morphia to keep the 
patient narcotized was administered. 
Within the sixteen hours after admis- 
sion twelve ounces of urine, contain- 
ing one-third volume albumin, were 
voided. Elaterium, gr. |, calomel, gr. 
iii, were given. On the morning of 
the second day labor came on, and in 
five hours after the first signs were 
noticed a macerated child was born. 
The hospital chart gives the fol- 
lowing : 
Duration of first stage, not noted. 
" of second stage, five hours. 
" of third " six " 
Extraction of placenta. 
On the day following her labor the 
patient suffered from a chill, the tem- 
perature rising to ioif°. Necrotic 
shreds of decidua were removed by 
an intrauterine douche. The patient's 
recovery was uninterrupted, and she 
was discharged on the twelfth day. 
An examination of the urine, obtained 
by the catheter two days after labor, 
revealed a few granular casts. The 
quantity of albumin gradually de- 
creased until upon dismissal a mere 
trace was revealed by the ring test. 
In this case only slight oedema was 
present. 
The first of these cases I had the 
privilege of observing under the di- 
rection of Prof. Winckel. The treat- 
ment was outlined by him, notwith- 
standing his advocacy of the use of 
chloral. In his work on obstetrics 
(1886) he describes his treatment as 
follows: "When convulsions super- 
vene I treat them, without exception, 
with chloral, gr. xv-xxx at each dose, 
by enema, and with chloroform. As 
soon as the patient becomes restless 
and the first signs of an approaching 
attack appear, chloroform is adminis- 
tered and continued until the spasms 
have ceased. The chloroform serves 
as a sedative until the chloral can act. 
The dose of the latter is repeated 
after each seizure, and the amount is 
increased without risk, until three 
drachms in twenty-four hours are 
given." His recognition, however, 
of the claims advanced for morphia THE USE OF MORPHIA IN ECLAMPSIA. 
3 
appears in the following sentence: 
"It must by further observation be 
shown whether morphia will exclude 
the accepted treatment by chloral 
and chloroform." 
In studying the treatment of 
eclampsia, it is important, first, to dis- 
tinguish between the form of treat- 
ment, which is effective in the convul- 
sive stage, and that in the stage of 
threatening intoxication. Veit, the 
strongest advocate of morphia, recom- 
mends in his clinical teaching, not 
the exclusive use of morphia, but its 
combination with eliminative treat- 
ment. Winckel, who is the exponent 
of the chloral treatment, emphasizes 
as an introduction to the subject of 
the therapy of eclampsia the use- 
fulness of the treatment by catharsis 
and diaphoresis as follows: "In the 
last ten years I have come gradually 
to the adoption of the following 
measures, the advantages of which 
I have recognized over those of other 
forms of treatment. To every 
gravida whose urine contains albu- 
min to a marked extent, is given, 
daily, a pill of aloes and colocynth, 
in order to induce a decided ca- 
thartic effect. In addition to this 
a warm bath is given. Secondly, we 
must consider the previous history 
of the case, the amount of albumen 
which has been present, the presence 
of tube casts, the deficiency in the 
excretion of urea and the severity of 
premonitory symptoms; for on these 
depends the choice between the in- 
duction of labor and palliative meas- 
ures. Thirdly, we must take into 
consideration the constitution of the 
patient. Strong, full-blooded women, 
who present the signs of vascular 
obstruction, are benefited by bleeding. 
In eclampsia we not only have the 
condition so aptly described by 
Auvard as a "strike on the part of 
the organs of elimination," but we 
have also three other elements en- 
tering into the pathology, namely: 
(1) The presence of a source of 
irritation. 
(2) The increased vascular tension. 
(3) The increased nervous tension. 
Venesection certainly relieves two 
of these conditions-the two former 
-by eliminating some of the poison 
in the blood and by reducing the vas- 
cular tension. How far the effect, in 
these directions, of the bleeding in- 
fluences the third element in the path- 
ology, the increased nervous tension, 
is a question of much importance. 
Morphia on the one hand and 
chloral on the other are given to meet 
special indications, and are not advo- 
cated, either as substitutes for other 
forms of treatment or to the exclusion 
of important accessory measures. 
Morphia is no longer useful when the 
convulsions and restlessness have 
ceased and the patient has fallen into 
coma. Its influence lies in its power 
to control convulsions; its danger 
is to be looked for in its effect 
upon the process of elimination. 
Whatever may be the pathology of 
eclampsia and whatever the relation 
between the condition of the kid- 
neys and the convulsions, it is 
clear that in eclampsia elimination is 
checked. When elimination is re- 
stored by diaphoresis, venesection or 
diuresis, the patient is benefited. It 
is equally clear that, unless the con- 
vulsions are controlled by chloroform, 
chloral, morphia, or by the induction 
of labor, the termination of the case 
is likely to be fatal. 
It is possible, by resorting to early 
treatment during pregnancy, to avert 4 
W. REYNOLDS WILSON. 
the dangers of eclampsia ; but a time 
comes in the treatment of certain 
cases where the choice must be made 
between those measures which will 
act, if time is given for their effect, 
and those which will act at once. 
These are the cases in which the con- 
vulsions are threatening life. The 
question is, in such cases: What are 
the means at our disposal which are 
most effective in controlling the con- 
vulsions ? In the second case which 
I have reported, each injection of 
morphia was followed by a cessation 
of delirium and was effective in avert- 
ing the convulsion. It is doubtful 
whether chloral would have been so 
rapid in its effects, for the advocates 
of the treatment by chloral recom- 
mend the administration of chloro- 
form to quiet the patient until the 
chloral acts. 
Morphia is serviceable, not only on 
account of the promptness of its 
action, but because it favors rather 
than retards the process of elimina- 
tion in one direction, namely, by dia- 
phoresis. The danger from its effects 
upon the kidneys has been overrated. 
Upon looking closely into the subject 
we find that morphia decreases to a 
slight extent only the excretion of 
urea. Wood, Bruton, Loomis,1 in dis- 
cussing the treatment of uraemia, 
allude to morphia " as an agent that 
not only has the power to control mus- 
cular spasm, but at the same time, by 
its action, tends to reopen the avenues 
of elimination, either by counteracting 
the effects of the uraemic poison on 
the nerve-centres, and thus facilitating 
the action of diuretics and diapho- 
retics, or itself acting directly as an 
eliminator." He cites a number of 
cases of uraemic poisoning, one of 
them a case of ante-partum eclampsia, 
in which morphia was used success- 
fully. The description of two of these 
cases will serve to show the action of 
morphia. The first case was that of 
a middle-aged man, suffering from 
chronic nephritis, in the course of 
which he was threatened suddenly 
with uraemic symptoms. These failed 
to yield to purgation and baths, and 
recourse was had to hypodermic injec- 
tions of morphia. As a result, the 
patient fell into a quiet sleep, during 
which diaphoresis was established. 
Twenty to thirty drops of Magendie's 
solution were given once a day for a 
number of weeks, together with one 
half-ounce of infusion of digitalis 
twice daily. The second case was 
one in which the convulsions of acute 
uraemic intoxication were arrested by 
morphia. The treatment was followed 
by profuse diaphoresis. Four hours 
after this the catheter was used, and 
five ounces of highly albuminous 
urine, containing blood and granular 
casts, were drawn. Loomis adds in 
conclusion : " It would appear that if 
a large hypodermic injection of mor- 
phia be administered at the onset of 
uraemic eclampsia, and repeated when- 
ever the premonitions of a convulsion 
are present, we offer these distressing 
cases the best chance of recovery. 
The almost uniform effect of morphia 
so administered is, First, to arrest 
muscular spasms, by counteracting 
the effect of the uraemic poison on 
the nerve-centres; Second, to estab- 
lish profuse diaphoresis; Third, to 
facilitate the action of cathartics and 
diuretics, especially the diuretic action 
of digitalis." 
If we can be thus assured of the 
eliminative action of morphia, we have 
'New York Medical Record, 1873. THE USE OF MORPHIA IN ECLAMPSIA. 
5 
in its use a form of treatment present- 
ing the advantage of both controlling 
the convulsions and aiding the excre- 
tion of the toxic element in the blood. 
I believe, however, that this is claim- 
ing too much for it, and that if we 
accept this we shall be tempted to use 
morphia in cases where other forms 
of treatment are demanded; for in- 
stance, in cases where venesection, 
chloral in its milder and slower effect 
and the induction of labor are indi- 
cated. This assertion, however, does 
not vitiate the claim of morphia to the 
first place among those drugs which 
are used for prompt sedative action. 
The results of carefully collected 
and carefully noted cases, at the hands 
of various observers, will alone solve 
the question of treatment. No prac- 
titioner can rely upon one drug or 
upon one method of treatment; we 
must have at our command all the 
resources in treatment, and must learn, 
from experience, which from among 
these to select. If this experience 
can be broadened by the study of the 
cases in other hands, the number of 
our resources is increased. Within a 
year two important discussions upon 
the subject of eclampsia have ap- 
peared in print; one in The Annals 
of Gynaecology and PaEdiatry, 
April, 1891, entitled " Disease and 
Functional Insufficiency of the Kid- 
neys in Child-bearing Women, by B. 
C. Hirst; " the other " A Discussion 
on Puerperal Eclampsia, in the Sec- 
tion of Obstetric Medicine and Gynae- 
cology, at the Annual Meeting of the 
British Medical Association, held in 
Bournemouth, July, 1891." It will 
be of interest to examine critically 
the remarks on treatment contained 
in both of these papers. In the first 
Dr. Hirst presents briefly the report 
of eight cases, two of which terminated 
fatally; the treatment in each case 
was as follows : 
Case I.-Chloral by the bowel, 
croton oil, chloroform as soon as pre- 
monitory signs of the attack appeared, 
and a hot wet pack. 
Case II.-The treatment was the 
same as in Case I, with the addition 
of moderate bleeding. 
Case III.-Bromide of potash, gr. 
cxx; chloral, gr. Ixxx; morphia, gr. |, 
hypodermically ; croton oil, gtt. i, and 
elaterium, gr. Hot wet pack for 
more than two hours. 
Case IV.-Chloral and bromide of 
potassium, croton oil, chloroform, hot 
wet pack and venesection to a moder- 
ate degree. 
Case V.-Treatment not mentioned. 
Case VI.-Chloral, chloroform and 
hot pack. 
Case VII.-Chloral, anaesthesia, hot 
pack and bleeding to the extent of 
twenty-four ounces. 
Case VIII.-A dessertspoonful of 
concentrated salts solution, every fif- 
teen minutes, for sixteen hours ; six- 
teen ounces in all. 
In the second paper the treatment, 
in order of preference, of those who 
took part in the discussion, was as 
follows : 
Galabin.-Venesection, to relieve 
venous congestion of the lungs and 
to arrest the convulsions. 
Byers.-States that next to chloral, 
morphia, given subcutaneously, seems 
most useful in controlling convulsions. 
Donovan.-In cases of threatened 
eclampsia, with marked albuminuria, 
small doses of chloral, saline, purga- 
tives. 
Edis. - Chloroform, followed by 
either venesection or the administra- 
ion of either chloral or morphia. 6 
W. REYNOLDS WILSON 
Swayne.-Venesection, followed by 
chloroform and chloral. 
Auvard. - Eliminative treatment, 
anaesthesia, venesection. 
Lawton.-Nitroglycerine, morphia. 
Lawrence.-Chloral, hypodermic in- 
jections of veratrum viride. 
Heywood - Smith and Harvey.- 
Blood-letting. 
Cameron.-Alludes to the effect of 
morphia in dilatation of the cervix, 
thereby hastening the delivery. 
The majority of those who took 
part in this discussion advocated the 
prophylactive treatment by the in- 
duction of labor in threatening cases. 
This coincides with the views ex- 
pressed by Hirst1 and Fry2 in this 
country. 
From a review of these discussions 
we learn that the choice of treatment 
depends upon the indications. The 
advocate of any single form of treat- 
ment finds himself at a loss in certain 
cases, and there are few who can say : 
" If I were compelled to employ but 
one remedy, it would be this or that." 
Morphia cannot be relied upon solely; 
there are conditions which interdict 
its use. Tyson states :8 
" Notwithstanding the enormous 
number of favorable cases which 
have been reported from the hypo- 
dermic use of morphia, I would still 
be afraid to recommend it in these 
cases. The reason the morphia treat- 
ment of eclampsia is not attended by 
fatal termination, I think, is tolerably 
plain. The vast majority of cases of 
Bright's disease, in connection with 
pregnancy, are cases of parenchy- 
matous nephritis or tubal nephritis. 
These cases bear morphia tolerably 
well. On the other hand, it is well- 
known that cases of interstitial nephri- 
tis do not bear the use of opiates." 
The risk here, however, is not so 
great as appears at first sight, for in- 
terstitial nephritis is not commonly 
associated with eclampsia. Galabin 
asserts that " Recent acute nephritis 
is commoner than the existence of a 
contracted granular, or even a large 
white kidney." Excluding the chronic 
forms of Bright's disease, the objec- 
tion to the use of morphia, on account 
of kidney affection, is unfounded, ac- 
cording to Fancourt Barnes,1 who 
states that in the majority of cases the 
convulsions are not due to nephritis, 
and asks : " If there be any analogous 
example of acute inflammation of an 
organ passing away in a few hours or 
even minutes." Wood, on the other 
hand, writes as follows : " Whenever 
the kidneys are seriously diseased the 
physician should be exceedingly care- 
ful in the administration of opiates, 
because the chief channel through 
which they are eliminated is choked 
up." 
It appears that we have to deal with 
views which are diametrically opposed. 
In contrast to the opinion of Wood, 
we have again the teaching of Veit, 
who impressed his listeners with the 
idea that they held in their hands the 
means of rescuing every woman in 
eclampsia, namely morphia, and the 
responsibility of a fatal case rested 
with them should they fail to use this 
means. 
In conclusion, let us study for a mo- 
ment the question of treatment from 
the standpoint of statistics. The treat- 
ment by morphia presents the lowest 
1 Annals of Gynaecology and Podiatry, 
April, 1891: 
2 American Medical Association, Washington, 1891. 
8 Annals of Gynaecology and Podiatry, 
April, 1881. 
1 British Medical Journal, II, April, 1891. THE USE OF MORPHIA IN ECLAMPSIA. 
7 
mortality, 3.3 per cent. (Veit). If we 
look into this more closely, however, 
we find that Veit obtains his statistics 
from over sixty cases, without giving 
the exact figures. The highest mor- 
tality, according to Hirst, is found in 
cases treated in this country, ranging 
at about 40 per cent. He presents a 
table, based upon the records of nine 
maternity hospitals, showing a mor- 
tality of 38.4 per cent, in seventy-eight 
cases. This is fallacious in one re- 
spect, namely, in that the cases which 
are treated in such institutions are 
frequently emergency cases, where the 
treatment is instituted too late. Dur- 
ing the past year, at the Philadelphia 
Lying-in Charity, two cases of eclamp- 
sia were treated; both of these were 
admitted to the hospital in a condi- 
tion of extreme danger, and after the 
greatest neglect. One case died, 
which shows at once a mortality of 50 
per cent. In addition to this, the want 
of care in recording cases in this coun- 
try-even in the most exact institu- 
tions-has much to do with the indif- 
ferent results. Galabin' states that 
" In the Guy's Charity, during 
venesection days, the mortality in 
fifty cases of puerperal eclampsia was 
30 per cent.; since venesection had 
been discontinued, the mortality in 
thirty-four cases had been only 20.5 
percent" ("Year Book of Treatment," 
1891). These statistics are also de- 
fective. It is easy to imagine that in 
the thirty-four cases, where the mor- 
tality was reduced to 20.5 per cent., 
the number of cases suitable for bleed- 
ing may have been small. If the wri- 
ter had selected fifty cases in which 
venesection was practiced, and thirty- 
four cases where it was not, the indi- 
cations for treatment being, generally 
speaking, the same in both sets of 
cases, his figures would have had more 
weight. If, again, by further observa- 
tion, he had completed his second set 
of cases to equal the first, by adding 
the record of the next sixteen cases 
treated in Guy's Charity-venesection 
being withheld-it is highly probable 
that some cases suitable for this treat- 
ment would be encountered, and the 
mortality be greatly increased. 
Winckel speaks of the possibility of 
reducing the mortality to from 7 to 10 
per cent, by the treatment now in 
vogue in Germany, whereas Lbhlein1 
" searching the records of various hos- 
pitals has collected 325 cases of puer- 
peral eclampsia out of 52,328 labors. 
Out of these 325 cases sixty-three died 
from convulsions, and fourteen from 
other causes. The mortality was thus 
19.38 per cent." ("Year Book of Treat- 
ment," 1891). 
The points which I desire to make 
in favor of the use of morphia, based 
upon the history of the cases which 
I have presented, upon the testimony 
of those who advocate its use, and 
upon the criticism of the statistics just 
under consideration, are the follow- 
ing: 
First, the efficiency of morphia in 
those cases where the life of the pa- 
tient is threatened by the severity and 
rapid recurrence of the convul- 
sions. 
Second, the absence of deleterious 
effects upon the process of elimina- 
tion, especially in those cases where 
the kidneys are acutely affected inci- 
dentally to the eclamptic state. 
'British Medical Journal, September, 1891. 
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