Eclampsia historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Importance of Historical Perspective

The importance of historical perspective lies in the fact that our current understanding of pathophysiology, classifications and management strategies is influenced by past hypotheses and scientific contributions, which have also shaped our current practice trends.

Origin

The term is derived from Greek and refers to a flash, a term used by Hippocrates to designate a fever of sudden onset.

Historical Perspective

Over time various theories and treatments based on those theories have been proposed.

Ancient Times

Theories

• THEORY OF FOUR HUMORS
  • In late 5^thand early 4^th BCE
  • The balance between Four humors, blood, phlegm, yellow bile, and black bile, resulted in health and illness.

• WET AND DRY THEORY
  • Women’s skin was considered wet, porous, and soft and it was thought that she could accumulate lots of moisture which resulted in an overabundance of fluids and led to illness.

• WANDERING WOMB THEORY
  • Hippocrates believed that dried up uterus wandered the body in search of moisture, and as it wandered the body, it could wreak havoc upon the liver, spleen, lungs, and head, leading to disease.

Treatments Offered

Treatment directed towards the restoration of internal equilibrium by mechanisms that increased elimination of excess fluids and could consist of:

• Altered diets
• Purging
• Blood-letting

Middle Ages

During the middle ages, between 400 CE and 700 CE, scientific progress, especially medical, came to a standstill as the Christians were opposed to human science and dissection. many medical schools were closed, such as at Athens and Alexandria. Hence, the main focus was on the compilation and rewriting. Later, the Christian influence began to decline and new theories emerged. In 1619, the word "eclampsia" first appeared in Varandaeus' treatise on gynecology.

Theories

• DOMINANT HUMOR THEORY
  • One theory that emerged suggested that one humor dominated the other humors and controlled an individual's physical and emotional characteristics, and was responsible for the signs and symptoms of eclampsia.

• MAURICEAU'S THEORY
  • In 17^th century, when medicine gained momentum again, Francois Mauriceau helped establish obstetrics as a specialty. He was the first to systematically describe eclampsia, and to note that primigravidas were at a greater risk for convulsions compared to multigravidas. He attributed convulsions to either suppressed lochia flow which could lead to inflammation, pain in the head, convulsions, suffocation, and death, or intrauterine fetal death which could lead to foul-smelling humors and predispose a woman to convulsions.

Treatments Offered

Increasing Christian beliefs greatly influenced treatments which consisted of charms, amulets, prayers. However, as time passed treatments offered in ancients times were again practiced, such as phlebotomies.

18^th and 19^th Century

Theories

• In the 18^th century, Bossier de Sauvages discerned eclampsia from epilepsy and believed that convulsions transpired due to nature trying to free the morbid elements from the organism. He also noted that eclampsia was acute in nature and epilepsy was chronic because convulsions due to eclampsia resolved once the precipitating cause was removed but epilepsy recurred over time. He also pointed out that eclampsia was not restricted to pregnancy and severe hemorrhage, various sources of pain, and vermicular infestations were several species of eclampsia.

• In 1797, Demanet noted a connection between edematous women and eclampsia.

• In 1843, John Lever discovered albumin in the urine of eclamptic women.

• In 1843, Dr Robert Johns pointed out an association between premonitory warnings, such as headache, short term loss of vision, severe pain in the stomach, edema of the hands, arms, neck and face, during the later months of pregnancy and the development of convulsions.

• In the 19^th century physicians continued to propose more theories. Dr Thomas Denman(1821) in his work entitled "Introduction to the Practice of Midwifery", concentrated on labours affected by convulsions. He attributed convulsions to specific customs and behaviours analogous to living in big cities and towns but also noted that the largest risk came from the uterus. According to him, expansion of the uterus during pregnancy placed considerable pressure on the descending blood vessels, resulting in regurgitation of blood in the head and overload of cerebral blood vessels resulted in convulsions.

• Dr William Tyler Smith(1849) in his work, “Parturition and the Principles and Practice of Obstetrics” challenged Denman's notion of cerebral congestion. He speculated that pregnancy was a state of increased fullness in Circulation. Dr Smith pointed out that if cerebral congestion was the rationale for seizures more cases would be anticipated during the second stage of labor as contractions during the second stage would interfere the most with the circulation of blood. He proposed other rationales such as:
  1. mechanical or emotional stimulus applied to the spinal cord
  2. variations in the wind, temperature, other atmospheric alterations
  3. bloodletting
  4. irritation of the uterus, uterine passages, intestinal canal, and the stomach
  5. the toxic elements
  • SMITH'S THEORY OF TOXIC ELEMENTS: Dr Smith speculated that the health of the pregnant woman depended on the exponential increase in the elimination of the waste elements, such as secretion of the bowels, and debris from the maternal and fetal system. Failure to eliminate such wastes could result in "toxemia", in which morbid elements accumulate in the system and could irritate the nervous system.

• In 1897, Vaquez and Nobecort were credited with the discovery of eclamptic hypertension and the concept of preeclamptic state was recognized. The presence of edema, headache, and proteinuria now raised concerns about the possibility of convulsions.

Treatments Offered

In the early 1800s:

• Bloodletting: In the early 1800s, it continued as a staple in the treatment and prevention of eclampsia. The quantity and frequency of bloodletting were determined by the strength of the patient and the severity of symptoms. The initial site for bleeding was the arm and repeated if necessary, that is if the convulsions persisted. In some cases, the jugular vein or temporal artery were also opened.
• Opiates: They were employed to curtail irritability of the female organs.
• Splashing cold water on patients face
• Placing the patient in a warm bath

If all other methods were ineffective, the Physician had to decide between expediting the childbirth or letting natural labor to start. According to Dr Denman, delivery was only hastened when the mother displayed the indications of being physiologically ready such as completion of dilation, rupturing of membranes and descent of the fetus, because interventions in the early stage of labor could increase maternal mortality.

In the late 1800s:

• Elimination of Toxins: When Smith’s theory of toxic elements emerged, treatments were targeted at the elimination of overabundant toxins. Some believed that meat toxins provoked eclampsia and advised against the consumption of meat products and prescribed diets consisting of vegetables, fruits and milk products.
• Preventative therapies: Now women with preeclamptic states, those who had headaches and edema of the upper extremities, were increasingly recognised and admitted to lying-in hospitals where they underwent procedures such as bleeding and purging to prevent seizures.