652 CALIFORNIA AND WESTERN MEDICINE
ETIOLOGY OF ECLAMPSIA
By P. 0. SUNDIN *
A review of the theories and conclusions of recent
writers and investigators. The fact is emphasized that
the cause of eclampsia is not yet definitely determined,
but the consensus of opinion is that it is a general
infection.
DISCUSSION by G. Carl H. McPheeters, Fresno; J. W.
Sherrick, Oakland; A. B. Spalding, San Francisco.
AFTER carefully going over the recent litera-
ture on this subject, the reference to eclampsia
as "the disease of theories" seems appropriate. That
the cause is some sort of a toxin is quite generally
stated, but of the nature and origin of the toxin we
are still uninformed.
Supporting the toxic theory there is an abun-
dance of evidence that focal infections are impor-
tant factors in early abortions, toxemias of preg-
nancy, and eclampsia.
It was once supposed that the kidneys were the
primary organs affected and that eclampsia, like
uremia, had its origin here. Some now believe that
there may be two forms of eclampsia-one known
as the renal type, in which the kidney is the pri-
mary seat of the disease and the liver secondarily
involved, and the second known as the hepatic type,
in which involvement of the kidney is secondary to
that of the liver.
Some endocrinologists recognize thyroid hypo-
activity and insufficient secretion to take care of the
increased metabolism in the liver as probably pro-
ductive of eclampsia, a theory supported by the fact
that patients with hyperthyroidism are made worse
by pregnancy.
The symptoms of eclampsia, particularly the
usual high fever in fatal cases, suggest systemic
infection.
Kellogg has recently shown that patients suffer-
ing from toxemia of pregnancy are very prone to
develop septicemia. In his experience, 14 per cent
of toxemics without convulsions and 25 per cent
of toxemics with convulsions developed septicemia,
irrespective of the method of delivery.
Kosmak in his recent review on the pathology
of toxemias has shown that the characteristic lesions
in many different organs are minute hemorrhages.
He says: "Eclampsia characterized by local cell de-
generation and necrosis, as a result of thrombosis
of the small vessels, is represented by eclampsia with
or without convulsions. Subcapsular hemorrhages
are common. The capillary vessels of the kidney
show stasis, and many contain actual thrombi. In-
farcts are present in the kidney, and are due to the
migration of emboli from other organs.
"Although kidneys and liver present the most
frequent and characteristic pathological changes at
autopsy, almost all of the organs may be more or
less involved. Hemorrhages may take place into
the lungs, pleura, pericardium, cranial cavity and
brain, gastric mucosa, peritoneum and skin." Polak
*P. 0. Sundin (H. W. Hellman Building, Los Angeles).
M. D. University of Southern California and University
of California College of Medicine, 1907. Practice limited
to Obstetrics and Gynecology. Hospital connections: Los
Angeles General Hospital, Hollywood Hospital, California
Lutheran Hospital, Florence Crittenton Hospital, City
Maternity and Los Angeles Department University Cali-
fornia Medical School Clinics.
VOl. XXIV, NO.
reports pathological renal changes in 98 per cent of
139 autopsies of eclampsia. Young and Miller have
come to the conclusion that infarcts in the placenta
is the causative factor. Also that in a definite num-
ber of instances early degeneration of a piece of
placenta whose circulation has been interfered with
may be the cause. The final conclusion of Young
and Miller and some other investigators is that "the
white placental infarct is the end-result of a hemor-
rhagic lesion by coagulation necrosis, the condition
is often multiple and may repeat in the same pla-
centa. There is clinical and histological evidence
that the primary lesion is the result of hematogenous
infection, generally found to be the teeth and ton-
sils. In other words, chronic sepsis is the primary
cause.")
Fritz Sachweh emphasizes the fact that during
the second half of pregnancy nitrogen retention and
hyperacidity of the blood are present, so as to sug-
gest a change in the protein metabolism, i. e., pro-
tein ingestion in the food is not oxidized to the
same degree as in non-pregnant women. Fats also
are oxidized only to a limited degree, whereas the
carbohydrates are used up completely.
Considering these facts, he suggested the hypothe-
sis that the development of eclampsia is favored by
an overabundance of meat and fat in the diet to-
ward the end of pregnancy. Experiences during
the war demonstrated that the best prophylaxis
of eclampsia consists in restricting meat during
pregnancy.
From an endocrinological point of view, Mas-
saglia's study of the hypofunction of the parathy-
roids in cats and dogs seems to prove that substances
commonly neutralized by parathyroid action reach
the kidneys unchanged and produce renal injury,
ending in nervous derangements, and even tetany.
He comes to the conclusion that the parathyroids
assist the liver in neutralizing intestinal poisons,
especially those which come from a meat diet.
John E. Talbot has shown, not only that the
placenta infarct is the result of hematogenous in-
fection of the placenta site, but also that the foci
of chronic septic infection forms the basis of much
of the pathology of toxemias. His conception is that
the processes involved are the same as those involved
in the production of all infectious diseases. He sug-
gests that in pregnancy the potential power of the
whole metabolic system is under a strain, whereby
derangement of the necessary balance between the
organs of metabolism is more readily reflected, and
symptoms are found which are common only in the
late results of a more chronic disease process, such
as chronic nephritis. He adds: "It is possible that
there may be hemorrhagic lesions in both the pla-
cental site and other organs, and scattered through-
out the body on the principle of hematogenous in-
fections." He is convinced that the toxemia of
pregnancy is almost never the result of a single
acute infection of short duration, and regards its
conception sufficiently broad to embrace the many
different types. This conception, that the disease is
a systemic infection, is consistent, not only with the
pathology, but also with the clinical picture.
In reviewing the observations of James J. Gil-
more we find that, in 29 pregnant women in whom
May, 1926 CALIFORNIA AND WESTERN MEDICINE
anemia could not be otherwise explained, 26 had
definite pus pockets. In sixty-six cases of early toxe-
mia, with nausea and vomiting, 31 patients had ton-
sillar infection, 16 had apical abscesses, and 6 had
both of these conditions. In other words, 80 per
cent had a focus of infection. And again, in a
series of fifty-seven cases of abortion and miscar-
riages unaccounted for by any other cause, 27 pa-
tients were found to have ihfected tonsils, 7 in-
fected teeth, 1 had both types of infection, 1 an
acute sinus infection. Dead fetus in uterus was
found nine times when the condition could not be
accounted for, save for a blood-born infection. Of
these 8 had diseased tonsils or teeth, and 3 had both.
In two instances a positive culture was obtained
from the amniotic fluid, and 1 from the fetal heart
blood. In forty-seven cases of pyelitis observed dur-
ing pregnancy and puerperium, 27 patients had in-
fected tonsils, 6 had abscessed teeth, 7 had both. In
a total of sixty-one cases showing increased blood
pressure with albumin and casts, but without toxic
symptoms, 70 per cent had a definite focus of
infection.
I am satisfied that if we guard our patient well
by insisting upon bi-weekly, and in the last month
of pregnancy, weekly observation, noting at these
visits the conditiQn of the urine, blood pressure,
weight-gain, and the minor complaints, including
constipation, edema, condition of the teeth and
gums, as well as restriction of food intake, espe-
cially meat and foods high in protein, the number
of toxic cases will be minimized.
Well-kept records will show a gradual rise in
the blood pressure, for instance, before edema, ab-
dominal distress, slight headache, nervousness, and
insomnia are evident enough to attract the patient's
attention to the general condition. Certainly, we
should pay attention to the condition of the teeth,
chronic local infection, and leucorrhea.
We know that the doctor who watches his patient
and transmits his knowledge to the prospective
mother, thereby decreases mortality and "convul-
sions out of a clear sky." We should not wait until
the last weeks of pregnancy to obtain the patient's
past history. A patient with a history of chronic
nephritis certainly cannot stand the strain of preg-
nancy as well as one free from past ailments.
CONCLUSIONS
The cause of toxemia of pregnancy is still un-
determined. Clinically and pathologically, the evi-
dences are that it is an infection. Chronic foci of
infection are to be looked upon with suspicion.
Excess protein intake and improper elimination
favor this symptom complex.
DISCUSSION
G. CARL H. MCPHEETERS, M. D. (Mattei Building,
Fresno, California)-We are indebted to Dr. Sundin for
a clear resume of our ideas of the etiology of eclampsia.
In commenting upon the causes which seem to lie back
of an eclamptic condition, I desire to emphasize the fact
that most such patients are poorly prepared for the re-
sponsibilities of pregnancy. They are anemic, overweight,
under weight, neurotic, poorly developed, afflicted with
serious menstrual irregularities, handicapped by focal in-
fections, including those of the urinary tract; or some
comhination of these conditions hefore pregnancy hegan.
These facts support another argument for prenuptial ex-
653
aminations and corrections of conditions calculated to
interfere with motherhood of all women before marriage,
or at least before pregnancy wherever possible.
I specially like the emphasis Sundin places upon thor-
ough physical examination of pregnant women, and upon
the office visits which the patient should make every week
or two weeks for observation and advice. Most patients
co-operate well when we explain the what, why and
how of the road they must travel. Very few patients
indeed develop eclampsia who are under close, careful
observation as outlined by the author. I believe eclamp-
sia is a complication of pregnancy due to infection, and
the toxins produced by such infection.
J. W. SHERRICK, M. D. (350 Twenty-ninth Street, Oak-
land, California)-Careful consideration of the etiology
of eclampsia results in a number of interesting theories,
some of which are rather bizarre, others important
enough to warrant further investigation. There are so
many factors involved, with resultant strain upon the
patient's physical condition and upon her nervous sys-
tem. The mother's metabolism is so extremely altered by
this physio-pathological process of pregnancy that it
seems unwise to attempt to explain the different mani-
festations on the basis of any one of the theories ad-
vanced. Every obstetrician appreciates the added strain
that foci of infection throws upon the organism and the
importance of carefully directed and prolonged prenatal
care, eliminating every pathological factor and influence
possible. But there are so many conditions in our com-
plex life that militate against a normal pregnancy and
leave the patient anemic, under par physically with little
physical and nervous system reserve, that I do not feel
that the real cause of eclampsia can be ascribed to infec-
tion. Rather, it seems just one of the more important
associated factors that serve to throw the balance against
the defense powers of the maternal organism. 'I do want
to emphasize the absolute necessity of anticipating and
dealing with these foci of infection, but I feel that there
is still some unknown toxic element working through
these more tangible influences.
A. B. SPALDING, M. D. (Stanford Hospital, San Fran-
cisco)-Doctor Sundin has reviewed in a very interest-
ing way some of the theories as to the causation of toxe-
mia of pregnancy. There seems to be an association of
focal infections to toxemia, but very little has been
brought out to prove that these focal infections do more
than influence the prognosis of the condition. We are still
ignorant as to the primary cause.
It seems to me that more progress could be expected
from a well-organized study of the post-toxic patient.
This is a very difficult line of research, because the
patients so frequently fail to co-operate.
From our limited experience at Stanford Medical
School, the test for renal function devised by Dr. Thomas
Addis seems to give a fairly good prognostic indication
as to the probability of toxemia in future pregnancies.
I believe before the toxic patient deliberately attempts
a succeeding pregnancy she should at least have a thor-
ough study of her kidney function and, if possible, a
more difficult study of her liver function. In the non-
pregnant state it is undoubtedly wise to remove from
the patient all sources of focal infection.
DOCTOR SUNDIN (closing)-I wish to thank Drs. Spald-
ing, McPheeters, and Sherrick for their interesting dis-
cussion of my paper. Apparen\ly, all agree that, since
the cause is unknown, prenatal dare is our best weapon
of defense for the present. We hope that the question of
etiology of eclampsia will soon be settled.
Dr. Charles M. Wharton, in charge of health and
physical education at the University of Pennsylvania,
thinks that the "daily dozen" and reducing and starva-
tion diets are downright "assaults" on health. "The latest
fad in the name of physical culture, the early morning
exercise by radio, is bad," Wharton said recently, "as it
selects the worst time of the day for heavy exercise.
Someone should call a halt against this wild scramble
for health by unnatural means," he added. "This indis-
criminate adoption of severe physical training destroys
the health of more people than it improves."-San Fran-
cisco Argonaut, April 1, 1926.