Note on the Treatment of 
Puerperal Eclampsia. 
BV 
CHARLES JEWETT, A.M., M.D., 
BROOKLYN, 
Professor of Obstetrics and Diseases of Children in 
the Long Island College Hospital; Fellow of the 
New York Academy of Medicine; New York 
Obstetrical Society, etc. 
REPRINT FROM VOLUME XII 
(KjnecoloQical 
1887. NOTE ON THE TREATMENT OF PUERPERAL 
ECLAMPSIA. 
BY CHARLES JEWETT, A. M., M. D., 
Brooklyn, N. Y. 
An agent that gives promise of improved results in 
eclampsia is a much-needed acquisition to our therapeutic 
resources. I venture, therefore, to ask your attention to the 
value of veratrum viride in the treatment of convulsions and 
its claims to a wider recognition. 
Its use for this purpose has been known to the profession 
for several years,1 but it has not yet received the attention 
which its importance deserves. This has been due in part 
to the fact that dangerous properties have been imputed to 
the drug by certain authorities, though unjustly, partly, no 
doubt, to the use of faulty preparations or faulty methods of 
administration by many practitioners who have given it a 
trial. No satisfactory conclusions can be drawn from its use 
by the stomach in eclampsic patients, owing to the uncer- 
tainty with reference to the amount retained and absorbed. 
I shall hope to show that the use of a reliable preparation of 
the veratrum viride is not only a safe, but, when given sub- 
cutaneously, a prompt and efficient means of controlling the 
convulsive paroxysms. 
As regards the physiological action of veratrum, its most 
1 The credit of first calling attention to the use of veratrum in the treatment 
of eclampsia is due to Dr. Herbert Fearn, of Brooklyn, N. Y. Am. Jour. Obstet., 
1871, p. 28. "Veratrum in Large Doses as a Substitute for Blood Letting in 
Puerperal Convulsions." 
Prof. Fordyce Barker has been for many years a well-known advocate of the 
utility of veratrum viride in this and other therapeutic applications. 2 
TREATMENT OF PUERPERAL ECLAMPSIA. 
remarkable property is its power to reduce the frequency 
and force of the heart's action and to diminish the arterial 
tension. Dr. E. R. Squibb discusses the physiological action 
and properties of veratrum in an instructive paper to be 
found in the Ephemeris for October, 1887. Alluding to 
the potency of veratrum as an arterial sedative, he cites the 
experiments of Prof. II. 0. Wood with its alkaloids.1 
" The carotid and subsequently the femoral artery of a 
dog were cut while under the influence of the alkaloids. 
The bleeding in both instances ceased spontaneously. The 
force of the circulation had been so greatly lessened by the 
alkaloids that there was spontaneous arrest of hemorrhage 
without dangerous loss of blood." 
The value of veratrum in eclampsia appears to depend 
on its effect upon the vaso-motor tonus. According to 
Percy, quoted by Peugnet (V. Y. M. IE 1872, p. 121), it 
is conveyed by the blood into thevasa vasorum, and through 
them paralyzes the vaso-motor nerves, the blood-vessels thus 
losing their contractile power. It thus relieves the vaso- 
motor spasm of the cerebral vessels, and the consequent 
cerebral anaemia to which the convulsions are believed to be 
due. It is also a spinal-motor depressant, though probably, 
as suggested by Peugnet, this effect is secondary to its action 
on the sympathetic through the vaso-motor nerves.2 
In excessive doses, veratrum causes a profound collapse; 
in lethal doses, it is believed to act as a cardiac poison. It 
is never necessary to push the drug to a dangerous degree, 
however, in eclampsia. Vomiting, pallor, and a sense of 
exhaustion are sometimes encountered from large medicinal 
doses, but these symptoms are soon relieved and are never 
followed by ill results. The writer has witnessed alarming 
prostration, simulating impending death, drom the use of 
1 " A Contribution to the Knowledge of the Physiological Action of the 
Alkaloids Viridia, Veratroidia, andVeratrum of Commerce and of the Resin of 
the Veratrum Viride," H. C. Wood, M. D., Am. Jour. Med. Sei., N. S., vol. 
lix, p. 36. 
2 According to Prof. J. A. McCorkle, the drug by overcoming the vaso- 
motor spasm of the renal vessels exerts a favorable effect also as a diuretic. CHARLES JEWETT. 
3 
veratrum in children for post-scarlatinal convulsions. The 
patients, however, rallied promptly under moderate doses of 
alcohol and morphia, and no injurious effects remained. A 
careful search of the literature of the subject fails to dis- 
cover a case of veratrum death from its use in convulsions. 
Peugnet states that he has found but a single recorded fatal 
case from its use in any class of cases, that of a feeble child, 
aged one year and six months, to whom thirty-five drops of 
the tincture had been given in divided doses. 
Dangerous symptoms, however, are said to supervene 
upon assuming the erect position while under the influence 
of full doses of veratrum. It is important, therefore, that the 
patient be kept in a recumbent posture during the treatment. 
Dr. Squibb recommends as the best preparation the fluid 
extract made from the rhizome of the plant. The rootlets 
he rejects as unreliable. The proprietary article known as 
" Norwood's tincture is of about half the strength of Squibb's 
fluid extract," but is probably not equally reliable. From the 
researches of Bullock and Wood, the alkaloids appear to 
possess no advantage over the whole drug. These conclu- 
sions are confirmed by Peugnet. The European plant, or 
veratrum album, can not replace the veratrum viride, or 
American hellebore, for our purpose. The former contains 
a principle not found in the American plant, by reason of 
which it produces in large doses an inflammation of the ali- 
mentary mucous membrane. It is also otherwise inferior. 
The preparation almost invariably used in my practice has 
been the fluid extract of the green hellebore of Squibb. 
As regards the mode of administration, the stomach of 
the eclampsic patient should not be trusted for the absorp- 
tion of the drug. The only reliable method of bringing 
the circulation rapidly under its influence is by the hypo- 
dermic syringe. Prompt effects and precision of dosage in 
this class of cases are generally impossible by the stomach. 
Some irritation at the seat of puncture follows the hypo- 
dermic use of the fluid extract, but with a clean needle sup- 
puration never results. 4 
TREATMENT OF PUERPERAL ECLAMPSIA. 
The average dose should be from ten to twenty minims. 
The smaller dose repeated in a half-hour will doubtless suffice 
in the majority of cases. Yet I have usually preferred to 
place the patient at once fully under the influence of the 
drug. The guide to the dosage is the frequency of the 
pulse. Experience seems to justify the statement that no 
convulsion will occur while the patient is sufficiently under 
veratrum to hold the cardiac pulsations below sixty to the 
minute. The average time required to develop the full 
effects of a single subcutaneous injection is thirty minutes. 
If the desired result is not attained after that interval, the 
injection should be repeated in the same or smaller amount, 
as may be required. Five-minim doses at longer intervals 
will suffice to maintain the diminished pulse-rate. I have 
rarely repeated the drug, however, after the circulation has 
been once brought profoundly under its effects, the total 
dosage seldom exceeding twenty to thirty minims of the 
fluid extract.1 
My experience with veratrum in eclampsia comprises 
twenty-two cases, most of them seen in consultation. Six- 
teen were women pregnant for the first time. In twenty- 
one cases, the first convulsion occurred before or during the 
first stage of labor. In one, the first attack was post partum. 
In sixteen, the labor was complicated with the use of forceps 
or version, twelve of the operated cases being primiparae. It 
will be granted that these were not of the most favorable class 
of eclampsic patients. In the whole number, there were six 
deaths, three by complications and three by eclampsia. One 
of the cases dying by convulsions was complicated with 
edema of the lungs. The mortality from all causes was 
therefore 27'2 per cent., 13'6 per cent, dying by eclampsia. 
Of the deaths by complications, one (that of the patient 
1 Much larger doses have been used with impunity by other observers. In a 
desperate 'case of puerperal eclampsia, reported to the Med. Soc. Co. Kings 
several years ago by Prof. E. S. Bunker, M. D., four hundred minims of Squibb's 
fluid extract of veratrum viride were administered by hypodermic injection dur- 
ing the first six hours of the treatment. Diminishing doses were continued for 
many hours longer. The patient made a good recovery. CHARLES JEWETT. 
5 
whose first convulsion was post partum) was due to pulmo- 
nary edema, two to septicemia. In each of the three cases 
dying by eclampsia, from twenty-four to thirty or more con- 
vulsions had occurred before the veratrum treatment was 
begun. If it be granted that the latter three cases were 
practically hopeless before treatment, and that the two septic 
deaths were preventable deaths, these results may be taken 
as affording some evidence of the value of the treatment. 
In the majority of cases, however, other measures were also 
used. Chloroform was given to gain time for the action of 
veratrum, and hydragogues were more or less freely used in 
most instances as a supplementary measure. 
But we need not base our estimate of veratrum on these 
results alone. The capabilities of the drug are more con- 
clusively shown by the unfailing certainty with which in my 
hands it has arrested the convulsive paroxysms, when given 
early. In all except the three cases fatal by eclampsia, the 
veratrum treatment was commenced before the eighth con- 
vulsion. In none, with a single exception, did a paroxysm 
occur after the treatment was established. This patient had 
already had no less than thirty convulsions, the pulse was 
172, and the woman nearly moribund. Sixty minims of the 
fluid extract in three doses reduced the pulse to only 100. 
The paroxysms continued, and the patient died within two 
hours. With this exception, the pulse fell in every case 
below sixty within a period varying from 12 to 45 minutes, 
after the full hypodermic dose. In no case was there a con- 
vulsion while the circulation was sufficiently under the 
influence of the drug to hold the pulse at sixty or lower. 
This experience, then, seems to show that in veratrum if 
given early we have a well-nigh certain means of controlling 
eclampsic convulsions. 
As regards the safety of the drug, I may say that in no 
instance has a dangerous prostration been noted. The most 
unpleasant effects experienced have been temporary nausea 
and depression. Even these symptoms have been transient, 
passing off in a few hours. 6 
TREATMENT OF PUERPERAL ECLAMPSIA. 
One of the above-mentioned cases is of especial interest, 
as going to show the possibility of long-continued use of 
veratrum without harmful results. The patient was a pri- 
mipara in the sixth month of gestation. She was seized with a 
convulsion, directly after which the urine was found loaded 
with albumen, turning solid with heat and nitric acid. The 
treatment was chloroform and the bromides. Two days 
later she had a second convulsion. I was then asked to see 
her. She was at that time partially unconscious and deliri- 
ous. Our first proposal to interfere with a view to terminate 
the pregnancy was abandoned owing to the religious scruples 
of the friends, the family being Catholics. Twenty minims 
of the fluid extract of veratrum were given in two doses by 
the mouth. Her physician informs me that the patient con- 
tinued to take this preparation in doses of six drops, three 
times daily for three weeks, wThen she was delivered. The 
drug was continued in diminishing doses for a week longer. 
The patient steadily improved under the treatment, had no 
further convulsions, and recovered rapidly after delivery. 
The customary measures were used for the treatment of the 
nephritis. 
To recapitulate, the advantages claimed for veratrum, 
when used in accordance with the plan above described, are 
briefly these: 
1. It is at once a harmless and an extremely potent 
measure. 
2. It is eminently a manageable agent, the pulse affording 
a ready and precise guide to the dosage. 
3. It is prompt in its action, and easy of administration. 
In conclusion, it should be noted that veratrum is not 
advocated as an exclusive reliance in the treatment of con- 
vulsions. 
Chloroform by inhalation, as the most prompt of all anti- 
eclampsic measures, should be given till the circulation has 
been brought fully under the influence of veratrum.1 Dur- 
1 Further experience in the use of veratrum in puerperal convulsions will be 
found in a recent [paper by Dr. I. E. Oatman, San Francisco, Cal., Proceedings DISCUSSION. 
7 
ing operations its use as practised in other artificial deliveries 
will be an additional safeguard against convulsions. 
Cathartics will be of great service to reinforce and supple- 
ment the treatment. 
The acceleration of the labor by judicious means and the 
induction of labor, when not spontaneously established, are 
always indicated on the occurrence of eclampsia. 
Int. Med. Cong., 1887; and another by Prof. J. D. Rushmore, M. D., Brooklyn, 
N. Y., on the use of veratrum viride in Kings Co., N. Y., with special reference 
to its control of puerperal convulsions. Gaillard's Med. Jour., November, 1887.