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Chapter 6 - Firewall Configuration and Administration
TRUE/FALSE
1. If the primary goal of a firewall is to block unauthorized access, the emphasis needs to be on
restricting rather than enabling connectivity
ANS: T PTS: 1 REF: 181
2. Any firewall hardware can support a proxy server.
ANS: F PTS: 1 REF: 185
3. The firewall administrator should test the firewall and evaluate its performance to ensure that the
network traffic is moving efficiently.
4. Computer systems have failed when critical computers were placed on the top floor of buildings that
were poorly air conditioned.
5. One of the disadvantages of a load-sharing setup is that total network performance declines.
ANS: F PTS: 1 REF: 200
MULTIPLE CHOICE
1. The cornerstone of most firewalls is the ____, a set of instructions based on organizational policy,
configured by the administrator.
a. rule set c. packet filter
b. IP forwarding set d. DNS
ANS: A PTS: 1 REF: 181
2. If you decide to first restrict all transmissions through the gateway except a specific set of services,
you are following the principle of ____.
a. deny all c. connectivity
b. least privilege d. permissive approach
ANS: B PTS: 1 REF: 181
3. The ____ approach processes firewall rules in top-to-bottom order.
a. Deny All c. Best Fit
b. In Order d. Last Fit
4. With the ____ approach, the firewall determines the order in which the rules are processed.
a. Deny All c. Best Fit
b. In Order d. Last Fit

ANS: C PTS: 1 REF: 182
5. A(n) ____ approach allows all packets to pass through except those specified to be blocked.
a. Allow-All c. Port 80
b. Allow-Some d. Except Video
6. A firewall must be ____ so its performance can grow along with the network it protects.
a. productive c. scalable
b. extensible d. robust
7. If a proxy server is in service, ____ should be disabled on routers and other devices that lie between
the networks.
a. PAT c. DNS
b. NAT d. IP forwarding
ANS: D PTS: 1 REF: 185
8. The IP range 10.x.x.x provides about ____ addresses.
a. 16.5 billion c. 1.05 million
b. 16.5 million d. 65,500
9. SSL supports firewall-based ____.
a. IP forwarding c. VPN
b. encryption d. application proxy
10. The formula for calculating memory usage for Check Point’s FW-1 NG firewall is ____.
a. MemoryUsage = (AverageLifetime)/(ConcurrentConnections)/(AverageLifetime + 50
seconds)*120
b. MemoryUsage =(AverageLifetime)/ (ConcurrentConnections)*(AverageLifetime + 50
seconds)*120
c. MemoryUsage = (ConcurrentConnections)/(AverageLifetime)+(AverageLifetime + 50
seconds)+120
d. MemoryUsage = (ConcurrentConnections)/(AverageLifetime)*(AverageLifetime + 50
seconds)*120
11. ____ is the hub for a large mailing list that features frequent announcements about security flaws.
a. Common Vulnerabilities and Exposures Database
b. CERT Coordination Center
c. SecurityFocus
d. The National Vulnerability Database
12. ____ provides a baseline index point for evaluating coverage of tools and services.
a. Common Vulnerabilities and Exposures Database
b. CERT Coordination Center

c. SecurityFocus
d. The National Vulnerability Database
13. It is good practice to set aside time to perform firewall maintenance ____.
a. daily c. monthly
b. weekly d. yearly
14. Different types of hardware can be secured in different ways, but one of the most important ways is to
____.
a. never update once you have a good configuration defined
b. buy products from the same brand
c. only use on network administrator
d. choose good passwords that you then guard closely
15. ____ firewalls are installed at all endpoints of the network, including the remote computers that
connect to the network through VPNs.
a. Distributed c. Integrated
b. Remote d. Routing
16. In 2003, GASSP was succeeded by ____.
a. GAAP c. GAISP
b. CISSP d. GASSPv2
17. GAISP recommends the ____ management of IT assets and resources.
a. environmental c. remote
b. network d. integrated
18. Having a ____ password in place prevents someone from starting up your computer and accessing
your hard disk files with a floppy disk called a boot disk.
a. BIOS c. supervisor
b. screen saver d. startup
19. ____ of frequently accessed resources, such as Web page text and image files, can dramatically speed
up the performance of your network because it reduces the load on your Web servers.
a. Hashing c. Redundancy
b. Caching d. Load balancing
20. A ____ network monitors the operation of the primary firewall and synchronizes the state table
connections so the two firewalls have the same information at any given time
a. caching c. hot standby

b. load balancing d. heartbeat
21. The ____ lets you extend their functionality and integrate virus scanning into their set of abilities.
a. Border Gateway Protocol (BGP) c. Open Platform for Security (OPSEC)
b. Open Shortest Path First (OSPF) d. Content Vectoring Protocol (CVP)
ANS: C PTS: 1 REF: 200-201
COMPLETION
1. A critical ____________________ is defined as a software- or hardware-related item that is
indispensable to the operation of a device or program.
ANS: resource
PTS: 1 REF: 184
2. Many companies use the Internet to enable a(n) ____________________ that connects internal hosts
with specific clients in other organizations.
ANS:
virtual private network
VPN
virtual private network (VPN)
PTS: 1 REF: 186
3. The administrator should periodically review a firewall’s ____________________ and analyze the
traffic that passes through the firewall, paying particular attention to suspicious activity.
ANS: logs
PTS: 1 REF: 191
4. A(n) ____________________ interface is software that enables you to configure and monitor one or
more firewalls that are located at different network locations.
ANS: remote management
PTS: 1 REF: 196
5. The even distribution of traffic among two or more load-sharing firewalls can be achieved through the
use of ____________________ switches, which are network devices with the intelligence to make
routing decisions based on source and destination IP address or port numbers as specified in Layer 4 of
the OSI reference model.
ANS:
layer four
layer 4
L4
PTS: 1 REF: 200

MATCHING
Match each item with a statement below.
a. boot-up password f. IP forwarding
b. firewall rules g. permissive
c. bastion host h. supervisor password
d. screen saver password i. caching
e. restrictive
1. Enables a packet to get from one network’s OSI stack of interfaces to another.
2. Set of rules that blocks all access by default, and then permits only specific types of traffic to pass
through.
3. The practice of storing data in a part of disk storage space so it can be retrieved as needed.
4. Primary intent is to let all traffic through and then block specific types of traffic.
5. Must be entered to complete the process of starting up a computer.
6. Password you need to enter to make your screen saver vanish so you can return to your desktop and
resume working.
7. Tell the firewall what types of traffic to let in and out of your network.
8. Used to gain access to the BIOS set-up program or to change the BIOS password.
9. Of central importance to the operation of the firewall software that it hosts.
1. ANS: F PTS: 1 REF: 183
2. ANS: E PTS: 1 REF: 181
3. ANS: I PTS: 1 REF: 198
4. ANS: G PTS: 1 REF: 181
5. ANS: A PTS: 1 REF: 196
6. ANS: C PTS: 1 REF: 196
7. ANS: B PTS: 1 REF: 181
8. ANS: H PTS: 1 REF: 196
9. ANS: C PTS: 1 REF: 184
SHORT ANSWER
1. Describe the need for firewall scalability.
ANS:
A firewall needs to adapt to the changing needs of the organization whose network it protects. More
Internet business and a growing staff are likely to increase the need for firewall resources. Be sure to
provide for the firewall’s growth by recommending a periodic review and upgrading software and
hardware as needed.
PTS: 1 REF: 183
2. Describe the importance of the bastion host’s performance.
ANS:

The bastion host, although it may not be the only hardware component in a firewall architecture, is of
central importance to the operation of the firewall software that it hosts. If the host machine runs too
slowly or doesn’t have enough memory to handle the large number of packet-filtering decisions, proxy
service requests, and other traffic, the entire organization’s productivity can be adversely affected.
That’s because the bastion host resides on the perimeter of the network and, unless other bastion hosts
and firewalls have been set up to provide load balancing, is the only gateway through which inbound
and outbound traffic can pass. Scalability and security are important not only to the firewall, but to its
bastion host machine as well. The bastion host needs sufficient memory to support every instance of
every program necessary to service the load placed on the machine.
PTS: 1 REF: 184
3. List the critical resources for a firewall’s successful operation.
ANS:
System memory
Hard drive capacity
Hard drive I/O throughput
System CPU capacity
Interface (Network card) data rate
Host OS socket performance
PTS: 1 REF: 184
4. What is IP forwarding?
ANS:
IP forwarding enables a packet to get from one network’s OSI stack of interfaces to another. Most
operating systems are set up to perform IP forwarding, as are routers. Proxy servers that handle the
movement of data from one external network to another perform the same function; however, if a
proxy server is in service, IP forwarding should be disabled on routers and other devices that lie
between the networks. It’s better to let the proxy server do the forwarding because it’s the security
device; having routers do the IP forwarding will defeat the purpose of using the proxy and make
communications less secure.
PTS: 1 REF: 185
5. What is an intrusion detection and prevention system?
ANS:
An intrusion detection and prevention system (IDPS)—software that can detect intrusion attempts and
notify administrators when they occur, or react dynamically to the intrusion—can be installed in the
external and/or the internal router at the perimeter of a network. IDPS capability is also built into many
popular software firewall packages, including Sidewinder, by Secure Computing.
PTS: 1 REF: 187
6. How should a firewall administrator guard against new risks?
ANS:

A firewall needs regular care and attention to keep up with the new threats that are constantly
appearing. It’s a good idea, after the firewall is up and running, to monitor its activities on an ongoing
basis and store, in the form of log files, all the data that accumulates. The administrator should
periodically review the logs and analyze the traffic that passes through the firewall, paying particular
attention to suspicious activity
PTS: 1 REF: 191
7. Describe best practices for adding software updates and patches.
ANS:
The best way to combat the constant stream of new viruses and security threats is to install updated
software that is specifically designed to meet those threats. A change-management program that
evaluates, schedules, and installs updates can help make sure that new software does not slow down
systems, cause applications to crash, or lead to other problems. Vendors will typically provide
information on available updates and security patches as they become available. You can also check
the manufacturer’s Web site for security patches and software updates. Develop a maintenance
window—a period of two or three hours that is set aside every month for performing improvements
such as software upgrades. It’s a good way for organizations—even small ones—to manage changes to
the network environment while minimizing the impact on production applications. It’s also a good idea
to participate in firewall-related mailing lists, not just to share ideas and ask questions of colleagues,
but to learn about new security threats as they occur and news about patches as they become available.
PTS: 1 REF: 192
8. What are the GAISP nine Pervasive Principles?
ANS:
Accountability—Define and acknowledge accountability and responsibility.
Awareness—All stakeholders with a need to know have access to security principles as well as
standards and practices and are informed of threats.
Ethics—Information use and protection is performed in an ethical manner.
Multidisciplinary—Security principles as well as standards and practices serve the perspectives of all
relevant stakeholders.
Proportionality—Controls are balanced against risk.
Integration—Security principles are integrated and coordinated with standards and practices, and both
are integrated and coordinated with other organizational principles, standards and practices, and
policies, and procedures.
Timeliness—Stakeholders act in a timely fashion to prevent and react to threats.
Assessment—Risks are assessed regularly.
Equity—Management acts respectfully
PTS: 1 REF: 194-195
9. What is a screen saver password? Why is it important?
ANS:
A screen saver is an image or design that appears on a computer monitor when the machine is idle. A
screen saver password is a password you need to enter to make your screen saver vanish so you can
return to your desktop and resume working. Configuring a screen saver password protects your
computer while you’re not working on it. It’s thus a good complement to a BIOS password, which
protects your computer during startup but not when the machine, though running, has been idle for a
time. A screen saver password can be easily circumvented by rebooting the computer, but a BIOS
password will be needed during the reboot.

PTS: 1 REF: 196
10. Describe the Content Vectoring Protocol (CVP).
ANS:
Many advanced firewalls support the Content Vectoring Protocol (CVP), which enables firewalls to
work with virus-scanning applications so that such content can be filtered out. For instance, you can
define a network object, such as a server that contains antivirus software, and have the firewall send
SMTP traffic to that server using CVP. Once you define the server as a network object, you set the
application properties for that server.
PTS: 1 REF: 201

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the time when menstruation would occur were the woman not
pregnant.
Treatment, in the different degrees of abortion, employed by
most physicians, is usually along some such lines as the following:
1. Threatened. A threatened abortion is one in which there is some loss of
blood, associated with pain in the back and lower abdomen, but without expulsion
of the products of conception. The treatment, as a rule, is absolute rest in bed and
the administration of powerful sedatives.
2. Incomplete. An incomplete abortion is one in which the fetus is expelled but
the placenta and membranes remain in the uterine cavity. The treatment is
removal of the retained tissues, followed by the same care that is given during the
normal puerperium. Prompt action in completing the delivery is important
because of the hemorrhage that usually persists until the uterus is entirely emptied
of its contents. Since the pregnant uterus is very soft, the retained membranes are
more often removed manually than instrumentally, for a curette may be very easily
pushed through the uterine wall, and peritonitis would be likely to follow.
3. Complete. A complete abortion, as the term suggests, is one in which all the
products of conception are expelled. The treatment and care are exactly the same
as are given after a normal delivery. This point cannot be stressed too strongly, for
it is because so many women fail to appreciate the necessity for adequate post-
partum care, that abortions are so often followed by ill health and invalidism.
Many doctors follow these various remedial measures with a
search for the cause of the abortion just past, in order that it may be
corrected if possible and recurrent abortions prevented.
A missed abortion occurs but rarely, and is one in which the
embryo, or fetus dies, and is retained within the uterine cavity for
months, or even years, sometimes without any unfavorable results to
the mother. In these cases, symptoms of abortion sometimes appear
and then subside without any part of the uterine contents being
expelled. In other cases there are no signs except that the abdomen
stops growing. There are cases on record in which the fetus has
become mummified and others in which it has been partly absorbed
by the maternal organism.
In addition to abortions which occur spontaneously there are also
induced abortions, and these are designated as therapeutic or
criminal, according to the motive for the induction.
Therapeutic abortions are resorted to when the patient’s
condition is so grave that it is apparently necessary to empty the

uterus in order to save her life. Such a condition may exist, for
example, when pregnancy is complicated by pulmonary tuberculosis,
heart disease, toxemia, hemorrhage or some condition which is
inherent to pregnancy. An abortion induced under these
circumstances is countenanced by law, as it is performed to prevent
the loss of life from disease; but an abortion is not legal if brought on
to save the woman from suicide, because of her unwillingness to
become a mother.
The Catholic Church, however, teaches that it is never permissible
to take the life of the child in order to save the life of the mother. It
teaches that, even according to natural law, the child is not an unjust
aggressor: and that both child and mother have an equal right to life.
There is apparently no reason why a therapeutic abortion should
be followed by ill health, for, since it is performed openly, it is done
under clean, and otherwise favorable conditions, and the patient is
given adequate after-care. It is only because the reverse conditions
frequently prevail: the unclean delivery and subsequent neglect
which go hand in hand with the secrecy of illegal performance that
abortions are followed so often by disaster.
As to the legal aspect of the matter, the laws relating to therapeutic
abortion vary in the different states. But they are fairly uniform in
their intent, and make quite clear the difference between this
procedure and the induction of abortion for any reason other than
medical necessity.
Dr. Slemons writes of the seriousness of criminal abortion in no
uncertain terms, in “The Prospective Mother.” “At Common Law” (an
inheritance from England) he tells us, “abortion is punishable as
homicide when the woman dies or when the operation results fatally
to the infant, after it has been born alive. If performed for the
purpose of killing the child, the crime is murder; in the absence of
such intent, it is manslaughter. The woman who commits an
abortion upon herself is likewise guilty of the crime.”
Premature Labor is the termination of pregnancy after the
seventh month, but before term. Premature births are much less
frequent than abortions or miscarriages. They usually occur
spontaneously, but are sometimes induced for therapeutic purposes,
or from criminal motives.

The premature baby’s chances of living are directly proportionate
to the length of its uterine life. This has already been stated, but will
bear repetition in view of the widely current fallacy that a seven-
months’ baby is more likely to live than one born after eight months
of pregnancy. The facts are that as a rule, the nearer pregnancy
approaches term, the more likely is the baby to survive, provided it
weighs four pounds or more, and is forty centimeters or more in
length. A smaller baby than this has but a slender chance to live.
We ordinarily designate as premature any baby that weighs
between 1500 and 2500 grams, or measures between thirty-six and
forty-five centimeters in length, and consider such a baby has a
favorable outlook if given special care. This special care of premature
babies will be described in connection with the care of the baby.
Causes. Syphilis was formerly thought to be a common cause of
abortion, but although this has been disproved by recent
investigations, the disease is still regarded as a frequent cause of
spontaneous premature labor. In fact, Dr. Williams considers
syphilis the most frequent single cause of premature births, and
regards the birth of a dead, macerated fetus, or a history of repeated
premature labors, or stillbirths, as strongly suggestive of syphilis.
“In my experience,” he says, “the recognition and treatment of this
disease is the most important matter in connection with the
prophylaxis of premature labor.... Some idea of the importance may
be gained from the fact that in a series of 334 premature labors, I
found that syphilis was the etiological factor in over 40 per cent.,
while toxemia, placenta prævia and fetal deformity were concerned
in 8.6 and 3.3 per cent., respectively. Sentex, who studied 485 cases
in Pinard’s clinic arrived at similar conclusions and found the
underlying cause to be syphilis in 42.7 per cent., albuminuria in 10.8
per cent., and abnormalities of the fetus in 11.1 per cent.”[3]
Other causes of premature births are the toxemias of pregnancy,
chronic nephritis, diabetes, pneumonia, typhoid fever, organic heart
disease, continuous overwork during the latter part of pregnancy,
and such poisoning as lead and illuminating gas, while of alcoholism,
Dr. Ballantyne says, “prematurity of birth is an undoubted result.”
Another important cause of premature births, of comparatively
recent recognition, is previous operation upon the cervix,
particularly high amputations; while placenta prævia and

malformations of the fetus, or monsters, are also reckoned with as
causative factors. Hydramnios sometimes brings on a premature
labor by so distending the uterus as to stimulate contractions.
Labor is sometimes induced prematurely when this procedure may
be expected to relieve an abnormality or complication which
threatens the life of the mother or baby, or both. Some of the
indications for this course are: seriously overtaxed heart or kidneys;
a marked disproportion between the size of the child’s head and the
mother’s pelvis, or a fetus that has been dead for two weeks or more.
However, the reasons for it and the methods employed in inducing
labor will be discussed more at length in the chapter on obstetric
operations.
A therapeutic induction of premature labor, like a therapeutic
abortion, is not of itself usually considered any more serious for the
mother than a normal delivery, since it can be performed with care
and cleanliness, qualities not usually associated with the work of
practitioners who are willing to do criminal operations.
Treatment. The nursing care of the patient after a premature
labor is the same as that given after a normal delivery. Much
invalidism would be avoided if all women could be convinced of the
importance of staying in bed just as long, and having just as good
care after a premature as after a full-term labor. The difficulty of so
convincing her is perhaps due to the fact that the small, premature
child is expelled more quickly and less painfully than a baby at term
and there is comparatively little blood lost in the course of its birth.
ANTE-PARTUM HEMORRHAGE

Fig. 44.—
Diagram of
centrally
implanted
placenta prævia.
Ante-partum hemorrhage, which is a
hemorrhage occurring before delivery, is another
serious complication of pregnancy. During the
early months, hemorrhages are usually due to
abortion, menstruation or lesions of the cervix
and are not severe as a rule. But during the last
three months hemorrhages are almost invariably
due to placenta prævia or premature separation
of a normally implanted placenta, and are often
profuse.
Placenta Prævia is one of the most serious
conditions met with in obstetrics, the maternal
mortality being about 40 per cent. and the baby
death rate about 66 per cent. The frequency with
which it occurs is variously estimated as from one
in 250 cases to one in every 1000.
In order to understand what is happening to
the patient in this condition, we must go back to
the question of the implantation of the ovum. We
learned that, as a rule, after the ovum entered the
uterus it attached itself to a point in the uterine
lining high up on the anterior or posterior wall. Unhappily, the
position of this point of attachment is a mere matter of chance, and
the ovum sometimes, but not often, is implanted so far down toward
the cervix that as the placenta develops at that site it partially or
completely overlaps the internal os. It is the extent to which the
placenta grows over the cervical opening that determines whether it
is of the central, partial or marginal variety.

Fig. 45.—Partial
placenta prævia.
Section of
uterine wall and
cervix showing
that part of the
maternal
surface of the
placenta which
extends over the
cervical opening
and is exposed
by dilation of
the internal os,
with an escape
of blood from
the open vessels
as a result.
Drawn by Max
Brodel. (From
“The Treatment
of Placenta
Praevia,” by
William B.
Thompson,
M.D.—Johns
Hopkins
Hospital
Bulletin, July,
1921.)

Fig. 46.—
Diagram of
marginal
placenta prævia.
A centrally implanted placenta prævia (Fig. 44) is one which
entirely covers the os; a partial placenta prævia (Fig. 45), as the
name suggests, only partially covers the opening, while if it is
implanted so high up that only its margin overlaps the os, it is
designated as marginal placenta prævia. (Fig. 46.)
Another classification groups all placenta
prævia as complete or incomplete, the latter
comprising the partial and marginal varieties, as
well as the lateral which is so attached that it
does not quite reach the edge of the internal os.
However, as these terms do not differ widely and
are clearly descriptive, the differences are of no
great moment to the nurse, as the treatment is
practically the same and the nurse’s duties quite
the same for all varieties.
Cause. Not much is definitely known about
the cause of placenta prævia, but it is evident that
multiparity is a factor, since the condition is
found about six times as frequently among
women who have borne children, as it is among
those who are pregnant for the first time. A
diseased uterine lining is probably the
fundamental cause, and this may explain why the
trouble is found more frequently among the
poorer classes, since such women as a class have
less skilled medical attention than those in better circumstance.
One theory is that an old endometritis results in a very unfertile
soil for the implantation of the ovum and as a result the ovum
migrates to other parts of the uterine cavity in its search for a more
favorable site, and comes to lodge near the lower segment.
Symptoms. The symptom of placenta prævia is hemorrhage,
occurring during the latter part of pregnancy or at the onset of labor.
The cause of the hemorrhage is the separation of that part of the
placenta covering the internal os, when the latter dilates, thus
presenting an exposed, bleeding surface. The hemorrhage is usually
so profuse that unless it is controlled, both mother and child may
bleed to death.

Treatment. Unhappily there is no preventive treatment for
placenta prævia, beyond that which is included in treatment for
endometritis, and good care during the preceding puerperium.
Fig. 47.—Position of Champetier de Ribes’ bag to
stop hemorrhage, from placenta prævia, by
pressure.
Since the great danger in this complication is from hemorrhage the
doctor’s principal effort is directed toward its control. Infection and
shock are also feared but the first step is to stop the bleeding. A
common method is to stimulate the uterus to contract; that
necessitates the removal of its contents, or the induction of labor.
The separation of the placenta leaves open, bleeding vessels in the
uterine wall and placenta, which can only be closed by pressure, until
the uterus contracts on its own vessels. The doctor sometimes makes
pressure with tampons of gauze, by rupturing the membranes and
bringing down the presenting part of the child to press against the
bleeding surface, or by introducing a rubber bag into the cervix and
pumping it full of sterile water. (Fig. 47.) By means of its weight and
downward traction, this bag presses against the bleeding areas and
thus checks the hemorrhage. It also tends to dilate the cervix, after

which the baby is sometimes born spontaneously and sometimes
delivered artificially.
Premature Separation of a Normally Implanted Placenta. A
placenta prævia, as has been explained, is abnormally situated. But it
sometimes happens that a placenta that is normally placed will
separate prematurely, with hemorrhage as the inevitable result. Such
a hemorrhage is termed “accidental” to distinguish it from the
unavoidable bleeding caused by a placenta prævia. If the blood
escapes from the vagina, the hemorrhage is called “frank,” but if it is
retained within the uterine cavity it is called a “concealed”
hemorrhage.
Causes. Endometritis is probably an underlying cause, though
very little is definitely known on the subject. Previous pregnancies
are believed to be a factor, as this accident occurs less often among
women who are pregnant for the first time than among those who
have borne children, and also as the frequency of the hemorrhages
apparently increases with the number of previous pregnancies.
Nephritis is believed to be a possible cause, as well as anemia,
general ill-health, toxemia, physical shocks, and frequently recurring
pregnancies.
Symptoms. In a frank hemorrhage, the chief symptom is an
escape of blood from the vagina, occasionally accompanied by pain.
A frank accidental hemorrhage occurs once in about every two
hundred cases, according to Dr. Edgar’s estimate, but, although more
frequent than placenta prævia, it is much less serious.
A concealed accidental hemorrhage, on the other hand, is an
extremely grave complication for both mother and child, for
according to observations made by Dr. Goodell, the death rate is 51
per cent. among mothers and 94 per cent. among babies.[4]
The
symptoms are acute anemia, abdominal pain, a general state of
shock, and usually an increased enlargement of the uterus. The blood
may be retained between the uterine wall and the placenta or
membranes, or its escape from the vagina may be prevented by the
child’s presenting part fitting tightly into the outlet and acting as a
plug.
Treatment. The treatment of a frank hemorrhage depends upon
its severity. If the bleeding is only moderate, labor is ordinarily

allowed to proceed normally and unassisted. If the bleeding is
profuse, however, the patient is usually delivered promptly.
The treatment for a concealed hemorrhage consists of emptying
the uterus speedily in order that the muscles may contract and stop
the bleeding by closing the uterine vessels; and of treating the
accompanying shock which may be almost, if not quite, as serious as
the hemorrhage itself.
It is very disappointing to have to realize that there is very little
that a nurse may do, before the arrival of the doctor, for a patient
who is having an ante-partum hemorrhage. As has been explained, it
is often necessary to pack the cervix or introduce a bag, for the
purpose of stopping the bleeding by pressure, and of stimulating the
uterine contractions which will expel the child and empty the uterus.
These measures are surgical operations and quite evidently the nurse
cannot attempt to perform them. She can, however, put the patient
to bed and have her lie flat, without a pillow, and, partly for the
mental effect upon the patient, apply ice-bags or compresses to her
abdomen. As nervousness and excitement only tend to increase the
bleeding, the nurse has an excellent opportunity to try to soothe and
quiet a frightened woman, and convince her that she can help
herself, in this emergency, by quieting her mind and body.
Pending the doctor’s arrival, the nurse should have a large
receptacle of water, boiling, to sterilize the instruments and bags that
he may want to use; clean towels and sheets, a nail brush, hot water,
soap, and a basin of an antiseptic solution for his hands.
TOXEMIAS OF PREGNANCY
There is probably no group of complications which prove to be
more baffling to the obstetrician than the toxemias of pregnancy.
Certainly they are challenging the best efforts of many earnest
investigators, for it is known that the toxemias cause some of the
gravest conditions that arise during pregnancy, and they are
suspected of being the underlying cause of still others which are as
yet unaccounted for.
Comparatively little is known of the origin of the toxemias, except
that they are due to pregnancy. But happily, a good deal is known

about preventing them, and also about relieving them, particularly in
the early stages; accordingly many mothers and babies are saved who
otherwise would perish.
The entire subject of the prevention and treatment of these
disorders will be somewhat simplified for the nurse if she will recall
the general question of the adaptations of the mother’s physiology
during pregnancy. She will then remember that there were certain
alterations of function which were necessary to keep the maternal
organism normal, while it bore the strain of supplying nourishment
to the fetus from its own blood stream, and received in turn the
broken-down products of fetal activity. If these adaptations are
insufficient to meet the demands made upon the maternal organism,
a serious toxic condition may result.
To put the matter briefly, there is in the toxemias of pregnancy a
disturbance of the mother’s metabolism, involving the liver and
kidneys, and a resulting retention within her body of something
which should be excreted. The retention of this material, which may
be of fetal or maternal origin, or both, may give rise to symptoms
which range anywhere from slight headache or nausea to coma,
convulsions and death.
Beyond these general facts, there seems to be deep obscurity
concerning the cause of this group of complications, of which
pernicious vomiting, pre-eclamptic toxemia and eclampsia are the
most widely and generally recognized.
While nephritic toxemia and acute yellow atrophy of the liver
cannot be designated, quite accurately, as toxemias due to
pregnancy, they are usually included in this group. This may be
because they are toxemias which have many features in common
with those of pregnancy, as to symptoms and treatment, and because
of the frequency with which they appear coincidently with
pregnancy, although not always due primarily to that state.
From the nurse’s standpoint, it will perhaps be as well to regard all
of the toxemias of pregnancy as manifestations of the same general
disturbance, which vary according to the stage of pregnancy at which
they appear, and which differ from each other chiefly in severity, or
degree, rather than in kind.

In all cases the patients need to have their toxicity lessened by
dilution, and this is accomplished by giving fluids, copiously, and by
increasing elimination by promoting the activity of the skin, kidneys
and bowels. And since the nervous system is irritated by the toxins,
sometimes slightly and sometimes profoundly, the patient must be
protected from outside irritation and stimulation. This means quiet;
a soft light, or even darkness in the room; gentle handling; and with
mildly toxic, conscious patients, a pleasant, reassuring and
encouraging manner. With those who are unconscious, each touch
must be the lightest and gentlest possible.
These are the main features of the nursing care: forcing fluids and
keeping the patient warm and quiet. They offer the nurse wide scope
in adjustment and adaptation to each patient, according to her
immediate condition and to the methods of the physician in charge.
There is a difference of opinion among doctors as to details of
treatment, but the fundamentals of the care are the same. In taking
up, in turn, these manifestations of disturbed metabolism during
pregnancy, we find that vomiting is the first to appear.
Pernicious Vomiting of Pregnancy usually occurs during the
first three months. We learned in the preceding chapter that a milder
form of the malady, known as “morning sickness,” is present in about
half of all pregnancies. This mild type ordinarily consists of a feeling
of nausea, possibly accompanied by vomiting, immediately upon
raising the head in the morning, and a capricious appetite. It appears
at about the fourth or sixth week and subsides in the course of a few
weeks, sometimes after no more care than the nursing which was
described, leaving the patient none the worse as a result of the
attack.
With some women, however, the distress does not disappear in
this prompt and satisfactory manner, in which case it is described as
“pernicious vomiting.” The nausea in the morning may then persist
for hours; it may occur later in the day, or even at night; it may come
on during a meal and consist of a single attack of vomiting, after
which food is taken and retained; or it may be so persistent that the
patient will be unable to retain anything taken by mouth at any time
of the day or night. Such a condition, is, of course, serious, and may
terminate fatally. The patient may become exhausted from lack of

food or because of the toxic condition which is responsible for the
vomiting, or both.
There seem to be three possible classifications of pernicious
vomiting: (1) One of reflex origin, (2) one of neurotic origin, and (3)
one due to a toxemia, resulting from disturbed metabolism. Not all
physicians accept the possibility of all of these factors, however, for
while some recognize both toxemia and neuroses as causes, they
question the possibility of a reflex cause. Others believe that all
nausea of pregnancy, from the mildest to the most severe form, is of
toxic origin, while still others contend that even the severest
pernicious vomiting is always neurotic. However, as toxicity under
any conditions is very likely to give rise to nervous symptoms, and as
a nervous, unstable woman may be made very ill by a slight degree of
toxicity, it may be that both factors sometimes enter into the
causation of this disorder.
Reflex vomiting. Those who subscribe to the theory of reflex
vomiting believe that it may result from the irritation caused by a
retroverted uterus, or occasionally by an ovarian cyst, an erosion on
the cervix or by adhesions.
The treatment for reflex vomiting, quite obviously, consists of
correcting the disturbing condition, whatever it may be, after which
the nausea usually subsides in a short time. The nurse should take
care that her patient resumes a regular diet very gradually, even after
the cause of the nausea has been removed, for the stomach has
become irritable and the vomiting habit, both mental and physical,
though easily established, is usually broken up with considerable
difficulty. Breakfast in bed; concentrated liquid foods or easily
digested solids, particularly carbohydrates; aerated waters; cold fruit
juices and cracked ice are easy to retain and tend to allay nausea.
Neurotic vomiting. Severe vomiting which is due to some kind
of mental stress or suffering, and commonly called “neurotic
vomiting,” is not always so easily relieved. In the opinion of many
psychiatrists the vomiting frequently constitutes a protection, or
possibly a protest, which the patient has developed subconsciously,
because of some reason for fearing, or not wanting, to become a
mother.
It is difficult to outline the nursing care of such patients with any
degree of precision, as no two can be cared for in quite the same way.

While in some cases the patient is a selfish, overindulged woman
who objects to motherhood because of its inconveniences, in others,
she is tortured by fear of inability to go through her pregnancy
successfully, though sincerely wanting to; or she may be bewildered
and overwhelmed by the prospect of the dangers of childbirth and
responsibilities of motherhood, a truly pathetic figure whose distress
may often be greatly relieved by the nurse who has enough insight to
grasp the situation. As I have discussed this subject more at length in
the chapter on mental hygiene, I shall say only a word here, as a
reminder that the nurse will need all of the tact, resourcefulness,
sympathy and understanding which she is capable of offering, if she
is to give real help to some of her patients who suffer from neurotic
vomiting.
In addition to the mental nursing, which will be necessary, the
patient also needs physical care, for though her trouble may be of
emotional origin, she is, nevertheless, physically ill. As a rule, the
best results are obtained by putting the patient to bed and separating
her from her family as completely as possible. A daily routine should
be adopted and rigidly observed, and the patient repeatedly assured
that the course being followed will end in recovery.
It is usually considered advisable not to offer food by mouth, in the
beginning, but instead to give nourishment, as well as large amounts
of saline and sugar solutions by enemata, during the first few days.
One routine is to give 500 cubic centimetres very slowly, every six
hours at first, gradually decreasing the treatments to one a day as the
patient improves. The rectum is irrigated with a simple enema, once
daily, immediately preceding one of the injections, consisting of an
ounce of dextrose or glucose and one dram of salt to a pint of water.
Small amounts of liquid nourishment are finally given by mouth,
and given frequently, the quantity being increased gradually as the
patient improves. Very light and easily digestible solid foods, chiefly
carbohydrates, are added by degrees, and in the end, five or six small
meals, rather than three full ones, are given in the course of the day.
In some cases the patient is induced to drink, daily, two or three
quarts of sugar solution (an ounce of lactose to a pint of water), and
to nibble at will on olives, walnuts, crisp crackers, or some such
articles of food, which are kept within reach on her bedside table.

These are usually retained, excepting in very severe cases, to the
patient’s great encouragement.
The duration and severity of the attacks vary widely. Some patients
are very ill and for a long time, even requiring an abortion before
showing signs of improvement, while others recover in a few days if
wisely managed. If a patient once suffers from neurotic vomiting, she
is very likely to have it in subsequent pregnancies, particularly if the
circumstances of her life remain unaltered.
Toxemic vomiting is regarded by some doctors as a very grave
and very rare complication of pregnancy, which is usually fatal; by
others as simply a severe form of the very common “morning
sickness,” which they believe is always toxic, no matter how mild;
while still others, as already stated, doubt the occurrence of such a
condition as toxemic vomiting of pregnancy. I mention these
differences of opinion in order that the nurse may be aware of their
existence and be prepared to adjust herself whole-heartedly to the
different methods of treatment for which they are responsible. For
no matter what else may vary, the earnestness and sincerity of the
nurse’s attitude must be a veritable Gibralter of reliability.
The chief symptoms of toxemic vomiting, in addition to
persistent vomiting, as described by those who recognize its
occurrence, are coffee-ground vomitus; a diminished amount of
urine, possibly containing albumen, acetone bodies and casts; coma
and sometimes convulsions. The disease may run its course swiftly
and the patient die in a week or ten days, or it may persist less
acutely for weeks, in which case there is extreme emaciation and
prostration. In those cases which come to autopsy there is a definite
and characteristic, central necrosis of the liver lobule.
The treatment and nursing care vary widely because so little is
definitely known about the cause, and because of the varieties of
theories concerning it which are held by different obstetricians.
Some believe that prompt emptying of the uterus is about the only
course which is effective, while others feel that because of the
probable toxicity of the patient it is advisable also to stimulate all of
the excretory organs. Accordingly, they give free purges, colonic
irrigations, hot packs and copious amounts of sugar and saline
solution by mouth, rectum, intravenously and by infusion.

Corpus luteum, too, is sometimes given hypodermically two or
three times weekly. Although this treatment is not in universal use or
favor, some patients seem to be given absolute relief by its
administration.
A fairly typical method of treating toxemic vomiting, and of which
the nursing care forms a large part is somewhat as follows: When the
vomiting is only moderately severe, the patient is put to bed and
isolated from relatives and friends, because of her nervousness
resulting from the toxemia. She is given an abundance of very cold, 5
per cent. lactose solution by mouth in water or lemonade; from four
to six ounces being given every half hour if she is able to retain it. If
she is unable to take, by mouth, a total of about three litres of this
solution, in the course of twenty-four hours, she is sometimes given
one or two litres (of a 10 per cent. solution) by rectum by means of
the drip method. At least three hours are devoted to giving this
amount of fluid, the rectum being first washed out with a simple
enema.
It is usually considered important to persist in giving small
amounts of practically any article of food that the patient fancies, in
order to encourage her in the belief that she can take nourishment
and also to accustom her stomach to receive and retain food. Olives
and nuts are particularly valuable for this purpose and are often kept
on the patient’s bedside table where she can reach them and nibble
on them at will. Ice cold fruits and fruit juices are useful, while
strained apple sauce, ice cold, is very valuable as a starting point
from which a more generous diet may be gradually developed. All
foods should be very cold except broths, which should be very hot.
The dietary is gradually increased to six small meals daily from
which fats and proteids are omitted.
In more severe cases, or if the patient does not improve, an
injection of 300 cubic centimetres of fresh 5 per cent. solution of
glucose is given under each breast daily, and sometimes a mild
sweat-bath, given with blankets and lasting twenty minutes. (See
page 197 for sweat-bath.)
In very severe cases when the patient is unable to retain anything
taken by mouth; loses weight and strength; when possibly the urine
decreases in amount and contains acetone bodies and ammonia, the
situation is serious and the treatment is more drastic. All effort to

give fluid by mouth is abandoned and in addition to the sub-
mammary injection of glucose solution, a colonic irrigation of one
and a half to two gallons of sodium bicarbonate solution (from 2% to
5%) at 110° F., is given once daily by the drip method. The daily hot
pack is continued; a mustard leaf is applied to the abdomen if
necessary to relieve the pain and nausea; glucose solution may be
given intravenously and also a nutritive enema, three times daily,
consisting of a raw egg, four ounces of peptonized milk and one-half
ounce of whiskey.
The method employed at the Toronto General Hospital in treating
patients suffering from toxemic vomiting is outlined as follows by Dr.
J. G. Gallie: “The patient is given as much as she is able to drink. A
nutrient enema is given three or four times daily, consisting of six
ounces of a 10 per cent. solution of glucose in saline. Bromide and
chloral may have to be added to the last nutrient in the evening. A
simple enema is given each morning. Nutrients are discontinued
when the urine becomes free of acetone bodies. In more severe cases,
where fluid cannot be taken by mouth, it may be supplied
interstitially or intravenously, a 5 per cent. solution of glucose being
used. When vomiting ceases, and solid food can be taken, the feeding
is begun very carefully with small quantities of carbohydrates.
Lactose is added where possible to any fluid taken. Frequent small
meals are then instituted—six between 7 a.m. and 10.30 p.m., thus
reducing to the smallest space of time the period of starvation during
the twenty-four hours. Protein may be added to the diet when nausea
is under control, but fat should be left out for some time.”
Such a course of treatment, quite evidently, is designed to relieve a
toxic condition, in which increased elimination is important, and to
quiet an irritable nervous system.
As the patient with toxemic vomiting is often very uncomfortable
because of a bad taste and dryness of her mouth, some kind of a
mouth wash which she finds refreshing should be used frequently.
And since a degree of toxicity which is capable of producing such a
condition as is described above will almost inevitably produce
nervous symptoms, as well, the nurse’s attitude toward her patient
must always be one of sympathy, encouragement and optimism.
When the patient’s condition is so desperate that pregnancy is
terminated, with the hope of saving her life, ether or nitrous oxide

gas, or both, is used as an anesthetic rather than chloroform, which
of itself tends to produce a liver necrosis.
Pre-eclamptic Toxemia is the most common of all the toxemias of
pregnancy, occurring several times in every hundred pregnancies. It
develops more frequently among women who are pregnant for the
first time than among those who have borne children, and one attack
usually confers an immunity against a recurrence.
As pre-eclamptic toxemia usually responds to treatment, but if
neglected, frequently ends in the much more serious disease of
eclampsia, the imperative need of supervision and care during
pregnancy are once more borne in upon us.
Symptoms. Pre-eclamptic toxemia seldom appears before the
second half of pregnancy, usually not until after the sixth or seventh
month, and the symptoms vary widely in severity. They may range
from headache and nausea, so slight as to cause the patient little or
no inconvenience, to coma and death.
The patient may be entirely normal for six or seven months and
then notice that her rings and shoes are a little tight, because of the
slight swelling of her hands and feet. Puffiness of the eyelids may
appear, and other parts of the body may also be slightly swollen.
Headache, dizziness, lassitude, drowsiness, depression,
apprehension, nausea and vomiting are all symptoms, as also are
high blood pressure and a diminished amount of urine, containing
albumen. The patient frequently complains of visual disturbance,
which may be only a slight blurring, but in severe cases may amount
to total blindness.
Other symptoms, when the condition is grave, are epigastric pain;
rapid pulse; extreme nervousness and excitement, which may
amount almost to insanity; or drowsiness, which grows deeper and
deeper until the patient sinks into a coma. Under such conditions,
she may die without recovering consciousness, but more frequently,
eclampsia ensues. The child may perish as a result of the toxemia
and a dead, premature baby be born.
Prevention is of course, the most important aspect of the
treatment and is accomplished by means of the pre-natal care and
supervision which were described in the last chapter. In this
connection must be mentioned again the danger, during pregnancy,

of overeating. It is more and more frequently observed that toxemic
seizures follow in the wake of a single, large, heavy meal, such as one
is so likely to take at Thanksgiving or Christmas time. This is
particularly true of patients who have had nausea or who have even
slightly disabled kidneys, which, though able to meet the ordinary
demands made by pregnancy, are inadequate to cope with the
sudden strain imposed by a large meal. In such a case, toxic
materials which should be excreted are retained within the body, and
the familiar symptoms of toxemia are the result.
Much the same condition is produced by the patient’s getting wet
or chilled. The excretory function of the skin is interfered with, under
such circumstances, and the kidneys are unable to do enough extra
work to make up for the skin’s failure, and again toxic material is
retained, instead of being excreted.
Treatment and Nursing Care. As might be expected, the
details of treatment and nursing care of a pre-eclamptic patient vary
with different doctors and with the severity of the attack. But the
essentials of treatment, the country over, may be summed up as rest
and elimination, coupled with close watching for unfavorable
symptoms.
The surest way to have the patient really rest is to put her to bed,
even in mild cases, and recovery is so hastened, thereby, that she is
well paid for the temporary inconvenience.
Since it is widely believed that the metabolic disturbance, in
toxemia, is related to the nitrogenous part of the diet, the course
usually followed in this particular is a reduction of the nitrogen
intake. This is accomplished by putting the patient on a very low
protein diet or a milk diet, consisting of two quarts of milk daily. This
amount of milk provides adequate nourishment, for the time being,
and also supplies a large part of the fluid which is needed to promote
elimination. In addition to this, however, the patient is given one, or
better still, two quarts of water every day, and free saline purges.
Very frequently this treatment is all that is necessary. The blood
pressure falls in a few days, the albumen in the urine gradually
disappears, the patient completely recovers and in due time has a
normal labor.

But in more severe and less amenable cases it is necessary to
increase the eliminative treatment and give copious colonic
irrigations; sweat baths, in the form of hot packs or hot air baths, and
even venesection and saline infusions, in order to relieve the
symptoms. Sometimes, even these are not enough and the high blood
pressure and albumen, which are probably the most significant
symptoms, will continue. If so, and the patient grows worse, or if she
simply fails to respond to the treatment, the usual practice is to
induce labor. A daily output of five grams of albumen to a litre of
urine, and a blood pressure of 200 millimetres are usually regarded
as insistent indications that pregnancy should be terminated.
Otherwise, eclampsia, always so dreaded, is practically sure to follow
and endanger the life of both mother and child.
It may be mentioned here that the normal blood pressure, during
the latter part of pregnancy, is about 120 millimetres. A gradual
increase to 130, or even 140 millimetres, may not be serious, but a
sudden rise or a pressure of 150 millimetres should be regarded with
alarm, even though all other symptoms be absent. The reason for this
is that eclampsia may, and sometimes does, occur with little or no
warning except the high, or suddenly increasing blood pressure.
Eclampsia. Pre-eclamptic toxemia, as the name suggests, is a
condition that frequently precedes eclampsia, and the importance of
the prevention, early recognition and prompt treatment of this
forerunner is due to the seriousness of eclampsia which threatens to
ensue. This disease, which may be defined as a toxemia occurring
before, during or after labor, is one of the gravest complications
which arise in obstetrics. It is usually associated with both tonic and
clonic convulsions, unconsciousness and coma.
Patients who have a tendency to kidney trouble and to digestive
disturbances, such as so-called “biliousness,” are evidently likely to
have eclampsia; and in eclampsia there is a peripheral necrosis of the
liver which occurs in no other condition. These facts suggest that
possibly when metabolism is proceeding normally, the liver converts
certain material, whose retention within the body is inimical to
health, into a form which the kidneys can excrete without great
effort; that if the liver fails in this function, the kidneys are unable to
stand the increased strain put upon them, as is evidenced by casts
and albumen which appear in the urine, and the retained material

gives rise to toxemia. It is possible that disturbed functions of other
glandular organs, such as the thyroid, may play a part in causing
eclampsia, but this, too, is only conjecture.
The frequency with which the disease occurs has been variously
estimated at from one in 500 to one in 100 cases, apparently being
more common in first pregnancies than subsequent ones, but more
serious when occurring among women who have had children
before. One attack is believed to confer an immunity, or, as Dr.
Chipman puts it, “the woman with eclampsia vaccinates herself.” The
average death rate from eclampsia is from 20 to 35 per cent. of the
mothers and about 50 per cent. of the babies, except where the
desired care can be given, either at home or in a hospital, when the
mortality is greatly reduced. These figures vary, somewhat, according
to the time of the onset, as the disease is usually more fatal if the
convulsions occur before or during labor, than afterward.
Some authorities feel, however, that eclampsia is quite as fatal
after, as before, labor.
Symptoms. The symptoms, as a rule, are those of pre-eclamptic
toxemia which have persisted and grown more severe, accompanied
by convulsions and coma. The blood pressure may be from 150 to
250 millimetres and the urine, in addition to showing many and
varied casts, contains albumen, which varies in amount from a few
grams per litre to more than a hundred in severe cases. In those
cases which prove fatal and come to autopsy, there is always found a
characteristic, peripheral necrosis of the liver, and since it is found in
no other disease it definitely establishes the diagnosis. It is true that
this is of no help to the poor woman who died, but it is of help to
those investigators who are so earnestly studying the disease with the
hope of finding its cause and cure.
Although there are frequently pre-eclamptic symptoms which have
grown worse, with or without treatment, it sometimes happens that
the patient has no warning discomfort and the first sign of the
disease is a convulsion; or a patient who has been treated for pre-
eclamptic toxemia may apparently recover, even to the extent of
having the albumen disappear from her urine, and suddenly have a
convulsion.
Convulsions, which are both tonic and clonic in character, occur in
about 99.5 per cent. of all eclamptic cases and are very distressing to

watch. They are sometimes preceded by an aura, but often are so
unheralded that they may even occur while the patient is asleep.
They ordinarily begin with a twitching of the eyelids; the eyes are
wide open and staring and the pupils are first contracted and then
dilated. The twitching extends to the muscles about the nose and
mouth, then to the neck and arms, and so on until the entire body is
convulsive. The patient’s face is usually cyanotic and badly distorted,
the mouth being drawn to one side; she clenches her fists, rolls her
head from side to side and tosses violently about the bed. She is
totally unconscious and insensible to light, and during the seizure
may not breathe beyond giving one or two struggling gasps. Her head
is frequently bent backward, her neck forming a continuous curve
with her stiffened, arched back. Another distressing feature is the
protruding tongue and the frothy saliva, which is blood stained if the
patient is not prevented from biting her tongue by the introduction
of some sort of a mouth gag between her teeth.
Such is the typical eclamptic convulsion.
The attacks vary greatly in their intensity and duration. There may
be only a few twitches, lasting ten or fifteen seconds or violent
convulsions lasting as long as two minutes, their number and
severity increasing with the seriousness of the patient’s condition. In
mild cases there may be but one or two convulsions, particularly if
the onset is either late in labor or postpartum. But as a rule, there are
several convulsions; ten, twenty or thirty, and sometimes, though
rarely, as many as a hundred.
The patient always goes into a coma after a convulsion and this
also varies in length and profundity, her condition during the
intervals being very suggestive of the probable outcome of the
disease. If the attacks recur frequently, as they usually do in extreme
cases, the patient is likely to remain unconscious during the entire
interval; but she will usually awaken between attacks that are far
apart, and this is regarded as a hopeful sign. The respirations are
labored and noisy as a rule, and the pulse full and bounding, in
which case the outlook is good. The temperature is often normal, but
may go as high as 104° F. or 105° F., dropping rapidly as the attacks
subside. But a weak, rapid pulse together with a high temperature,
and above all, a persistently high blood pressure, no matter what the
other symptoms may be, are always unfavorable.

Concerning the varied results of eclampsia, the opinion seems to
be growing that if it develops during late pregnancy, labor is likely to
set in and a premature child be born spontaneously; in some cases,
however, for reasons already given, labor is induced, while in others
the mother dies undelivered. The fetus may die, after which the
convulsions practically always cease and the infant is often born later
in a macerated state; or the patient may recover, go to term and give
birth to a normal, healthy baby.
When eclampsia occurs during labor the pains usually increase in
force and frequency, thus hastening delivery, after which the
convulsions usually cease. It will be noted that death or expulsion of
the fetus is in almost all cases followed by immediate cessation of the
symptoms and by ultimate recovery.
Treatment and Nursing Care. There is so little definite
information about the cause of eclampsia that there is quite naturally
some difference of opinion as to the best methods of curative
treatment. Unquestionably, prevention is of first importance and this
is accomplished through the watchfulness and care during the
antenatal period as described.
Dr. Edgar characterizes eclampsia as a preventable disease, and
though an occasional case will develop in spite of preventive
treatment the general results achieved tend to bear out his definition.
For example, in a series of 1200 maternity cases at Bellevue Hospital
during 1920, prenatal care was given to 900 women and not one case
of eclampsia occurred among them, while among the remaining 300
women who had not been seen during pregnancy, there were ten
eclamptics. It is but fair to bear in mind that as some of these
patients were taken into the hospital because of their having
eclampsia, the proportion is abnormally high. The Henry Street
Settlement reports through its maternity service that there was but
one case of eclampsia among 7600 women who were given prenatal
care by its nurses in 1920. These figures, contrasted with the average
of one case in about every 500 pregnancies, furnish astounding
evidence of what can be done through prenatal care in the prevention
of this one disease alone.
As to curative treatment, the variations of opinion are after all of
little consequence to the nurse, for there is almost entire unanimity
concerning the general principles, and it is these that shape the

nursing care. Broadly speaking, they comprise effort to dilute the
toxic material in the system, promote its elimination through the
various excretory channels and quiet the patient’s nervous
excitability.
Since eclampsia occurs only in connection with pregnancy, and the
convulsions usually cease if the fetus dies or is born, one line of
reasoning is that the most effective way to treat the disease is to
terminate pregnancy. Formerly this was almost always done, and is
still practised by some obstetricians. Those who do not agree with
this theory contend that the eclamptic woman is a very ill woman
whose nervous system is so irritated that the slightest stimulation or
irritation works harm. In view of this they feel that manual or
instrumental dilation of the cervix, preparatory to delivering the
child through that channel, or delivery through an incision in either
the abdominal wall or cervix, constitutes a shock that outweighs the
advantages of emptying the uterus; therefore, that as a rule, less
harm is done by noninterference, quieting the patient and increasing
her eliminative functions, than by terminating pregnancy. This line
of reasoning also takes into consideration the fact that from 15 per
cent. to 20 per cent. of the cases of eclampsia are postpartum,
indicating that convulsions may occur even after the uterus has been
emptied.
The growing tendency is to adopt a middle course and treat each
individual case according to the conditions and indications which it
presents. Thus the same doctor will hastily induce labor in a case
where the blood pressure and albumen remain alarmingly high, or
increase, in spite of all efforts to reduce them, and in another case
will go to the extreme of conservatism, doing nothing but quiet the
patient with morphia or chloral, or both, and stimulate all of her
excretory organs with abundant fluids.
But the nurse’s duties, and I may say her opportunities, for she is
privileged to do much, are virtually the same no matter which course
is followed, except, of course, the preparation for delivery, if this is
performed.
The nurse is concerned with helping to reduce the intake of
nitrogenous food, or proteids; diluting the toxines retained in the
body; promoting the activity of the kidneys, bowels, liver, lungs and
skin; guarding the patient against all avoidable stimulation from

without, such as noise, light, ungentle handling and undue resistance
to the patient’s convulsive movements; and protecting her from
injuring herself by biting her tongue, falling out of bed or striking the
wall or head of the bed during convulsions.
By striving to accomplish these general results for her eclamptic
patient the nurse will aid immeasurably in saving her life.
A milk diet is the means of reducing the nitrogen intake; or in
some cases even that small amount of proteid is deemed too much,
and only water is given until 24 to 48 hours after the convulsive
seizures have ceased. From three to five litres of these fluids should
be given in the course of twenty-four hours, in order to increase
elimination by way of both kidneys and skin, and it usually taxes the
nurse’s patience and ingenuity to give this amount, for the patient
will seldom take large quantities of fluids willingly, even when quite
conscious. A surprising amount of water may be given to the sleeping
or unconscious patient by dropping it into her mouth from the point
of a teaspoon, taking care to give it only at those moments when she
is lying quite still. If the nurse attempts to hold the restless patient’s
head, or so much as places her hand upon the chin to steady it in
order to give water, the irritation, though slight, may be enough to
cause a return of the tossing and struggling.
Lithia water and cream-of-tartar lemonade (a teaspoonful of
cream of tartar to a pint of water), are frequently given because of
their diuretic and diaphoretic action; but whatever the fluid, it must
be given persistently, with greatest gentleness and with care that the
patient does not choke nor aspirate it into her lungs and thus
possibly cause pneumonia. Food even in liquid form is not given
while the patient is unconscious, because of this danger of aspiration
and subsequent pneumonia.
The bowels are stimulated to greater activity by powerful purges,
such as croton oil, in olive oil, dropped on the back of the tongue, or
salts or castor oil given by stomach tube.
Copious colonic irrigations, alternating with hot packs so that one
or the other is given every six, eight or twelve hours, according to the
seriousness of the case, are frequently given and with excellent
results. A colonic irrigation may be given by means of the Murphy
drip method or through a rectal tube so contrived that a two-way
flow of fluid is possible. Water, normal saline (2 drams of salt to a

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