Vertigo alone is, like the last symptom, not of much moment unless constantly recurring.

Headache, accompanied by backache and pains in limbs, when more or less of daily occurrence, certainly should cause us some anxiety. When the last group are associated with a dry, harsh, sallow skin and more or less oppression about the chest with a frequent pulse, we should handle our patient with great care.

Coma or convulsion is the climax of kidney failure in the pregnant as in the non-pregnant.

Eclampsia will be handled at length later on.

The pathology of kidney failure in pregnancy is not different from the pathology in the non-pregnant.

Given this pre-organic period of kidney failure, or some latent form of kidney lesion with the kidney laboring, then pregnancy will simply give the kidney more work than it can accomplish, and then we have the symptoms of failure.

Bouchard says: "In order that intoxication may be invoked it is not sufficient that the kidney should be diseased, but that its permeability should be diminished to a degree such that it can no longer eliminate in twenty-four hours the quantity of poison which the organism forms in twenty-four hours."

The pregnancy being terminated, and the bowels, the skin, and the lungs being forced to help out the kidney, equilibrium is restored, and we teach that if the trouble has not lasted long enough we do not have any lasting kidney failure.

Again, we can conceive the pre-organic period of kidney failure being present in pregnancy, and some exciting cause, like fright, exhaustion, cold, etc., may produce a rapid dissolution by eclampsia, and then in the dead-room we would find no kidney degeneration. But generally we will find the changes in the kidney present where death occurs during pregnancy from kidney failure that we would find in the nonpregnant's death from kidney failure.

Treatment. The treatment divides itself in kidney failure generally into two parts, viz: First, striving to restore equilibrium so promptly as to prevent organic changes in the kidney. Second, temporizing with the kidney after it is organically involved by giving it the least possible work by dieting and by keeping the skin, the bowels, and the lungs at the highest possible eliminative potency. But treatment of kidney failure in pregnancy divides itself, first, into trying to prevent

the serious climax of kidney failure, which is eclampsia; second, treating eclampsia.

Prophylactic Measures. The patient should be under rather close surveillance, and yet we should make the effort to prevent it being oppressive. The idea she was a powder magazine and that she was being watched that she did not explode, to say the least, is very depressing and is apt to intensify the melancholia that is more or less prominent in all pregnancies and characteristic of kidney failure. You must watch her if possible without depressing her, but watch her at all hazards.

Eliminants of all kinds should be urged. Great cleanliness of the skin and stimulation of its functions by baths, massage, and warm clothing; lastly, and only to be used when absolutely necessary, medical diaphoretics.

The bowels should be free, and yet too much purging will deplete your patient to the point that she will be unable to rally from, even if she passes through, the exhaustion produced by labor, especially since anemia is a prominent symptom in kidney failure.

Diuretics are of questionable value, but the partaking of great quantities of fluid have a prominent place in the advice given my patients unless heart complications are present producing symptoms. which would be greatly aggravated by large quantities of fluid.

Gentle Exercise in the Open Air. Exercise to keep the different organs functionating at their best, so that the waste may be as nearly as possible equalized by repair--in the open air, so that as much oxygen as possible may be inhaled and considerable poison exhaled with the expired air. Protect the patient from all mental and physical strain; ward off all shocks; have surroundings as cheerful as possible.

Vegetables, especially those having a laxative tendency, should be encouraged. Fruits should be forced.

Where symptoms become prominent restrict her to a milk diet. These failing, we have to meet the most alarming complication that appears in pregnancy, that is

Eclampsia. After more or less protracted struggle with the symptoms partially sketched above as a rule, suddenly, with little or no additional warning of its nearness, the patient, possibly in the midst of a conversation, becomes inattentive, and when those around are attracted by her silence they observe a peculiar far-away look, presently a slight twitching about the face or hands, then the face twitchings become more

and more violent and rapidly the convulsive movements extend more or less down the body. The head is turned from side to side; the tongue is protruded; and a tonic spasm of the muscles of mastication closes the lower jaw upon the tongue, wounding it unless guarded.

Then inspiration ceases almost entirely and there occurs a gasping expiration with a hissing sound, driving out the saliva colored with blood if the tongue has been injured. The eyes are rolled up until only the whites are seen.

The face becomes livid, swollen, and distorted by the muscular contractions into the ghastly sardonic grin, causing the most beautiful female face to become a horrible mask of startling ugliness. The lividity extends in my experience over the whole body. This condition lasts a varying length of time-most authorities say never over one half a minute. When apparently longer they say the mistake is made of counting several paroxysms as one. Then the patient relapses, and either after a longer or shorter interval has succeeding paroxysms of greater and greater intensity, in one of which she may die, or she sinks into coma which may continue until death, or after the first or some subsequent convulsion she lies in a more or less comatose condition, from which she slowly and gradually rises to a semi-consciousness from which she may be aroused to answer in a very confused way. This semi-consciousness continues an indefinite time, six, twelve, twentyfour, even thirty-six hours, and in some rare cases even much longer, but generally within twenty-four hours she is restored to a mystified consciousness in which she has no definite idea of what has occurred. Slowly things are restored to her consciousness, but generally there are vacant periods of time and haziness about other periods. Then comes the anxious after-period of convalescence to see whether there is present a permanent kidney lesion. The symptomatology has been fairly well covered, except that no mention was made of the appearing of numbness in the different parts of the body.

But the prodromic symptoms of eclampsia are the same as those credited to Bright's disease in the non-pregnant.

The pathology is the pathology of Bright's disease.

Etiology. We have an exalted condition of the nervous system due to some centric or eccentric cause associated with a laboring kidney; the great additional debris resulting from gestation produces a toxemia beyond the eliminating ability of the impaired kidneys unassisted by the skin and with diminished assistance from a torpid bowel; thus we

have the initial nervous exaltation heightened by the resultant toxemia to such an extent that an explosion occurs or is produced by the addition of some shock not necessarily of any great magnitude, and we have the convulsion.

I think the arguments about primiparity being a cause of eclampsia are very weak. Certainly there are more eclamptics among primipara, just as the eruptive diseases are more common in childhood. Any irritation may be sufficient to institute a convulsion when the nervous system is in a sufficiently exalted state just as in strychnia poisoning or in

tetanus.

Treatment. (Prophylactic-Treating Eclampsia-After-Care in Convalescence.) The prophylactic treatment has already been covered above.

Treating Eclampsia: (1) Medicine; (2) blood-letting; (3) hastening labor; (4) cesarean section; (5) induction of premature labor.

Medical treatment: Chloroform to surgical anesthesia in the majority of cases will control the convulsion. But alone it is not sufficient, for you can not keep it up indefinitely, and it is not curative. As soon as the convulsion is controlled stop the chloroform and watch your patient, and at the first twitching of any part of the body push the chloroform again.

Chloral: Thirty-grain doses by the mouth or sixty grains by the rectum, and we have reliable authority for very large amounts in twentyfour hours.

On technical grounds potash is objected to, but the bromide of sodium renders considerable help. Croton oil on the tongue to force elimination, certainly by the bowel possibly by the skin.

Elaterin or jalap and calomel by the mouth if she can swallow.

Jaborandi or its active principle, pilocarpine, have some strong supporters, but the depression it produces makes it a questionable agent in this condition.

Veratrum viride I object to on the same grounds as pilocarpine. Morphine I have left for the last, as it properly only comes after the others. It has been highly recommended, especially by C. C. P. Clark, who recommends it hypodermically from the beginning in one and one-half grain doses, to be repeated as needed, but I do not think it is allowable until you have more or less exhausted the measures suggested above, or until you have obtained some elimination and evacuated the

uterus.

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Blood-letting, either general or local, is thought highly of by many, but in my opinion it is too costly with the exhaustion natural to uremia. and the after-coming labor with its more or less hemorrhage.

Hastening labor: If labor is very rapid, as it often is in eclamptics, there is no call for hastening, but if there is any delay assistance should be given to hurry delivery.

Cesarean section has a very doubtful if any place in my consideration. Only when the mother is dead and the child is alive should its removal by cesarean section be considered.

Induction of labor: This impresses me as the most important question to be decided in the treatment of eclampsia. Gooch said, some time since, "take care of the convulsion and let labor take care of itself." This has been the war-cry of those opposing active interference. It has all the strength that an epigram carries, which is great, however lacking in wisdom it may later be shown. If the fetus is at a viable age, then many concede that it is possibly allowable in grave cases as a last resort.

But this same majority oppose it if the fetus has not reached the viable age. It is opposed by many on the ground that it will excite convulsions and that labor will produce the additional shock to the already struggling vitality that will topple it over. In reply I say every means known to us should be used in kidney failure to prevent eclampsia, but that when a true eclamptic convulsion occurs the time for temporizing has passed. The uterus should be emptied as soon as possible, because, if pregnancy has a causal relation, then it should be stopped before it produces permanent kidney alteration or death from kidney failure.

If blood-letting produces any beneficial effect, even temporarily, then by taking away the fetus, the amniotic fluid and the more or less hemorrhage natural at such a time you would do more good. With the uterus emptied we would have a much better chance of obtaining vicarious elimination by the bowels.

After the uterus is emptied there is much less objection to the use of morphia. As to the additional shock, if necessary obliterate the reflexes by anesthesia.

Lastly, so far as the child is concerned, the mother's life, with me, far outweighs the life of the fetus in utero, especially so when we know that eclamptics generally abort, the fetus dies in utero, or if it is born alive it has a precarious existence.