Prophylaxis consists not only in the avoidance of high temperature and the ingestion of pure foods, but also in the eschewing of such foods as each individual has found to be indigestible. Thus potatoes may be perfectly digestible by one person, yet another, apparently normal person, may fill with gas after their ingestion.

Lavage and enemata are the speediest ways of removing the poisonous material from the alimentary canal.

Emetics are dangerous, since they may be followed by oliguria, permitting the poison already absorbed to remain in the system. Non-depressing salines are useful.

The antipyretic becomes a matter of individual choice.

Among the favorites may be mentioned beta-naphthol, charcoal, salol-arsenite of copper-thymol, guaiacol and its compounds, boric acid, and the mineral acids.

Lavage, enemata, and auto-zymotic, and stimulation seem to formulate the approved treatment.

LOUISVILLE.

PUERPERAL ECLAMPSIA: ITS CAUSE AND INDICATIONS FOR TREATMENT.*

BY W. B. STONE, M. D.

Puerperal eclampsia, as defined by all our authors, is epileptiform convulsions peculiar to and occurring in pregnant females before labor, during confinement, or after delivery.

For the sake of brevity and needless recitation, I shall purposely omit its symptomatology, and take it for granted that you are all historically, if not clinically, acquainted with its symptoms in detail.

Our older authors recognized three varieties, the hysterical, the apoplectic, and the epileptic, from their fancied resemblance to this malady.

That a paroxysm of hysteria, a stroke of paralysis, or a fit of epilepsy can and often does occur during pregnancy or shortly after delivery, all will admit; but that the clinical history or prodromic symptoms of puerperal eclampsia are wanting in hysteria, apoplexy, or epilepsy, no one can deny.

Thus we see, so far as these diseases are concerned, puerperal eclampsia has no relation to nor dependence upon the causes of either hysteria, apoplexy, or epilepsy, but is a disease sui generis.

*Read before Southern Kentucky Medical Association, 1898.

I believe there have been about five theories advanced upon puerperal eclampsia from Hippocrates down to the present time, each one purporting to approximate at least the true etiology of the disease, all admitting, however, the true pathogenesis to be as yet undiscovered. The first theory was, "that it is a cerebro-spinal congestion;" (2) "that it is a general cerebral anemia;" (3) "that it is an anemia of the cerebro-spinal centers with meningeal congestion;" (4) “that it is a neurosis;" (5) that it is a blood poisoning, nephritic in its origin, the toxic agent by some claimed to be urea, by others carbonate of ammonia, and still by some one thing, by others another.

And I believe we might with prudence add the sixth theory, which admits all the claims of the other five, but asserts the etiological factor to be stipulated in the sum total of the fifth theory; that it is not urea, carbonate of ammonia, extractives nor soluble ptomaines alone, but a retention in the blood of all these excrementitious substances, which it is the function of the excretory organs, especially the kidneys, to eliminate, and that this inability to eliminate on the part of the kidneys is due to nephritis brought about by mechanical pressure on the renal vessels by the fetus during gestation.

As it would require too much time, and, besides, be beyond the scope of this little paper, to enter into an explanation and discussion of the merits and demerits of all these theories, suffice it to say that all, no doubt, are correct in so far as the pathological lesion claimed in each theory is often found, and incorrect in a great many of them, inasmuch as, no doubt, effect has often been taken for cause. That is to say, no doubt in one case there has been found cerebro-spinal congestion, in another general cerebral anemia, and another anemia of cerebrospinal centers with meningeal congestion, and still another a neurotic element may seem to play an important rôle in the precipitation of an eclampsia; yet these lesions are in all probability the post hoc rather than the propter hoc.

It is to the merits of this last or sixth theory, that the primary cause is a toxemia resulting from renal inflammation induced by mechanical pressure on the renal vessels by the fetus in utero during. gestation, aided by excrementitious material accruing from all other sources, such as constipation, arrest of perspiration, and doubtless. fetal metabolism, that I desire to call your attention at present.

While all our leaders assert the cause to be about as above stated, yet they all leave us in the dark as to how the mechanical pres

sure is affected so as to produce a nephritis. This is the point that has prompted me to write this paper, as I believe it to be nothing more nor less than uremic convulsions occurring as under other circumstances, save that in this malady the nephritis is mechanical in cause, while in uremic convulsions under other circumstances the nephritis may or may not be mechanical, and that students of medicine and possibly many practitioners may have failed to comprehend the modus operandi of this mechanical pressure.

First, I desire to call your attention to the boundary of the abdominal cavity. A rough but practical description is to say it is bounded above by the diaphragm, below by the floor of the pelvis, behind by the vertebral column, and in front by the abdominal muscles. So, gentlemen, you see that there are two of these boundaries that are resisting, the floor of the pelvis and spinal column; two that are irresisting, the abdominal and diaphragmatic boundaries.

Thus, you see, as the abdominal contents enlarge during pregnancy, the corresponding abdominal capacity that must inevitably take place can do so only at the expense of two of these boundaries: the superior and anterior. Now as nature has very neatly and accurately adjusted these two ends (the contents and capacity), it is in exceptional cases that she fails to keep up an equilibrium; but in case of unnaturally large contents or unusually small capacity, which of course makes every pregnancy, even in multiparæ, a law to itself, nature fails to keep the capacity apace with the enlarging contents, and pressure on the renal vessels excites a nephritis, and hence our trouble.

I think this last presumption to be corroborated in the fact that by far the great majority of convulsions occur in primipara whose abdominal walls have never before been accustomed to this unusual relaxation

and pressure.

Allow me to add, as a final presumption, that if the etiology as set forth in this paper be true-that it is a nephritis, and is nothing more than we find in a genuine "Bright's disease" in the absence of pregnancy-then may we not have a genuine case of the so-called puerperal eclampsia due to a nephritis entirely independent of mechanical pressure or any thing that pertains to pregnancy? Allow me to answer, yes, and add that no doubt we often have cases due to this cause, and I believe that if mechanical pressure could be eliminated in a given case, it would unavoidably fall on "Bright's disease."

Now, gentlemen, with this brief and in many respects defective pre

liminary discussion, I will endeavor to show you at least how I conceive the mechanical pressure operates to effect a nephritis.

First, with a normal-sized fetus and a normal quantity of liquor amnii and a normal abdominal capacity, we would have no unnatural pressure on the renal vessels and consequently no nephritis nor eclampsia.

Second, admit that we have a normal-sized fetus and a normal amount of liquor amnii, with an abnormally small abdominal capacity, and we will have increased pressure on the renal vessels and consequently nephritis and eclampsia.

Third, suppose we have an unusually large fetus and an excessive amount of liquid amnii, with a normal abdominal capacity, and we will have increased or abnormal pressure on the renal vessels.

Lastly, suppose we have an abnormally large fetus and an unusually large quantity of liquor amnii, with an unusually large abdominal capacity, and we will have no excessive pressure on the renal vessels and consequently no nephritis from mechanical pressure.

I think it would be needless to further illustrate how abnormal pressure on the renal vessels can take place during pregnancy, and will now, in conclusion, give you my opinion as to how the pressure effects a nephritis.

In the first place, the renal arteries are given off from the abdominal aorta nearly at a right angle, and the renal veins enter the ascending vena cava in the same manner. So you can imagine how a fetus in utero with a loss of the equilibrium between the contents and capacity exerts a pressure on these vessels thus given off, and by pressure on the renal artery prevents the normal amount of blood from entering the kidney through that vessel, and by the same pressure on the renal veins prevents the blood from returning from the kidneys. Thus you see the pressure exerted on these vessels produces an ischemia on the arterial side and a stasis on the venous side—a renal insufficiency—a condition that can not exist long in any organ without producing, sooner or later, an inflammation.

Indications for Treatment. If the cause of puerperal eclampsia as set forth in this paper be true, then the indication for treatment must necessarily resolve itself into two classes, medical and surgicalmedical, to overcome spasm and to excite to increased action the vicarious functions, the skin and bowels; surgical, to relieve mechanical pressure on the renal vessels. With these two cardinal indications.

met, though you may lose your patient, you have, as Dr. Henry Heartshorne has aptly said, succeeded, as rational treatment is a success, though you lose the patient.

To overcome the spasm, I believe chloroform by inhalation to be the ideal antispasmodic. To stimulate the bowels to increased action, I believe compound jalap powder to be the ideal hydragogue. To stimulate the skin to overaction, I believe pilocarpine stands at the head as a sweater.

So, then, chloroform as an antispasmodic, compound jalap powder as a hydragogue, and pilocarpine as a sweater meet all the indications from a medical standpoint and approximate a specific treatment.

Rupture of the water sac and bleeding in suitable cases meet all the surgical indications, so far as I am able to perceive. Rupture of the water sac relieves mechanical pressure on the renal vessels and insures labor at an early date, a thing greatly to be desired, as all mechanical pressure is thereby relieved and the kidneys given a better opportunity to functionate for themselves.

Bleeding in plethoric subjects lowers pressure in both the arterial and venous systems, and eliminates a minimum quantity of the poison, and at the same time relaxes the system and thereby aids the chloroform in overcoming spasm.

I do not intend to convey the idea in these indications that such adjuvants as bromide of potassium, veratrum viride, in suitable cases, and all other tried medicines of virtue are not to be admitted, but only that these are the indications to be met.

I wish, as a last remark, to enter a protest against the use of morphine in this disease, as physiologically it is contraindicated in the whole range of its symptoms, arresting all the secretions of the body, thereby producing constipation and arrest of perspiration, thus antagonizing the rational indications to be met medicinally in this malady, and would seem to act synergistically to the poison instituting the disease..

Finally, in conclusion, I wish to say that I would employ the treatment indicated, both medical and surgical, as soon as the clinical symptoms announce themselves, which are head, stomach, and eye. symptoms, in the later months of pregnancy, with edema of the extremities, especially the superior and face. Then with these evidences of nephritis corroborated by albuminuria upon the application of heat and nitric acid, would suggest to institute the treatment and not wait for a convulsion.