morphia was injected hypodermically, and she was kept partially under the influence of chloroform until all twitchings ceased. After recovering consciousness she suffered severely from pains in her back and head. These were relieved temporarily by fifteen-grain doses of antipyrine. Within fifteen minutes after taking the drug she would pass into a quiet sleep. She commenced to pass from one to two quarts of water daily almost immediately after the birth of the child, and the albumen disappeared in about a month.

Remarks. To recapitulate briefly; of these eleven cases of albuminuria, nine mothers recovered and four children were born alive. One case in which convulsions did not occur, was not seen until labor had set in naturally. The mother made a good recovery, but the child was still-born. In the four cases in which temporizing measures were instituted until labor pains came on, convulsions occurred in three, one mother died, and three recovered; the child perished in all four. In the two cases

in which labor was excited after convulsions occurred, both children were born dead, one mother recovered, the other died. In the four cases in which labor was induced, after a temporary trial of expectancy, but before convulsions took place, all the mothers made good recoveries and the four children lived.

The question of when to induce premature labor in these cases is sub judice. Whenever discussed there is usually great diversity of opinions expressed. Some eminent authorities, such as Fordyce Barker and Playfair, maintain that it should be undertaken only in a limited number of cases, and that in these exceptional cases the indications must be confirmed by other symptoms than those which are to be discovered by an examination of the urine. This advice may be adapted to a city practice, among the intelligent and the rich, where the most careful supervision can be maintained and attention to the smallest details are carried out religiously and systematically. In country practice this is often impossible; a physician is seldom consulted by a pregnant woman until called to her accouchement. Headache, nausea, slight swelling of the feet and legs, are symptoms so commonly met with in pregnant women, that the ignorant, knowing nothing of their significance in some cases, pay but little heed to them, until the fatal paroxysm occurs, when the obstetrician may be miles away with almost impassable roads between him and his patient.

The great difficulty in many of these cases is to know when the time arrives for expectancy to cease and surgical measures

to begin. The quantity of albumen in the urine is no certain criterion of the extent of the toxæmia existing. In some of the most alarming cases, there are but slight traces of albumen; in a few, I believe, none at all; in case Number V of my series the urine passed about two hours before a convulsion, and when she was suffering from a severe headache, did not coagulate more than one-tenth in the tube after boiling and adding nitric acid.

In a recent lecture by Dr. Whitaker, of Cincinnati, on chronic Bright's disease, which will probably hold good in cases of albuminuria of pregnancy, to a degree at least, it was pointed out that the nervous symptoms showed themselves in inverse proportions to the dropsy; that the dropsical effusions form reservoirs for the excess of urea not eliminated by the kidneys; hence, the amount of oedema or dropsical effusion present will not give any definite indication for interfering surgically, as some of the most urgent cases may present but very little swelling of the body.

Again, it has been stated that labor should never be induced until the nervous sentinels give the alarm; but, I have seen two cases, at least, of convulsions, one of which ended fatally, in which the nervous premonitions preceded but a few minutes. the onset of an eclamptic seizure. One of these cases, read before the Dominion Medical Association in 1885, was a young pregnant woman, apparently in robust health, who while taking a bath on a summer's day, about two hours after a hearty meal, became suddenly sightless, reeled and almost immediately became unconscious, and went into a convulsion. Another case, seen with Dr. Pomeroy, of Dresden, was a young primipara, about seven months advanced in pregnancy, who arose and dressed herself one morning, milked several cows, prepared her husband's breakfast, and seemed perfectly well. During that meal she spoke of a headache, and almost immediately had a fit. In spite of our efforts the convulsions, continued and she died in about twenty-four hours.

Judging from cases like these, it is manifestly unwise to await the appearance of nervous signals before resorting to the induction of premature labor. The evidence, therefore, of the approach of convulsions must be uncertain and unreliable, and if we cannot obtain satisfactory indications from the urine, it is certainly not always safe to remain inactive till nervous disturbances become pronounced.

I believe it to be also indisputable that the albuminuria is due to mechanical and other causes consequent upon the preg

nant condition. This is shown by the rapid disappearance of albumen and increase in the quantity of urine immediately after the delivery of the child, except when the kidneys have received irreparable damage.

Therefore, if these causes are removable by a procedure almost devoid of danger, if carefully undertaken and carried ont, and in view of the desperate out-look presented by these cases, from permanent damage to the kidneys, albuminuria retinitis, with, may be, permanent impairment of vision, anæmia exhaustion, and eclampsia, I am convinced of the necessity for the regular and systematic examination of the urine of all pregnant women; and if albumen be found with hyaline casts and a deficiency of urea, of the advisability of inducing premature delivery when pregnancy has advanced to or beyond the seventh month, and the symptoms do not immediately and substantially improve under treatment; which they do not, in my experience. This rule would not apply to cases of pregnancy occurring in chronic nephritis, which would be differentiated by a microscopical examination of the urine, and in which surgical interference might prove dangerous; moreover, in true nephritis the nervous centres acquire a certain tolerance, and eclampsia is not so likely to occur.

Nor yet, do I think, would it be wise to at once resort to this procedure if one be not called to a case until nervous phenomena, such as headache, disturbance of vision, etc., are present to a marked degree. It would be safer under these circumstances to first act upon the various emunctories, eliminating as much of the poison as possible, and by appropriate sedatives allay nervous irritation to an extent that uterine pains would not be an additional factor in the production of an eclamptic attack.

Even in those cases in which expectancy is carried out successfully as regards the mother, who, after a most anxious season of doubt and fear escapes unscathed, the danger to the child is so imminent as to receive our serious consideration.

The instructive paper by Drs. Charpentin and Butte, at the Washington Congress, on experimental uræmia, pointed out conclusively that the child might be killed by a direct intoxication of the maternal blood surcharged with urea; the clinical history of my cases bears out this experimental research in a most emphatic manner. Out of my eleven cases, the child survived in only four, and in these labor was induced. This is I think a powerful argument in favor of the production of premature labor in the albuminuria of pregnancy.

One of the strongest objections to the measure is the fact that it does not always prevent convulsions, as in the last two cases of my series. I believe, however, that if in these cases interference had been invoked earlier, the convulsions would not have occurred, and that the induction of labor is too often delayed until an extreme irritability of nervous centres renders convulsions unavoidable.

In conclusion, it is known that many processes observed in disease are of a conservative nature, e. g., the sweating in rheumatic fever, the diarrhoea from offending matter in the alimentary canal, the vomiting from indigestion, and as Dr. Whitaker has pointed out, the oedema in albuminuria. It is fair to conclude that the frequency of spontaneous expulsion of the fœtus in puerperal albuminuria is of the same nature, and should direct our attention to this, the natural way to recovery. In six cases of the series, here given, labor came on without assistance, two before and four after convulsions took place. It would appear from this, that we are only following in nature's wake in restoring to surgical interference in these cases.

THREATENED ABORTION OF TWIN PREGNANCY: DEAD FETUS CARRIED TO FULL TERM.

BY S. B. SNYDER, M. D., FULTON, MICHIGAN.

The following case contains some interesting features, and in certain particulars I feel it worthy to be recorded:

I was called to see the patient, Mrs. C., aged thirty-eight, July 14, 1886. She had had uterine and lumbar pain, and hæmorrhage for four days. At the time of my visit the pain had nearly ceased, but the hemorrhage continued quite profuse. Pulse, 120; temperature, 101° Fahrenheit. On examination the os was found undilated and normal. With this condition I determined to try to prevent the threatened abortion, and ordered the patient to remain in bed, keeping perfectly quiet, and administered opiates.

For two days her condition remained unchanged. The case was kept under close observation. Improvement was slow. At the end of a week, however, her pulse was 90 and temperature normal, and so much improved that I dismissed the case.

November 27, 1886, I was called again to see the patient. She was in the first stages of labor; head presentation. The child was soon delivered; it was some below the average size.

The cord was traced up through the os, showing that the membranes were still within the uterine cavity. To excite contraction the uterus was kneaded, when it soon became hard. Clasping the tumor with both hands, firm pressure was made downwards and backwards, which soon effected the expulsion of the remaining contents of the uterus. On examination of the membranes and placenta I found a foetus, weighing less than one pound, enclosed in its membranes, perfectly preserved, evidently having died at the time when I was first called to see her. There were two complete sets of membranes with a common placenta.

I must add that during the four days prior to my first visit, the family had employed an "irregular," who advised the production of abortion.

A CASE OF WOUND OF GREAT TOE BY RUSTY-NAIL; WITH FREE INCISION OF SURROUNDING NERVES.

BY GEORGE CHAFFEE, M. D., BLUE HILL, NEBRASKA.

About noon on January 1, I was called to a patient, a baker by occupation, who on the previous evening had stepped on a rusty nail, running it well into the pulp of the great toe. Patient having just lost a friend in Switzerland from tetanus, caused by a similar accident, I found him very much exercised over his misfortune. In fact, he already complained of a peculiar stiffness in the jaw. This patient walked half a block to his home before the nail was removed. On examination the wound presented nothing unusual. No laceration, simply a punctured wound. The skin surrounding it was bright red; some pain; no swelling. Knowing that in traumatic tetanus, division of the nerves connecting with the cicatrix is recommended, I decided to make the operation at once. Muriate of cocaine was used hypodermically as a local anesthetic. I then made an incision nearly as deep as the parts would allow. The incision was elliptical in form, and the edge of the scalpel was kept about one-third of an inch from the punctured wound all the way around. I then applied linseed meal poultices for the next forty hours. Incision united by first intention. Gave no medicine, but prescribed a good novel, and agreeable company when not reading. Up to this date, February 7, this patient has shown no signs of reflex excitement. He is now doing his work. Perhaps the results would have been satisfactory without the oper