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tion for the purpose of surrounding himself with a halo of brilliancy for the delectation of those who happen to be spectators, but to do his work with the most painstaking thoroughness, so that there is nothing to explain, nothing to apologize for, and nothing to do over again, for it is a fact that incomplete or unfinished operations are fraught with great danger, and are often disastrous to the patient.

Puerperal Eclampsia-A Method of Treatment.

BY J. W. YOUNG, M. D., BLOOMFIELD, IOWA.

READ BEFORE THE WESTERN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, OMAHA, NEBRASKA DECEMBER 27TH, 1894.

OU ask what is the cause of puerperal eclampsia? I answer, simply a mechanical obstruction of a flow of the urine and a damming back in the pelvis of the kidneys and ureters, to the extent of interfering with the proper working of this gland, by means of a gravid uterus pressing upon the kidneys and ureters; also a loaded rectum will at times obstruct one ureter.

It is a fact that eclampsia is more apt to occur in the robust and in the first labor. You ask why? The abdominal walls in the strong individual and in the first pregnancy, give way slowly under the pressure of the rapidly developing uterus, and consequently the pressure of this organ would be proportionately greater on the ureters and kidneys; therefore, this sewer of the body is obstructed and the glandular action of the kidneys retarded by the pressure, more than it would be in the delicate, or in those who have a flaccid abdominal wall.

Anatomists give meagre descriptions of the course of the ureters and the relation they sustain to other organs, yet we all know these compressible tubes must cross on the brim of the pelvis, and one of them must lie in apposition to the rectum, and that they pass the uterus on either side and enter on the posterior side of the bladder; therefore a moment's reflection will convince any one that undue pressure from a gravid uterus does obstruct; and largely dilated ureters caused by this obstruction, have been found often on post-mortem examinations.

Chemical change can and does take place in retained urine. If the pressure is great enough and the glandular action of the kidneys is retarded and urea or its constituents are left in the blood or absorbed by reason of injury to the lining of the kidneys or tubes by stretching these structures; thereby, ptomaines and waste matters and even microbes can get into the circulation, and the action of these foreign materials on the nerve centers is to cause convulsions during the tempestuous period of childbirth.

If the urine of an eclamptic patient be examined before, during or immediately after a seizure, it will generally be found to contain albumen

in greater or less extent.

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Giovanni and other eminent writers claim, that in certain forms of Bright's disease, there is often a cellular infiltration of the sympathetic ganglia which supply the kidneys, and that the diseased conditon of these organs is due to some lesion of the ganglia controlling the secretion of the urine.

If a disease of the sympathetic nervous system can and does cause an abnormal condition of the kidneys, is it not equally true that a temporary pressure of a gravid uterus, not only on the kidneys and ureters but on the ganglia controlling urinary secretion, can and does cause all the phenomena we find in eclampsia.

We must also not forget the fact, if the seizure has not been profound and the attack can be controlled before the brain structure has been injured by the terrible convulsions, the patient usually recovers completely in a short time after delivery, and no lesion of the kidneys or other organs. remains.

There are few more trying ordeals to the young practitioner than to have a case of eclampsia. Imagine the young doctor watching a case of labor, everything progressing as well as could be expected, the patient bearing her pains as best she can, being comforted by the doctor's encouraging words, and the attending ladies, with over-kindness and sympathetic smiles, thinking the agony will soon be over, when lo! the scene is changed in an instant. The eyes of the expectant mother are rolled upward. The head and trunk are often drawn to one side, with purple face, hissing breath, and both tonic and clonic convulsions, make a scene which can never be forgotten by all concerned.

What is to be done now? First, if the patient is robust and full of blood, I would open a vein in the arm and abstract from one to two pints of blood. Next hurry the birth of the child with all possible dispatch, by any means compatible with the safety of the child and mother, and thereby relieve the pressure on the kidneys and ureters. Next, while the delivery of the child is being effected, if the pulse is rapid and the convulsions return every few minutes, with total or almost complete unconsciousness, I would, after thirty minutes from bleeding, inject eight to twelve minims of tinct. veratrum viride. If there was no break in the convulsions in one hour after giving the veratrum and the pulse was down, with moist skin, I would inject hypodermically a half grain of morphia.

These are powerful remedies and I would add a word of caution to any using them, to well weigh the actual condition of the system, because in so urgent a case we are apt to strike harder than is necessary, and sometimes do more damage than good. In the use of verafrum, bring the pulse down to normal, waiting thirty minutes at least between injections. When it is necessary to use morphine, I find it best to used a maximum dose and then wait till its full effects are seen.

I bleed when there is an abundant supply of blood, with a view of removing a part of the poison in the blood and to remove a part of the pressure in the brain.

I give veratrum with a view of controlling the blood pressure and its relaxing tendency to spasm in the muscular system in general, also for its diuretic effect on the kidneys.

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I give a full dose of morphine afterwards for its calming effect on the system, and its well known action in albuminuric conditions.

I have used chloroform and ether inhalations, but am forced to say I have received but little good from either.

Usually the patient is unable to swallow, and all the medicine is given hypodermically, and even if the patient can swallow, you might just as well put medicine in a "slop barrel" and expect results, as to expect bromide and chloral to enter the circulation from the stomach while the system is under so much excitement.

Narcotics and sedatives injected into the rectum are not to be depended upon, as they are usually expelled during a convulsion.

I am rather of the opinion that nearly all convulsive seizures during labor are due to one and the same cause, and that is poisonous matter in the blood, caused by mechanical obstruction in the urinary apparatus. If only a small amount of ptomaines or other poisons are affecting the nerve centers we shall have light convulsions, with the mind clear between the spasms, but if the condition is grave and the life threatened, all mentality. between the spasms is obliterated, and the case will require heroic treat

ment.

If microbes are found which excite eclampsia who can say that the waste material in the circulation caused by the pressure on the kidneys and ureters did not cause the development of microbic creatures. Dr. Joseph Price, of Philadelphia, Penn., recommends cream of tarter taken in half ounce doses, occasionally during the latter weeks of pregnancy, to be a useful prophylactic in those cases that will be subject to eclampsia. My own observation is that if the bowels are kept open by this remedy which also stimulates the kidneys, we may feel sure of baffling this dread malady.

Delaware has a new medical law. It provides for two boards of examiners, regular and homeopathic medicine being represented, and imposes a fine of $500 or not more than one year's imprisonment for persons convicted of practicing without a license. The law went into effect in July.

Harvard College has appointed a physician to look after the general health of its students. He is expected not necessarily to treat them when they are sick, but to so direct their lives that they will not get sick. The physician selected is Dr. George W. Fitz, Instructor in Physiology and Hygiene in the Lawrence Scientific School.

Illegitimates in Paris. From statistics as given in our French exchanges, we present the following: There were 1117 births in Paris for the week ending April 21st, 1895; of these 296 were illegitimate; for the week ending June 23rd there were 287 illegitimates out of 1078 births, and for the week ending July 6th there were 1050 births with an illegitimacy of 305. Other weeks present about the same proportion. The figures are significant. Such a condition of affairs, did it exist in America, would excite the gravest anticipation.

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Report of a Case of Nephrectomy for Hydronephrosis and Renal Calculus.

(WITH ILLUSTRATION.)

BY JABEZ N. JACKSON, A. M., M. D., KANSAS CITY, Mo.

Adjunct Professor Anatomy, University Medical College of Kansas City; Surgeon to All Saints and Scarritt Hospital, and St Joseph's Orphans' Home, etc., etc.

READ BEFORE THE MISSOURI STATE MEDICAL SOCIETY, HANNIBAL, MO., MAY 22, 1895.

ENTLEMEN:-1 present to you today the report of, with exhibition of pathological specimen from a case which has proven of such interest to myself and may, I hope, prove likewise to you. It is a case of nephrectomy for hydronephrosis and renal calculi; the operation having been done two weeks and a half ago.

The patient was Mr. William Griffin, age 37, an Englishman by birth and a plumber by trade. He presented himself first to me at my office the latter part of April, being referred to me by his former physician, Dr. W. C. Burke, who was leaving Kansas City to take up his abode in California. In a hasty consultation I made the following notes: He was a man of apparently good health, but slightly anemic. Inquiry into his family history showed that he came from a very vigorous ancestry; no chronic, hereditary or specific diseases being chronicled in their family. He had himself, however, never been exceptionally hale and hearty since boyhood, though he had suffered from no special malady. The first time he had been under medical care was 12 years ago, when a vague bladder trouble had been diagnosed, which apparently yielded soon to medical treatment, Six years ago in Salt Lake City, he was treated again for what his doctor pronounced albuminuria, but declared him well after one month of treatment. About one year later he was one night seized with a sharp localized pain low down on the right side, nearly over McBurney's point. This yielded to opiates in a few hours, though some weakness and constipation. were noted for a few days afterwards. He resumed his work without loss of time, and was apparently all right. About one year later he had a similar attack, lasting three days, diagnosed as intestinal colic, with localized pain again at the same point. He now noticed a slight swelling, which was very tender, just above McBurney's point, but which with the subsidence of the attack, disappeared. The prominent symptoms were localized pain and tenderness, obstinate constipation, slight elevation of the temperature and nothing more. Again resumed work after two or three days, feeling first rate. In a little less than one year the third attack, symptoms same; in six months, the fourth attack, likewise. Since then, to be brief, the attacks have recurred at gradually decreasing intervals, until in the past six months they have been occurring every three to four weeks. Never, however, was he detained from business more than a few days. In the last year the swelling which had before appeared and disappeared in the right side became persistent, enlarging slightly with each new attack, and remaining stationary in the intervals. The symptoms of which he

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He

complained each time were definite, sharp, localized pain and tenderness in the right side, varying slightly from iliac fossa to the lower border of the liver, attended by constipation and slight transient fever, and in the last few months very slight night sweats. Tenderness had now become permanent over the tumor, but not acute. Recalling his old bladder trouble, and presumed albuminuria, 1 at once inquired for kidney symptoms. He affirmed that his kidneys were absolutely all right; that there was no trouble with them; urine always normal in quantity, and apparently in quality; never suppression or retention; never excessively profuse. had never had any characteristic nephritic colic, or radiating pains from the seat of trouble; had never passed any blood in urine that he could perceive, nor sand or sediment. In fact, there was an entire absence of kidney symptoms. His physician, Dr. Burke, had examined urine and found no pus, albumen, crystals or other abnormal constituents. On physical examination I outlined distinctly a tumor on the right side, running from a little below McBurney's point upwards to the lower border of the costal arch, and extending inwards to the lower border of the rectum muscle; dullness on percussion, and fluctuations were observed.

After a hasty examination, I told him he would have to be operated upon, but would not give positive diagnosis, though from prominent symptoms, I inclined to the diagnosis of recurrent appendicitis with retro-peritoneal abscess.

I was to leave the city that evening for Chicago, to attend the National Association of Railway Surgeons, and suggested to him that he take the matter under advisement, with other consultation, if desired, and report to me upon my return. This he did, and presented himself at my residence on Sunday afternoon, May the 5th, with preparations made to go to the hospital at once. I sent him to All Saints' Hospital that evening, and had him prepared as usual for abdominal section, by saline cathartics administered that night, and a copious enema the next morning. operation was set for ten o'clock Monday morning.

The

Before taking the patient to the operating room I called in my friends and colleagues, Drs. Crowell and Wainright, who were to assist me, and together we again examined the case carefully. We now discovered that the tumor was not fixed, but slightly movable, and with definite described boundaries. The extreme probability of enlarged kidney was, therefore, suggested. A second urinalysis was now made, but with negative results. We agreed, however, that an operation was imperative, and the patient was removed to the operating room. The field of operation was carefully prepared, and the chloroform and ether mixture, used for anesthesia, was administered by Dr. B. A. Lieberman.

Operation. An incision was made from McBurney's point well up to the lower border of the costal arch, a little external to the right linea semilunaris. As soon as the muscles were reached the possibility of appendiceal abscess was excluded, in the absence of the characteristic œdema of the muscles found in these conditions, as Keen has noted. A free incision was, therefore, made down through the abdominal muscles throughout the entire length of the wound. The peritoneum was then picked up, and

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