these obstacles that stand between the patient who is suffering from a malignant case of diphtheria and a curative dose of antitoxin?

I will not attempt to answer this question but feel that a few words may not go amiss.

First of all there should be a campaign of education or a society for the prevention and cure of diphtheria, the same as is done in regards to tuberculosis. There should be continued warning through the press against the causes of diphtheria, the same as is done in regard to typhoid fever; that is, to instruct the people that a sore throat, no matter how simple it may appear, might end in a serious case of diphtheria, also to teach them that there is only one remedy for that disease, but it must be administered in the early stages.

If it is a good thing to tell the people what to do if they have lung trouble or signs of tuberculosis, why should it not be a good thing to warn them against throat trouble and diphtheria? If it is a good thing to advocate general and compulsory vaccination against smallpox, why not advocate general and compulsory use of antitoxin in diphtheria. Second, we should look upon all acute diseases of the throat with a great deal of suspicion. Suspect diphtheria until we can prove the contrary. Let us be ever mindful of the fact that our case of quinsy or follicular tonsilitis may turn out to be a malignant case of diphtheria or the starting point of an epidemic. If you are unable to make a positive diagnosis by examination use antitoxin, thereby making a serum test as you would make a therapeutic test in making a diagnosis of syphillis.

Now as to the third reason, you will find the most difficult. When you are called to a patient suffering from diphtheria and confronted with objections to the use of antitoxin, you will often find that the life of the patient depends on your ability to overcome the prejudice. Let us not overestimate the short comings of this much maligned but valuable remedy, nor underestimate the wisdom of insisting upon its use, for as to its value we have ample proof.

In conclusion, I will say that we should all realize that we have placed at our command this remedy through the zealous

work of men whose memory would not be too well honored if a little story of their discovery were placed in every school book and a monument erected on every hill top.

While we are waiting for those masters of scientific research in medicine to throw more light on the causes, prevention and cure of some of the other fatal diseases, such as poliomyelitis, cancer and others, let us try to spread the reflection of the light that has already been thrown on the way to the prevention and cure of one of the most dreaded disease of childhood.

ECLAMPSIA.

BY DR. WILLIAM C. STIFF, PLYMOUTH, PA.

READ NOVEMBER 13, 1912.

Eclampsia a word of Greek, origin, meaning to flash out, or a shining forth.

Eclampsia is a symptomatic disorder characterized by convulsive or epileptiform seizures occurring suddenly prior to, during, or after labor.

The etiology is still obscure. It has been attributed to the accumulation of urea in the blood, to the formation of carbonate of ammonia in the system (Hirst) to sudden anaemia of the brain, and to microbic infection by some French authors.

More recent observers teach us that it is more probably due to toxemia, due to insufficient excretion of toxic products by the kidneys and liver resulting in the storing up in the system of those substances.

The probable result of this retention of poisonous materials in the blood is an irritation of the arterioles, causing sudden and extreme contraction of their walls, or small thromboses and embolisms in the capillaries, which is the probable immediate cause of the convulsions.

More recent study has exploded the vague and insufficient terms uraemia and urinaemia.

However, it is well to take into consideration the extreme irritability of the child-bearing period with its increased intraabdominal pressure, or pressure upon the ureters with the

kidneys taxed to dispose of the excrementitions matters of the mother and fetus; nephritis, the kidneys of pregnancy, kidneys perhaps diseased yet functionally sufficient; or may be anatomically healthy kidneys yet under their double work functionally insufficient.

Pregnancy tends to the retention of poisons in the body, the urine of the pregnant woman being less poisonous than when normal.

Blood serum of the eclamptic is more toxic than normal; the toxicity being in indirect proportion to that of the urine. The poison is believed by some to originate in the foetus and placenta, but a commonly accepted theory is that the poison is of maternal origin due to impaired metabolism and retention caused by impaired elimination of the kidney capacity.

The albuminuria of eclampsia is probably secondary, following the direct action of the toxins on the renal epithelial cells in its efforts of elimination.

These conclusions are the result of careful histological study of a large number of cases of puerperal eclampsia.

Eclampsia occurs about once in 300 cases of pregnancy; more frequently in primiparae and more often in women illigitimately pregnant. More often during labor, next in frequency during carrying period and least often during puerperium. It occurs ten times as often in multiple pregnancies and where climatic conditions interfere with the activity of the skin the disease is more prevalent.

Symptoms: We should be prepared to cope with this disease where we find evidence of kidney disease or disturbance during pregnancy.

The prodromal symptoms are: Sharp pains in the head, epigastrium, or under the clavicle, complaints of dark spots obscuring the vision, great restlessness or stupor, this being generally followed by a stare, contracted pupils, twitching of the eyelids, and rolling of the eyes, mouth pulled to one side, neck affected and head jerking first toward one shoulder then toward the other. The spasm spreads to the trunk and upper extremities; the arms flexed, fingers contracted over the thumb and arms working spasmodically to and from the medium

line of the chest. Legs are not often affected, though the thighs may be flexed tonically upon the abdomen. Consciousness is lost during the attack and continues some time after. Each convulsion deepens the stupor and finally the patient sinks into unbroken coma. The convulsions last but a moment or two and the temperature usually mounts.

Prognosis: While maternal mortality was about 30 per cent. in general practice and in hospitals ranging from 38 per cent. to 66.6 per cent., modern methods of treatment have reduced this to as low as 5 per cent. in a series of cases. Foetal mortality remains about 50 per cent.

Treatment is prophylactic, medicinal and surgical. Where the pregnant woman is carefully attended by a physician eclampsia rarely develops if the urine is examined for albumen and total amount of urea at intervals, and where indicated surgical measures employed. Careful hygienic and dietetic measures added to the above practically eliminate eclampsia.

In the presence of prodromal symptoms little reliance can be placed in drugs. The potassium salts will aid in the elimination by their irritant action upon the kidneys. Large quantities of water ingested and repeated introduction of normal salt solution into the blood-stream will accomplish more than drugs. During the attacks chloroform administered to control has its advocates but we cannot rely upon this alone. Diaphoresis and catharsis must be employed. Hot wet-pack, hot air or vapor, or hot baths aid the skin in eliminating, the two former being more practicable in private practice. This in conjunction with the injection of normal salt solution subcutaneously or under the breasts is advocated by many to-day. Free catharsis may be induced by drop doses of croton oil placed well back upon the tongue. Elaterium in quarter grain doses, rubbed up in butter, introduced in the same manner, or, if the patient can be induced to swallow, concentrated solution of epsom salts in dessert spoonful doses every fifteen minutes will be helpful. For the succeeding stupor often following convulsions and in which the patients often die, epsom salts is most efficient.

Phlebotomy Venesection is at present somewhat in disfavor

but Hirst says the reaction following the criticism of the indiscriminate use of the lancet has been too pronounced. While bleeding in every case of eclampsia will be attended with bad results there have been many women rescued from impending danger of pulmonary edema and apoplexy by the timely use of the lancet. Physicians in the country who have to deal with full-blooded people find blood-letting in eclamptics equally as imperative as in pneumonia. Hirst reports fifteen cases where blood-letting was resorted to with but one death and recommends venesection at the proper time, viz.: before pulmonary edema appears. Morphine reported upon by older statisticians gives a death rate of 57 per cent. according to Winckel but Viet claims by heavy dosage (1⁄2 gr. in each convulsive seizure, with a total of 3 grains in from four to seven hours, and 41⁄2 grains in twenty-four hours), has produced results of but two deaths in sixty cases.

Charpentier advocates chloral above all other drugs and quotes a mortality of only 3.5 per cent. in 114 cases. Winckel also endorses chloral, 30 to 60 grains, administered by enema and we should not hesitate to give 2 to 3 drams in twenty-four hours or even more in grave cases.

The American physicians have advocated veratrum viride during the past forty years. Fearn in 1871 reported eleven of his own cases and two from professonal friends treated with large doses of this drug, none of these eclamptics dying in convulsions, but one dying of puerperal sepsis. Rushmore reported eighty-five cases with twenty deaths treated with veratrum viride, and the American Gynecological Society reports twenty-two cases with four deaths.

We should consider well the reported cases and the methods of treatment.

Caffeine, oxygen and nitrite of amyl, I do not have reports upon; and pilocarpine is condemned. Edinburgh reports 66.6 per cent. mortality of cases treated with this drug and it predisposes to pulmonary edema.

Cesarean section proposed by Halbertsma has not proven successful and is not regarded as justifiable.