In case of over-production of toxins and under-elimination by the kidney the road is a short one to an eclamptic seizure. The degree of intoxication regulates the severity of the attack, while the nature of the soil in which the toxic elements are sown governs the quality of the seizure. Some women are easily influenced by the eclamptic toxins, while others resist them to the last extremity. In this latter class prodromata are frequently noted and eclampsia is prognosticated; but it rarely comes, or if it does it is more readily overcome by appropriate measures. I wish it were possible in the present state of our knowledge to fix or differentiate precisely what these mysterious toxins are. If their source even were better understood we might do more efficient work in their elimination. It is probable, in my view, that they come in large groups from the intestinal tract, either the result of putrefaction or waste; that they enter the blood in excess of what the kidneys and other emunctories can eliminate, finally causing eclampsia in those women whose systems are easily wrought upon by this group of phenomena.

It is a well-known fact, and one, moreover, not to be lost sight of in this relation, that pregnancy causes a modification of woman's economy often to an extreme degree. It exaggerates her nervous force and diminishes her resisting powers; it perverts her mental stamina and lessens her physical energy. The functions of organs whose province is especially to eliminate toxins, and so preserve health, are now so disturbed as to prevent the exercise of their offices to their full extent, hence she easily falls a prey to toxemia.

I place very little importance upon the mere presence of albumin in the urine of a pregnant woman, except as a warning that should induce careful watchfulness. How many women with albuminuria escape eclampsia! and, again, how many eclamptics fail to exhibit albuminous urine! Yet it must not be forgotten that a large percentage of albumin means less elimination of toxins, and such a condition may become, under favoring conditions, the avantcourrier of an eclamptic seizure of maximum intensity.

I shall not take time in this presence to discuss the microbic theory of eclampsia, for it is a proposition that remains to be demonstrated. Moreover, if in the present state of our knowledge we adhere to the belief that toxemia is a causative factor, we shall find ourselves on more substantial foundations as to successful

treatment, which, without further circumlocution, let us proceed to consider.

TREATMENT.-In order to arrive at an intelligent treatment there must be a clear understanding of the conditions we are called upon to treat. Let it be understood, then, that we are dealing with a subtle toxemia not yet understood as to origin or material, nor even as to its modus operandi, but still one that arises from ingesta, intestinal putrefaction, and fetal metabolism, one or all, and that the organs of elimination are either sluggish or suspended in action. Symptomatically, we usually have to contend with severe headache, edema, albuminous and scanty urine, diminished urea excretion, and, finally, cyanosis, convulsions, and coma or semi-coma. The first group of symptoms pertains to the preeclamptic state, while the last belongs to true eclampsia.

Again, the woman may be anemic or plethoric, young or middleaged, a primipara or a multipara, and the symptoms grave or moderate in their manifestations. Finally, the eclamptic seizure may be antepartum, intrapartum, or post-partum. All these factors serve to modify or control the details of treatment to be proposed in a given case.

The treatment of eclampsia, too, should be further classified into (a) preventive and (b) curative. The preventive treatment may be subdivided into medicinal and hygienic, and the curative into medicinal and obstetric.

The preventive treatment of eclampsia affords an interesting field in which the clinician may display his talent and ingenuity in the application of hygienic measures and drugs to avert an impending danger of the gravest import. Given a pregnant woman in the seventh or eighth month with the prodromes of eclampsiathat is to say, who manifests the phenomena incident to the preeclamptic state-and what shall be done?

Manifestly the first duty will be to interrogate the kidney as to its sufficiency and integrity. A qualitative and quantitative analysis of the urine should be made at the outset. Albuminuria is not an unfailing symptom of renal disease or insufficiency, nor is a scanty twenty-four hours' output a reliable index of kidney failure, nor yet is a diminution of urea excretion an infallible indication of approaching eclampsia. Exceptionally, all of these conditions may coexist, and yet eclampsia not result. These are indi

cations, singly and collectively, that there is existing toxemia, that there is defective elimination, and that something must be done to correct a faulty relationship between nutrition and excretion.

If the prodromes and the physical signs are recognized early it may be expected with reason that hygiene and medicine will correct the errors that are so rapidly tending toward eclampsia. Air, food, and drink must be supplied in ample quantities and of good qualities; so, too, must we insist upon exercise, active or passive —walking, driving, light calisthenics, or massage, according to the taste or tolerance of the patient. These are all good agents to employ, but the object sought should be to limit the source of toxins that are being absorbed and to promote their elimination.

One of the surest ways in which to control the supply of toxins appears to be, from abundant testimony, to place the woman upon an exclusive milk-diet. This will serve at once not only to diminish the supply of toxins, but to increase the fluids of the body, flush the kidneys, and favor the elimination of toxic material. Water, too, should be freely given in definite quantities and at regular intervals. I speak from a considerable experience when I say that distilled water is one of the best diuretics that can be administered to a woman in the eclamptic state. Two quarts a day is not too much, and it may be given still or charged, according to the taste of the patient. It dilutes the toxins and hastens their exit from the economy.

The bowels of the pre-eclamptic, too, demand supervision. Constipation must not only be prevented, but intestinal toxins must be unloaded and the intestinal tract kept free. These are commonplace observations, perhaps, but they are essentials that cannot be omitted in a consecutive clinical picture of the management of a woman with eclamptic prodromes. Drugs are not specified in kind, but each physician will invoke the aid of an intelligent pharmacology. It should be remembered, however, that forcing the kidneys without supplying copiously of fluids is to be reprehended. Potassium salts, that have been so frequently employed, and as I believe to the detriment of eclamptic patients, should be avoided; they favor the production of intestinal toxins, and besides tend to diminish red blood-corpuscles—an element that must be conserved. The tendency of the disease is toward anemia—a tendency that must be antagonized, not favored, by our therapeutics.

There are two other remedies of which just here I wish to speak, for they belong to the therapeutics of the condition we are discussing—that is, the pre-eclamptic state. These are blood-letting and glonoin. If there is a full artery at the wrist, with a tendency to cyanosis in the pre-eclamptic, venesection may be resorted to with possible benefit. One good full bleeding is permissible, but it should be used with caution in repetition. I fear its employment during an eclamptic seizure, but here-i. e., in the pre-eclamptic state-it is admissible, and in selected cases it will often prove beneficial. But, again, we must bear in mind that copious and repeated blood-letting may foster an irrecoverable anemia. If there is high arterial tension-vasomotor spasm-glonoin in full doses is a valuable remedy. It combats this condition without depleting the patient, and moreover helps to set the kidney to work. Let us now dismiss the pre-eclamptic state and take up the treatment of true eclampsia.

Suppose a physician is summoned as a consultant in a case where convulsions have already set in, what is to be done? Here let us recall the three forms of eclampsia, (a) antepartum, (b) intrapartum, (c) postpartum. The treatment will be, first, medicinal, and second, obstetric. The first indication of treatment in antepartum eclampsia is to control the convulsions. An attempt wisely enough may be made to do this through the administration of chloroform by inhalation as well as the administration of chloral by the rectum. An eclamptic woman swallows with difficulty or not at all, as she rarely rouses to full consciousness between the fits. Hence it is better to administer chloral by the rectum. For my part I would administer chloroform rather tentatively in these cases. If the convulsions were not promptly controlled or diminished in frequency or severity by its vigorous and skilful administration, I should institute measures at once to empty the uterus of its contents; and this brings us face to face with the most interesting question in the obstetric management of puerperal eclampsia-viz., the induction of premature labor for its relief.

A considerable experience has convinced me that a prompt evacuation of the uterus constitutes the most important method of dealing with eclampsia. While the womb remains gravid we are hampered in our therapeutics. Two lives are at stake, and in our anxiety to preserve both we may save neither. By addressing

ourselves assiduously to a speedy delivery of the fetus we contribute in the largest measure to the conservation of both lives. With the fetus once delivered there is a freer opportunity to deal with the woman in the most masterful or even heroic manner. Fortunately, eclampsia rarely occurs until the fetus has reached the period of viability, hence its speedy delivery becomes its greatest safeguard; for every hour increases its liabilty to death from maternal toxemia, as well as diminishes its chance of survival after premature delivery, since the fetus absorbs toxins as well as the mother.

How many times has the fetus been destroyed by prolonged chloroform anesthesia, full morphinism, or extreme chloralization! One or all of these means, to be sure, may be used with comparative safety to the mother if the fetus is out of the way. How often, too, has the fetus succumbed to prolonged intoxication from the mother's blood!

If I am called to an eclamptic woman who is within a month of term I lay down as a cardinal principle for my own guidance that it is my duty to proceed with all diligence to effect delivery. Why should not this be done? Will anyone tell us why it is not good obstetric practice to proceed to aid nature in the accomplishment of her own desires? I regard the appearance of eclampsia as an expression of the economy that it has carried an offending fetus as long as it can be tolerated. The toxemia incident to its presence can no longer be endured without calamitous results, and eclampsia is but an expression of that fact-a danger signal. I offer this suggestion as a pivotal point in the discussion of the propriety of the induction of labor, and one, if admitted, that must be conclusive in determining it in the affirmative. If we should appeal to statistics they would tell us that the mortality in antepartum eclampsia is seven times greater than in postpartum eclampsia. Surely this speaks in no uncertain fashion commendatory of speedy delivery. But we are told that convulsions do not always cease after delivery. True, but is that a valid argument against the induction of labor? Postpartum hemorrhage does not always cease after the delivery of the placenta and secundines; but who will affirm that it is not proper in such a case to begin the treatment by clearing out the uterus? If convulsions continue after delivery we are now in a better position than before to push medici