or that numerous individuals with albuminuria do go through labor without convulsions. So convinced am I that the disorder is one of the effects of the impetus sanguinis and the cerebral and spinal hyperemia, and a result rather of the quantitative than of the qualitative force of the blood, that I have placed at the head of this article the words puerperal convulsions instead of the words puerperal eclampsia, which, if I had obeyed the dictates of our modern fashion in medicine, I should have chosen for its caption.

The Student, therefore, will please observe that I have placed the words puerperal convulsions at the head of this article because I was unwilling to follow in the track of a small number of writers, who have recently regarded puerperal convulsion as symptomatic of the morbus Brightii in pregnant women, and who limit the use of the word eclampsia to cases of albuminuria with uræmia, in pregnant women. The researches of Dr. Blackall and Dr. Bright relative to dropsical and other affections, led to the detection of certain diseased conditions of the kidneys, which, in consequence of his publications, have been called Bright's disease, or morbus Brightii. Dr. Bright's first case, which led to his important investigations, was observed by him in the year 1825. These researches ended in establishing the opinion now, I believe, everywhere adopted, that the urine becomes loaded with albumen wherever Bright's disease exists, and that Bright's disease may consist either in hyperæmia of the kidney, in granular or fatty degeneration of it, or in atrophy of the organ, in any of which states the nitrogenous element accumulates beyond normal measure in the blood, and so, gives rise to uræmia, or urinous blood. Meanwhile, the blood loses a large portion of its albumen, which passes off in solution by the kidneys. Any person in whose blood is accumulated a certain extra quantity of urea is poisoned thereby, intoxicated, or disordered by what is denominated uræmic intoxication. This toxic condition is manifested by weakness, by vertigo, by amblyopia, by hemeralopia, amaurosis, startings of the tendons, and by convulsions resembling epileptic fits, but which are true eclampsias, none other being so except these uræmic convulsions. Such is the doctrine they teach.

It is well known that certain animal products remaining within, from want of elimination, and others accidentally entering the vital stream, do produce disorders whose characteristics depend on the nature of the noxious material or residue accumulated in the blood. Thus, in cases where pus enters the circulation, as in pyogenic phlebitis, the symptoms of purulent intoxication become obvious and peculiar. The influence of opium, tobacco, wine, belladonna, arsenic,

pus, urea, &c., are each peculiar, though they all give rise to states of intoxication, so that there may be vinous, alcoholic, cinchonic, pyæmic, cholæmic, or uræmic intoxication. All these forms of intoxication, or, to speak more correctly, all these toxic conditions differ according to the special powers of the poisoning material, and there is as great a difference between the intoxication of uræmia and pyæmia as there is between the intoxication of beer and that of chloroform, ether, or champagne.

These modern writers insist that the convulsions of pregnant women are effects of uræmic intoxication, and they regard the cases as special, and as requiring a special and distinguishing name. Hence, they call those convulsions eclampsia, and the word signifies albuminuria, uræmia, or morbus Brightii, three expressions that are really syno

nyms.

In ordinary cases, however, of dropsy from Bright's disease of the kidney, convulsive disorders appear not to occur so frequently as they do where the uræmia occurs in a pregnant woman. Dr. Bright, in his 4to. vol., Reports of Med. Cases, &c., 1827, found in his first 25 cases only two instances (cases 12 and 13), in which convulsions occurred. The Case 12, Gallaway, occurred in a broken-down syphilized drunkard. The 13th case, Drudget, died convulsed on the seventh day after his admission into Guy's Hospital. The other 23 cases of Bright's disease evinced no convulsive affection whatever. In 35 other cases by Dr. Bright, related in Guy's Hospital Reports, p. 189, for 1843, there were only three instances of convulsion-thirty-two of the number having been exempt.

Dr. Imbert Gourbeyre, whose admirable prize essay illustrates the 20th vol. Mem. of the Imp. Acad. of Med. of Paris, 1856, tells us at p. 341, that in 164 observations of albuminuria in pregnancy, by various authors, whose names he cites, there were 94 cases of albuminuria accompanied with eclampsia, 65 cases of albuminuria without any eclampsic attack, and 5 cases of eclampsia in women whose urine contained no albumen. In 41 albuminuric pregnant women, Blot found only seven of them attacked with eclampsia.

Will the Student then endeavor to settle for himself the question, whether "the presence of urea in the blood does or does not cause the convulsions of puerperal women? Will he determine whether or no every albuminuric is a uræmic woman? Will he consider whether the hyperæmic state of the brain induced by the presence and obstructing pressure of the gravid womb, and the hysterical tendency superinduced by the state of pregnancy, by panic, by pain, by fatigue, by violent haste in the circulation, by modifications of the blood brought about in the

increased throbbing of the heart, the muscular effort, &c. &c., may be fairly admitted as coequal at least with the uræmia or albuminuria in the causation?"

It is to Dr. J. C. W. Lever, the distinguished accoucheur at Guy's Hospital, London, that we are indebted for the first intimations of some connection of albuminuria with puerperal convulsions. In Guy's Hospital Reports, vol. i., second series, p. 495, the Student will find Dr. Lever's paper, entitled "Cases of Puerperal Convulsions," with remarks by J. C. W. Lever, M. D. In the four first cases in Dr. L.'s series of 14 cases, the state of the urine was not noticed, and it was only in Case 5 (Ellen D―), that "the great similarity that presented in her appearance and that of patients laboring under anasarca with the morbus Brightii," induced to an examination of the urine. It was found to be highly albuminous; and though it might perhaps have been owing to some transient cause, Dr. Lever "examined the urine in every case of puerperal convulsions that has since come under 'his' notice, both in the Lying-in Charity of Guy's Hospital, and in private practice; and in every case but one, the urine has been found albuminous at the time of the convulsions." Dr. L. further investigated the urine in more than fifty women in labor. In no case did he detect any albumen except in those in which there had been convulsions, or in which symptoms readily recognized as precursors of childbed fits were noticed.

CASE. Philada., Sept. 9th, 1856, 2 o'clock A. M. At one o'clock. just an hour ago, I delivered Mrs. S. S- a primipara, 22 years of age, of a daughter, after a labor of 15 hours, in which she suffered more than women commonly do.

Two weeks ago, I observed her feet to be cedematous, and took away a portion of the morning urine, which proved by nitric acid and by ebullition to contain no trace of albumen. Yesterday morning, Sept. 7th, at 10 o'clock, I found her in pain, and with increased oedema of the feet, which pitted on pressure. On testing the urine by heat in a test tube it was found to contain about 20 per cent. of albumen. She was pale, but in very good spirits. The labor pains having be come frequent, I was called to her at 63 P. M. She had rigidity of the os uteri, and seemed to suffer excessive anguish when the pains were on. At 11 P. M. she said she was dizzy, but without headache, and though the pulse was not very large, frequent, or hard, I took 10 ounces of blood from the arm. The child was born as the clock struck one-the placenta came off in seven minutes, and I came away to make this note. Now here is a case of Bright's disease, or

albuminuria, in a primipara, who, throughout a most painful labor of 15 hours, exhibited no sign whatever of coming eclampsia, unless indeed the slight vertigo above mentioned was such a sign. I left her at half past one perfectly comfortable, and I expect that the urine of the 10th inst two days hence, will display no signs of any remaining morbus Brightii. Was Mrs. S. uræmic? She had no uræmic intoxication. Sept. 9th, 10 o'clock A. M. Mrs. S. is as well as people usually are in the first day of a lying-in. Sept. 11th, 10 o'clock P. M. Neither the urine of last night or that of this morning contains any trace of albumen; so that a very considerable albuminuria has disappeared.

Dr. Lever's statement above cited was made in the vol. of Reports for 1843, now 13 years ago, since which time the idea has gradually overspread the republic of medical letters, and has of late made great progress, particularly since 1850, as any one may perceive who will examine the bibliography of the subject given by Gourbeyre. That author says the word uræmia, supew and apa, made its first apparition in the French press in 1854, in the Gazette Hebdomadaire, vols. iii. and iv. Since that year the word uræmia is become in very general use in Europe and in the United States.

I have already indicated the causes that should inevitably give rise to the oedema of pregnant women, and pointed out the reasons why those causes should equally operate to establish a hyperæmic state of the encephalon, the superior extremities, the lungs, &c. It is also manifest that the intrusion of a gravid womb into the abdomen, thrusting away in its rise the whole mass of the intestines, often in pregnant people overburthened with residues of digestion, must exert a considerable obstructing influence on the emulgent veins. Any arrest or stasis of the renal circulation thus produced could not but bring about a transient morbus Brightii, which consists in engorgement or hyperæmia of the kidneys; but inasmuch as the most enormous oedema gravidarum is usually found to disappear within three or four days and sometimes sooner, after the birth of the child, so, the hyperæmia of the kidney, arising from obstructed emulgent veins, might disappear in like manner and from the same cause. In fact, the albuminuria puerperarum does disappear very soon after the birth; and that, whether the woman has had eclampsia or not. If this be a correct view of the facts, I see not what shadow of reason any man can discover for attributing the convulsion to the uræmia, rather than to the engorgement, hyperæmia, or increased impetus sanguinis in circulation. In the meanwhile I am very far from maintaining that the constitution of the blood is an indifferent in the causation, for I do believe that blood rendered morbid or abnormal, by whatsoever

cause, cannot but prove promotive of various disorders of the nervous mass, as well as of the tissues it governs and innervates, to maintain them in their power and their life.

But the Student should endeavor to obtain a clear and concise opinion as to Bright's disease of the kidney, and therefore he should ask what is Bright's disease? Dr. Bright, himself, Reports, &c., p. 67, considered there are three varieties, viz: the first, which he deemed to be a hyperæmic state, in which the kidney loses its firmness, has a yellow mottled appearance, with gray appearance when incised, and with the tubular portion of a lighter color than natural. In the second form the whole cortical portion becomes a granulated texture, with copious interstitial deposits of opaque white substance. In the third form the kidney is rough or scabrous to the touch, with numerous surface projections as big as pin-heads, yellow, red, and purplish. Such are the generalities, which I can only state here for want of space to fill out the picture at length, after the author. But this is sufficient to show that engorgement of the kidney from pressure on the emulgent might well, and must ofttimes, in pregnant women, cause the very greatest hyperæmia of the kidney, and so bring about those lesions of structure or function that result in albuminuria. If this engorged state should end in inflammation of the kidney, we might well expect to discover altered appearance of it, and great alterations in the excreted matters. For example, if a portion of the urine should be drawn off with a catheter and put aside to settle-and if, after becoming completely settled, a drop should be taken by a small pipette from the bottom of the vase or glass, and examined by a microscope, the saline and other substances that should fall to the bottom of the fluid could be seen and studied. Accordingly it does happen that we perceive not only the salts, as urates and phosphates, but what are called tubulicylinders, or casts of the tubuli uriniferi. They are probably either cylindrical coagula of albumen moulded in the tubuli uriniferi of the pyramids, or they may be true exudation-corpuscles shed by inflamed mucous membrane of the tubuli, and cast off, like croup deposits in a larynx. These cylindrical casts are very commonly to be discovered in pregnant women who suffer from oedema and other allied symptoms, as hydræmia, transitory forms of amaurosis, tinnitus, cephalalgia, &c. &c., which the modern neology interprets as uræmic signs, but which the older school explained by the pressure and obstruction. Let the Student choose for himself which school he will follow-but let him never fail, when consulted about a pregnant woman's health, to examine, first her feet, to learn whether they be oedematous or no, and if they be found swollen, let him dread an eclampsia if she be primipara,

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