and particularly if she have a bounding pulse and the slightest cephalalgia. For a great many years past, long before the name uræmia was concocted by the Germans, I have never failed to inquire for cedema in pregnant patients of mine, nor ever failed to be wide awake and watching for the signs of coming eclampsia, if to my question, "How is your head," there came the alarming reply, "It aches." If upon hearing such an answer I failed to open a vein for my patient, I felt guilty of gross neglect of duty, and for the most part was punished for the offence by being compelled to witness the shocking spectacle of a patient in eclampsia.

For my own part, it is sufficient for me then to see that my patient is a primipara, and that she has oedema of the feet and ankles. I can never look upon such signs and not see in them the threatened mischiefs of eclampsia. Still it is wisest for the Student to go farther than this, and discover, if he can, in the lowest stratum of the morning urine, any tubuli-casts, or cylinders, if any there be-in order to judge from them in regard to the state of the kidneys as a viscus. If he believes the tubuli-casts are exudation corpuscles, then he must believe that the patient has albuminous nephritis-and that she is in peril of passing into the second stage of morbus Brightii.

The same motive, to wit, the desire to make a perfect diagnosis, should lead him to test the urine for albumen. Let him take a clean iron spoon, if he have not at hand a proper test-tube, and half filling it with the urine of the patient, let him heat it over a lamp until it boils. The heat coagulates the albumen, which appears as an opaque substance in the urine, or as shreds falling to the bottom of the spoon, or granules, or lastly, as a solid mass which sticks to the spoon like so much boiled white of egg, and will not fall out even if the spoon be turned bottom upwards.

Or let him put some of the suspected urine in a glass or in a testtube, and drop a drop of nitric acid into it. If there be any albumen there it will be at once seen in the coagulum caused by the admixture of the acid. The proportion of the albumen in the urine should be calculated so as to get at some opinion concerning the quantity lost. What now is albuminuria, for that is the question? Is albuminuria a disease or is it a symptom? Such is the question put by Gourbeyre. Is albuminuria a leak from a disordered and imperfect kidney of one of the important materials of the blood? Is albuminuria a result of modified power of hæmatosis, and is it not rather a disease of the blood vessel, the endangium, than of Bowman's capsules or Malpighi's corpuscles? Gourbeyre quotes Frerichs to show that in 292 postmortem examinations of morbus Brightii, the lesions of the kidneys were

more numerous than any others; there was heart disease 99 times, emphysema 77, diseased liver 46 (22 cirrhosis), disease of the spleen

30-p. 52. Dr. Gour

beyre insists that morbus Brightii, commonly called albuminuria, and albuminuric nephritis, is nothing more or less than disalbumination of the

blood, and that disalbu. mination of the blood may take place in per sons whose health is per fect as far as the kidney is concerned, and in whose urine neither tubuli-casts nor the least trace of albumen can be detected. What then, I repeat, is albuminuria of gestation? Is it not a vitiated state of the blood, dependent on morbid changes super. induced by pregnancy in the blood-membrane, and is it anything else than a symptom of hydræmiai Is it not in many of the cases developed during the labor in consequence of the violence of the circulation? The very

strongest advocate of the doctrine of uræmic intoxication as causative of eclampsia, Dr. C. Braun, says, at p. 282, op. cil that there is no constant relation of the quantity of albumen in the urine to the period of labor in

which the convulsions break out, but the amount of albumen does

augment in the ratio of the repetitions of the eclampsic paroxysms. To me it appears that this admission strengthens the opinion that childbed fits depend not so much on the qualities of the blood, as on its impetus in circulation, and that its morbid qualities are rather results than causes.

To set the matter more clearly before the eyes of the Student, I annex two figures, which I have taken from Ecker's edition of Rudolph Wagner's Icones Physiologica. Fig. 91 is a magnified section of a portion of kidney, in which the artist has represented several of the tubuli uriniferi proceeding upwards (H H), and dividing as they go to terminate in capsules. Two of these capsules are seen on the left upper portion of the picture, at B B, while others are seen dispersed in various parts of the field. These capsules are the blind sacs in which the tubuli uriniferi (H H) end, and we may suppose that if water were injected by an Anell's syringe into one of the urine pores of a nipple in the pelvis of the kidney, the liquid would flow towards. a Bowman's capsule by t, to fill and distend it.

Fig. 92 exhibits a magnified view of a Bowman's capsule, with its contents. The letter a in 92 and 91 is a branch of a small artery, which is one of the delicate ramifications of the renal artery. It enters a Bowman's capsule, and, after turning and winding in numerous convolutions within the capsule a, goes out as a vein e. This mass, tangle, or congeries of small vessels within the capsule is the Malpighian corpuscle of the kidney, and is the secretory apparatus of the organ. The urine is separated from the blood brought by these convoluted vessels to the interior of a Bowman's capsule, and when formed, or secerned, it flows forth through the excretory

Fig. 92.

duct, outlet, or tube marked h. Let the Student trace the course of one of these excretory ducts going out from any one of the Bowman capsules, and he may follow the track down into a pyramid where numerous excretory ducts have combined to make one of the tubuli uriniferi which are marked with the letter H H.

If we consider that the Malpighian corpuscles are very numerous in the kidney-that the vascular apparatus for secreting the urine is inclosed in the little casket called Bowman's capsule, it is natural to suppose that whatever should prevent the free escape of blood entering a capsule B, or from flowing out again by H, must cause hyper

æmia or engorgement, not only of the Malpighian corpuscle, which will enlarge and fill up the capsule, and so check the secerning actions there, but that the same obstruction acting on the effluent blood of the emulgent vein, must produce hyperemia of the entire substance of the kidney, and so give rise to the first stage of morbus Brightii. How can any person doubt that the pressure of the gravid womb and of overloaded bowels lying behind the womb, must very often intercept, in a measure, the effluence of the blood that is driven into the kidney and into the Malpighian corpuscles by the emulgent artery? Or who can deny that if Bright's disease is in its first form, nothing more than hyperæmia of the kidney, a pregnant woman, more than any other, should be likely to bring on morbus Brightii? This rationale of albuminuria of pregnancy appears to me so clear, that I believe the Student cannot fail to understand it well; and if he should really understand this curious apparatus of secretion, I think he will never forget, on seeing that a pregnant woman has oedema of the feet, that she is very likely also to have hyperæmia of the kidney; that hyperæmia of the kidney is a first stage of morbus Brightii, and that morbus Brightii, albuminuria, uræmia, uræmic intoxication, amaurosis, twitchings, deafness, vertigo, cephalalgia, and eclampsia, etc. etc., are so closely allied that where the sign of one is present, the other is not far distant; and so ought to be watched, and by prudent, wise measures obviated.

The attack of convulsions has been supposed to have some connec tion with irritation of the nervous system occasioned by the dilatation of the os uteri. Possibly this may in some examples be true, yet we meet with many cases where the os uteri is fully dilated before the seizure, and not a small proportion are met with in persons who have already been delivered. Dr. Collins, in speaking upon the idea that the dilatation of the os uteri is causative of the disorder, says: "This fact might be brought forward to support the opinion that puerperal convulsions are caused by the irritation produced in the dilatation of the mouth of the womb. This, however, is not the case, as we not unfrequently find patients attacked when the os uteri is completely dilated, and all the soft parts relaxed. I conceive we are quite ignorant as yet of what the cause may be; nor could I ever find, on dissection, any appearance to enable me to even hazard an opinion on the subject."

Nevertheless, since the introduction of ether-inhalation in Surgery, and the proposal to use it in Midwifery, the anaesthetic powers of the ether and other articles employed in that way have served to shed no

little light upon the state of the brain in our eclampsia: in my Letters to the Class, sub voce, I have expressed my views upon the nature of the alterations discoverable in the functions of different parts of the encephalon during eclampsia.

While I consider that the attack, or onset, is caused by long-continued or violent determination to the head, by the rapid revolution of the blood excited by pregnancy and labor, or by too intense perception of the pains of labor, I conclude that the profound insensibility ought to be regarded as anæsthesia caused by the presence of much black blood in the brain; that when the black blood grows blacker and blacker, so as to render the patient dark as an Ethiop, the convul sion is nearer and nearer to its close; that as soon as the black blood comes to deluge the cerebellum, the convulsions cease-and that, if it pervades the medulla oblongata, the patient dies from abolition of power in the sources of the vagus nerve. An individual might perish very soon from inhaling ether or chloroform, which is capable in certain persons of directing its anæsthetic force first upon the respiratory brain. But, if the respiratory brain forget in its sleep, or in its asphyxia, to cause the respiration! What then?

The author before cited, Dr. Collins, in a foot-note on p. 200, states, "that of nineteen cases recorded by Dr. Joseph Clarke, sixteen were first children. Of thirty-six by Dr. Merriman, twenty-eight were first children. Of thirty by himself, twenty-nine were first children. So that of the eighty-five cases, seventy-three were first pregnancies."

This statement is susceptible of very different interpretations, for it may lead to the opinion that the firm, elastic abdominal muscles and integuments do so press the womb backwards as to cause the obstructions to the circulation already spoken of; or it might be insisted that the said firmness of the integuments does lead to a hinderance of the flow in the emulgent veins, and so causes the hyperæmia or Bright's disease, with its albuminuria and its eclampsia. Let the Student judge for himself.

As to the frequency of puerperal convulsions, we have a tabular statement of it, which I here present, as it was printed in Churchill's Midwifery, edited by Dr. Condie, 1851, p. 436.

In 103,354 cases of parturition there were observed 172 cases of convulsions, by the following authors:—