convulsion when the child's head was distending the vulva. She was delivered inside of five minutes with forceps, but she had two other convulsions inside of thirty minutes, and I believe would have had more only I gave here heavy doses of veratrum hypodermatically and reduced her pulse from 140 to less than 60 inside of an hour. I encouraged bleeding in this case as much as possible, yet the amount of blood loss was small. We sometimes meet with a fulminating type that goes on to death rapidly in spite of our efforts.

A girl 21 years of age came in to the Methodist Hospital in the evening in labor. She had no medical advice during her pregnancy. About 2 a. About 2 a. m. she went into a convulsion which was rapidly succeeded by two more before my arrival. The cervix was well dilated and I proceeded to deliver with forceps. There was a moderate hemorrhage and we adopted other remedial treatment, but the convulsions continued and she went into coma and died about four hours after the first convulsion. In this instance I believe labor to have been the exciting cause of the convulsions, which might have been warded off by a few days' treatment before labor came on.

These things must be taken into consideration because the largest number of eclamptic seizures come on before labor begins and unfortunately many a case of eclampsia is not recognized until the convulsion occurs.

When the cervix is dilated or easily dilatable and an easy delivery can be effected under ether, there is no question but immediate delivery is the treatment to be adopted; but in serious cases I believe operative treatment only precipitates the fatal termination, and I am most decidedly opposed to allowing operative interference to take place preceding the convulsive seizure in eclamptic conditions, only under surgical anesthesia.

PROPHYLAXIS-The important point in the management of eclampsia is prophylaxis, and this is best accomplished by keeping the bowels open, taking two quarts of water daily and plenty of exercise in the open air. Add to this a reduction of tea and coffee to one cup daily and meat or eggs in moderate quantity, once daily and eclampsia will very rarely occur. I also believe most of us do not fully appreciate the value of calomel in small doses as a stimulator of secretion and elimination. I am not entering into a discussion of the value of calomel as a cholagogue, but it is an all round stimulator of secretions and as a diuretic it materially increases the solid constituents of the urine. It may be given in one-tenth doses,

three or four times a day, for periods of a week or ten days, twice a month safely with great advantage in many cases.

The bi-monthly examination of urine is good, but to be really valuable it must comprise an estimation of the total solids eliminated as well as tests for albumin, for it is not unusual for convulsions to ccur before there is any albumen in the urine, notwithstanding the fact that albumin always appears in the urine with the onset of convulsions, and there is frequently albumin in the urine without eclampsia. At least one complete examination of the urine microscopically, as well as chemically, should be made as early as possible in every pregnancy in order to know if there is any organic disability of the kidneys.

I attach very much importance to the first appearance of clinical symptoms, especially headache, backache, visual disturbances, restlessness, insomnia and anorexia. The fact is, that the normal pregnant woman has a general feeling of well being, or as they say, "I feel good," and any departure from general good health should receive our immediate attention.

The question then arises how best to safeguard the patient's interests in eclampsia without convulsions; or in eclamptic convulsions in primipara with a close cervix, possibly a few weeks premature. I would say, quiet nervous irritation, promote dilution of toxines, secretion and elimination.

There are only a limited number of drugs that are worth considering in emergency. As an anesthetic, ether is the only drug to be considered and its application is very limited. During the convulsion no anesthetic can be used only during the early premonitory symptoms, and one should hardly think of continuing the patient under an anesthetic to ward off convulsions. In my opinion morphine stands high on the list, but to be effective must be give heroically. Morphine is objected to because it checks elimination. This is true of every organ but the skin; but it does quiet the nervous system, slows the pulse and respiration, relieves vascular tension and promotes sweating. A quartette of conditions that are highly desirable from a clinical standpoint, but it should be given if at all in one-third to one-half grain doses hypodermatically, to be repeated with great caution.

Morphine should not be combined with atropine if one desires these results. One advantage of morphine is that every physician always has it in his pocket, so that it is immediately available, and this is not always the case with the other drugs. I have confidence in chloral in these conditions in moderate doses, a maximum of thirty grains, but on account of its de

pressing effects I think it well to fortify it with a stimulating dose of morphine. Sodium bromide is good in large doses, but in so grave an emergency its action is so slow that I think its use should be supplemental to other and more active drugs only.

Veratrum viride is valuable. I know of no contra-indication to its use, only, slow, low tension pulse. If given immediately hypodermatically in full doses and repeated until the pulse is slowed to 60 beats, and the tension relieved, it promotes the action of the liver, bowels, kidneys and skin, in short, secretion and elimination from all the outlets. This is an important result of administering veratum. It may cause nausea and vomiting, but even this is conducive to the welfare of the patient. This plan of treatment borders on the heroic, and perhaps is not applicable to all the milder cases. But we are dealing with desperate conditions and cannot afford any dillydallying in our treatment.

Nitroglycerine or sodium nitrite may be effective in relieving pulse tension, but cannot be depended on to slow a very rapid pulse, and it is a question as to whether drugs that lower blood tension and do no more are of very much practical value in these cases. Pulse tension is often protective in its nature. I consider veratrum a good remedy in high tension, with frequent pulse, when convulsive seizures are not imminent. To promote elimination, I am inclined to believe that we have been using too drastic measures in the way of calomel, epsom salts, Co. jalap, croton oil, sweating, etc.; and while it is well to evacuate the alimentary canal thoroughly with calomel or castor oil, it is not necessary or best to resort to drastic measures. The fact is that sweating, hydrogogue cathartics, and bleeding concentrate the toxines and increases the thirstiness of the blood and tissues. In brief, increases the abnormal condition that we are striving to counteract.

The next most important measure is dilution of toxines, and I know of nothing so effective as the ingestion of large quantities of water. Normal salt solution can be given either continuously or intermittently by the bowels to the amount of two, three or four quarts daily and hot drinks may be given by the stomach. If there is no organic disease of the kidneys they will promptly resume operations. The skin will soon become active, elimination progress rapidly and the patient be on the road to recovery.

In brief, dilution of toxines is the beginning of elimination and water is the most potent diuretic. Bleeding may be resorted to, followed by normal salt solution, but I must con