not be removed until the child is 7 or 8 years of age, and even then not unless the indications are very clear.

What are these indications? The most important one is that the tonsil from frequent previous diseases has become changed in structure, so that infectious material can not be discharged. When the leukocytes can not emigrate easily into the follicles, on account of fibrous tissue, when the canals are more or less obliterated, when minute abscesses are suspected, then the tonsils must come out. Mere enlargement, unless the degree is such as to interfere with deglutition or breathing, should not be a sign for operation. After puberty, however, the function of the tonsils may be disregarded and any enlarged tonsil or abnormal tonsil can be removed without question.

In the young child the question of the removal of the tonsils offers a complex problem, which can only be solved by a careful consideration of the past history, especially in regard to resistance to respiratory infections, the state of the nutrition, the condition of the blood and finally the local anatomical changes. To do the patient justice the pediatrist and surgeon should confer on every case in which an operation is suggested.

1460 South Grand Avenue.

ECLAMPSIA*

A. J. CHALKLEY, M. D. LEXINGTON, MO.

There is nothing that frightens a mother more than a spasm in her child, and there is nothing that gives a physician more concern than a puerperal convulsion. I never knew but one mother to get used to spasms. She had several children and they all have had spasms whenever any febrile condition existed. The physician realizes that the spasm of teething and gastro-enteritis is rarely fatal, and he can relieve the patient and encourage the mother, but he is always in grave doubt as to the outcome of eclampsia and it puts him on his guard as to how best to take care of the patient.

Eclampsia may be classified as anti-partum, intra-partum, and post-partum. The antipartum is the most common and the most seri

ous.

It sometimes occurs in the first half of pregnancy, but nearly always toward the latter half, and more frequent the nearer the term is approached.

Seventy to 80 per cent occur in primipara. The convulsion often comes very unexpectedly;

* Read before the 14th District Society at Marshall, April 23, 1914.

and the expression, "like a bolt from a clear sky," is a very appropriate one. The number of convulsions varies from one or two in favorable cases to a hundred or more in fatal cases. The immediate cause of death is usually edema of lungs or apoplexy.

There is something peculiar about the prevalence of eclampsia, sometimes being suggestive of an epidemic. No doubt most of you read the article in this journal last autumn, by Dr. Miller of Liberty, stating that after not seeing a case for fifteen years, he had six within a short time, four of which proved fatal. I had two within four months after a lapse of five years. The average is given as one in every 200 to 500 labors. In Tarnier's clinic in Paris there was one case in every forty-seven labors. in 1872, and one in 730 in 1882.

Eclampsia has been called "the disease of theories." We are not satisfied now to consider it solely a kidney affair. The renal origin was long considered the true cause, and has many advocates to-day, due to the fact that in min and casts in the urine. But many women a large percentage of the cases there was albuwith nephritis do not have eclampsia and many have eclampsia without presence of albumin or casts in urine.

Pathologists have discovered a degenerative change in the liver in most cases, so the liver was looked on as the exciting cause for a time. Some have considered it to be of pure nervous origin. The main lesions are in kidney, liver, and brain and the clinical and pathological history give evidence of some poisonous substance in the circulation which produces thrombosis and consequent necrosis in the various organs. Whether the poison is from fetal metabolism or what the origin is, is not certain. But the theory of auto-intoxication has the floor at present.

Sajous expresses it as follows: "During pregnancy the mother's blood becomes increasingly laden with waste products, those of the developing fetus being added to her own. To protect her organism, her adrenal system, including of course, the thyroid apparatus, becomes increasingly active, owing to the exciting action of these products on the testorgan, to insure destruction of all wastes as soon as they are found. When the adrenal system does not become sufficiently active to enhance adequately the blood's antitoxic properties, including the phagocytosis, the toxic wastes are allowed to accumulate in the blood in sufficient quantities to produce convulsions, i. e., the eclamptic seizure.

My first experience with eclampsia was while an intern at the St. Louis City Hospital. I saw two cases within a few days of each other

treated by one of the senior interns. Both died without regaining consciousness. I think both were primipara in the last half of pregnancy. Five years ago I saw a case in consultation in a primipara. The first convulsion came on immediately after a normal labor. The patient only had one convulsion, and has borne a healthy child since, without any return of the trouble.

At six o'clock Sunday morning, Sept. 21, 1913, I was called to see Mrs. L., aged 18, primipara, who expected to be confined the next day. She had been in splendid health and spirits during the entire pregnancy and was delighted at the prospect of an heir. She retired Saturday night apparently in perfect health and joked with her husband. She slept peacefully all night, but when I reached her Sunday morning found her unconscious and in a few minutes had her first convulsion. They continued about every thirty minutes. Skin was dry, pulse full and bounding, and of high tension. Labor had not begun. After trying to stop convulsions by the usual means, I called in Dr. Fredendall and we brought on labor as rapidly as possible and finally delivered her of a dead child. The patient had a good free hemorrhage, and after delivery convulsions got further apart, and about the time I would think it safe to leave her, a terrific

spasm would occur again. She had altogether about thirty convulsions and remained unconscious until Tuesday night, after which she gradually recovered her former health and is now, much to my chagrin, about three months pregnant. She does not to this day recall anything from Saturday night to Tuesday night.

Her urine at time of confinement was loaded with albumin and casts. I did not test for urea but there had been no edema, headaches, uneasiness, or adverse symptoms of any kind. The albumin persisted for about six weeks. Her grandfather and one uncle died of Bright's disease.

The second case, Mrs. S., aged 16, primipara, occurred on Jan. 4, 1914, and was almost an exact duplicate of the first except that she

was only about six months pregnant. The

morning of her trouble I was making a call in the neighborhood when I was asked to see Mrs. S. She was complaining of headache, and there was some edema of lids. I prescribed for the head and a diuretic and asked for a specimen of urine. I had been back in town only a short time when I was called to see her on account of convulsions. The use of chloroform, morphin and hot packs did not stop the convulsions, so I started in for as rapid delivery as possible. The dilatation and delivery in this case was more difficult than in that of Mrs. L. On the second day she re

gained consciousness after about twenty-eight convulsions. The first of her urine that I was able to obtain was by catheterization. It was loaded with albumin. Her recovery was rapid and apparently complete.

With these two patients I was left in practically constant attendance for three days and nights and had opportunity to observe them closely and use many of the suggested remedies.

I used chloroform to control the convulsions, and started in immediately on elimination by use of elaterim and crotin oil and hot packs of entire body and pilocarpin. I also used morphin in the hopes of quieting the frequency of convulsions. I have not used tincture veratrum viride nor thyroid extract. I failed to derive any benefit from the morphin or packs and almost none from the pilocarpin, but did get some edema of lungs in the first case, which was probably due partly to the pilocarpin and partly to general weak condition of the patient. I attribute the recovery in these two cases to the prompt delivery.

Dr. Ballantyne, physician to the Royal Maternity Hospital of Edinburgh, advocates the following treatment. If any of the prodromata of eclampsia occur, the first step is to put the patient on a milk only diet, and keep her on it until albumin is only a trace, and

still persist, then one or all of the following blood-pressure falls to normal. If symptoms six measures are resorted to: venesection, 10 to 12 ounces; transfusion, 2 or 3 pints; stomach washing, Na,CO,; introductions of magnesium sulphate, 6 ounces, into stomach by tube; large enema, and hot pack. Then if these fail induce premature labor.

In a recent letter from Professor Williams of Johns Hopkins in regard to the experimental evidence that chloroform causes degeneration of the liver lobules, he now recommends ether where an anesthetic is necessary. Dr. E. W. Saunders of St. Louis, lays stress on milk and

fruit, and salt-free diet, has great faith in

veratrum and venesection. Thinks chloroform is unsafe, and advocates as early and rapid delivery as compatible when convulsions arise.

I am a firm advocate of frequent urinalysis in pregnant women, especially in primipara and those we are waiting on for the first time, and we should keep on the lookout for any of the symptoms of pre-eclamptic state such as persistent headaches, edema of face, hands or feet, lessened amount of urine, lessened amount of urea, presence of albumin and increase in blood-pressure, and then use every means possible to prevent the toxemia of pregnancy.

When we get more light on the etiology of eclampsia we will be better prepared to prevent and treat it.

THE USE OF THE GIANT MAGNET IN GENERAL PRACTICE*

W. H. LUEDDE, M.D.

ST. LOUIS

The use of magnets (loadstones) for the removal of fragments of steel or iron from the body is a practice at least two thousand years old. It is advised in the Agur-Veda of Sucruta. In the twelfth century, Gilbertus Anglicus is said to have removed an iron fragment from the esophagus. In 1656, Fabricius of Hilden, on the advice of his wife, removed a fragment by the same method, from the superficial layers of the cornea.

The modern development of these means for removing metallic fragments, imbedded in the tissue by accident, has been almost entirely within ophthalmic practice. It dates from the introduction of the electro-magnet by Hirschberg in 1877.

The original Hirschberg magnet was a socalled "hand magnet." It consisted of a small bar of soft iron wrapped in a coil of fine wire through which the current of several galvanic cells was passed, magnetizing the iron core. Into one end of this core tips of various shapes could be inserted. The whole instrument was so small that it could easily be held in the hand. It had more power and greater adaptability than anything previously devised, and became deservedly popular. It was soon replaced by larger ones of the same general type.

Among the modifications of the "hand magnet" was one suggested by Sulzer, who thought to get more power by a horseshoe shaped magnet so that the attraction of both poles could be exerted on the fragment.

With fragments nearly round or cubical there might indeed be a gain of efficiency by this arrangement. However, the majority of fragments are slivers, which have a marked longitudinal axis. Where the single pole of the magnet is used such fragments are attracted in their long axis and the resistance of the tissue is equal to that exerted against the smallest diameter of the piece. When a body comes under the influence of a magnet it is polarized. If the positive pole of the magnet is turned toward the object, the negative end of the fragment is drawn toward it and vice versa. The magnetic poles of the fragment are at the opposite extremities of its long axis. When such a fragment is drawn by a horseshoe magnet, both poles of the magnet being directed toward it, the fragment will approach in a direction at right angles to its long axis, manifestly more than doubling the tissue resistance.

*Read in the General Session of the Missouri State Medical Association, at the Fifty-Seventh Annual Meeting held at Joplin, May 12-14, 1914.

Another modification of the "hand-magnet" is the "innen-pol" magnet. In appearance it looks more formidable than a hand magnet, but really is not. The coil of wire is not placed immediately around the bar of iron to be used as a magnet, but in such a way as to include the whole field of operation, theoretically, to magnetize the metal to be removed as well as the iron bar which is to give the direction and force for its removal.

The special value of the "innen-pol" magnet becomes less apparent when we remember that as soon as any particle of metal is attracted by a magnet it becomes magnetized. The awkward coil about the field of operation is super

Fig. 1.-Author's giant magnet. Tips are of a variety of shapes and may be sterilized by boiling. Height of stand can be adjusted to operating table.

fluous for this purpose. The force with which the fragment within the coil of an "innen-pol” magnet is drawn toward the iron bar in the hand of the operator depends on the relation between the mass of the fragment and the size of the bar according to the well-known law of magnetic attraction.

"Attraction varies directly as the mass of the two bodies and inversely as the square of the distance between them."

Given a fragment of a certain size, the force exerted by an "innen-pol" magnet would be practically no greater than if the same bar were made up as a "hand magnet," while the latter is easier to handle.

A noteworthy achievement was the construction of the very large or "giant" electro-magnet. For the development of a special ophthalmic technic and the demonstration of the greater usefulness of this instrument the profession was indebted to Haab about 1892. Experience with the "giant" magnet has proven it in ophthalmological practice to be a safer and more reliable means for removing metallic particles than the small magnet. Those particles which are lodged in the deeper structures of the eye can be brought forward to a desirable point for

work, because even the smallest bit of iron or steel may set up a destructive chronic inflammation if left within the globe. While such tiny particles may not be dislodged by a hand magnet even when directly in contact with it, this giant magnet has proven successful in every case in my own experience. It was its superior power as demonstrated on a small particle of casting lodged in a crystalline lens for over two weeks after other so-called "giant magnets" had failed-that led to my purchase of the magnet and its installation at St. Luke's

Pan Electric Service and Appliance Company, St. Louis. The adjustable iron stand was built by Smith and Davis Mfg. Company, under direction of Mr. B. F. Jones. The core is over 4 inches thick and 2 feet long and is covered by a coil of insulated copper wire several inches thick. A general description and report on its use in ophthalmic practice was published in the American Journal of Ophthalmology, July, 1910.

If such a magnet is an absolute necessity to the ophthalmologist, how may it be useful in general practice? Perhaps the record of recent cases will be the best answer to this question.

magnet of about one hour each on subsequent days and moist packs to soften the scar tissue in which it was encapsulated to permit the broken needle to slip through the tiny opening in the skin, after which the patient could walk home without further discomfort.

Case 1 was a patient of Dr. H. G. Nicks; permit me therefore to insert here his written report of another case in his own practice.

CASE 2.-"We all know how difficult it is to find a needle buried in the tissues, and that failure often. attends our attempt at removal, even after the best radiograph. The muscular movements can and frequently do move the small particle away from the location at the time the exposure is made. Even the extension or relaxation secured at the time of operation by the hands of the operator or his assistants will change its position. Anything, therefore, that will locate the metal or limit the amount of dissection necessary will be welcome. This last the magnet has certainly accomplished in my hands. Indeed so successful has it proved that I would have refused to operate without its assistance in my last case where a needle had entered the foot. It had broken and the parts were separated fully 1 cm. (Fig. 3). They were imbedded deeply and yet no difficulty was found in removing both through the same incision. The larger

Fig. 4. Radiograph showing broken needle near deep palmar arch.

CASE 1.-Mrs. R.; fragment of needle in foot for five months. Attempted surgical removal, after Roentgen-ray localization at time of accident (Fig. 2), resulted in failure and additional disability from wound in sole of foot. Foot more or less painful since, especially when walking. Immediately on exposure of the foot to the magnet, the fragment was definitely localized by the pulling sensation experienced by the patient and the raising up of a flap of skin where it lay. The immediate surgical removal was now rendered certain, but the patient would have no cutting done. It required two exposures to the

Fig. 5. Showing "stomach tube" extension tip holding three wire nails over 4 inches each in length at extremity. Tube suspended over door knob at distance corresponding to distance from pharynx to stomach. (Tape line figures indistinct.)

piece was a fraction over 2 cm. in length, the smaller 6 mm. The success attending the use of Dr. Luedde's magnet in my two cases, the one already reported by him and removed under his direction, and this last experience of my own, has fully proved its usefulness."

CASE 3 occurred in the practice of Dr. H. G. Mudd. A fragment of a needle was so firmly buried in the tendon achillis as to defy the grasp of forceps, etc. Instead of extensive and possibly harmful dissection, two exposures to the magnet with a little manipulation of the tip removed the fragment. Note the importance of repeated trials and the use of manipulation.

Simply to turn on the current will cause the magnet to exert a steady traction on the fragment, but often an interrupted traction secured by rapidly making and breaking the current will dislodge a fragment when steady traction fails. When the fragment has remained in the