Jepson has published a case of pregnancy with triplets complicated with fibroids in which he performed hysterectomy with success. There are a number of cases where myomectomy has been done, and the pregnancy has gone on to term and successful delivery.

In doubtful cases it requires the finest judgment to reach a decision as to whether hysterectomy or myomectomy shall be performed. When the tumor is subperitoneal or pedunculated, and interference is necessary on account of the size, or degeneration of its substance, or twisting of a long pedicle, myomectomy should be chosen, and may be done without influence on the pregnancy. If, however, the tumors involve the lower segment of the uterus, and are interstitial or sessile, hysterectomy is the only proper procedure. One authority has said in the treatment of fibroids complicated with pregnancy proceed just as you would where pregnancy does not exist. The existence of pregnancy does not seem to complicate the operation in the least, nor exercise any influence whatever over the result obtained.

Myomectomy, in suitable cases, is a benign operation, but it is not to be forgotten that a good part of the cases of pregnancy complicated with fibroids and which are amenable to treatment by myomectomy would do well if left alone until the natural termination of pregnancy.

There is a class of cases, however, where intervention is imperative. This comprises those cases where the tumors occupy the inferior zone of the uterus and compromise the space in the pelvic outlet, and would prevent engagement of the head and rotation if engagement were possible. There are but two procedures to be thought of in this class; the one is artificial evacuation of the uterus before the third month, the other is hysterectomy. If the case has been allowed to go to term either by design or oversight, the Porro operation is the one to be employed.

In view of the fact that pregnancy in a fibroid uterus is, in many instances, a condition of serious import, I have felt justified in presenting this communication, hoping that we may be able to define a line of conduct to be pursued in the presence of the various complications that may be encountered in the management of these cases.

I do not advocate the artificial evacuation of the uterus excepting when the condition of the patient is such as to increase the danger attending the operation of hysterectomy.

Myomectomy may be done when the judgment of the operator justifies the procedure.

Hysterectomy should be the procedure of election in all cases where the inferior zone of the uterus is involved, and especially when the volume of the tumor is sufficient to interfere with parturition. I can conceive of certain rare conditions that might justify non-interference until full term, when the Porro operation should be done.

CASE.-Mrs. C., aged 37 years, married four months. Her family history was good and she always had good health excepting she had been treated for kidney trouble a few months prior to her marriage.

Two months after marriage her menses ceased and she thought herself pregnant. Two months later she discovered a tumor in the lower part of the abdomen. She called her husband's attention to the growth, and both were surprised at the size. I saw the case on August 19, and made the diagnosis of multiple fibroma of the uterus complicated with pregnancy. The lower part of the uterus contained one large fibroid and several smaller ones. One was situated in the left broad ligament and presented downward, causing the cul-de-sac to bulge.

Various tumors could be demonstrated occupying the hypogastrium and extending as high as the umbilicus. Owing to the dangerous location of the tumors, and the patient being in good condition for operation, hysterectomy was advised.

She entered St. Francis Hospital on August 20, and on August 24 supravaginal hysterectomy was performed, no special difficulty being encountered. Recovery was uneventful, and she left the hospital at the end of four weeks. The uterus contained a mass of fibromata, in the center of which was a two-months' fetus.

205 EAST DOUGLAS AVENUE.

ALBUMINURIA AND NEPHRITIS OF PREGNANCY
AND LABOR.

BY

ROBERT W. STEWART, M.D.,
Cincinnati, Ohio.

THE ever-interesting problems of the relationship of pregnancy and labor to kidney changes and to eclampsia has engaged the writer for a number of years. Anything, therefore, which seems to throw light upon this subject is, to his mind, a justifiable basis for an article, for even if the matter be not finally settled, there is always the probability of a nearer approach to the truth.

IN THE AMERICAN JOURNAL OF OBSTETRICS, Vol. XLVIII, No. 21, 1903, the writer published the results of four hundred and forty-two examinations of the urine of eighty-five pregnant women. Of these specimens nine were taken during the second month, seventeen during the third, twenty during the fourth, fortythree during the fifth, forty-four during the sixth, sixty-nine during the seventh, seventy-one during the eighth, and one hundred and sixty-eight during the ninth. Thirty-eight of the women were primiparæ, twenty-one secundiparae and twenty-six multipara. The range was, certainly, a fairly comprehensive one. Albumin was found in thirteen cases, or 15.3 per cent. Not a trace of it was found, at any time, in seventy-two cases, or 84.7 per cent. It occurred seven times in the ninth month, or oftener than in all the other months combined. In eleven of these cases it disappeared, and in one, in which casts appeared, even these disappeared under medical treatment. In one case the albuminuria persisted.

The details of the examinations of the urine in this last mentioned case are repeated here for purposes which will appear further along.

Mrs. K., primipara.

May 25, 1901.-Sp. gr. —; neut.; no albumin; no sugar; epithelium.

June 20.-Sp. gr. 1022; acid; no albumin; no sugar; epithelium cal. oxalate.

July 26.-Sp. gr. 1020; acid; trace albumin; no sugar; one long hyaline and one hyalo-granular cast; few leucocytes. There is some edema of face and extremities. Patient was put to bed; milk diet with plenty of water, and calomel gr. 1-10 every half hour for ten doses were given. Salts next morning.

July 29. Urine showed: Sp. gr. 1031; acid; faint trace albumin; no sugar; one granular cast; few leucocytes; epithelium.

Nothing further developed, and the urine was found to be free of all danger-threatening elements on August 2d, 13th and 24th, September 2d and 5th. The last-mentioned was voided about four hours before labor began. Confinement September 5th.

Undoubtedly here was a mild case of nephritis, which yielded readily to the treatment indicated. It was so much like all the other cases of albuminuria except for the occurrence of casts, so much like them in yielding to treatment, that one can scarcely conceive of there being any difference but one of degree in the two processes.

The characteristic which dominates the results of these investigations is that simple flushing out of the bowels, and incidentally the kidneys, restores to the normal what might have proved to be a serious pathological lesion in the pregnant woman, and that, too, without in any way interfering with the pregnancy. Clinical evidence is frequently taken as proof of pathological condition without any greater strain upon the credulity than is here presented and, if there were no other factors to be considered, it would not be claiming too much to say that the pregnancy had but little, if anything, to do with the occurrence of albuminuria, or even of nephritis. This characteristic certainly goes a long way in proof of the falsity of the theory that pregnancy produces a persistent and increasing tendency to the production or retention of poisonous materials in the mother's system. This view' is strengthened by the fact that in the cases reported there was no return of the symptoms after they had once been removed, and particularly by the fact that 84.7 per cent. pregnant women showed no albuminuria.

The writer has now to add to these cases the record of five cases which show evidences of the nephritis of pregnancy.

CASE I. Mrs. S., multipara. Last menstruation August 15-18, 1902. Quickening, December 20, 1902. Time of expected confinement, May 22, 1903.

November, 1902.-Urine: Sp. gr. 1015; acid; no albumin; no sugar; epithelium.

Sp. gr. 1015; acid; no albumin; no sugar; epithelium

Dec. 12,

Jan. 17, 1903,

Patient delivered May 28, 1903, 2:25 A.M.; F.; R. O. A. Normal, but prolonged, labor (12 hours).

May 28, 10 A.M., urine drawn by catheter (strict asepsis). First since labor: Sp. gr. 1016; acid; moderate amount of albumin; no sugar; one hyaline, one epithelial cast, 8-10 leucocytes; epithelium. Treatment as before mentioned was instituted.

May 29,
May 30,

Sp. gr. 1022; acid; no albumin; no sugar; epithelium

June 2.-Sp. gr. 1020; acid; no albumin; trace sugar; few leucocytes; three long hyaline casts, on border line between casts and cylindroids.

June 4.-Sp. gr. 1014; acid; faint trace albumin; trace sugar; few leucocytes; epithelium. Quantity in 24 hours, 68 ounces. June 3.-Sp. gr. 1014; acid; faint trace albumin; no sugar; epithelium; one cylindroid; few leucocytes.

June 11.-Sp. gr. 1012; acid; very faint trace albumin; epithelium.

June 15.-Sp. gr. 1011; acid; no albumin; no sugar; few leucocytes. Complete recovery.

CASE II.-Mrs. H. Primipara.

This patient was sent to me August 11, 1902, with the statement that she was within about a week of term and that albumin had suddenly developed in the urine.

Previous history good; a little nervous at times, otherwise no evidence of constitutional ailment; fairly developed and nourished; anemic. Heart and lungs normal; abdominal enlargement showed patient to be near "term;" fetus, L. O. A. position and alive.

No untoward event had marked the course of a normal pregnancy until two or three days before my first visit, when albumin in moderate quantity was found in the urine. The patient had been spending the summer in a Michigan resort where the climate and hygienic surroundings were of the best, but her physician, Dr. B. K. Rachford, felt that, should anything occur, the facilities for treatment were not so good as he could wish.

The urine showed on date above mentioned Sp. gr. 1016; acid;