A good illustration of it is given by Tanner,' who states that four out of seven women he attended suffering from Bright's disease during pregnancy, aborted, one of them three times in succession.

Symptoms. The symptoms accompanying albuminuria in pregnancy are by no means uniform or constantly present. That which most frequently causes suspicion is anasarca-not only the dematous swelling of the lower limbs which is so common a consequence of the pressure of the gravid uterus, but also of the face and upper extremities. Any puffiness or infiltration about the face, or any cedema about the hands or arms, should always give rise to suspicion, and lead to a careful examination of the urine. Sometimes this is carried to an exaggerated degree, so that there is anasarca of the whole body.

Anomalous nervous symptoms-such as headache, transient dizziness, dimness of vision, spots before the eyes, inability to see objects distinctly, sickness in women not at other times suffering from nausea, sleeplessness, irritability of temper-are also often met with, sometimes to a slight degree, at others very strongly developed, and should always arouse suspicion. Indeed, knowing as we do that many morbid states may be associated with albuminuria, we should make a point of carefully examining the urine of all patients in whom any unusually morbid phenomena show themselves during pregnancy.

The condition of the urine varies considerably, but it is generally scanty and highly colored, and, in addition to the albumin, especially in cases in which the albuminuria has existed for some time, we may find epithelium cells, tube-casts, and occasionally blood corpuscles.

Treatment. The treatment must be based on what has been said as to the causes of the albuminuria. Of course, it is out of our power to remove the pressure of the gravid uterus, except by inducing labor; but its effects may at least be lessened by remedies tending to promote an increased secretion of urine, and thus diminishing the congestion of the renal vessels. The administration of saline diuretics, such as the acetate of potash, or bitartrate of potash, the latter being given in the form of the well-known imperial drink, will best answer this indication. The action of the bowels may be excited by purgatives producing watery motions, such as occasional doses of compound jalap powder. Dry cupping over the loins, frequently repeated, has a beneficial effect in lessening the renal hyperæmia. The action of the skin should also be promoted by the use of the vapor bath, and with this view the Turkish bath may be employed with great benefit and perfect safety. Jaborandi and pilocarpin have been given for this purpose, but have been found by Fordyce Barker to produce a dangerous degree of depression. The next indication is to improve the condition of the blood by appropriate diet and medication. A very light and easily assimilated diet should be ordered, of which milk should form the staple. Tarnier2 has recorded several cases in which a purely milk diet was very successful in removing albuminuria. With the milk, which should be skimmed, we may allow white of egg, or a little white fish. The tincture of the perchloride of iron is the best medicine we

1 Signs and Diseases of Pregnancy, p. 428.

2 Annal. de Gynec., 1876, tom. v. p. 41.

can give, and it may be advantageously combined with small doses of tincture of digitalis, which acts as an excellent diuretic.

Finally, in obstinate cases we shall have to consider the advisability of inducing premature labor. The propriety of this procedure in the albuminuria of pregnancy has of late years been much discussed. Spiegelberg is opposed to it, while Barker thinks it should only be resorted to "when treatment has been thoroughly and perseveringly tried without success for the removal of symptoms of so grave a character that their continuance would result in the death of the patient." Hofmeier, on the other hand, is in favor of the operation, which he does not think increases the risk of eclampsia, and may avert it altogether. I believe that, having in view the undoubted risks which attend this complication, the operation is unquestionably indicated, and is perfectly justifiable, in all cases attended with symptoms of serious gravity. It is not easy to lay down any definite rules to guide our decision; but I should not hesitate to adopt this resource in all cases in which the quantity of albumin is considerable and progressively increasing, and in which treatment has failed to lessen the amount; and, above all, in every case attended with threatening symptoms, such as severe headache, dizziness, or loss of sight. The risks of the operation are infinitesimal compared with those which the patient would run in the event of puerperal convulsions supervening, or chronic Bright's disease becoming established. As the operation is seldom likely to be indicated until the child has reached a viable age, and as the albuminuria places the child's life in danger, we are quite justified in considering the mother's safety alone in determining on its performance.

Diabetes.-The occurrence of pregnancy in a woman suffering from diabetes may lead to serious consequences, and has recently been specially investigated by Dr. Matthews Duncan. This must be carefully distinguished from the physiological glycosuria commonly present at the end of pregnancy, and during lactation. It is probable that diabetic patients are inapt to conceive, but when pregnancy does occur under such conditions, the case cannot be considered devoid of anxiety. From the cases collected by Dr. Duncan it would appear that pregnancy is very liable to be interrupted in its course, generally by the death of the foetus, which has very often occurred. In some instances no bad results have been observed, while in others the patient has collapsed after delivery. Diabetic coma does not seem to have been observed. Out of twenty-two pregnancies in diabetic women four ended fatally, so that the mortality is obviously very large. Too little is known on this subject to justify positive rules of treatment; but if the symptoms are serious and increasing, it would probably be justifiable to induce labor prematurely, so as to lessen the strain to which the patient's constitution is subjected.

CHAPTER VIII.

DISEASES OF PREGNANCY-Continued.

Disorders of the Nervous System.-There are many disorders of the nervous system met with during the course of pregnancy. Among the most common are morbid irritability of temper, or a state of mental despondency and dread of the results of the labor, sometimes almost amounting to insanity, or even progressing to actual mania. These are but exaggerations of the highly susceptible state of the nervous system generally associated with gestation. Want of sleep is not uncommon, and, if carried to any great extent, may cause serious trouble from the irritability and exhaustion it produces. In such cases we should endeavor to lessen the excitable state of the nerves, by insisting on the avoidance of late hours, overmuch society, exciting amusements, and the like; while it may be essential to promote sleep by the administration of sedatives, none answering so well as the chloral hydrate, in combination with large doses of bromide of potassium or sodium, which greatly intensify its hypnotic effects.

Severe headaches and various intense neuralgia are common. Amongst the latter the most frequently met with are pain in the breasts, due to the intimate sympathetic connection of the mammæ with the gravid uterus; and intense intercostal neuralgia, which a careless observer might mistake for pleuritic or inflammatory pain. The thermometer, by showing that there is no elevation of temperature, would prevent such a mistake. Neuralgia of the uterus itself, or severe pains in the groins or thighs-the latter being probably the mechanical results of dragging on the attachments of the abdominal muscles are also far from uncommon. In the treatment of such neuralgic affections attention to the state of the general health, and large doses of quinine and ferruginous preparations whenever there is much debility, will be indicated. Locally sedative applications, such as belladonna and chloroform liniments; friction with aconite ointment when the pain is limited to a small space; and, in the worst cases, the subcutaneous injection of morphia, will be called for. Those pains which apparently depend on mechanical causes may often be best relieved by lessening the traction on the muscles, by wearing a well-made elastic belt to support the uterus.

Paralysis. Among the most interesting of the nervous diseases are various paralytic affections. Almost all varieties of paralysis have been observed, such as paraplegia, hemiplegia (complete or incomplete), facial paralysis, and paralysis of the nerves of special sense, giving rise to amaurosis, deafness, and loss of taste. Churchill records twenty-two cases of paralysis during pregnancy, collected by him from

various sources. A large number have also been brought together by Imbert Goubeyre, in an interesting memoir on the subject, and others. are recorded by Fordyce Barker, Joulin, and other authors; so that there can be no doubt of the fact that paralytic affections are common during gestation. In a large proportion of the cases recorded the paralyses have been associated with albuminuria, and are doubtless uræmic in origin. Thus in nineteen cases, related by Goubeyre, albuminuria was present in all; Darcy, however, found no albuminuria in five out of fourteen cases. The dependency of the paralysis on a transient cause explains the fact that in a large majority of these cases it was not permanent, but disappeared shortly after labor. In every case of paralysis, whatever be its nature, special attention should be directed to the state of the urine, and, should it be found to be albuminous, labor should be at once induced. This is clearly the proper course to pursue, and we should certainly not be justified in running the risk that must attend the progress of a case in which so formidable a symptom has already developed itself. When the cause has been removed, the effect will also generally rapidly disappear, and the prognosis is therefore, on the whole, favorable. Should the paralysis continue after delivery, the treatment must be such as we would adopt in the non-pregnant state; and small doses of strychnia, along with faradization of the affected limbs, would be the best remedies at our disposal.

There are, however, unquestionably some cases of puerperal paralysis which are not uræmic in their origin, and the nature of which is somewhat obscure. Hemiplegia may doubtless be occasioned by cerebral hemorrhage, as in the non-pregnant state. Other organic causes of paralysis, such as cerebral congestion, or embolism, may, now and again, be met with during pregnancy, but cases of this kind must be of comparative rarity. Other cases are functional in their origin. Tarnier relates a case of hemiplegia which he could only refer to extreme anæmia. Some, again, may be hysterical. Paraplegia is apparently more frequently unconnected with albuminuria than the other forms of paralysis; and it may either depend on pressure of the gravid uterus on the nerves as they pass through the pelvis, or on reflex action, as is sometimes observed in connection with uterine disease. When, in such cases, the absence of albuminuria is ascertained by frequent examination of the urine, there is obviously not the same risk to the patient as in cases depending on uræmia, and, therefore, it may be justifiable to allow pregnancy to go on to term, trusting to subsequent general treatment to remove the paralytic symptoms. As the loss of power here depends on a transient cause, a favorable prognosis is quite justifiable. Partial paralysis of one lower extremity, generally the left, sometimes occurs, from pressure of the foetal occiput, and may continue for days, or weeks, with a gradual improvement, after parturition.

Chorea.-Chorea is not infrequently observed, and forms a serious complication. It is generally met with in young women of delicate

1 Thèse de Paris, 1877

health, and in the first pregnancy. In a large proportion of the cases the patient has already suffered from the disease before marriage. On the occurrence of pregnancy, the disposition of the disease again becomes evoked, and choreic movements are re-established. This fact may be explained partly by the susceptible state of the nervous system, partly by the impoverished condition of the blood.

Prognosis. That chorea is a dangerous complication of pregnancy is apparent by the fact that out of fifty-six cases collected by Dr. Barnes' no less than seventeen, or one in three, proved fatal. Nor is it danger to life alone that is to be feared, for it appears certain that chorea is more apt to leave permament mental disturbance when it occurs during pregnancy than at other times. It has also an unquestionable tendeney to bring on abortion or premature labor, and in most cases the life of the child is sacrificed.

Treatment. The treatment of chorea during pregnancy does not differ from that of the disease under more ordinary circumstances; and our chief reliance will be placed on such drugs as the liquor arsenicalis, bromide of potassium, and iron. In the severe form of the disease, the incessant movements, and the weariness and loss of sleep, may very seriously imperil the life of the patient, and more prompt and radical measures will be indicated. If, in spite of our remedies, the paroxysms go on increasing in severity, and the patient's strength appears to be exhausted, our only resource is to remove the most evident cause by inducing labor. Generally the symptoms lessen and disappear soon after this is done. There can be no question that the operation is perfeetly justifiable, and may even be essential under such circumstances. It should be borne in mind that the chorea often recurs in a subsequent pregnancy, and extra care should then always be taken to prevent its development.

Tetanus.-Tetanus has not infrequently been observed in connection with pregnancy in the tropics, where the disease is common. In temperate climates it is exceedingly rare, and has been more often met with after abortion than after labor at term. Little is known of this complication of pregnancy, either as to its cause, or of the modification of the symptoms which may show themselves. The risk to the patient, however, is very great. Out of thirty cases recorded-twentyeight by Simpson and two by Wiltshire-only six recovered.

Disorders of the Urinary Organs. Retention of Urine.-Disorders of the urinary organs are of frequent occurrence. Retention of urine may be met with, and this is often the result of a retroverted uterus. The treatment, therefore, must then be directed to the removal of the cause. This subject will be more particularly considered when we come to discuss that form of displacement (p. 223); but we may here point out that retention of urine, if long continued, may not only lead to much distress, but to actual disease of the coats of the bladder. Several cases have been recorded in which cystitis, resulting from urinary retention in pregnancy, eventually caused the exfoliation of the entire mucous membrane of the bladder, which was cast off, some

1 Obst. Trans., 1869, vol. x. p. 147.

2 Ibid., 1863, vol. iv. p. 13.