THE ALBUMINURIA OF PREGNANCY.

BY H. MCHATTON, M.D., MACON

Case No. 1.-White, twenty-four years, 4 para. Previous labors protracted, but normal, last six years ago. Personal history, neurotic. Began to suffer with digestive troubles about the middle of seventh month, which gradually increased to middle of eighth month.

Nov 18. Urine 1023-normal.

Nov. 19. Urine 1023-two-thirds albumin. Headache, spots before eyes, constant vomiting, with rapid loss of strength. Calomel and soda, 10 grains each, at bedtime. Saline to follow in the morning.

Nov. 20. Urine half albumin, symptoms no better. Introduced three bougies at 8 P. M. Pains began in one hour, median forceps, delivery at 3 A. M. of 21st. Urine 1010, less albumin.

Nov. 23. Urine 1006-trace of albumin.

Nov. 26. Urine 1018-no albumin. Maximum temperature 992. Uneventful recovery.

Case No. 2--White, twenty-five years, primipara Personal history perfect, about seven and a half months pregnant.

Feb. 27. Headache, nausea, spots before eyes, slight edema of legs, face, neck and hands. Urine 1020. Normal.

March 3. No improvement in condition. Urine 1015, ten per cent. albumin. (The rest of the urinary record in this case is shown by photograph in days. Specimen of

6th, 1008; specimen of 8th, six hours before delivery; 9th, about eight hours afterwards.)

On 4th, 5th and 6th unpleasant symptoms increased in spite of usual treatment.

March 6. At 6 P. M. temperature 99, pulse 124, respiration 22. Two bougies inserted. Some pains by morning

of the 7th, which continued in an intermittent manner. Two more bougies inserted at 6.30 P. M. Pains good, but complicated by rigid os. Low forceps 6 a. M. of the 9th. During the last eight or ten hours of labor there was delirium, alternating with short naps and stertorous breathing. At the time of delivery, T. 99, P. 112, R. 22.

Maximum temperature of 100 on the morning of the third day, due to retained clot. Convalescence normal.

Case No. 3.-White, twenty-two years. Previous history good up to three days ago, when she began to complain of severe headache, poor vision, spots before her eyes, etc. Swelling of face, eyes and legs were noticed by the family.

March 10. 5 A. M., had a convulsion. Dr. H. P. Derry was summoned; found about 40 per cent. albumin in urine. Two more convulsions before 10 A. M., when she was admitted to maternity ward of Macon Hospital. T. 96 2-10, P. 66, R. 20. Between six and six and a half months pregnant; os closed and rigid, complete anesthesia, manual dilatation, sufficient to admit of packing, lower segment and cervix packed with gauze; 10.45 A. M., convulsion, some pains; 6.30 P. M., convulsion, fair pains; 9 P. M., manual dilatation again; 10 P. M., high forceps, living child, which died in a few hours; 12 midnight, T. 100 2-10, P. 82, R. 26; 14th, albumin, a trace. 15th,

none.

Temperature dropped to normal a few hours after delivery. Convalescence normal. Patient states that the previous three days to admission and first twenty-four hours in hospital are a complete blank to her.

Case No. 4-White, about twenty-two years, primipara. Seen in consultation. Nothing unusual remarked by attending physician during pregnancy. Urine normal two days before confinement, which was also normal;

two hours after confinement violent convulsion, which was repeated every thirty or forty minutes until death, which was about eight hours after first convulsion. Urine about 70 per cent. albumin.

In the first three cases there were no casts at any time. In the fourth case, no examination was made of the only specimen secured.

The importance of this type of cases can best be appreciated by the fact that these four were seen in an obstetrical practice of moderate size in a period of four months. Since the practical control of pueperal fever, cases of this class are one of the most important problems of obstetrics, for on their early recognition depends the life of both mother and child.

The importance of the diagnosis of the pre-eclamptic stage is fully emphasized by the statistics of Green (Edgar's Obstetrics), which shows the maternal mortality in ante-partum eclampsia to be 46 per cent.; fetal mortality 69 per cent.; in intra-partum eclampsia maternal mortality, 25 per cent.; fetal mortality, 25 per cent.; in postpartum eclampsia mortality of mothers, 7 per cent.

In my remarks on these cases I shall confine myself to cases of this type, and not take into consideration the ten or twelve per cent. that occur without albumin, as I propose to take up that condition in a future paper.

The first and second of the above cases show conclusively that our urinary examinations are not made as often as they should be. Many valuable lives would be saved could we secure examinations or have the patients make some of the simpler tests themselves every two or three days after the fifth month.

It is also important in every case of pregnancy to secure a specimen of urine at the earliest possible period, and to make a complete examination of this specimen, so at a

later day we will be in a position to know if we have an acute condition to deal with or an acute exacerbation of a chronic disease, as it will materially influence our prognosis. The mere recognition of albumin in moderate amount is of no material significance in many cases, as it occurs very often in conjunction with no symptoms of importance and can be easily controlled by ordinary hygienic measures. These cases demand constant watching and attention, for no one can tell when we will have an explosion. Combine the presence of albumin with the symptoms and signs of a beginning toxemia and we have a most grave condition, one that will tax our skill and judgment to the fullest extent.

Our first effort will of course be to control the condition by the use of medical and hygienic agencies—all the fresh air the patient can be induced to take, the observance of the best hygienic rules, and the most important single measure in this stage, an exclusive milk diet, persistent efforts to eliminate the poison through the natural outlets, bowels, kidneys, liver and skin, by the usual methods and according to the indications in each individual case. If in spite of our treatment we find that the symptoms of the pre-eclamptic state still exist, or even increase in severity, we have only one resource left, namely, empty the uterus by the least dangerous method in the given case.

When the patient has been under observation from the first, as in cases one and two above, we can usually secure a sufficient time limit to enable us to induce labor, and, as a rule, have no convulsions. Having decided that it is dangerous to let the pregnancy continue, my rule is to give the patient ten or fifteen grains of calomel and soda at bedtime, and begin early in the morning with magnesia sulp. 2-drachm doses every two hours until ten or fifteen evacuations have been produced. Then have her