Chapter I: The Pathological Exaggerations of Physiological Processes

It is always difficult, frequently impossible, to draw the boundary-line at which normal functional activity becomes pathological. As remarked by Spiegelberg, all the diagnostic penetration of the physician is demanded to recognize this transition. Then, a high exercise of judgment is necessary to determine when to preserve a wise and masterly inactivity, when to adopt measures of active interference.

Alterations in the Constitution of the Blood.

CHLOROSIS AND HYDRÆMIA.

Recent investigations show that qualitative and quantitative changes occur in the constitution of the blood of the normal pregnant woman. The {406} red corpuscles, albumen, and iron diminish, while the white corpuscles, fibrin, and aqueous elements increase. Virchow describes this increase in the number of white corpuscles as a physiological leucocytosis dependent upon the growth of the lymph-vessels and corresponding hypertrophic changes in the pelvic and lumbar lymphatic glands. The total blood-mass is also increased--a change especially notable in the second half of pregnancy. When the number of red blood-corpuscles is abnormally diminished the woman becomes chlorotic. If, in addition, the albumen is abnormally diminished, hydræmia results. Chlorosis and hydræmia can only be regarded as independent affections in the absence of cardiac and renal lesions. They are seldom traceable to pregnancy in the absence of individual predisposition. Effusions into the subcutaneous connective tissue, pleural and peritoneal cavities, are liable to occur. Sudden exudations into the pleural cavity are particularly dangerous, while effusions into the subcutaneous tissue of the abdomen, vulva, and lower extremities are annoying and may interrupt pregnancy.

TREATMENT.--The indications for treatment are obvious. The quality of the blood must be improved, elimination of the aqueous elements attempted, and local disturbances alleviated. Nutritious food, iron in combination with non-irritant diuretics, fulfil the first two indications. Blaud's pill, which Niemeyer and Spiegelberg extol so highly, is an excellent tonic preparation. Basham's iron mixture is admirable in its effects.

PROGRESSIVE PERNICIOUS ANÆMIA.

Gusserow[2] was the first to observe and describe a peculiar form of progressive pernicious anæmia occurring during gestation. The disease is of rare occurrence, and nothing is known as to its etiology. Chlorosis and hydræmia, however, may be mentioned as predisposing causes.

[Footnote 2: _Arch. f. Gyn._, ii. p. 218.]

PATHOLOGY.--The alterations in the constitution of the blood are identical with those in anæmia and hydræmia, and produce similar effects. Evidences of fatty degeneration are found in the musculature of the heart, intima of the arteries, and portions of the capillary walls; retinal hemorrhages are constant lesions. The number of white corpuscles is not increased, and signs of leukæmia--splenic tumor, swelling of the lymphatic glands--are wanting. The condition is that of oligæmia or oligocythosis.

The prodromal symptoms occur during the first half of pregnancy, are obscure, and cannot be distinguished from the effects of chlorosis and hydræmia. After the disease has passed through its incipient stages, food, iron, and tonics seem to have no influence upon its course. During the second half of pregnancy abortion or premature labor usually occurs spontaneously. Under these conditions the shock and hemorrhage resulting from parturition are sufficient to cause a lethal issue in many cases.

PROGNOSIS.--Graefe[3] has collected 25 cases of this rare affection: 1 case recovered, 2 cases were discharged improved; the others died before or shortly after labor. The prognosis is obviously grave.

[Footnote 3: _Diss._, Halle, 1880.]

TREATMENT.--As food, iron, and tonics have little or no effect upon the disease after it has passed through its incipient stages, therapeutic resources are limited. The evacuation of the uterine cavity, as shown by {407} Graefe's cases, exercises a favorable influence upon the course of the affection. Gusserow advises the artificial interruption of pregnancy whenever grave symptoms occur, and the weight of professional opinion is very decidedly in favor of such a course. Negative results have attended all efforts at transfusion.

HÆMOPHILIA.

Kehrer[4] has recently called attention to the apparent influence of pregnancy in the development of the hemorrhagic diathesis. This influence, however, is seldom observed, and then only in cases of distinct, individual predisposition.

[Footnote 4: _Arch. f. Gyn._, x. p. 201.]

TREATMENT.--The induction of premature labor, or, at times, of abortion, is indicated.

PLETHORA.

The experiments and observations of Spiegelberg[5] and Gscheidlen prove the possibility of the occurrence of plethora during gestation. Actual increase of the red corpuscles, albumen, and iron in the blood is observed during the second half of pregnancy, and then only under the most favorable conditions. As described by Spiegelberg, the symptoms are--mammary and cerebral congestions, palpitation, vertigo, constipation, hepatic torpor.

[Footnote 5: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 58.]

TREATMENT.--Restricted diet, muscular exercise, and an occasional saline purge will relieve the troublesome symptoms. Spiegelberg is convinced of the value of bleeding in selected cases.

Circulatory Disturbances.

Among the circulatory disturbances due to pregnancy, mechanical oedema and the varices of the pelvis and lower extremities deserve attention.

De Cristoforis of Milan describes a mechanical inferior venous hyperæmia, the result of the pressure of the gravid uterus on the iliac veins. The mechanical oedema of the abdominal walls, vulva, and lower extremities, intensified by chlorosis and hydræmia, is usually associated with venous ectasis. The oedema may become so excessive that locomotion is rendered difficult, while the labia are enormously distended and the subcutaneous tissue of the abdominal walls becomes pendulous. Toward the end of pregnancy, when the uterus sinks into the pelvic cavity, the oedema and varices frequently abate.

Active measures for the relief of the symptoms produced by oedema are frequently indicated. Threatened gangrene of the skin from hyper-distension may render puncture of the hydropsical regions necessary. It is quite possible to interrupt pregnancy by this little operation, especially if the labia are punctured. Elevation of the lower extremities, rest in the horizontal position, elastic bandages and stockings, local hot packs, mild diuretics, usually fulfil all indications for treatment.

Varices are observed more frequently among multiparæ, but may occur in primiparæ. They are usually developed during the second half {408} of pregnancy. The principal trunk of the saphena is first involved, and subsequently the lateral branches. Congeries of veins are observed on the inner sides of the legs and thighs, especially in the vicinity of the knees. The iliac veins may become dilated, as shown by the condition of the vulvar veins and the occurrence of hemorrhoids. Varices incommode the patient, but seldom cause serious disturbances. Sometimes, however, their tunics are lacerated, and serious even fatal hemorrhage may result. Spiegelberg[6] records four cases of fatal hemorrhage from the rupture of varices in pregnancy. Then there is always the danger of phlebitis and the processes of thrombosis and embolism, even when the loss of blood is insignificant.

[Footnote 6: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 235.]

TREATMENT.--The regular and gentle evacuation of the bowels will frequently relieve the distressing symptoms due to hemorrhoids. Fordyce Barker points out the fact that aloes is not contraindicated by pregnancy. A pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, is a very good remedy. Frequent hot fomentations in conjunction with narcotic ointments will relieve the pain from the congestion of the piles. Attempts at reduction must be instituted with extreme care. It is usually impossible to completely cure the condition during pregnancy, and there is danger of interrupting gestation. Elevation of the lower extremities and equable compression by an elastic bandage or rubber stocking relieve the symptoms caused by varices of the saphena. P. Ruge[7] and A. Martin have seen favorable results from the hypodermatic injection of ergotin.

[Footnote 7: _Berl. Beitr. z. Geb. u. Gyn._, Bd. iii. p. 7.]

Disorders of the Alimentary Canal.

THE UNCONTROLLABLE VOMITING OF PREGNANCY.

Nausea, even vomiting, in the morning, before or shortly after meals, during the early months of gestation, is so common and devoid of injurious effect that it is regarded as physiological. Robert Barnes views it as a normal means of discharging superfluous nervous energy. The uncontrollable vomiting of pregnancy, in which the stomach retains absolutely nothing, is a grave disorder. The patient vomits glairy mucus, clear or colored by the bile. Ultimately the vomit is mixed with blood. Violent retching, intense nausea, pyrosis, and hiccough are constant and distressing symptoms. The woman becomes emaciated. The buccal cavity is dry, the tongue red and shining, the teeth and gums covered with sordes, the breath horribly fetid, the skin dry and harsh. Salivation is frequently observed. Constipation and extreme thirst usually coexist. The epigastrium is tender upon pressure. The woman becomes restless and irritable from loss of sleep and painful efforts at vomiting. A fever of typhoid type is developed, with a quick, rapid, thready pulse. The urine is sparingly secreted, concentrated, and contains albumen and tube-casts. Jaundice is frequently noticed. Extreme marasmus supervenes, and the woman succumbs to some intercurrent disease or dies of exhaustion in muttering delirium. Phthisis and diarrhoea are intercurrent affections which may hasten the lethal issue.

{409} Between the slight nausea upon rising in the morning and the state of extreme marasmus thus briefly sketched every degree of pathological variation may be observed.

It is a remarkable fact that the incessant vomiting, retching, and hiccough seldom interrupt pregnancy until near its end. The muscular effort and loss of blood at this time may precipitate the fatal termination.

Occasionally, spontaneous abortion or premature labor occurs before the patient's condition is desperate. Under these circumstances the severe symptoms may disappear immediately. The same sudden cessation of the vomiting is frequently observed after quickening, rapid excentric hypertrophy of the uterus, and death of the foetus.

The COURSE of the disorder is chronic. Cases terminate by recovery or death in from two to three months. Alarming symptoms are usually developed from the second to the sixth month--very seldom during the seventh and eighth months.

Fortunately, the uncontrollable vomiting of pregnancy is a rare affection. So few cases are recorded in German medical literature that Hohl[8] has denied the existence of the condition. Carl Braun[9] in a fabulous experience of over one hundred and fifty thousand obstetrical cases has never seen a fatal case.

[Footnote 8: _Grundriss d. Geburtshülfe_, Kleinwächter, 1881, p. 197.]

[Footnote 9: _Lehrb. d. Gynaekologie_, Wien, 1881, p. 842.]

PATHOLOGY AND ETIOLOGY.--As the essential predisposing cause of this disorder it is necessary to bear in mind the increased functional activity of the nervous system in general, and of the spinal cord in particular, during pregnancy. Increased reflex mobility is apparent in all the so-called sympathetic affections.

Peripheral irritants are not wanting. The growing ovum stretches the uterine fibres, and consequently irritates the uterine nerves. Bretonneau adduces many facts in favor of this theory. Vomiting is severer in first pregnancies, and occurs during the first half of pregnancy. Vomiting is observed in connection with passive distension of the uterus caused by the unusually rapid growth of the ovum, as in hydramnion and multiple pregnancy. Immediate cessation of all symptoms is frequently noted after quickening, rapid excentric hypertrophy of the uterus, death of the foetus, evacuation of the uterine contents. Henry Bennet directs attention to the importance of congestions, inflammations, and lacerations of the cervix uteri as etiological factors. Graily Hewitt maintains that uterine displacements, with or without incarceration, producing irritation of the uterine nerves, are potent causes. The round gastric ulcer, chronic catarrhal gastritis, are sufficient causes in many cases.

Diseases of the endometrium, decidua, foetal envelopes, or of the foetus itself may supply adequate excentric irritants.

Frerichs has pointed out the connection of hyperemesis with the renal insufficiency of Bright's disease. Kiwisch finds a sufficient cause in the relation between the hyperæsthetic gastric nerves and the hydræmic condition of the blood of the pregnant woman. Lebert and Rosenthal are of the opinion that hyperemesis is symptomatic of extreme general inanition of nervous tissue. Numerous other theories more or less ingenious, and adequately explanatory of certain cases, exist in the literature of the subject. Notwithstanding the extent and accuracy of etiological research {410} into the uncontrollable vomiting of pregnancy, a large class of cases remains in which no organic change capable of objective demonstration can be found.

DIAGNOSIS.--The diagnosis of the uncontrollable vomiting of pregnancy is not so easy as at first apparent. Guéniot[10] pertinently calls attention to three distinct elements: (1) The diagnosis of pregnancy; (2) the diagnosis of the adjuvant or determining cause of hyperemesis; (3) the differential diagnosis between the uncontrollable vomiting of pregnancy and obstinate vomiting from some other cause entirely independent of the pregnant condition.

[Footnote 10: _Thèse Agrégation_, Paris, 1863.]

Experienced clinicians have committed mistakes, particularly in the third element. Trousseau once made the diagnosis of uncontrollable vomiting of pregnancy in a case in which the autopsy revealed cancer of the stomach. This case was observed by Depaul. Charpentier[11] reports a serious error in diagnosis made by Beau. The case was diagnosticated as hyperemesis of pregnancy. The autopsy showed that the obstinate vomiting was probably due to tuberculous meningitis.

[Footnote 11: _Traité pratique des Accouchements_, Paris, 1883, t. i. p. 621.]

PROGNOSIS.--Severe vomiting in pregnancy is always ground for anxiety, and the prognosis must always be guarded. The majority of cases terminate in recovery without the interruption of pregnancy. Guéniot records 118 cases: of these, 46 died; of the 72 survivals, 42 recovered after the spontaneous or artificial evacuation of the uterine contents. Recovery usually, though not always, rapidly follows the cessation of pregnancy. The prognosis is absolutely unfavorable after the appearance of fever and typhoid symptoms.

TREATMENT.--The treatment of hyperemesis may be effective. Its efficiency, however, depends largely upon the accurate recognition of the adjuvant and determining causes. A rational therapeusis must consist in the elimination of these etiological factors. The treatment naturally resolves itself into (1) hygienic; (2) medical; (3) gynæcological; (4) obstetrical.

Hygienic.--The hygienic treatment is of avail in the minor degrees of the disorder, although not without influence in the more serious cases. Diet is of primary importance. Let the patient breakfast upon a small cup of strong coffee or tea, half a cup of milk and lime-water, a morsel of cracker or toast early in the morning, in bed, and lie quietly for one or two hours following the meal. Small quantities of easily-digestible food at short intervals will be tolerated when the patient has given up all pretence at keeping to regular meals. Liquid foods, as sparkling koumiss, egg-albumen in water, iced milk with lime- or soda-water, commend themselves. Absolute dietetic rules, however, cannot be maintained. The stomach of the pregnant woman is proverbially capricious and fanciful. Charpentier narrates the history of a case suggestive in connection with this subject. The patient, four months advanced in pregnancy, in a critical condition from uncontrollable vomiting, came under the care of Beau in the Hôpital de la Charité. One day she asked for Bordeaux crawfishes. Beau granted her request. On the first day two crawfishes were retained; on the second, six; on the third, crawfishes ad libitum, bouillon, and milk. Within six days {411} the vomiting disappeared. Cazeaux and Guéniot cite cases in which ham and paté de foie gras were retained after the rejection of easily-digestible foods. It is necessary to respect these caprices and fancies.

When everything is rejected absolute stomach-rest is indicated. Then nutrient enemata may be tried. Of the great value of rectal alimentation under these conditions there can be no doubt. Henry F. Campbell of Georgia relates the history of a case in which he nourished the patient for fifty-two days by the rectum alone. There is danger, however, of irritating the rectum and causing diarrhoea--a peculiarly unfavorable complication at this time; and this fact must be clearly borne in mind. Of the various nutrient enemata, peptonized milk, cream, defibrinated blood, Leube's beef-and-pancreas mixture, eggs, and beef-tea containing albumens are among the best. From four to six ounces should be exhibited not more frequently than once every six hours.

Inunctions of oil are of undoubted value. Absolute moral and physical rest frequently exercises a favorable influence. Seyfert advised his patients to go home on a visit to their mothers, and return to the conditions to which they were accustomed prior to marriage. Coitus may be a disturbing factor. Rest in the horizontal decubitus exercises as favorable an influence as in sea-sickness.

Medical.--There are few drugs in the Pharmacopoeia which have not been vaunted as specifics by some and found utterly worthless by others. This fact indicates, as remarked by Schroeder, that all remedies are unreliable, and that spontaneous cures frequently occur. Various effervescent liquids, as dry champagne, carbonic-acid water containing one drachm of potassium bromide to the siphon, are sometimes grateful. Subnitrate of bismuth and the antacids are of great value in cases of excessive gastric acidity. Oxalate of cerium, a much-vaunted remedy, is of very little value. Small doses of the tincture of nux vomica are useful in cases of gastric catarrh. The various local anæsthetics are of great importance. Small doses of creasote, carbolic acid, tincture of aconite-root, hydrocyanic acid, and the volatile oils have been used with varying degrees of success. Of this class of remedies cocaine hydrochlorate deserves especial attention. On a priori grounds there is much in its favor. Clinical experience with the drug is not such as to warrant very positive deductions. W. Otto[12] has employed cocaine in sea-sickness, especially in pregnant women, with favorable results. Manassein[13] reports several cases of hyperemesis of pregnancy cured by its exhibition. The subject is certainly worthy of thorough investigation. G. Gaertner of Vienna states that 0.1 cocainum muriaticum has no toxic effect upon adults. Doses of 0.015-0.02 of the solution (cocain. muriat. sol. Merck, 1.0; aq. destill. 9.0) may be given to an adult three times daily without fear of toxæmia. Goodell recommends drop doses of wine of ipecacuanha and tincture of belladonna, repeated every fifteen minutes.

[Footnote 12: _Berl. klin. Woch._, 1885, No. 43.]

[Footnote 13: _Ibid._, 1885, No. 35.]

Of all medical agents, however, opium, the bromides, and chloral are the most reliable. A clyster containing thirty or forty drops of the deodorized tincture, or a half-grain suppository of the aqueous extract of opium, sometimes produces a happy effect. Hypodermatic injections of morphine will frequently allay the distressing symptoms after the failure of other measures. In the German hospitals large doses of the bromides {412} and chloral are exhibited per rectum with gratifying success in many cases.

Flying blisters, the ether spray, and the faradic current applied to the pit of the stomach may give relief in the milder forms of the disorder.

Gynæcological.--Under the gynæcological treatment of hyperemesis quite a number of important operative procedures are included: 1. If bimanual examination reveals a displacement of the uterus capable of producing symptoms, the organ must be replaced if possible, and retained in position by a properly fitting pessary. 2. Henry Bennet suggested the cauterization of the cervix in all cases, basing his therapy upon his peculiar views of the pathology of the condition. Welponer, Sims, and Jones recommend the application of a 10 per cent. solution of argentic nitrate to the vaginal portion of the cervix in all cases, irrespective of the condition of the cervical tissues, when other means have proved useless. Carl Braun[14] bears testimony as to the value of this procedure. 3. As an ultimate resource before artificially interrupting gestation, the plan of dilating the os externum and cervix uteri with the index finger should be tried. Copeman[15] of Norwich, England, desirous of inducing abortion in the case of a patient afflicted with hyperemesis, pushed his finger through the cervical canal to the membranes and attempted to puncture the amnion with a sound. Failing to accomplish his purpose, he went home for assistance, and returned at the expiration of two hours. To his surprise, the uncontrollable vomiting had ceased. Since 1875, when he published the results of this experience, cases have accumulated proving the great value of this method. W. Gill Wylie[16] of New York has devised a steel dilator to substitute the finger. When the os externum is at all patulous, the index finger is the safest and most efficient dilator. The method is a purely empirical one, does not always secure the desired result, and frequently causes abortion or premature labor. Still, as the ultimate gynæcological resort it has important functions.

[Footnote 14: _Lehrb. d. g. Gynaekoloqie_, 1881, p. 841.]

[Footnote 15: _Brit. Med. Journal_, 1875, 1879.]

[Footnote 16: _N. Y. Med. Record_, Dec. 6, 1884.]

Obstetrical.--The evacuation of the uterine contents, if effected before the development of the febrile stage, is usually followed by immediate disappearance of all distressing symptoms. In the large majority of cases, however, the same end may be secured by a judicious combination of the hygienic, medical, and gynæcological methods of treatment to which attention has been directed. The weight of professional opinion is decidedly opposed to the procedure. For practical purposes the induction of premature labor may be excluded from consideration. The woman usually recovers or dies before the period of foetal viability. Carl Braun[17] gives expression to the very general professional conviction upon this subject in the following words: "I myself have never observed a lethal issue in consequence of the uncontrollable vomiting of pregnancy, lay the greatest weight upon the expectant management and more modern medicamentation, and am of the opinion that after a conscientious estimate of all considerations and contraindications, artificial abortion can be omitted, notwithstanding its permissibility from a scientific point of view when extreme danger to maternal life has been determined by several physicians."

[Footnote 17: _Lehr. d. g. Gynaekologie_, 1881, p. 842.]

{413} PTYALISM.

The excessive secretion of saliva is a rare disorder of pregnancy. At all times distressing, it may seriously endanger the patient's life when the quantity of fluid amounts to several quarts per diem. The parotid and submaxillary glands are swollen and tender. The buccal mucous membrane is red and tumid. The absence of fetor serves to distinguish the salivation of pregnancy from the ptyalism of mercurial poisoning. A generous diet and the free exhibition of iron mitigate in some degree the distressing symptoms. Dewees recommends a strictly animal diet. Astringent mouth-washes, small doses of potassium iodide, and subcutaneous injections of atropine over the submaxillary glands are indicated, but seldom influence the condition.

TOOTHACHE.

Toothache in pregnancy may be a purely functional disorder. In the majority of cases, however, actual caries is present. During gestation the secretions of the buccal cavity are sometimes altered, and become sufficiently acid to dissolve the lime salts out of the enamel. Again, when for any reason an insufficient quantity of lime salts is ingested with the food, the foetus is supplied with ossific materials derived in part from the maternal teeth. The condition of pregnancy is not infrequently detected in the dentist's chair from these changes. Popular recognition of these dental changes gave origin to the familiar saw, "For every child a tooth." The indications for treatment are obvious. Quinine and local anæsthetics relieve the symptoms of the functional forms of the disorder. Caries may be prevented, to a certain degree, by extreme attention to the teeth and secretions of the buccal cavity and a free, generous mixed diet. Doubtless, the popular belief, that an absolute fruit diet will limit the deposition of ossific material in the foetal skeleton and render labor easier, is responsible for much of the caries observed in American women. It is needless to say that such a belief is utterly without foundation in fact. When structural changes in the teeth have occurred the decalcified dentine should be excavated, and temporary fillings of oxyphosphates or gutta-percha inserted. This little operation can be performed rapidly, without pain or fatigue, and preserves the contour of the teeth.

CONSTIPATION.

Constipation is a usual, sometimes a troublesome, attendant upon gestation. The etiological factors are mechanical interference of the gravid uterus with intestinal peristalsis, defective innervation of the bowels, and alterations in the intestinal secretions. When the rectum becomes filled with scybalous masses the condition predisposes to abortion or premature labor. Diet is of primary importance in securing regular evacuations of the bowels. Fresh fruits, brown bread, oatmeal porridge are useful to this end. Enemata have obvious advantages over all drugs. In the selection of aperient remedies care must be taken to choose laxatives and avoid drastic cathartics. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia, Hunyadi, Friederichshalle, and Pullna mineral waters, may be included in the list.

{414} DIARRHOEA.

Diarrhoea is a less frequent but more dangerous disorder during pregnancy than constipation. In the early and latter months of gestation diarrhoea is liable to occur from mechanical compression of the rectum by the gravid uterus. Dysentery, with tormina and tenesmus, is a particularly unfavorable complication. The dangers are apparent. Not only is the blood impoverished, but abortion or premature labor may be induced. Every diarrhoea occurring during pregnancy demands immediate attention. Small doses of argentic nitrate in combination with opium, in pill form, are useful in mild cases of diarrhoea, while the deodorized tincture of opium in starch-water enemata is indicated in dysentery.

Diseases of the Liver.

In normal pregnancy the functions of the liver in the secretion of bile and the excretion of cholesterin are not materially modified. The case is different with the glycogenic function. Blot in 1856 detected the presence of glycogen in the urine of nearly half the pregnant women examined. He concluded that this glycosuria was physiological. Tarnier in 1857 called attention to certain structural changes in the liver occurring during normal gestation. The liver is enlarged in volume, and a peculiar fatty infiltration within the lobule is perceptible. De Sinéty confirmed Tarnier's observations, finding the fatty infiltration within the centre of the lobule, seldom near the periphery. Robert Barnes and Ewart have added corroboratory testimony. Tarnier ascribes the physiological glycosuria announced by Blot to the fatty infiltration observed by himself. Each of these three functions of the liver, the secretion of bile, the excretion of cholesterin, and the glycogenic function, may undergo pathological exaggeration during pregnancy.

ICTERUS.

Icterus is observed with relative infrequency during gestation. Two distinct forms are recognized--simple jaundice, with bright-yellow coloration of conjunctivæ and skin, without fever and cerebral symptoms; and malignant jaundice, with dull-yellow coloration of conjunctivæ and skin, with fever and cerebral symptoms.

Simple Jaundice.--Simple icterus may occur at any time during pregnancy, runs its usual course, and exercises, as a rule, no serious influence upon the maternal health. The effect upon the foetus is grave. If the icterus is intense and lasts for a considerable period of time, the foetus dies and gestation is interrupted. All the foetal tissues are found to be stained with the biliary coloring matters--a condition termed by Lobstein cirrhonosis.

ETIOLOGY.--The causes of simple jaundice in pregnancy are identical with those which produce the condition in the non-gravid state, and are frequently obscure. It is in a high degree probable that pressure from the gravid uterus is without influence, since the symptom may appear at any time during gestation. The pathological condition usually present is catarrh of the mucous membrane of the duct or of the duodenum in the vicinity of the orifice, causing a narrowing of its lumen.

{415} SYMPTOMS.--The conjunctivæ, skin, and urine are colored bright yellow, and there is entire absence of febrile and cerebral symptoms.

The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the same as in the non-pregnant state. In view of the possible causative relation between simple and malignant icterus, and the injurious effect upon the foetus, medical treatment should be instituted at once. Restricted diet, mercurials or ipecacuanha, followed by saline cathartics, are the more important measures. Artificial abortion or the induction of premature labor has no effect upon the condition. This operative procedure is indicated in the interest of the child, however, when the icterus is intensive, of long duration, the foetus living and viable, the frequency of the foetal heart-beats diminished, and there is reason to fear its death. Carl Braun recognizes very distinctly the force of this indication.

Malignant Icterus.--Malignant icterus, due to the acute yellow atrophy of the liver of the pregnant woman (Rokitansky), is a very rare disease. Carl Braun has observed the condition only once in twenty-eight thousand cases from 1857 to 1863.

ETIOLOGY AND PATHOLOGY.--Very little is known as to the causes of acute yellow atrophy of the liver. Virchow ascribes one case coming under his own observation to compression of the lower half of the liver and gall-bladder by the growing uterus. The rarity of the affection and its occurrence irrespective of the time of pregnancy prove the limited operation of this etiological factor. It is in a high degree probable that the disease may have its starting-point in simple catarrhal icterus.

The liver is ochre-colored, shrunken to one half its volume, and flaccid. On section no signs of lobular structure are visible. Microscopical examination reveals total destruction of the acini and hepatic cells. In the place of the glandular elements, fat-globules, fine granular detritus, crystals of leucin and tyrosin are noted. The spleen is enlarged and the kidneys show acute inflammatory changes. Extensive ecchymoses are observed under the skin, pericardium, and gastric mucous membrane.

SYMPTOMS.--The prodromal symptoms of acute yellow atrophy of the liver are usually overlooked. A trivial jaundice with slight elevation of temperature may precede by several days the development of cerebral symptoms. Difficulty in speech, headache, disorders of the senses followed by delirium, convulsions (cholæmic eclampsia), and coma are the more important symptoms of cerebral origin. The pulse is remarkably frequent and small. The temperature is at first elevated several degrees, but becomes subnormal prior to death. The urine is sparingly secreted, highly colored by the bile-pigments, and contains albumen, tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the urates are diminished. The combination of symptoms points to the retention within the system of the waste products usually excreted by the liver and kidneys. Ultimately, a condition of complete hepatic and renal insufficiency obtains.

DIAGNOSIS.--The dull yellow color of the skin and conjunctivæ, with fever and cerebral symptoms, is a sign of greatest diagnostic value. Physical exploration reveals tenderness on pressure over the hepatic region, and rapidly diminishing area of hepatic dulness on percussion. Care must be taken to exclude acute phosphorus-poisoning--a toxæmia {416} simulating very closely acute yellow atrophy, and repeatedly confounded with that affection.

PROGNOSIS.--No case of recovery has been recorded up to the present time. The disease pursues a rapidly fatal course, terminating within a few days after the development of the icterus.

TREATMENT.--Therapeutic measures must be addressed to prophylaxis. It is necessary to regard simple icterus as a possible prodrome of the malignant form of the disorder.

DIABETES MELLITUS.

The most superficial discussion of the disorders of pregnancy would not be complete without some mention of diabetes. The existence of physiological glycosuria during pregnancy and lactation has been demonstrated. Bernard has shown that sugar appears in the placenta of calves at an early period, attains its maximum in the third or fourth month, and when the glycogenic function of the foetal liver is established entirely disappears. The relation between physiological glycosuria and that pathological exaggeration of a normal process, diabetes mellitus, is very obscure. It is, however, a clinical fact that diabetes mellitus occurs more frequently in the pregnant than in the non-gravid woman. Diabetic women are less apt to conceive. When conception does occur, pregnancy is liable to interruption from the death of the foetus. Under these circumstances glucose is found in the amniotic liquor and foetal urine. A case related by Bennewitz and cited by Matthews Duncan indicates that diabetes mellitus may be developed during successive pregnancies, and entirely disappear during the intervals. The influence of pregnancy in developing a latent diabetic tendency may be accepted as established. A clinical observation of some importance is that diabetic coma is seldom developed.

PROGNOSIS.--Matthews Duncan[18] has collected the histories of 22 pregnancies in fifteen women varying in age from twenty-one to thirty-eight years: 4 of the 22 pregnancies terminated fatally by collapse, rather than by coma. The majority of the children died during pregnancy after attaining to the age of viability. Two children were feeble at birth, and died a few hours later. One infant was diabetic.

[Footnote 18: _Obstet. Trans._, vol. xxiv. p. 256.]

TREATMENT.--The hygienic and medical treatment of diabetes mellitus occurring during pregnancy does not differ from the therapy in the non-gravid state. There is great diversity of opinion upon the subject of the induction of premature labor. On a priori grounds it would seem to be indicated in the interest both of the mother and the child in the graver cases. In the entire absence of authoritative clinical experience, however, the operation must be resorted to with an extreme degree of caution.

Diseases of the Kidneys.

Albumen is found in the urine of from 3 to 5 per cent. of all pregnant women.[19] In parturient women albuminuria is of much more frequent occurrence. Leube's researches indicate the existence of physiological {417} albuminuria in the pregnant as in the non-gravid state. It is a matter of great practical difficulty to determine the limits of this normal functional activity. In a large proportion of cases the boundary-line between health and disease is passed. The physiological function undergoes pathological exaggeration, and various forms of nephritis are produced.

[Footnote 19: Schroeder, _Lehrb. d. Geburtshülfe_, Bonn, 1884, p. 373.]

ETIOLOGY AND PATHOLOGY.--The types of renal disease to which pregnancy stands in more or less direct causal relation are numerous.

1. Leyden describes a condition, the kidney of pregnancy, which may be regarded as the intermediate stage between health and disease. The amount of albumen is increased; hyaline and granular casts, with renal epithelium, showing fatty changes, appear in the urine. This fatty degeneration of the cells covering the glomeruli and lining the uriniferous tubules is not of an inflammatory nature. Anasarca of the lower extremities is usually present. The condition may last for an indefinite period of time without causing serious symptoms. With the expiration of the term of pregnancy it may disappear, leaving no trace of its former existence. On the other hand, the kidney of pregnancy may be the starting-point of some serious renal lesion.

2. Latent chronic interstitial nephritis, chronic tubal nephritis, and lardaceous degeneration of the kidney are usually influenced unfavorably by pregnancy, and, in turn, may lead to the interruption of that state. Chronic interstitial nephritis and chronic tubal nephritis may have their origin in the kidney of pregnancy. The cirrhotic kidney is distinguished from the other forms by the abundant aqueous urine, containing comparatively little albumen--none at all at times--cardiac hypertrophy, and hard pulse. In the differential diagnosis of chronic tubal nephritis and the kidney of pregnancy chief reliance must be placed upon the history of the case and the course of the affection. Albuminuria is a very inconstant symptom of the lardaceous kidney, especially in the beginning and ultimate stages of the disease.

3. Mixed types of chronic Bright's disease are frequently observed. Thus, the interstitial and tubal forms of the disease may be combined. Lardaceous degeneration may be present with either form, and fatty changes are common in all the types of Bright's disease. Eclampsia is of relatively infrequent occurrence in chronic Bright's disease, although anasarca and its consequences may cause the interruption of pregnancy.

4. Acute Bright's disease is one of the most serious disorders occurring in the course of pregnancy. The urine is diminished in quantity, and contains a large amount of albumen, tube-casts, and red blood-corpuscles. Eclampsia is of frequent occurrence, and usually induces abortion or premature labor.

The causes of renal disease and of its symptom albuminuria are not always evident. In the kidney of pregnancy there is no inflammatory change. The cells covering the glomeruli and the glandular cells lining the uriniferous tubules undergo fatty degeneration, and are cast off as the result of anæmia.

In the acute and chronic forms of renal inflammation there is a variety of probable etiological factors. Mechanical pressure from the gravid uterus may impede the return of venous blood and determine congestion of the kidneys. This explanation is rendered more probable by the fact {418} that albumen usually appears in the urine after the fifth month, when the uterus has attained considerable size. Albuminuria is of comparatively more frequent occurrence in primiparæ with tense abdominal walls. It is frequently observed in cases of large ovarian cysts and uterine fibroids. The increased functional activity of the organs, the elevation of blood-pressure, the alterations in the constitution of the blood, are doubtless potential factors. When any latent tendency to Bright's disease exists, exposure to cold and impeded cutaneous functional activity are more likely to develop the disease in the pregnant than in the non-gravid state. Compression of the ureters is regarded by Halbertsma as a cause of great importance.

SYMPTOMS.--The symptoms of Bright's disease in pregnancy are neither uniform nor constantly present. Anasarca frequently directs attention to the patient's condition long before the appearance of more significant signs. Oedematous swellings of the face, hands, arms, feet, legs, and labia majora are always suspicious, and should lead to an examination of the urine. These oedematous swellings are wandering--appear when the patient is lying down, and disappear when she rises and walks about. Sometimes, toward the end of pregnancy, they become less marked, not infrequently entirely disappearing, while the albuminuria is increasing. The skin covering the oedematous portions of the body is dry, of a chalkish-white appearance, and the surface temperature is depressed.

Anomalous nervous phenomena, such as headache, vertigo, dimness of vision, spots before the eyes, ringing in the ears, sudden deafness, obstinate nausea and vomiting, sleeplessness, neuralgia, are often observed, and should always excite suspicion. These various nervous symptoms may be viewed as produced by the retention within the blood of certain substances normally excreted by the kidneys.

Convulsions, due to renal insufficiency, may occur during pregnancy, but are observed more frequently during parturition and the puerperium.

Attention has already been called to the characters of the urine. It is necessary to remember that in the granular, contracted kidney and lardaceous degeneration albuminuria may escape observation.

Bright's disease strongly predisposes to abortion or premature labor.

PROGNOSIS.--Any organic disease of the kidneys is serious. When the disease is extensive and involves both organs the prognosis is especially unfavorable. Accurate conclusions as to the dangers of Bright's disease during pregnancy are not justified by the present state of our knowledge. It is only possible to say, in a general way, that the prospect of recovery is less favorable than in the non-gravid state. Owing to the strong predisposition to abortion and premature labor, the chances of the foetus surviving pregnancy are relatively slight. Even if the child is not prematurely expelled from the uterus, it usually succumbs to the influence of the excrementitious products retained within the maternal blood.

TREATMENT.--In view of the serious complications arising in pregnancy from interference with the functions of the kidneys, the absolute necessity of chemical examination of the urine at regular intervals in every case, especially during the latter half of gestation, is apparent. When pathological albuminuria is present, rational therapy will be directed to the removal of the cause. Evacuation of the uterine contents is the only mode of removing the pressure from the gravid uterus, but {419} we have a variety of expedients, hygienic and medical, which must be invoked before resorting to such a radical procedure.

Hygienic.--The diet should be restricted, as far as possible, to milk, and nitrogenous articles of food must be forbidden. The functional activity of the skin can be maintained by frequent baths in lukewarm water. Vapor baths are of still greater value. Hot-water baths are employed on an extensive scale in the obstetrical clinics of the Vienna General Hospital. Carl Braun, Josef Spaeth, and Gustav Braun give testimony to their efficacy. Indeed, in Vienna chief reliance is placed upon the hot-water bath as a prophylactic and remedial agent. Breus[20] has recently described the method usually practised. The patient is placed in a bath-tub filled with water at a temperature slightly above 99° F. The tub is then covered with a heavy blanket, leaving the face free, and the temperature of the water is gradually elevated to 110° or 112° F. She remains in the bath thirty minutes. A towel wrung out of ice-water and placed upon the head relieves any distressing cephalic sensations. While in the bath the patient drinks large quantities of water. Upon emerging from the bath she is covered with a warm sheet and enveloped in an upper and lower layer of thick blankets, so that only the face is exposed. Within a very few minutes free perspiration is observed. The sweating is continued for two or three hours. According to the gravity of the case the hot-water bath may be repeated once daily for an indefinite period. The relief of all threatening symptoms under this simple plan of treatment alone is surprising. Sometimes the hot-water bath acts as an efficient excitant of uterine contractions, and premature labor is induced. A. Sippel[21] calls attention to this fact, and proposes hot-water baths as a harmless method of induction of premature labor. Although such an event is not undesirable, it is unusual, and occurs only when the temperature of the water reaches a great elevation or the baths are frequently repeated, or, finally, when there is a very decided predisposition to the interruption of pregnancy. The lateral or latero-prone posture during sleep serves to relieve in some degree the kidneys of the pressure from the gravid uterus, and should be advised.

[Footnote 20: _Arch. f. Gynaek._, vol. xix. p. 219.]

[Footnote 21: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]

Medical.--The exhibition of non-irritating diuretics, such as the acetate and bitartrate of potassium, in large quantities of water, causes an increased secretion of urine and lessens the congestion of the renal vessels. Among the mineral waters Bilin, Giesshübel, Preblau, Selters, and Vichy deserve commendation. Benzoic acid, in conformity with Frerichs' suggestion, is employed in Vienna. The tincture of the chloride of iron, alone or in combination with small doses of tincture of digitalis, is an efficient diuretic, and at the same time an excellent tonic.

Cathartics which produce large, watery stools without much irritation supplement the action of diuretics. The compound powder of jalap and the saline purges fulfil this indication. Care must be taken, however, to avoid the drastic effects of too large a dose.

Jaborandi and pilocarpine have been, and are at the present time, extensively used to aid in the elimination by the skin of retained excrementitious matters. The weight of authority is decidedly against the exhibition of this remedy. At best, it is uncertain in its action. It is a cardiac depressant, and frequently stands in a causal relation to {420} pulmonary oedema. For these reasons the drug has been condemned in unequivocal terms by Carl Braun and Fordyce Barker. The same effect, with less risk, can be produced by the hot-water baths.

Local Treatment.--In the acute forms of Bright's disease various modes of counter-irritation are useful. Wet and dry cups and leeches applied to the loins are indicated. Frerichs recommends pills of the extract of aloes and tannin with the view of restoring the normal tonus to the blood-vessel walls.

By a judicious combination of these varied therapeutic resources, hygienic and medical, threatening symptoms may be averted. Cure of Bright's disease, acute or chronic, is seldom if ever achieved during pregnancy. Not unfrequently, however, notwithstanding all efforts, the amount of albumen steadily increases, hydræmia becomes more pronounced, hydropsies appear with threatening cerebral, cardiac, or pulmonary symptoms. More active treatment is demanded, and the subject of the induction of premature labor must be seriously considered. Without entering into a detailed discussion of the arguments for and against the artificial premature interruption of pregnancy under these conditions, let it suffice to say that clinical experience furnishes overpowering evidence in favor of the operation. The weight of professional opinion is also very decidedly in favor of the artificial induction of premature labor. In the selection of the method for the induction of premature labor it is well to bear in mind the possible excitant effect on uterine contractions of hot-water baths, as pointed out by A. Sippel.[22]

[Footnote 22: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]

Skin Diseases.

Diseases of the skin occur with comparative frequency during pregnancy. Latent diatheses are roused into activity. The graver forms of skin disease usually disappear during or shortly after the puerperium. These facts point to some causal relation between the diseases and gestation. Under the increased activity of the glandular system the growth of hair may be stimulated, giving origin to a condition termed by dermatologists hirsuties gestationis. Slocum[23] relates the history of a case in which a woman in successive pregnancies grew a full beard. Anomalous deposits of pigment, constituting the condition known as chloasma uterinum, are observed, more especially among pregnant women exposed to sunlight. Chloasma is interesting from a diagnostic point of view, since it is liable to be confounded with pityriasis versicolor, an affection of frequent occurrence during pregnancy. The red nose of acne rosacea may be one of the first signs of pregnancy. General pruritus, a rare affection, belongs to the class of idio-neuroses (Hebra). Spiegelberg relates the history of a case of general pruritus occurring in an old primipara. The affection made its appearance in the second month, and continued without material abatement of symptoms throughout the period of gestation. Pruritus of the vulva is a common disorder of pregnancy. It is usually symptomatic of eczema, some inflammatory condition of the genitalia, or diabetes mellitus. The treatment must be directed to the removal of the cause. Vaginal douches containing vegetable or mineral astringents will {421} afford relief when the itching is due to acrid vaginal secretions. Dilute solutions of corrosive sublimate in water or alcohol (1:100 or 200), followed by compresses saturated with tar-water, are recommended very highly by Spiegelberg.

[Footnote 23: _New York Medical Record_, 1875.]

Pregnancy cannot be regarded as a cause of psoriasis. When that affection exists, however, it is usually aggravated. The elder Hebra[24] in 1872 described a rare form of skin disease occurring in the course of pregnancy which he called herpes impetiginiformis, and of which he encountered five cases. Grouped vesicles upon inflamed bases appear about the genitalia, and subsequently diffuse themselves by successive crops over the body. Great prostration, rigors, and intense fever accompany the eruption. Four of the five cases terminated fatally. Milton and Duncan Bulkley a few months later described a rare skin affection peculiar to pregnancy which they designated herpes gestationis. Erythema, papules, vesicles, and bullæ are developed. Vesicles predominate, appear on the lower extremities, subsequently spreading over the body. Intense itching and burning attend the vesicles. Urticaria, neuralgia, and other neurotic troubles accompany the affection. The disease appears early in pregnancy, continues until after delivery, and is apt to recur with succeeding pregnancies. The constitutional symptoms are much less severe than in the condition described by Hebra. At the meeting of the American Dermatological Society, 1885, L. A. Duhring[25] called attention to the relation of impetigo herpetiformis, herpes gestationis, pemphigus, and certain other forms of disease to dermatitis herpetiformis. Attention was briefly directed to the identity of the impetigo herpetiformls of Hebra with dermatitis herpetiformis. Herpes gestationis was a misnomer, the affection being found in men as well as in women. The disease was the vesicular variety of dermatitis herpetiformis. The peculiar forms of pemphigus observed during pregnancy, not of syphilitic origin, may be viewed as examples of the same disease. Duhring thinks that "we stand on the threshold of our knowledge of the disease."

[Footnote 24: _Wiener Med. Woch._, No. 48, 1872.]

[Footnote 25: _Journal of Cutaneous, etc. Dis._, October, 1885, p. 317.]

Neuroses.

Of all the neuroses occurring in the course of pregnancy, puerperal eclampsia is of chief clinical importance. Puerperal convulsions, however, occur more frequently during labor and the lying-in period than during gestation. For this reason the subject is usually discussed in connection with the pathology of the puerperium. The various psychoses are referred for a similar reason to the same chapter.

TETANUS.

Tetanus, a rare affection, especially in women, is occasionally observed in pregnancy. It occurs with greatest relative frequency in hot climates after abortion and the removal of placental or decidual remains. Sir James Y. Simpson collected 28 cases which sustained some relation to abortion or labor. Mr. Waring[26] has collected 232 cases occurring in a tropical climate.

[Footnote 26: _Indian Annals_, 1855.]

{422} The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases, only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.

In the entire absence of knowledge of the pathology of the disease, TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite of amyl are the remedial agents usually employed.

CHOREA.

Chorea occurs in pregnancy as an accidental complication or as the direct result of that state. It is a rare disorder of pregnancy. Spiegelberg has observed 3 cases; Barnes has collected 56 cases; Fehling[27] brings the number up to 68; altogether, 84 cases are on record.

[Footnote 27: _Lehrb. d. Geburtshülfe_, 1882, p. 239.]

ETIOLOGY.--The investigations of Robert Barnes show that where chorea arises in pregnancy in the large majority of cases there is a history of chorea in childhood, acquired predisposition prior to pregnancy, or hereditary "nervous diathesis predisposing to chorea." The connection between rheumatism, endocarditis, and chorea is a well-established fact. The precise nature of this relation is unknown. Hughlings Jackson has constructed the theory of "embolism of the small branches of the middle cerebral artery supplying the structures near the corpus striatum." Robert Barnes[28] calls attention to the following facts, which invalidate this ingenious theory: "(1) The frequent recovery of choreic patients; (2) the occasional immediate cessation of choreic fits upon delivery; (3) the progressive character of the disease during pregnancy, convulsions increasing in severity, and the gradual development of mania in some cases; (4) the fact that embolism is rare during pregnancy." In the absence of any definite cause, Spiegelberg refers a large number of these cases to the class of reflex neuroses. All the elements essential to a reflex neurosis are present. We have (1) a predisposition to chorea, inherited or acquired; (2) inanition of the central nervous system incident to the hydræmic state of the blood in pregnancy; (3) various potential peripheral irritants in connection with the sexual organs. Intense emotions, terror and the like, may act as exciting causes.

[Footnote 28: _Obstetric Medicine and Surgery_, London, 1884, p. 379.]

COURSE AND SYMPTOMS.--Chorea usually makes its appearance in the course of the first half of pregnancy, and continues until the beginning of labor. Sometimes choreic attacks are witnessed during parturition. In only 3 out of the 84 recorded cases the disease continued after the puerperium. Primiparæ are more frequently affected than multiparæ. The disease is liable to recur with succeeding pregnancies, entirely disappearing in the intervals. The choreic movements are the same as in the non-gravid woman affected with the disease. They are usually bilateral. As in chorea in the non-gravid state, transitory albuminuria and glycosuria may be observed. The increase of urates and phosphates in the urine is interpreted as the result of nervous excitement and muscular activity. Pregnancy is interrupted in about one-half the cases. The child may be born alive and affected with the disease.

PROGNOSIS.--Out of the 84 cases, 23 terminated fatally as the result of complications. Mania, loss of memory, grave cerebral and spinal lesions are occasionally traceable to the chorea of pregnancy. The {423} prognosis with reference to the child is unfavorable, from the tendency to the premature interruption of pregnancy.

TREATMENT.--The palliative treatment of chorea occurring in pregnancy is unsatisfactory in the extreme. All the specifics of greater or less value in the non-gravid state are frequently without influence during gestation. The diet must be nutritious and easily digestible. Large doses of iron and quinine are indicated. As in other convulsive disorders, during the paroxysms chief reliance is placed upon anæsthetics, subcutaneous injections of morphine, potassium bromide, and chloral. Charcot recommends the exhibition of large doses of bromide of potassium through a considerable period of time. Clifford Albutt extols succus conii. In over one-half the recorded cases the most judicious combinations of hygienic and medical therapeutic resources have proved of no avail. In view of the prognosis, the induction of premature labor is usually indicated, in the interest of both the mother and child, at an early stage of the disease. Sometimes the question of the artificial induction of abortion comes up for consideration. In view of the grave cerebral and spinal lesions which may result from the affection, the mother is justly entitled to the benefit of the doubt. It may not be amiss to add that this indication for the induction of abortion is not generally recognized.

EPILEPSY.

Epilepsy is usually an accidental complication of pregnancy. Spiegelberg[29] is responsible for the observation that in chronic epilepsy pregnancy sometimes modifies the course of the affection in a favorable manner. The seizures occur less frequently and are not so violent in character. Acute epilepsy may be developed as the result of pregnancy when a latent predisposition, inherited or acquired, exists. The epileptogenous zone in acute epilepsy comprehends the distribution of the ischiatic nerve. Acute epilepsy disappears with the cessation of pregnancy, but is apt to recur with succeeding gestations.

[Footnote 29: _Lehrb. d. Geburtshülfe_, 1882, p. 241.]

The occurrence of acute or chronic epilepsy during pregnancy is of great diagnostic interest from the resemblance of the epileptic seizures to the convulsions produced by renal inadequacy. The urine secreted during or after an epileptic fit is usually free from albumen. In the severest forms of puerperal eclampsia the urine may also be entirely free from albumen and tube-casts. In the ultimate stages of amyloid degeneration[30] and atrophy of the kidney, the most formidable forms of Bright's disease, albumen may not appear in the urine.

[Footnote 30: Carl Braun, _Lehrb. d. g. Gynaek._, 1881, p. 827.]

The DIAGNOSIS is usually cleared up by the history of the case and the course of the affection.

The PROGNOSIS with reference to mother and child is favorable. Epilepsy rarely leads to the premature interruption of pregnancy.

The TREATMENT is the same as in the non-gravid state.

Disorders of the Special Senses.

Disorders of the special senses usually occur in the course of pregnancy as symptoms of acute or chronic Bright's disease. Amblyopia, amaurosis, {424} ringing in the ears, sudden deafness, loss of taste and smell, may be developed under the influence of renal inadequacy before or after the occurrence of puerperal convulsions. Apart from the disorders of the special senses dependent upon lesions of the kidney, disturbances of vision are of chief clinical interest.

Amblyopia, hemeralopia, and color-blindness are occasionally observed as the result of nutritive disturbances in the retina. Nyctalopia, Spiegelberg says, is not recorded in the literature of the subject.

The PROGNOSIS is favorable as a rule. The disorders of vision usually disappear during the puerperium, and evince no tendency to recurrence.

Generous diet, iron, and a tonic plan of treatment are indicated.

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