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VOL. IX.

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No. 7.

ALBUMINURIA OF PREGNANCYRETINITIS-INDUCED PREMATURE DELIVERY.*

BY S. D. RISLEY, M. D., PHILADELPHIA. Mrs., æt. 35, consulted me in September, 1884, because of rapidly failing vision. She was pallid and very feeble, having quitted her bed in order to make the visit to the city. She was brought by her husband, a capable physician of large experience, who related that she was pregnant, between the fourth and fifth months; that she had from the first suffered very much from morning sickness, and later from violent morning headache, with which she awoke. The pain was chiefly frontal and subsided toward midday. Its duration steadily increased, however, until it became quite constant and more and more severe, at last confining her to her room and much of the time to her bed. Within the preceding week these symptoms, especially the headache, had very much ameliorated, but with the diminished pain begun the failing vision, which rapidly declined until in O. D. V = counts fingers at two feet eccentric fixa

vealed the usual appearances of pronounced albuminuric retinitis.

In O. D. Mac: = em. while the most prominent part of the nerve = + 3.5 D. There was marked infiltration of retina, giving a snow-bank appearance around the nerve, and extending far into the peripery of the eye ground. The nerve margins, and in many places the retinal vessels, were quite hidden by the swollen and opaque retina. There were numerous linear hemorrhages scattered throughout the eye ground.

In O. S. there were no hemorrhages, and the swelling was not so great, but the retinal infiltration was very marked, and the nerve The margins could be seen with + 2 D. gray-white appearance extended as teriorly as the ophthalmoscopic picture; the veins were tortuous, and both arteries and veins were lost in many places in the opaque retina. A specimen of urine immediately procured became an almost solid mass on boil

ing, and after standing two days showed only of supernatant fluid.

The patient had had albuminuria in a former pregnancy, which had terminated normally in all respects. The albuminuria had disappeared after parturition, and did not reappear during a subsequent pregnancy.

The very serious nature of her accident

was apparent. There was still more than four months before her gestation would naturally terminate. Long before its completion, however, she would be hopelessly blind. If even her life were spared to the full time, she would then be exposed to the serious accidents which hang like a pall over the childbed of the albuminuric woman.

Having in view this outlook-full of foreboding-I suggested to her husband the advisability of induced labor, but asked for counsel. Later in the day, Dr. William Goodell, of Philadelphia, in consultation with the patient's husband and myself, also advised abortion. This advice was given to the patient, who very promptly refused on moral grounds to accept it; and every argument failed to shake her determination. It was then suggested that she return to her home, lay the matter before her clergyman, and be governed by his advice. The subsequent history is well told in the following letters from her husband:

OCTOBER 5TH, 1884.

MY DEAR DOCTOR: Owing to my great distress of mind I have failed to write you earlier of my wife's condition. Soon after our return home, Mrs. 's clergyman, saw her, but it was only after a great deal of argument on his part that she was convinced of her duty as to accepting the means offered for her relief. She finally acquiesced, and on the Saturday following our visit to you I introduced the first sponge-tent, which was followed by three others, when on Tuesday morning she began labor, and was delivered of a living foetus at about the fifth month. She at once went into an unconscious condition without convulsions. The urine was then about 25 per cent. albumen, and contained hyaline and epithelial casts, containing granular matter. Sp. gr. L010. She remained in this condition until Friday evening, when there were gleams of intelligence, but evidences of right hemiplegia, with consequent aphasia, which remains complete, whilst intelligence is growing brighter. *** The albumen has gradually diminished until now there is a mere trace. The gran. matter and casts cannot be found. The quantity of urine. voided rather above the normal than below it. Yours, etc.,

On November 1st he writes again, as follows:

MY DEAR DOCTOR: *** There are still

traces of albumen in the urine, but the microscope reveals nothing to indicate serious lesion when complete involution of the womb shall in the kidneys. I am trusting to the time have been established, for the removal of all traces of impaired function in that organ. The aphasia still exists. There are times when from sudden impulse or quickened emotion, she may utter a complete and intelligible sentence, bearing with it complete sense of her meaning, but when she is asked to repeat it, or any part of it, she utterly fails. Her intelligence is quick, and she comprehends all that is said to her or done for her, and thoroughly appreciates her condition. Frequently, when by all the effort she can command she fails to make her nurse or physician understand her, she gives vent to an expression of disappointment or despair, as "Oh Mercy!" or "Oh my!" words which never seem to fail her. She can sing any air, in perfect time with which she may be acquainted, and always the air which may be called for. The retinal trouble has certainly very much improved *** as shown by her improved vision. had Dr. of our city, examine her eyes last week. He still finds exudation spots on the retina of both eyes, and in the region of the macula in the right eye very considerable. Her diet has been milk exclusively until within the past few days, when she was permitted to have several roasted oysters with the gills and muscular portions taken out. She has taken the Buffalo Lithia-water with much benefit, and until recently the strychnia mixture with Basham's and mild aperients. I trust that the cerebral defect may pass away by solution of what is evidently an embolism, or by the establishment of collateral circulation without leaving disorganization.

Yours, etc.

I

Physicians and Surgeons.

About two months ago, Daisy B., æt. 9, came to my Dispensary Clinic for treatment. She had been sick for two years, and despite various treatments was constantly losing

weight, and bid fair to succumb to the malady. The child presented the following symptoms: Marked pallor of face; puffiness about the eyes; pallid lips and gums; sordes on the lips, gums and tongue; enlarged tonsils, on both of which were excavated gangrenous ulcers, which bled frequently; hemorrhages from nose and gums, often alarming; dropsical swellings of both lower limbs, feet and ankles; purpura hemorrhagica over abdomen, back, arms and limbs; large ecchymotic discoloration around both ankles; appetite entirely absent; great thirst; constant fever; bowels diarrhoeic; urine colorless, passed in large quantities both day and night, and of intense saccharine odor. The child was weak, listless, and could not be induced to leave the house.

The entire history was elicited at the first examination, with the exception of that portion pointing to the diabetic condition. The enlargement of the liver and spleen made out by percussion and palpation, co-added to the other symptoms, led me to the diagnosis of pernicious anæmia following a long-standing chronic malaria. In accordance therewith, I prescribed 8-grain doses of quinia thrice daily, and inunctions of ungt. hydrarg, and ext. of belladonna rubbed over the region of the liver and spleen.

The second visit of my patient proved the utility of the treatment in ameliorating the fever, and diminishing the hepatic and splenic symptoms. Whilst in my office, she desired

that it was due to traumatism, of eight years' standing. The amputation was performed six years ago. Two years ago he contracted syphilis, and says that the primary lesion was burned with nitric acid. For the first six weeks of the present illness he was attended by a physician of Armstrong county, Pa., who has informed me that he gave him specific treatment, i. e., iodide of potash.

When first called to see the patient, I found him sitting on a lounge, with a crutch by his side, and in an exceedingly good humor. He asked for a private conference, and gave me a minute account of his trouble. If any symptom was omitted, it was because the patient's memory was at fault. He acknowledged to being a whoremonger, and stated that he was in the habit of working for a few months, and then going on a spree until his money was exhausted. His present illness was the ending of such a debauch.

At first sight I made up my mind that I had a common combination of causes to deal with; there was an hysterical element in the case, and very probably masturbation.

The principle trouble complained of was weakness, and inability to move about. The patient and his friends had made a diagnosis of "wasting of the muscles" or "dry consumption," and insisted that I should confirm it; this I refused to do, until the case had been under observation long enough. It was true that the muscular system was atrophied to some extent, but I have frequently seen typhoid patients much more emaciated, and only lately met a young physician whose physical proportions were about the same, but the cause in the latter was the morphine habit.

I have seen progressive muscular atrophy in the clinics of Arnold, of Baltimore, but none of his patients bore the slightest resemblance to this individual. The treatment adopted was tentative. General anæmia, anorexia, constipation, seemed to be as much to blame as atrophic disturbance.

After emptying the intestinal canal of a large amount of fecal matter, by the use of calomel and a saline, his appetite returned to some extent, and his tongue assumed a nor

mal appearance, instead of a dirty yellowish coat, and the breath lost its foul smell. The respired air is not the seat of bad odors always, the condition of the buccal cavity frequently is the source of the trouble. To stimulate the circulatory function, warm baths and massage were ordered, and at first tr. ferri chloridi was prescribed as a tonic; this, however, was soon changed to calcium fluoride. His improvement was steady for about three weeks, when his friends demanded a consultatation; this was refused because of the character of the men chosen, and so the patient passed out of my hands.

At this time the patient is in the same condition as when I first saw him. It is possible, nay probable, that he has progressive muscular atrophy, because there is a history of syphilis, and the evidences of masturbation are visible. Both are powerful for evil when their influence is exerted upon the human system, but the other factor, namely, hysteria, contributes its share toward making an interesting and obscure case.

[For the Summary.] DIAGNOSIS OF EARLY PREGNANCY.

BY DR. C. COLEMAN BENSON, BALTIMORE, MD.

Early pregnancy, that is from the second week after conception, can be readily and harmlessly ascertained by the careful introduction of the uterine sound and digital touch, and the following physical signs will be presented to the examiner: there will be lengthening of the body of the uterus with curving at one angle of it, near the os, of the fallopian tube, either left or right, flaccidity of the uterine walls, marked dilatation of the internal os, and of the canal of the cervix, with pouting and cedema of os tincæ, and plugging of the canal, due to congestion of the endometrium.

If we recall the physiological conditions of the uterus at the period of conception, we shall find increased vascularity with excessive thickening and rugation of its lining mucous membrane, conditions which always precede