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ALBUMINURIA IN PREGNANCY.
ALBUMINURIA IN PREGNANCY.
969
should
undoubtedly form part of the routine daily investigation of every such case, but to suggest that albuminuria in the absence of a raised blood pressure is of no significance is to imply that treatment is unnecessary, and this may be disastrous. The only known cause of the toxaemias of pregnancy, in Mr. GIBBERD’S view, is pregnancy, and he does not discuss the possible predisposing LONDON: SATURDAY, OCTOBER 31, 1931. factors ; but his papers throw much light on the immediate and remote prognosis. He lays stress ALBUMINURIA IN PREGNANCY. on the pre-eclamptic nature of the albuminuria THE rapid increase and improvement of ante- and quotes the interim report of the Committee natal work throughout the country means that on Maternal Mortality as showing that in twomore and more women are having their urine thirds of the fatal cases of eclampsia investigated regularly examined throughout pregnancy. There the urine was not adequately tested before the is, therefore, a growing need that practitioners fits started, and that in the majority of the remainshould have a clear conception of the significance ing cases where albumin had been discovered of albuminuria in pregnancy and of the treatment reasonable treatment had not been immediately necessary to avoid complications which may come begun. In 8000 deliveries by the Guy’s Hospital in its train. Mr. G. F. GIBBERD has lately given obstetric department in the last five years, he us a valuable exposition of these matters,! and it says, 300 cases of albuminuria of pregnancy were is appropriate to consider his opinions in con- discovered and treated. There were only two junction with those expressed by Dr. G. W. cases of eclampsia-one of the rare fulminating THEOBALD at p. 948. type, and the other in a patient who refused Dr. THEOBALD suggests that the albuminuria treatment for her albuminuria. Dr. THEOBALD associated with pregnancy can be accounted for believes that 20 per cent. of eclampsia is of the by mechanical means, among which he places fulminating type, a very high estimate. He has first lordosis and the diminished thoracic capacity also reported two cases of eclampsia without associated withthe later months of pregnancy. albuminuria,2 but these must be exceedingly rare. He shows clearly that dogs pass small quantities Mr. GIBBERD finds that 3 to 5 per cent. of all of albumin when placed in a position of marked previously normal women develop albuminuria lordosis; on the other hand, such experiments during pregnancy, and that more than half of these, hardly reproduce the normal anatomical condition in the absence of proper treatment, sustain of the abdomen late in pregnancy. His success permanent renal damage. Ten per cent. of them in producing slight albuminuria in non-pregnant show patent chronic nephritis, while 50 per human beings by maintaining a modified Walcher cent. have recurrent albuminuria in subsequent He infers in these the existence of an position for 40 minutes will also be criticised as pregnancies. " bearing little relation to the normal. Again the occult nephritis," but unfortunately he does not slow deep breathing which, he shows, may cause explain clearly the character of the chronic transient albuminuria is by no means usual in nephritis usually found, nor estimate the consethe later stages of gestation. There will be general quent interference with health and limitation of agreement, however, with his observation that life. It is well known that death from chronic of the incidence experimental orthostatic nephritis may follow albuminuria of pregnancy is affected albuminuria by diet-that after a meal after a period of years, but Mr. GIBBERD’s estimate rich in protein albuminuria appears earlier and is that this is the fate in 10 per cent. of all cases is of larger amount than after a meal poor in protein. unexpectedly high. It is to be hoped that in the Moreover his proof that venous congestion of near future he and other workers will be able to the kidney causes albuminuria in dogs is supported offer a more precise ultimate prognosis. What is by a certain amount of clinical evidence that the fate of his many cases of occult nephritis venous congestion sometimes plays a part in where there are no further pregnancies ? If the presence of chronic nephritis is proved in causing the albuminuria of pregnancy. Thus a raised intra-abdominal pressure is more frequently a pregnant woman Mr. GIBBERD rightly holds that seen in primiparae than multiparse, and so is the pregnancy should be ended, both because albuminuria-both being more marked as full it increases renal destruction and because the term approaches. But cases are common in which child has little chance of survival. His proposed the pressure is raised yet there is no albuminuria treatment is based upon his figures, and may be and this indicates the operation of one or more briefly described under the headings of rest, additional factors, notably toxaemia. Further, diet, and if necessary termination of pregnancy. the appearance of albuminuria in the early stages There is general agreement on the outstanding of pregnancy makes it certain that albuminuria importance of rest in the treatment of all renal must often be non-mechanical in origin. We are disease, and if his figures showing permanent forced to conclude that in no case of albuminuria renal damage in a large proportion of cases of of pregnancy is it safe to presume that the cause albuminuria of pregnancy are confirmed by other is solely mechanical. Blood pressure estimations observers the prevalent treatment of this condition
THE LANCET.
1 THE
LANCET, Sept. 5th, p. 520,
and
Sept. 12th,
p. 576.
2
Jour. Obst. and Gyn. Brit.
Emp., 1929, xxxvi., 803.
970
BRITISH COLLEGE OF OBSTETRICIANS AND
must be severely criticised and altered. Ambulatory treatment combined with a diminished diet and saline aperients must be replaced by absolute rest in bed until albumin can no longer be detected.
GYNÆCOLOGISTS.
had not recognised the force of the argu. ments adduced by the innovators. Both insight and tact were displayed on either side over a
Colleges
considerable
period, during which the services which of obstetrics and gynaecology might college discharge for the good of the public were steadily made prominent. Thus it came to be recognised by prominent members of the Royal Colleges that they had not to protect their institutions from trespass, and these took, finally with readiness, the liberal view that public needs would be met by a body which would be of an auxiliary and not of a competing character. The principal argument for the foundation of the College of Obstetricians and Gynaecologists was, of course, the desire to combat maternal mortality, where the figures are an admitted reproach when the progress of medicine and surgery in every other branch is estimated. A College of the nature projected it was felt would provide fuller opportunities for the development produced. The bowels should be kept regular, but clinicians: of exact knowledge, would raise the standard of ,differ considerably about the value of purgationL education on the subject, and give to the practi.and diaphoresis. Mr. GIBBERD favours both inL tioner an added prestige. No one denies that in moderation. He induces labour in all severe cases the institution of the College we have a certain that fail to react to strict medical treatment, asI separation of diseases peculiar to women from other .outlined above, after a trial of two or three days. branches of medicine and surgery, and that this He also insists that even slight cases which fail to) does not accord with that unity in scientific clear up completely after a fortnight’s treatment medicine which is the accepted ideal. But the should have labour induced. His figures show a cleavage, such as it is, will not be of a nature to very definite increase in the incidence of both embarrass the public, and, with the development of patent and occult nephritis where the albuminuria the activities of the new College, it will be closed up, has been allowed to continue three weeks or more. so as to represent only such a division of function as belongs to all orderly growth. It is urgently our that standard of obstetrics should necessary and while the Fellows and Members be raised ; BRITISH COLLEGE OF OBSTETRICIANS AND of the young corporation may regard this as their GYNÆCOLOGISTS. prime responsibility, they cannot fail to extend our THE British College of Obstetricians and Gynaeco- wisdom along general gynaecological lines. It is good to see that the Royal College of logists held its full dress ceremonials on Friday, Oct. 23rd, when Prof. BLAIR BELL, the President, Physicians of London has already asked the conferred certain honorary Fellowships of an College of Obstetricians and Gynaecologists for a international character, admitted the newly elected panel of names for the examinership for the Fellows and Members to their College, and then Conjoint Diploma ; this is a practical step towards presided over the first annual dinner of the new that fusion of interests which was held up as corporation. The proceedings went with a smooth- necessary by speakers at the first annual ness and dignity which augurs well for the future. of the College. For medicine to serve the public It is widely known that the foundation of the practically, it is particularly valuable that the College was attended with considerable difficulty. medical profession should itself present a general The idea of a separate medical corporation to take uniformity of view. :particular charge of obstetrics and gynaecology did not at first commend itself to many professional leaders, nor, which was very important to the RACIAL HERD-IMMUNITY OF THE MAORI. pioneers of the movement, was it wholly acceptable AN appendix to the latest annual report of the to the Royal Colleges of Physicians and Surgeons. The successful promoters of the new College can Director-General of Health for New Zealand contains be congratulated alike upon their diplomacy and some statistics on the differential immunity of pure their energy. Individual converts, they saw, and cross-bred Maoris. A group of some 2000 would be obtained in sufficiency when the support children, aged 5 to 15, which included full, three. of the Royal Colleges was obtained, and they quarter, half, and quarter bred Maoris, werE concentrated upon this issue. They knew that submitted to four. immunity skin tests-Schick, before the aims and ideals of the new College could Dick, Pirquet, and Casoni (intradermal injection be recognised as sound, it would have to be shown of hydatid cyst fluid). According to these tests, that it would be able to do something which the the susceptibility of the group to diphtheria, existing Colleges could not do. To prove a negative scarlet fever, and tuberculosis definitely declined is always hard, and a period of wrangling might with age in the same way as is usual with pure well have ensued if the leaders of the Royal European stocks. No age gradient was however
Difficulties will arise where the woman has no available domestic help, but this drastic treatment must be achieved if its necessity is proved. ’The accepted view is in favour of a diet consisting of glucose and large quantities of fluid in the first few days of treatment, but the continuation of a protein-free diet possibly for many weeks is open to objection. Probably the greatest degree of metabolic and renal rest is to be got by providing enough protein for the normal anabolic processes of the body at rest ; for otherwise we shall unduly increase endogenous protein katabolism. All will agree that protein in excess of need means more renal work, both directly in excreting the excess and indirectly by the specific dynamic action
a
.
banquet
969
should
undoubtedly form part of the routine daily investigation of every such case, but to suggest that albuminuria in the absence of a raised blood pressure is of no significance is to imply that treatment is unnecessary, and this may be disastrous. The only known cause of the toxaemias of pregnancy, in Mr. GIBBERD’S view, is pregnancy, and he does not discuss the possible predisposing LONDON: SATURDAY, OCTOBER 31, 1931. factors ; but his papers throw much light on the immediate and remote prognosis. He lays stress ALBUMINURIA IN PREGNANCY. on the pre-eclamptic nature of the albuminuria THE rapid increase and improvement of ante- and quotes the interim report of the Committee natal work throughout the country means that on Maternal Mortality as showing that in twomore and more women are having their urine thirds of the fatal cases of eclampsia investigated regularly examined throughout pregnancy. There the urine was not adequately tested before the is, therefore, a growing need that practitioners fits started, and that in the majority of the remainshould have a clear conception of the significance ing cases where albumin had been discovered of albuminuria in pregnancy and of the treatment reasonable treatment had not been immediately necessary to avoid complications which may come begun. In 8000 deliveries by the Guy’s Hospital in its train. Mr. G. F. GIBBERD has lately given obstetric department in the last five years, he us a valuable exposition of these matters,! and it says, 300 cases of albuminuria of pregnancy were is appropriate to consider his opinions in con- discovered and treated. There were only two junction with those expressed by Dr. G. W. cases of eclampsia-one of the rare fulminating THEOBALD at p. 948. type, and the other in a patient who refused Dr. THEOBALD suggests that the albuminuria treatment for her albuminuria. Dr. THEOBALD associated with pregnancy can be accounted for believes that 20 per cent. of eclampsia is of the by mechanical means, among which he places fulminating type, a very high estimate. He has first lordosis and the diminished thoracic capacity also reported two cases of eclampsia without associated withthe later months of pregnancy. albuminuria,2 but these must be exceedingly rare. He shows clearly that dogs pass small quantities Mr. GIBBERD finds that 3 to 5 per cent. of all of albumin when placed in a position of marked previously normal women develop albuminuria lordosis; on the other hand, such experiments during pregnancy, and that more than half of these, hardly reproduce the normal anatomical condition in the absence of proper treatment, sustain of the abdomen late in pregnancy. His success permanent renal damage. Ten per cent. of them in producing slight albuminuria in non-pregnant show patent chronic nephritis, while 50 per human beings by maintaining a modified Walcher cent. have recurrent albuminuria in subsequent He infers in these the existence of an position for 40 minutes will also be criticised as pregnancies. " bearing little relation to the normal. Again the occult nephritis," but unfortunately he does not slow deep breathing which, he shows, may cause explain clearly the character of the chronic transient albuminuria is by no means usual in nephritis usually found, nor estimate the consethe later stages of gestation. There will be general quent interference with health and limitation of agreement, however, with his observation that life. It is well known that death from chronic of the incidence experimental orthostatic nephritis may follow albuminuria of pregnancy is affected albuminuria by diet-that after a meal after a period of years, but Mr. GIBBERD’s estimate rich in protein albuminuria appears earlier and is that this is the fate in 10 per cent. of all cases is of larger amount than after a meal poor in protein. unexpectedly high. It is to be hoped that in the Moreover his proof that venous congestion of near future he and other workers will be able to the kidney causes albuminuria in dogs is supported offer a more precise ultimate prognosis. What is by a certain amount of clinical evidence that the fate of his many cases of occult nephritis venous congestion sometimes plays a part in where there are no further pregnancies ? If the presence of chronic nephritis is proved in causing the albuminuria of pregnancy. Thus a raised intra-abdominal pressure is more frequently a pregnant woman Mr. GIBBERD rightly holds that seen in primiparae than multiparse, and so is the pregnancy should be ended, both because albuminuria-both being more marked as full it increases renal destruction and because the term approaches. But cases are common in which child has little chance of survival. His proposed the pressure is raised yet there is no albuminuria treatment is based upon his figures, and may be and this indicates the operation of one or more briefly described under the headings of rest, additional factors, notably toxaemia. Further, diet, and if necessary termination of pregnancy. the appearance of albuminuria in the early stages There is general agreement on the outstanding of pregnancy makes it certain that albuminuria importance of rest in the treatment of all renal must often be non-mechanical in origin. We are disease, and if his figures showing permanent forced to conclude that in no case of albuminuria renal damage in a large proportion of cases of of pregnancy is it safe to presume that the cause albuminuria of pregnancy are confirmed by other is solely mechanical. Blood pressure estimations observers the prevalent treatment of this condition
THE LANCET.
1 THE
LANCET, Sept. 5th, p. 520,
and
Sept. 12th,
p. 576.
2
Jour. Obst. and Gyn. Brit.
Emp., 1929, xxxvi., 803.
970
BRITISH COLLEGE OF OBSTETRICIANS AND
must be severely criticised and altered. Ambulatory treatment combined with a diminished diet and saline aperients must be replaced by absolute rest in bed until albumin can no longer be detected.
GYNÆCOLOGISTS.
had not recognised the force of the argu. ments adduced by the innovators. Both insight and tact were displayed on either side over a
Colleges
considerable
period, during which the services which of obstetrics and gynaecology might college discharge for the good of the public were steadily made prominent. Thus it came to be recognised by prominent members of the Royal Colleges that they had not to protect their institutions from trespass, and these took, finally with readiness, the liberal view that public needs would be met by a body which would be of an auxiliary and not of a competing character. The principal argument for the foundation of the College of Obstetricians and Gynaecologists was, of course, the desire to combat maternal mortality, where the figures are an admitted reproach when the progress of medicine and surgery in every other branch is estimated. A College of the nature projected it was felt would provide fuller opportunities for the development produced. The bowels should be kept regular, but clinicians: of exact knowledge, would raise the standard of ,differ considerably about the value of purgationL education on the subject, and give to the practi.and diaphoresis. Mr. GIBBERD favours both inL tioner an added prestige. No one denies that in moderation. He induces labour in all severe cases the institution of the College we have a certain that fail to react to strict medical treatment, asI separation of diseases peculiar to women from other .outlined above, after a trial of two or three days. branches of medicine and surgery, and that this He also insists that even slight cases which fail to) does not accord with that unity in scientific clear up completely after a fortnight’s treatment medicine which is the accepted ideal. But the should have labour induced. His figures show a cleavage, such as it is, will not be of a nature to very definite increase in the incidence of both embarrass the public, and, with the development of patent and occult nephritis where the albuminuria the activities of the new College, it will be closed up, has been allowed to continue three weeks or more. so as to represent only such a division of function as belongs to all orderly growth. It is urgently our that standard of obstetrics should necessary and while the Fellows and Members be raised ; BRITISH COLLEGE OF OBSTETRICIANS AND of the young corporation may regard this as their GYNÆCOLOGISTS. prime responsibility, they cannot fail to extend our THE British College of Obstetricians and Gynaeco- wisdom along general gynaecological lines. It is good to see that the Royal College of logists held its full dress ceremonials on Friday, Oct. 23rd, when Prof. BLAIR BELL, the President, Physicians of London has already asked the conferred certain honorary Fellowships of an College of Obstetricians and Gynaecologists for a international character, admitted the newly elected panel of names for the examinership for the Fellows and Members to their College, and then Conjoint Diploma ; this is a practical step towards presided over the first annual dinner of the new that fusion of interests which was held up as corporation. The proceedings went with a smooth- necessary by speakers at the first annual ness and dignity which augurs well for the future. of the College. For medicine to serve the public It is widely known that the foundation of the practically, it is particularly valuable that the College was attended with considerable difficulty. medical profession should itself present a general The idea of a separate medical corporation to take uniformity of view. :particular charge of obstetrics and gynaecology did not at first commend itself to many professional leaders, nor, which was very important to the RACIAL HERD-IMMUNITY OF THE MAORI. pioneers of the movement, was it wholly acceptable AN appendix to the latest annual report of the to the Royal Colleges of Physicians and Surgeons. The successful promoters of the new College can Director-General of Health for New Zealand contains be congratulated alike upon their diplomacy and some statistics on the differential immunity of pure their energy. Individual converts, they saw, and cross-bred Maoris. A group of some 2000 would be obtained in sufficiency when the support children, aged 5 to 15, which included full, three. of the Royal Colleges was obtained, and they quarter, half, and quarter bred Maoris, werE concentrated upon this issue. They knew that submitted to four. immunity skin tests-Schick, before the aims and ideals of the new College could Dick, Pirquet, and Casoni (intradermal injection be recognised as sound, it would have to be shown of hydatid cyst fluid). According to these tests, that it would be able to do something which the the susceptibility of the group to diphtheria, existing Colleges could not do. To prove a negative scarlet fever, and tuberculosis definitely declined is always hard, and a period of wrangling might with age in the same way as is usual with pure well have ensued if the leaders of the Royal European stocks. No age gradient was however
Difficulties will arise where the woman has no available domestic help, but this drastic treatment must be achieved if its necessity is proved. ’The accepted view is in favour of a diet consisting of glucose and large quantities of fluid in the first few days of treatment, but the continuation of a protein-free diet possibly for many weeks is open to objection. Probably the greatest degree of metabolic and renal rest is to be got by providing enough protein for the normal anabolic processes of the body at rest ; for otherwise we shall unduly increase endogenous protein katabolism. All will agree that protein in excess of need means more renal work, both directly in excreting the excess and indirectly by the specific dynamic action
a
.
banquet