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The Kidney of Pregnancy
Department of Reviews and Abstracts CONDUCTED BY HUGO EHRENFEST,
M.D.,
ASSOCIATE EDITOR
Collective Review The Kidney of Pregnancy By EDGAR F.
SCH~n'I"Z,
l\1.D., ST. LODs, }ilo.
REVIEWIXG recent literature the so-called kidney of. pregIolleXnancy, with its associated conditions of edema and hypertension, is struck by the variety of classifications of kidney disease en011
countered, and the rather confusing nomenclature employed. For our purpose it .is not essential to minutely examine the foundations on which these various overlapping and often conflicting divisions of pathology and symptomatology are based. It ·will suffice here to bring out the more salient points of those facts which seem fairly well established. In studying renal involvement dUl"ing gestation one must necessarily differentiate a true nephritis from those nephropathies under discussion, for upon this differentiation depends our future attitude on what may be called the kidney of pregnaney. Any case in which renal (·hanges appear prior to conception cannot strictly be classed with the type of disease under discussion, even if the symptoms are aggravated by the subsequent impregnation. Nor should a case in which permanent renal damage is found following delivery be placed in this category, for v. Leyden long ago pointed out that one of the characteristics of the true nephl"opathies of pregnancy is the rapid disBppearance of all symptoms following the emptying of the uterus by natural or artificial means. Heynema11 10 and others have recently again emphasized a point in differential diagnosis, by calling attention to the fact that the kidney of pregnancy is manifestly based primarily on degenerative processes, while a true nephritis is primarily of inflammatory origin. It is true that borderline types will be enCOUIltercd now and then, where it will be difficult to determine which COI1dition dominates the clinical picture, but in thc main the kidney of pregnancy does not show thc ehanges found in nephritis. The newer views on this subject are taking a much broader interpretation of the symptom-complex exhibited, and have followed the line of reasoning so ably statcd b;" Atchleyl in the concluding paragraph of his article, in which he says, "One must express the feeling that the investigation of this disease (nephritis) has been hindered b.\' an intereRt too closely reRtricted to the kidneys. A broader study of" the chemical balances of the body as a whole may demonstrate Hwt the kidne.\' is of secondary importance, both from an etiologic and pathologic standpoint." 102
REVIE\VS AXD ABSTRAC'rS
103
\Vorking along these lines many new and interesting avenues of investigation have been opened by workers the world over. EckeW found that in those cases exhibiting moderate degrees of intoxication, with albumin, edema and hypertension, there was no nitrogen retention. Losee and Van Slyke13 showed that in the kidney of eclampsia there was neither marked nitrogen retention, nor severe acidosis, and concluded from this that the toxemia is not a uremia. ,7.;angemeister lG in his rather exhaustive work on this subject demonstrated that although a definite retention of sodium-chloride occurred in the body duringthe edemas of pregnancy, the total percentage or all salts excreted in the urine was still relatively high, which proycd that no marked insufficiency for salt elimination by the kidney existed. lIe further ~howed that in the early stages of the disease there v,asno functional disturbance in the water output of. the renal parenchyma, oliguria occurring only as a later development. The pathologic picture of a degeneration, the lack of nitrogen retention, the relatively unimpaired salt elimination, the clinical observation that the nephropathies of pregnancy tend toward a spontaneous cure aftcr delivery without causing permanent renal changes, force one to the conclusion that the renal pathology is not responsible for thc symptom-complex, that the kidney is not primal;ily involved, that its function is not seriously impaired until late in the disease, that the changes which occur are of a secondary nature, and that we must look elsewhere for a causative factor rather than cling to the older ideas which are no longer tenable. The development of the 1fic\'0-capil1ary 'l'onometer by Danzer and Hooker 4 has given a new impetus to the study or extrarenal factors in all pathologic kidney conditions, especially those connected with pregnancy. It is now possible directly to observe over long periods of time the individual capillary and its tiny blood stream, and to accurately cheek any deviation from the normal which may exist. 'esing modifications of this technic, various observers have brought to light some interesting and instructive observations. \Vorking with the capillaries under the finger naiL they shmved distinctive changes in both the vessel wall and its fluid contents, in the various degrees of intoxication, found associated with the kidney of pregnancy. IIinselmann,9 inYestigating those cases showing evidence of hnJertension, was able to demonstrate a diRtinct spasm in segments of the capillary wall with a resulting dilatation in other portions of the tube. He was able to observe the contents or the capillaries stagnate with eaeh contraction, the color of the blood gradually changing from red to bIlle, and in the 'worst cases all flow ceasing. vVhen relaxation occurred and the flow became reestablished or strengthened the blood again changed color, this time the blue giving way to a normal red, and the overdistention becoming less marked. He found these spasms to be intermittent in character, and their duration and frequency bor(' it direct relation to the severity of th(' symptoms. In one very marked case there was compl(lte stagnation for fi5 per cent of the time the patient was under obRenatioTl. An intereRting point to be noted is that following delivery the spasms became fe'wer and of shorter duration, that the overdistended portion of the capillary gradually returned to its normal caliber and that coineident with these changes, the blood pressure began slowly to fall. The Rame result waR obtained, bnt to a
lU-l:
TIlE .UJERlCAX .JOt:R:-
lesser degree, following appropriate treatmellt, which will be discussed later. IIinselmann concluded from these findings that the capillary spasm found in the skin was only a part of a generalized vessel contraction throughout the body, and thus gives some support to those investigators who have long hcld that the kidney changes found in pregnancy are duc to a spasm of thc blood vessels in the glomeruli. Xevermann 11 ('olllpal'ing' t11r capillary action in the pregnant and lwnpregnant state found that no difference existed, normal gestation cvidently causing 110 change in this portion of the vascular system. As soon, however, as any symptom of an intoxieation entered the clinical picture, the findings became abnormal with a resulting stagnation of 1he capillary hlood and a dilatation of the vessel wall. He further showrd that v~nesection with the removal of 300 to 500 C.c. of blood improved the capillary circulation, decreased the number and duration of the spasmf-;, produeed a better interchange of blood, and symptomaticallv seemed to be of benefit to the patient. All of this occurred, howev~r, with a fall in blood pressure of only 20 or 30 mm. of mercury. This observation fits in nicely with the work done by Krogh,lZ who found that capillary tension did not deppnd on blood pressure, but on the tonus of the capillary wall, and that if stasis exiRted in the capillary the tonus suffered. At this time it seems fairly well established that a rise in blood pressure is due to a diminntio~ in' the calibrr of certain portions of the yascular system, the result of a contraction or spasm of the vessel walls. The causative faetor of this spasm is still clothed in utter darkness, which up to the present has defied all attempts at clarification. Some consider it as a part of a genrral toxic eondition associated with pregnancy, but Bumm has shown that one may inject as much as 1000 C.c. of blood from a toxic patient into a nontoxic one and cause not the slightest disturbanee. Gessner emphatically denies the existenee of a toxic suhstance cireulating in the blood, and points out that any poison ·whichacts onr a period of weeks or months must canse changes in tIl(> interstitial tissue as well as in the blood vessels. Such changes are not found in the nephropathies of prcgnancy, the pathology here lwing essentially that of a nutritive disturbance of the secreting cells. 'I'he question of ('(lema in pregnancy has from time immemorial been much associated with rhanges in the kidne~' suhstance and only in rerent years have we got awa:v from the old dirtum, and adyanced into a rlC"wer and broader understanding of this e0l1111lirated condition. %allgrl11eistrr 1ll considers the primary canse of edema to he due to some rxtrarenal fartor whieh produrrs a change in the lining of the capillary wall with a resulting transudation of fluid into tbe tissue. This roncept.ioll is he ld b~T many other inYeRtigators, and perhaps typifies the most prevalent attitude of present-da~' observrrs. Fink,6 howeYer, in his rath('r inlerrstingo ohsen'ations 011 the causation of edema, sharpl~' attacks this thror.v. and Huggoest;; some ypry plausible arguments based 011 the nnwer conception of i he nature of colloids and the la,,'s of osmosis. High hlood preSSl\l'e al'tifieiall.\' prodnced, he maintains, has neyer caused an edema to manifest itself, even if the vessels were greatly onrdistrndrd with fluid. and' points out that the interehange of liquid from vrssel to tissne is not to hr looked upon as merely a filtration proeess. Edema is not essentially the result of a
]{Evn:w~
A:--:n
ABi-;'I']{A("I'i-;
1O,j
kiduer iuvolvement, but in this ('ollception dppends rather on the quantita tive relationship of the organil' and inorganil·. substances ill the hody to the physiologic processes of the ti~i·;ue cell. If this relationship is disturbed, molecules and eleetrom's of VHl'ious sub:.;tances, illg'csted 01' pI'olluced by metabolic changes, are :.;et free ill the body in exec:.;s of cell requirenwllt, and become temporarily stored in varil·m, organs, especially the subeutaneou:.; tissue. If the individual cell groups are unable to dispose of thcse proclucts by speedy eliminatioll 1hey become fixed in the ti,;sue and thu,; the bodr eolloid:.; are placed in a ,;tate where water absorption becomes imperative. 'Ve have, 1herefore, in pregnan(~y, edemas becoming manifest as soon as a dis1Ul'hell relationship exists hetwel'll the molecules pre';(,llted to the organism by the metabolic processes of both mother and fetus, and the ahility of the maternal cells to properly rid themselves b.v elimination of these excess substances. Finke is in agreement -with those authorities who state that edema is rrsponsible for the l,idney changes in wegnaney, but differs with them in his concrption of the rnod1ls operandi by which the pathology is produced. He contends that the procl'SS is mechanical rather than toxic, that the colloids of the renal par(·nchyma absorb fluid because of the excess of unused molecules stored ill the cell, that the resulting swelling causes pressure to be exerted on the capillary blood supply with intrrfrrence in the circulation and consequent cell damage, producing albuminuria and cast formation. He considers edrma not as a watel' retention following kidney changef;, hut water retention "'it h kidney changt's, the causative factor of which 1ies outside the urinary apparatus. From the brief summary of the literature 11rre presented it will be apparent that the kidney is no longer looked upon as the chief factor ill the production of those symptoms which we have come to recognize as part of the picturr of the kidney of pregnancy. }Iost invei-ltigators are agreed that the actnal changes in the renal parenchyma are sec'mdary, depending upon some t'xtrarenal factor, the nature of which has not as yet been definitely established. '1'he fin;t essential, therefore, in outlining a rational tlH'rapy for this dass of eases. is au accurate diagnosis, which takes into consideration the possibility of a primary kidney involvement aggravated by pregnanc? 'Vhr1'e this unfortunate complication can he ruled out, the treatment as outlinell in the follo\ving paragraphs wouIel serm indieated. All authorities are agrpell that rest in hed is the treatment par e;rcelZenee for the nephropathif'f; of pregnancy, for hy this si~ple measure the extra work, incident to the ered posture, is taken fl'om the capillaries; the heat regulation heeomes simpler, a more even body temperature resulting; less llIns('ular and nervous energ~' is expended, and the quantity of food and liquid nrcessary to maintain p1'oprr nutrition can be much redueed. The diet should he bland, ayoiding those substanees which tend to produce a rise in blood pressure, as spiees, coffee and alcohol. Protein and fat can be rrc1nced to a total intake of 60 or 70 grams per day, as the experiences of the Cf'niral European countries during the war, when these substances werr' not easy to prO(,11re, demonstrated the ad"antage of thrse low figures, in the decrease in the number of severe intoxications recorded. Salt must be restricted to a minimum in any lliet prescribed for patients suffering from this condition, af; "'e know
]06
'filE A;\;IEHlCAX .J(WI\XAL (W OBS'l'ETRlC:-: AXIl GYXECOLOGY
that sodium chloride is retained in the tissues and predisposes to the formation of edema. Liquid intake must be cut down to snch a quantity that the hody is not overburdened by an excess of fluid which cannot be properly eliminated hy the kidneys. A good working rule which may be of s(,l'Yice in properly adjusting the amount of liquid ingested is to give only as much fluid per month in 24 hours, as the amount of urille exereteu in the same time. }"rom what has jnst bepn said it will be apparent that a milk diet, as formerly prescribed, is not. suitable for theRe cases, as milk COlltains too m1lch water, increasing the fluid intake above the desired amount, and too much salt and protein to (~ome within the required limits. ,Ve 11111st rely on carbohydrates to supply the deficipneies in the reduced -values of other foodstuffs, and keep up the body weight hy a generous supply of such substall('es as rice, flour, potatoes and sugar, ete. In thos(' ('as<'s whieh sho,,' IlO impl'OY('l1Hmt under the treatment outlined 01' 1rl]('r(' p]'('eelampti('. symptoms begin to manifest themselves, f:pecial nl('asures must 1)(' adopted, the lllost important. of whieh is venesedioll. \Ve haY(' seen that tIle mere taking' away of a re1ati-ve1y small quantit~, of hl()(Hl il' of immense hendit in reestablishing the capillan' flow and re<1u('illg the angiospHsms 1vhi(~h an' so prominent a factor in this disease. It is, thcrefo]'(" advisahle to take from the eirculatioll :WO OJ' 500 e.r'. of blood whelleYf'l' theindicatiol1 arisl's, and 10 repeat this Jlroced1il'c a t short interva Is nntil the desired result is 0 htained. The que:,;tion of the termination of pregnanC',)' is one which hardly comeR 'within ill(' seop<, of 1II is ]'('V ie\\', inaslllueh as 11'e have limited ourRelves 10 the ('ollsidel'a1ioll of 1he ki(hley of pregnancy per se without taking up either eelampsia or true JlephritiR. It is selfevident that whpre no· improYel11<'llt ean be brought ahollt after a prolonged trial of the aboye mentiolled measures, and where with the most careful attention 1he pa1iellt rapidly lweollles 1VO],S<', the uter11S 11l1Ist he emptied. REFEREXf:ER
(1) Al'eh. lilt. lied.. HilS, xxii. (:2) B11IJilNJ/:"11: Deutsche med. Wclmsehr., (:n Beckman.n: ZClltralhl. 1'. rtyn1ik., 1!);Z1, xlv, [)fl5. (4) Am. Jour. Physio!., In20, xlii. (fi) Ztsehl'. f. Ucll1ll'tsh. 11. G~'llak.. lxxxi, 1. (6) Ztschr. f. Gcburtsh. u. GYllak., lxxxiv, 1. (7) Gibson: S'lrg'., G.YlH'C. !lnd Ohst., xxxii, 51:!. (8) GCSINWT: Zcntrnlhl. f. Gyniik., 1920, xlh",.lLi4. OJ) Zelltndhl. f. G'yniik., IH21, xlv, (jO:~; ~fiillChcn. mcd. Wclmsc!Jr., 1[12J, lxviii, SJO. (10) Thpl'ap. Hall!monatshcfte, 1fl21, xxv, 1::.1, Zcntl'alhl. f. Gyniik .• 1!J21, xlv, S:lS. (ll) ,Jaschkr: Zcntralhl. f. G'yn1ik., 1[120, xlil-, 1274; A1'(·h. f. Gyniik., ('xiI', 2.')5. (12) Krogh: Jour. Physiol., May, IH:W, liii, :m9. IT!) Los(( and Van 8lykc: Am. Jour. }I.. d. Se., ,January, ] H17, eliii, !H. ( I +) Zputnllhl. f. GyIlUk., 1920, xliv, 1125. (15) Schmidtmnll: ~lonatseh. f. Gehll1't,h. n. GYllak., H)21, lv, D2. (1(i) Ztsellt'. 1'. Geburtsh. u. Gynak., lxxxi, 491. 301 METROPOLITAK BLDG. In:! I, xlii, lim).
M.D.,
ASSOCIATE EDITOR
Collective Review The Kidney of Pregnancy By EDGAR F.
SCH~n'I"Z,
l\1.D., ST. LODs, }ilo.
REVIEWIXG recent literature the so-called kidney of. pregIolleXnancy, with its associated conditions of edema and hypertension, is struck by the variety of classifications of kidney disease en011
countered, and the rather confusing nomenclature employed. For our purpose it .is not essential to minutely examine the foundations on which these various overlapping and often conflicting divisions of pathology and symptomatology are based. It ·will suffice here to bring out the more salient points of those facts which seem fairly well established. In studying renal involvement dUl"ing gestation one must necessarily differentiate a true nephritis from those nephropathies under discussion, for upon this differentiation depends our future attitude on what may be called the kidney of pregnaney. Any case in which renal (·hanges appear prior to conception cannot strictly be classed with the type of disease under discussion, even if the symptoms are aggravated by the subsequent impregnation. Nor should a case in which permanent renal damage is found following delivery be placed in this category, for v. Leyden long ago pointed out that one of the characteristics of the true nephl"opathies of pregnancy is the rapid disBppearance of all symptoms following the emptying of the uterus by natural or artificial means. Heynema11 10 and others have recently again emphasized a point in differential diagnosis, by calling attention to the fact that the kidney of pregnancy is manifestly based primarily on degenerative processes, while a true nephritis is primarily of inflammatory origin. It is true that borderline types will be enCOUIltercd now and then, where it will be difficult to determine which COI1dition dominates the clinical picture, but in thc main the kidney of pregnancy does not show thc ehanges found in nephritis. The newer views on this subject are taking a much broader interpretation of the symptom-complex exhibited, and have followed the line of reasoning so ably statcd b;" Atchleyl in the concluding paragraph of his article, in which he says, "One must express the feeling that the investigation of this disease (nephritis) has been hindered b.\' an intereRt too closely reRtricted to the kidneys. A broader study of" the chemical balances of the body as a whole may demonstrate Hwt the kidne.\' is of secondary importance, both from an etiologic and pathologic standpoint." 102
REVIE\VS AXD ABSTRAC'rS
103
\Vorking along these lines many new and interesting avenues of investigation have been opened by workers the world over. EckeW found that in those cases exhibiting moderate degrees of intoxication, with albumin, edema and hypertension, there was no nitrogen retention. Losee and Van Slyke13 showed that in the kidney of eclampsia there was neither marked nitrogen retention, nor severe acidosis, and concluded from this that the toxemia is not a uremia. ,7.;angemeister lG in his rather exhaustive work on this subject demonstrated that although a definite retention of sodium-chloride occurred in the body duringthe edemas of pregnancy, the total percentage or all salts excreted in the urine was still relatively high, which proycd that no marked insufficiency for salt elimination by the kidney existed. lIe further ~howed that in the early stages of the disease there v,asno functional disturbance in the water output of. the renal parenchyma, oliguria occurring only as a later development. The pathologic picture of a degeneration, the lack of nitrogen retention, the relatively unimpaired salt elimination, the clinical observation that the nephropathies of pregnancy tend toward a spontaneous cure aftcr delivery without causing permanent renal changes, force one to the conclusion that the renal pathology is not responsible for thc symptom-complex, that the kidney is not primal;ily involved, that its function is not seriously impaired until late in the disease, that the changes which occur are of a secondary nature, and that we must look elsewhere for a causative factor rather than cling to the older ideas which are no longer tenable. The development of the 1fic\'0-capil1ary 'l'onometer by Danzer and Hooker 4 has given a new impetus to the study or extrarenal factors in all pathologic kidney conditions, especially those connected with pregnancy. It is now possible directly to observe over long periods of time the individual capillary and its tiny blood stream, and to accurately cheek any deviation from the normal which may exist. 'esing modifications of this technic, various observers have brought to light some interesting and instructive observations. \Vorking with the capillaries under the finger naiL they shmved distinctive changes in both the vessel wall and its fluid contents, in the various degrees of intoxication, found associated with the kidney of pregnancy. IIinselmann,9 inYestigating those cases showing evidence of hnJertension, was able to demonstrate a diRtinct spasm in segments of the capillary wall with a resulting dilatation in other portions of the tube. He was able to observe the contents or the capillaries stagnate with eaeh contraction, the color of the blood gradually changing from red to bIlle, and in the 'worst cases all flow ceasing. vVhen relaxation occurred and the flow became reestablished or strengthened the blood again changed color, this time the blue giving way to a normal red, and the overdistention becoming less marked. He found these spasms to be intermittent in character, and their duration and frequency bor(' it direct relation to the severity of th(' symptoms. In one very marked case there was compl(lte stagnation for fi5 per cent of the time the patient was under obRenatioTl. An intereRting point to be noted is that following delivery the spasms became fe'wer and of shorter duration, that the overdistended portion of the capillary gradually returned to its normal caliber and that coineident with these changes, the blood pressure began slowly to fall. The Rame result waR obtained, bnt to a
lU-l:
TIlE .UJERlCAX .JOt:R:-
lesser degree, following appropriate treatmellt, which will be discussed later. IIinselmann concluded from these findings that the capillary spasm found in the skin was only a part of a generalized vessel contraction throughout the body, and thus gives some support to those investigators who have long hcld that the kidney changes found in pregnancy are duc to a spasm of thc blood vessels in the glomeruli. Xevermann 11 ('olllpal'ing' t11r capillary action in the pregnant and lwnpregnant state found that no difference existed, normal gestation cvidently causing 110 change in this portion of the vascular system. As soon, however, as any symptom of an intoxieation entered the clinical picture, the findings became abnormal with a resulting stagnation of 1he capillary hlood and a dilatation of the vessel wall. He further showrd that v~nesection with the removal of 300 to 500 C.c. of blood improved the capillary circulation, decreased the number and duration of the spasmf-;, produeed a better interchange of blood, and symptomaticallv seemed to be of benefit to the patient. All of this occurred, howev~r, with a fall in blood pressure of only 20 or 30 mm. of mercury. This observation fits in nicely with the work done by Krogh,lZ who found that capillary tension did not deppnd on blood pressure, but on the tonus of the capillary wall, and that if stasis exiRted in the capillary the tonus suffered. At this time it seems fairly well established that a rise in blood pressure is due to a diminntio~ in' the calibrr of certain portions of the yascular system, the result of a contraction or spasm of the vessel walls. The causative faetor of this spasm is still clothed in utter darkness, which up to the present has defied all attempts at clarification. Some consider it as a part of a genrral toxic eondition associated with pregnancy, but Bumm has shown that one may inject as much as 1000 C.c. of blood from a toxic patient into a nontoxic one and cause not the slightest disturbanee. Gessner emphatically denies the existenee of a toxic suhstance cireulating in the blood, and points out that any poison ·whichacts onr a period of weeks or months must canse changes in tIl(> interstitial tissue as well as in the blood vessels. Such changes are not found in the nephropathies of prcgnancy, the pathology here lwing essentially that of a nutritive disturbance of the secreting cells. 'I'he question of ('(lema in pregnancy has from time immemorial been much associated with rhanges in the kidne~' suhstance and only in rerent years have we got awa:v from the old dirtum, and adyanced into a rlC"wer and broader understanding of this e0l1111lirated condition. %allgrl11eistrr 1ll considers the primary canse of edema to he due to some rxtrarenal fartor whieh produrrs a change in the lining of the capillary wall with a resulting transudation of fluid into tbe tissue. This roncept.ioll is he ld b~T many other inYeRtigators, and perhaps typifies the most prevalent attitude of present-da~' observrrs. Fink,6 howeYer, in his rath('r inlerrstingo ohsen'ations 011 the causation of edema, sharpl~' attacks this thror.v. and Huggoest;; some ypry plausible arguments based 011 the nnwer conception of i he nature of colloids and the la,,'s of osmosis. High hlood preSSl\l'e al'tifieiall.\' prodnced, he maintains, has neyer caused an edema to manifest itself, even if the vessels were greatly onrdistrndrd with fluid. and' points out that the interehange of liquid from vrssel to tissne is not to hr looked upon as merely a filtration proeess. Edema is not essentially the result of a
]{Evn:w~
A:--:n
ABi-;'I']{A("I'i-;
1O,j
kiduer iuvolvement, but in this ('ollception dppends rather on the quantita tive relationship of the organil' and inorganil·. substances ill the hody to the physiologic processes of the ti~i·;ue cell. If this relationship is disturbed, molecules and eleetrom's of VHl'ious sub:.;tances, illg'csted 01' pI'olluced by metabolic changes, are :.;et free ill the body in exec:.;s of cell requirenwllt, and become temporarily stored in varil·m, organs, especially the subeutaneou:.; tissue. If the individual cell groups are unable to dispose of thcse proclucts by speedy eliminatioll 1hey become fixed in the ti,;sue and thu,; the bodr eolloid:.; are placed in a ,;tate where water absorption becomes imperative. 'Ve have, 1herefore, in pregnan(~y, edemas becoming manifest as soon as a dis1Ul'hell relationship exists hetwel'll the molecules pre';(,llted to the organism by the metabolic processes of both mother and fetus, and the ahility of the maternal cells to properly rid themselves b.v elimination of these excess substances. Finke is in agreement -with those authorities who state that edema is rrsponsible for the l,idney changes in wegnaney, but differs with them in his concrption of the rnod1ls operandi by which the pathology is produced. He contends that the procl'SS is mechanical rather than toxic, that the colloids of the renal par(·nchyma absorb fluid because of the excess of unused molecules stored ill the cell, that the resulting swelling causes pressure to be exerted on the capillary blood supply with intrrfrrence in the circulation and consequent cell damage, producing albuminuria and cast formation. He considers edrma not as a watel' retention following kidney changef;, hut water retention "'it h kidney changt's, the causative factor of which 1ies outside the urinary apparatus. From the brief summary of the literature 11rre presented it will be apparent that the kidney is no longer looked upon as the chief factor ill the production of those symptoms which we have come to recognize as part of the picturr of the kidney of pregnancy. }Iost invei-ltigators are agreed that the actnal changes in the renal parenchyma are sec'mdary, depending upon some t'xtrarenal factor, the nature of which has not as yet been definitely established. '1'he fin;t essential, therefore, in outlining a rational tlH'rapy for this dass of eases. is au accurate diagnosis, which takes into consideration the possibility of a primary kidney involvement aggravated by pregnanc? 'Vhr1'e this unfortunate complication can he ruled out, the treatment as outlinell in the follo\ving paragraphs wouIel serm indieated. All authorities are agrpell that rest in hed is the treatment par e;rcelZenee for the nephropathif'f; of pregnancy, for hy this si~ple measure the extra work, incident to the ered posture, is taken fl'om the capillaries; the heat regulation heeomes simpler, a more even body temperature resulting; less llIns('ular and nervous energ~' is expended, and the quantity of food and liquid nrcessary to maintain p1'oprr nutrition can be much redueed. The diet should he bland, ayoiding those substanees which tend to produce a rise in blood pressure, as spiees, coffee and alcohol. Protein and fat can be rrc1nced to a total intake of 60 or 70 grams per day, as the experiences of the Cf'niral European countries during the war, when these substances werr' not easy to prO(,11re, demonstrated the ad"antage of thrse low figures, in the decrease in the number of severe intoxications recorded. Salt must be restricted to a minimum in any lliet prescribed for patients suffering from this condition, af; "'e know
]06
'filE A;\;IEHlCAX .J(WI\XAL (W OBS'l'ETRlC:-: AXIl GYXECOLOGY
that sodium chloride is retained in the tissues and predisposes to the formation of edema. Liquid intake must be cut down to snch a quantity that the hody is not overburdened by an excess of fluid which cannot be properly eliminated hy the kidneys. A good working rule which may be of s(,l'Yice in properly adjusting the amount of liquid ingested is to give only as much fluid per month in 24 hours, as the amount of urille exereteu in the same time. }"rom what has jnst bepn said it will be apparent that a milk diet, as formerly prescribed, is not. suitable for theRe cases, as milk COlltains too m1lch water, increasing the fluid intake above the desired amount, and too much salt and protein to (~ome within the required limits. ,Ve 11111st rely on carbohydrates to supply the deficipneies in the reduced -values of other foodstuffs, and keep up the body weight hy a generous supply of such substall('es as rice, flour, potatoes and sugar, ete. In thos(' ('as<'s whieh sho,,' IlO impl'OY('l1Hmt under the treatment outlined 01' 1rl]('r(' p]'('eelampti('. symptoms begin to manifest themselves, f:pecial nl('asures must 1)(' adopted, the lllost important. of whieh is venesedioll. \Ve haY(' seen that tIle mere taking' away of a re1ati-ve1y small quantit~, of hl()(Hl il' of immense hendit in reestablishing the capillan' flow and re<1u('illg the angiospHsms 1vhi(~h an' so prominent a factor in this disease. It is, thcrefo]'(" advisahle to take from the eirculatioll :WO OJ' 500 e.r'. of blood whelleYf'l' theindicatiol1 arisl's, and 10 repeat this Jlroced1il'c a t short interva Is nntil the desired result is 0 htained. The que:,;tion of the termination of pregnanC',)' is one which hardly comeR 'within ill(' seop<, of 1II is ]'('V ie\\', inaslllueh as 11'e have limited ourRelves 10 the ('ollsidel'a1ioll of 1he ki(hley of pregnancy per se without taking up either eelampsia or true JlephritiR. It is selfevident that whpre no· improYel11<'llt ean be brought ahollt after a prolonged trial of the aboye mentiolled measures, and where with the most careful attention 1he pa1iellt rapidly lweollles 1VO],S<', the uter11S 11l1Ist he emptied. REFEREXf:ER
(1) Al'eh. lilt. lied.. HilS, xxii. (:2) B11IJilNJ/:"11: Deutsche med. Wclmsehr., (:n Beckman.n: ZClltralhl. 1'. rtyn1ik., 1!);Z1, xlv, [)fl5. (4) Am. Jour. Physio!., In20, xlii. (fi) Ztsehl'. f. Ucll1ll'tsh. 11. G~'llak.. lxxxi, 1. (6) Ztschr. f. Gcburtsh. u. GYllak., lxxxiv, 1. (7) Gibson: S'lrg'., G.YlH'C. !lnd Ohst., xxxii, 51:!. (8) GCSINWT: Zcntrnlhl. f. Gyniik., 1920, xlh",.lLi4. OJ) Zelltndhl. f. G'yniik., IH21, xlv, (jO:~; ~fiillChcn. mcd. Wclmsc!Jr., 1[12J, lxviii, SJO. (10) Thpl'ap. Hall!monatshcfte, 1fl21, xxv, 1::.1, Zcntl'alhl. f. Gyniik .• 1!J21, xlv, S:lS. (ll) ,Jaschkr: Zcntralhl. f. G'yn1ik., 1[120, xlil-, 1274; A1'(·h. f. Gyniik., ('xiI', 2.')5. (12) Krogh: Jour. Physiol., May, IH:W, liii, :m9. IT!) Los(( and Van 8lykc: Am. Jour. }I.. d. Se., ,January, ] H17, eliii, !H. ( I +) Zputnllhl. f. GyIlUk., 1920, xliv, 1125. (15) Schmidtmnll: ~lonatseh. f. Gehll1't,h. n. GYllak., H)21, lv, D2. (1(i) Ztsellt'. 1'. Geburtsh. u. Gynak., lxxxi, 491. 301 METROPOLITAK BLDG. In:! I, xlii, lim).