essential element of digestion. It is also an excremental organ, insomuch as it receives the blood from the portal system which is charged, in part at least, with the products of augmented blood-supply to the pelvic organs and of the enormous developmental work which takes place in that region. The portal blood must be loaded with these excrementitial matters, and greatly increased duty must, consequently, be imposed upon the liver. As an emunctory, the liver is usually equal to the emergency; but this function must be supplemented by the increased eliminative capacities of the skin, lungs, and kidneys. In health these organs preserve their compensatory activities; but ineffective power in either may lead to accumulations in the blood which will poison the entire organism and produce disastrous results. The lungs eliminate carbonic acid; the skin dissipates animal heat, and excretes water, urea, and salts; but the kidneys are the chief emunctory glands. Upon them devolves mainly the elimination of the useless and poisonous products of secretion and tissue change. They have no recre mentitial function to execute. Through them the waste is finally discharged. This office is a relentless necessity. The compensatory organs are absolutely inadequate to assume the duty and maintain health. During pregnancy the work is vastly increased, and a larger quantity of abnormal elements find their way into the urine. With the progress of uterogestation the more urgent is renal elimination, and the more imminent the danger of disturbance of the function.

I need not now detain the reader with a recital of the pathological phenomena of the albuminuria of pregnancy; but I cannot permit the occasion to pass without impressing upon him the importance of early recognition of the initial sign of its presence. I have more than once expressed the opinion that puerperal eclampsia and its lamentable consequences were too often attributable to neglect. I hold that the pregnant woman should be under the continuous observation of a competent physician; and when such is the case, he is responsible for the occurrence of avoidable disease. I believe, furthermore, that if such observation were diligently and intelligently pursued, the cases of eclampsia would be greatly diminished, and the mortality would be reduced to its minimum.

I venture to call attention to another circumstance too

often forgotten. More women die of renal disease during the period of child-bearing life than men of the same age. The ordinary result of complete recovery from puerperal nephritis after delivery is too often accepted as inevitable, and the patient is discharged without even an admonition of the peril which may hasten her untimely death.

I will remind you also of the physiological relationship and reciprocal dependence of the excretory functions of the lungs, skin, intestinal tract, and kidneys. Disturbance of this close connection may speedily develop great disorder.

Until recently, the appearance of albumin in the urine was universally held to be the symptom of threatening danger, notwithstanding the facts that in very many cases no grave compli cations occurred; and in many other cases, even when the symptoms denoted serious lesions of the kidneys, all traces of disease speedily and spontaneously subsided after the evacuation of the uterus. There can no longer be any doubt that albumin does appear in the urine during health as a physiological phenomenon; but whether such a condition is ever present during pregnancy is yet a mooted question.

Physiological albuminuria has been ascribed to various causes. The presence of albumin in the urine of the new-born has been attributed, by Ribbert, to the protoplasmic condition of the cells of the glomeruli; by Rosenback, to superfluous albumin in the blood, due to too rapid disintegration of bloodcorpuscles; and by Senator, to the increased vascular pressure in the glomeruli, coincident with increased loss of water through the skin and lungs, and disintegration of blood-corpuscles. In the urine of the healthy adolescent, it is ascribed to rapid growth and development; and in the urine of healthy adults, to excessive muscular activity, the ingestion and digestion of highly-albuminous foods, mental excitement, and cold bathing.' Does the state of pregnancy present any conditions analogous to these alleged causes of physiological albuminuria occurring in males and non-pregnant persons? If so, why should not a similar result follow? It may be straining facts too far to insist that the increased arterial tension, the blood degradation, the rapid growth and development, the mental disquietude, the augmented cutaneous and pulmonary exhalations, and anemia

1 Medical News, August 29th, 1885.

of pregnancy are phenomena similar to those present in otherwise healthy infants, adolescents, and adults, in whose urine albumin may be found; but the conclusion will not appear so over-drawn when to those conditions may be added the probable disturbance of the functions of the liver, the almost constant presence of alimentary and nervous perturbations, and possible ingestion of an excessive quantity of highly-albuminous foods, which are occasional factors in the causation of albuminuria. Special mention is made of cold bathing as a cause of physiological albuminuria. May not sudden chilling of the cutaneous surface, rapid dissipation of heat, and consequent determination of chilled blood to the internal organs be an equally effective agency, when the result of imprudent exposures and insufficient clothing? Cold bathing, though a frequent, is not such a common practice among pregnant women as other indiscreet exposures of the person to chilling influences.

Pregnancy exhibits during its progress many other phenomena not unlike those frequently associated with albuminuria in non-pregnant persons, and believed to be active agencies in the cansation of such pathological conditions. The most common immediate cause of puerperal albuminuria, and perhaps an equally frequent cause in the non-pregnant, is the increased tension of blood in the glomeruli, either from increased afferent pressure or undue efferent resistance. The arterial tension of pregnancy finds its causes in the enlarged left ventricle, greater blood mass, blood degradation, disturbances of the excretory organs, especially of the skin and bowels, and derangements of the nervous system, either local, general, or reflex. The efferent resistance may be either capillary or venous, and may be due to functional or mechanical conditions. If, then, these phenomena are physiological in the pregnant female, and pathological in the non-pregnant, and in each instance stand in like etiological relation to albuminuria, must the appearance of albumin in the urine differentiate an abnormal from a normal pregnancy? Experience tells us that in many cases of pregnancy very large quantities of albumin appear in the urine without the occurrence of any serious complication, and that it usually disappears after delivery, and sometimes after the death of the fetus in utero. It may be physiological in a few, functional in many more; but we must in the future, as in the

past, continue to regard it as pathological in the majority of cases, and as a danger signal of the gravest importance.

With this ensemble of physiological conditions and pathological possibilities, do you marvel that some pregnant women get sick and a number die ? It is no answer to tell me that the ailments and mortality of pregnancy are incidents of education and civilization. If so, the most effective method of hygiene would be the relegation of every pregnant woman to besotted ignorance, barbarism, and beastliness-a remedy more revolting even than "Vou-doo" medicine, which traces cause and effect, and disease and recovery to stupid, disgusting and criminal superstitions. In view of the facts that among civilized people the average lifetime is greater, the mortality of the lying-in is less, and more women live out the allotted life-time now than during any previous period of medical history, I repudiate any analogy derived from the customs, habits, practices, and their results among nomadic, aboriginal, and barbaric races and peoples. With the progressive improvements in the conduct and management of the pregnant and puerperal states, the expectancy of life and longevity of the post-cessation life have increased.

The hygiene of pregnancy demands an acuteness and accuracy of diagnosis not always or easily acquired. The physiological so frequently approaches the pathological that differentiation of disease is involved in embarrassing obscurity. The insidious beginning of morbid processes is often so illy-defined, and the consequences of delay are so disastrous that the accoucheur cannot afford to abide the issue of complete development when the diagnosis is plainly written in the picture of a grave disorder threatening immediate danger. He must be alert, accurate, ready, and self-reliant.

The present occasion does not permit me to engage in a detailed description of the special disorders of pregnancy. I must assume that you are quite as competent as I am to recognize and treat such diseases. But, following the line of argument previously pursued, I must insist that the most effective method of prevention of the morbid complications of pregnancy consists in the preservation of the normal functional activities of the excretory and emunctory organs.

The constant and necessary physiological relation subsisting

between the skin, lungs, alimentary tract, and kidneys demands vigilant supervision. Constipation should be relieved. No fecal mass should be allowed to accumulate in the intestines. The bowels should be kept in a solvent condition, and an evacuation should be secured every day, either by regulating the diet and habits of the patient, or by such mild, but sufficiently effective therapeutic agents as a skilled discretion may suggest.

It often happens that patients deceive themselves by inattention, and their medical attendant either by evasive or exaggerated statements concerning the state of their bowels.

a rule, one can verify or not, as the case may be, such statements by an examination of the tongue and conjunctivæ, by mal-odor of the breath and person, and by inquiries in regard to the condition of the stomach, appetite, and digestion, the nature and quantity of food, when and how often taken, and whether the ingestion of food and drinks are accompanied or associated with any sense of fulness, discomfort, flatulence, or acidity. Not only will a careful investigation detect the existence of habitual constipation when a positive assurance to the contrary has been given, but it may disclose the cause, and indicate at once the method of treatment.

The inspection of exposed cutaneous surfaces will be greatly aided by palpation. Cleanliness of the skin, and the free functional activity of the sebaceous and sudoriparous glands must be secured by necessary tepid or hot ablutions or bathing. Cold bathing is not always safe. The drinking of large and unnecessary quantities of liquids—an injurious habit with very many people-imposes augmented labor upon those organs charged with the exhalation of fluids. Excessive micturition and profuse sweating are occasionally annoying results of the excessive consumption of liquids.

The respiration may be embarrassed by the mechanical repletion of the abdominal cavity, and by the altered contour of the thorax, which are unavoidable conditions. This discomfort may be greatly aggravated by flatulent distention and over-loading of the alimentary tract, due to the ingestion of acescent and unsuitable foods, and to constipation before referred to. A more significant disturbance of the respiration may result from the blood degradation and anemia.