Perhaps there is no one thing connected with ante-partum care which has been so perfunctorily or carelessly done, as the examination of the urine.

That this is a very necessary part of such care, I presume none will deny, but that the routine application of heat or nitric acid to a small sample of urine occasionally is a sufficient working basis for our knowledge of renal conditions, is a superstition which cannot be too soon dispelled. For the absence of albumin does not necessarily indicate proper functional activity on the part of the kidney, unless other necessary tests are made, which show normal kidney elimination. Furthermore it is to be remembered that it is not so much the presence of albumin in the urine which promises trouble, as it is lack of the product of nitrogenous tissue known as urea.

The normal amount of urea elimination by the kidneys ranges from four hundred to six hundred grains per day according to sex, and varies somewhat with the amount of exercise and character of the diet taken by each individual. In order to estimate the proper functional activity of the kidneys. the sample of urine examined must be taken from a twentyfour hours' collection, the amount of urea per ounce is then accurately measured by the use of a ureameter, and the result multiplied by the number of ounces passed in the twenty-four

hours.

In the pregnant state, the daily output of urine is almost invariably greater than the three pints which is the average daily normal amount.

But in the four to six pints of urine passed daily, during the later months of pregnancy, the total amount of urea tends to fall considerably below normal.

Especially is this true, if the patient eats but sparingly of meats and other nitrogenous foods, which is another factor in favor of limiting the amount of such foodstuffs in the pregnant state, as by so doing there is less work put upon the kidneys and therefore much less danger of overtaxing them or inducing such organic changes as will result in systemic absorption of urea.

The urine should be tested for albumin and urea, not less frequently than once in two weeks during the latter months of

pregnancy, and whether there be albumin present or not, if the amount of urea is markedly deficient, and especially if there is headache, or skin irritations of any kind, such measures should be taken at once, as to insure proper elimination of nitrogenous waste, if the dreaded uremic complications are to be avoided at the last.

There is one other important factor in the care of the expectant mother which is well worthy of consideration, if the lying-in chamber is to be shorn of its horrible uncertainty as to results.

I refer to the necessity of ante-partum examination, relative to the position of the child, so that in case of malpresentation, there may be an opportunity of correcting it before labor comes on. For with rare exceptions, the child maintains practically the same position throughout the last month of pregnancy, which it assumes at time of delivery.

Except in cases of overfat, or very rigid abdominal walls, or in hydraminos, palpation is not difficult, and a little experience soon teaches one, whether the child's back lies toward the right or left of the mother, while the small parts, such as knees, elbows, and feet glide about freely under the examining fingers, on the opposite side.

Except in twins, finding the limbs on one side of the abdomen, confirms the location of the dorsum on the opposite side, while numerous small parts found near the middle of the abdomen, usually indicates a dorso-posterior position of the fetus.

To determine whether the head or the breech occupies the upper uterine segment, it is necessary to remember that the head is susceptible to ballottment, that it can be tossed from side to side between the hands, or be easily pressed down by light thrusts of the hand through the abdominal wall, while the breech, because it lacks the flexible attachment to the trunk, which marks the head, has but little mobility.

The head is also hard and globular and presents a depression between itself and the trunk, and even when it occupies the lower uterine segment can easily be found by placing the hands over the lateral surface of the lower abdomen, and by gentle deep pressure toward the iliac fossa, then toward the

median line, the head is caught between the examining hands.

The location of the fetal heart is also a guide as to the position of the child, for if the fetal heart is found to the left of the median line, it indicates the back of the fetus lies to the left, while if the heart beat is found to the right of the median line, the body of the child occupies the right side of the uterus.

If the heart beat is found below the level of the umbilicus it means with rare exceptions, that the head presents, while the heart beat above the level of the umbilicus indicates a breech presentation.

After determining the position of the child, it is well to gain some knowledge of the maternal parts which form the exit gateway into life, for if the pelvic diameters are decidedly abnormal, there is less risk in precipitating labor before full term, than to wait until the child has reached the limit of its intra-uterine growth.

For the purpose of external measurement of the pelvis, the 'pelvimeter is, of course, necessary to obtain the important diameters, which are the interspinal, intercristal, oblique, and external conjugate, the latter of which is of the greater practical value in warning us of danger from a contracted pelvis.

It is generally conceded by authorities that these external measurements, if accurately taken, give fairly reliable evidence of the shape and internal capacity of the pelvis, and that when all these measurements are small the pelvis is somewhat contracted; if the interspinal is equal to or greater than the intracristal diameter, the pelvis is flattened, and that unequality of the external oblique diameter is evidence of asymmtry."

It may be safely assumed that the pelvis is contracted when the external conjugate falls below 16.5 cm. or 6 1-2 inches, or that it is ample if this same diameter reaches or exceeds 21 cm. or 8 1-4 inches.

After the external examination has been made and the measurement taken, confirmatory evidence should be obtained by a thorough internal examination, to further determine the presentation, possibility of pelvic deformity, and conditions of the soft parts.

Dilated veins about the labia or vagina, excess in leucor

rhoea, eroded cervical tissues, or tumors, all being possibilities, which if unrelieved may occasion unfortunate complication during delivery, or the lying-in state.

May the time speedily come, if it is not already here, that a physician when called to a case of confinement may go, not in fear and trembling to solve an unknown problem, with no knowledge of the patient's pelvic diameters, with no idea as to whether he will find a head, shoulder, or breech presenting, to guide him. But may he go, buoyed up with that absolute knowledge of the patient's constitutional condition and pelvic possibilities, which, can never be his, unless he has bestowed that accurate and prolonged ante-partum care which in the majority of cases not only insures his patient against misfortune, but himself against unnecessary loss of time, trouble, and reputation.

While it is not the purpose of this paper to go into minute details regarding the diet, dress, exercise, urinary tests and ante-partum examination so necessary in the care of women during the pregnant state, yet it is my deeply grounded belief founded upon experience that much of the curse resting upon the child-bearing woman of to-day may be lifted if intelligent and persistent care be given her during those nine months of waiting, when she joins hands with God in the great work of creation.

IMPERFORATE ANUS.

BY J. EMMONS BRIGGS, M. D., BOSTON.

"The rectum is the terminal part of the large intestine and extends from the sigmoid flexure to the anus. It varies in length from six to eight inches" (Gray's "Anatomy," p. 886; eleventh edition). "The development of the intestinal cavity. is one of the earliest phenomena of embryonic life. The original intestine consists of an inflection of the hypoblast," which divides into three parts, "the foregut, midgut, and hindgut. The ends of the foregut and hindgut do not communicate with the surface of the body, the buccal and anal orifices being subsequently formed by involutions of the epiblast, which later on form communication with the gut. From the foregut, the pharynx, esophagus, stomach, and duodenum form the hindgut, a part of the rectum, and from the middle division the rest of the intestinal tube-are developed."

Later in fetal life the anal depression should coalesce with the rectal pouch and the hindgut communicate with the surface of the body. In about one case in seven thousand this fails to occur and the child is born in a condition known as imperforate anus or imperforate rectum.

There are several varieties of imperforate anus and rectum which will be described:

Ist. Where a thin septum divides the rectal pouch from the anal dimple.

2d. Where the rectal pouch is well formed but the anal dimple absent.

3d. Where the rectal pouch ends high in the pelvis, the anal dimple being present or absent.

4th. Where the rectal end terminates in the bladder, urethra, or vagina.

Ist. In this first variety there exists a thin diaphragm of tissue which separates the rectal pouch from the anal dimple. This is the most simple variety of imperforate anus. It is recognized by a bulging of the anus during forcible pressure upon the abdomen, or while the child is straining or crying.