other. The ureters are single, normal in size, and enter the bladder with a normal relation in the trigone. The blood supply is maintained by many small branches from the abdominal aorta. There are two suprarenals which are normal in size and position.

This specimen is to be differentiated from a case of complete absence of one kidney, in which case the "anlage" of one of the two kidneys either fails to bud from the Wolffian duct, or it passes through the first stage and becomes arrested and absorbed before it has completed its ascent. The position of this specimen and the fact that there are two ureters entering the bladder on different sides is quite sufficient evidence to show that these were two separate and distinct organs in embryonic life, and that they fused while in the pelvis and did not afterward rotate. To acquire this variety of fusion it must be assumed that the renal buds during the period of their closest apposition are on different vertical levels, so that the caudal pole of one of the buds touches and fuses with the cephalic pole of the opposite mass. This is probably due to a chronological variation in the renal outgrowth from the two Wolffian ducts, one bud being given off earlier than the other, or it may be due to the fact that one may be given off at a higher level than the other.

Inasmuch as the trigone in these cases is normal, one could not even suspect the anomaly by cystoscopic examination but with pyelography an accurate diagnosis would be more easily accomplished.

These specimens of fused kidney represent two extreme types of the anomaly and there are many varieties between them.

THE HYGIENE OF PREGNANCY.

BY

GEO. W. KOSMAK, M.D.,

Attending Surgeon.

Foreword. In publishing the following paper in the pages of the BULLETIN the writer feels that its character demands a few words of explanation. It is a presentation to a lay audience of the essentials of the hygiene of pregnancy based largely on personal experiences in answering the questioning of the average patient. The paper was read on two occasions during the past winter at gatherings of parents, once in a public school and again at the New York Academy of Medicine, the meeting in each case being held under the supervision of the Public Health Education Committee of the Medical Society of the County of New York. Medical information properly presented to the lay public through the medium of qualified professional organizations, in now quite generally admitted to constitute an educational movement of great value and moment.

In no field of medical practise is this truer than in obstetrics. The numerous and very sensible questions asked by the audience after the reading of this paper, seemed to show that the facts of the same were appreciated and the belief that its form and contents might be of value to others undertaking a similar task, has served the writer as an excuse for bringing it out in the pages of the BULLETIN.

By way of introduction the speaker is compelled to admit that he has set himself a difficult task in attempting to present within the alloted time in a satisfactory manner such an important subject as the hygiene of pregnancy, or in simpler words, the care which a woman. should have while she is developing within her another being. A woman who is about to have a child is almost universally regarded as an object of interest and sympathy and very justly so, because she fulfills in this manner the highest function of her sex. In order for a woman to bear healthy children with the least danger to herself, it is necessary that proper care be extended to her from the earliest months of pregnancy. If a married woman takes note of this fact she will assure herself a much safer delivery than if the calls of nature are disregarded. The day has passed when a mother can go from her work, deliver herself of a child and then within a few hours return to her tasks. Our modern life has changed this entirely, and likewise the knowledge that we now have of the influence of the mother's condition on her offspring. In order to afford you an insight into the care to be extended to a woman who is pregnant I cannot undertake to prescribe for all the ailments that are often associated with this period. I can simply detail in a very brief manner the course of pregnancy and give you suggestions as to how to lead a proper life during this time.

Let us suppose that a healthy, young married woman who has previously had uninterrupted monthly periods finds that the flow does not appear at the expected time. From what she knows of these matters in a general way she imagines that she has become pregnant and the cessation of menstruation may ordinarily be accepted as a presumptive sign of pregnancy. There are exceptions, however, for both mental and physical disease may cause a stoppage of the flow. The discussion of this subject, however, is not opportune to this lecture. By the time a second period has been skipped, the woman who is presumably pregnant also experiences a fullness in the breasts, usually regular attacks of nausea and vomiting every morning and some disturbances of the bladder. The breasts appear rather full and if the nipple is squeezed a small amount of watery fluid is discharged. They also become tender and give rise to various sensations which are occasionally annoying. On waking in the morning the patient frequently finds herself nauseated

and is compelled to vomit and this condition may last for an hour or longer every morning. What is known as "morning sickness" may be of the slight degree just referred to or it may become so extreme as to require medical treatment. In such cases the patient ought not to attempt to do anything for herself, but consult proper medical advice at once, as a continuance of this process may result in placing her life in great danger. A patient in the earlier months of pregnancy will also have the desire to pass her water frequently and there may be other annoying symptoms which are chiefly due to the pressure of the growing womb on the bladder. These disturbances disappear ordinarily within a few weeks. In addition to these presumptive signs of pregnancy we find that by the fourth month or a little later, the mother experiences peculiar sensations in the lower part of her abdomen which are due to the movements of the growing child in the womb. When the signs referred to are present the patient can usually assure herself that she is pregnant and at this time, if not before, she ought to consult and engage a physician who will take care of her during the coming confinement. It is not advisable for a woman to wait until the last month before securing medical advice, as a great many things are likely to come up during pregnancy which a physician alone can properly treat. I shall refer to this subject again a little later.

The ordinary duration of pregnancy is about 39 or 40 weeks, approximately nine calendar months. The commonest form of calculating when a given pregnancy will be terminated is by counting forward 280 days from the beginning of the last menstrual period. This allows seven days for the period and the time of conception. The simplest way in which to figure the expected time of labor is to count back three months, or forward nine months from the first day of the last period and then add seven days. This is not an absolute date but the birth of the child may be looked for within a week usually of this calculated date. It is quite essential that every married woman keep a careful track of her menstrual periods, not only as to the date, but the character and amount of the flow. It very often happens that a woman apparently has a menstrual period after she has become pregnant but this is not common and as a rule it is safe to figure the termination of the pregnancy from the first day of the last regular monthly period. As already stated it is important that a pregnant woman should take very good care of her mind and body during this period for she is devoting herself to a process by which a new being is brought forth into the world and she must put herself and keep herself in such good condition that this birth will take place with the least amount of danger either to her or to her child. Let us take up some of the features of this personal care. Pregnant women often imagine that they must eat for two persons and consequently eat and drink so much that it causes them considerable distress. The digestion of a pregnant woman

is very easily upset and indigestion must therefore be avoided as it is very apt to lead to unfortunate consequences. A woman during this time should eat the food that she is ordinarily accustomed to, modified merely to the extent that it will be easily digested and in a certain sense laxative; that is, aid in keeping the bowels open. It is also very important in pregnancy that those organs in the body which get rid of the waste material should be kept in perfect condition. These include the bowels, the kidneys and the skin. In order to keep them in such good condition the diet must be light and yet satisfying and nutritious; a large proportion of liquids, comparatively little meat and a generous supply of fresh fruits and vegetables constitute an ideal diet for a pregnant woman. As already stated the accumulation of waste products in the body must be promptly gotten rid of and this is greatly aided by fluids, at least two pints being taken during the day, largely in the form of ordinary water. Other liquid foods include milk, broths, and cocoa. If a patient is accustomed to drink tea or coffee it is not necessary to stop their use altogether but they had better be cut down in amount. Tea drinking to excess is especially bad for the pregnant woman as it produces nervousness and constipation. Alcoholic drinks had best be avoided during pregnancy as they are indirectly apt to injure the child.

Most women suffer from more or less pronounced constipation during pregnancy. It is due in part to the pressure of the enlarging womb upon the lower portion of the bowel and also to the lessened amount of physical exercise which pregnant women take. The use of laxative food is preferable to the taking of cathartic medicines during this period and if fruits both fresh and stewed are included in the diet, together with graham or bran bread, corn meal, oatmeal and similar cereals, and plenty of fresh water is also drunk, laxative medicines can usually be avoided. If the patient persists in being constipated it is better to consult a doctor than to resort to purgative medicines purchased from the druggist without any knowledge as to what they may contain. There is great danger in taking strong cathartics of producing a miscarriage.

Every pregnant woman should spend at least two hours of each day in the open air. She may walk to the point of becoming tired and may keep this up until the very last weeks of pregnancy. All fatigue or dangerous exercise and sports should, however, be avoided and likewise unnecessary shopping expeditions with long rides in crowded cars and sojourn in crowded stores. It is necessary that a pregnant woman should conserve her strength and build it up rather than tear it down with violent or exhausting exercise. There is nothing better for the pregnant woman than to keep up her ordinary household duties as long as possible.

It is the purpose of clothing to keep the body warm and by doing so an even circulation of blood is maintained over the entire surface

and the sweat glands are kept active. It is therefore advisable for a pregnant woman to wear sufficiently warm clothing except in the heat of summer and to wear it evenly distributed over the body, avoiding all constricting bands either around the waist or the legs. It is much better to have the dress made in one piece so that skirt bands become unnecessary and especially in the later months the discomfort produced by weight of the skirts may be overcome by using a pair of suspenders made of wide tape which hold the petticoats from the shoulders. The union underwear now so generally sold at reasonable prices is an excellent and light protective for the body and should be more universally employed than it is. It is desirable to discard the ordinary corset early in pregnancy for by its pressure around the waist it is apt to crowd the pregnant womb downward and so interfere with its proper growth and development. Shoes should be sensible as regards wide toes and low heels, for a woman during pregnancy finds it necessary to throw her shoulders backward in order to maintain her upright position and high heels interfere with this very much, so that in the course of time the ankles are weakened and the patient complains of pain in the legs. This can all be avoided if common sense shoes are worn.

The skin must be kept in good condition at all times during pregnancy and this may best be obtained by frequent bathing. Cold baths as a rule are unnecessary and a hot bath is apt to be weakening. Warm baths with the use of plenty of soap taken at night several times a week constitute an excellent means for keeping the pores of the skin open. Plenty of fresh air is essential to a pregnant woman, both day and night, as she is breathing not only for herself but for her baby. Sleeping rooms must be ventilated no matter how cold the outside air.

It is the duty of every mother to nurse the coming baby and in preparation for this the mother should take proper precautions to have her breasts in good condition and should so regulate her own life that the task of nursing will be a benefit to her and the child. Special attention must be given to the development of the breasts and nipples. As the breasts enlarge during pregnancy they must not under any circumstances be constricted by tight clothing or corsets. In cases where the nipples are flat they may be developed like any other muscle by exercise, and if gently pulled upon two or three times a day with the fingers they will become erect much more readily than if left alone. There is a mistaken notion prevalent among the laity that the nipples must be hardened for the baby to nurse properly, when on the contrary, what is desired is to have them soft and pliable so that the skin will not become cracked from the baby's suckling efforts, therefore alcohol and other astringent lotions should not be applied but the breasts and nipples washed every day if possible with soap and warm water and then anointed with lanoline, which is a fatty substance that is absorbed by the skin and renders the latter soft and pliable.