swelling of the backs of the hands; but all these symptoms of dropsy disappeared on her prematurely giving birth to her last child, which occurred at the eighth month. The child did not survive. She continued free from dropsical symptoms for ten months; but five weeks before admission, after exposure to bad weather and also to the wet of the laundry in which she worked, the swelling again returned, rapidly progressed, and increased to her present condition. She is now five months gone with child. At the commencement of this last attack she noticed that her water was the colour of blood, and she retained but little at a time. There were no signs of heart-disease, and the sounds of respiration were feeble, with the addition of mucous murmurs in the large tubes.

As the bowels were sluggish, she took the compound jalap powder each morning, and the infusion of digitalis and bitartrate of potash three times a day. The amount of urine increased, but the dropsical condition nevertheless continued on the increase, and so great had the tension of the skin of the lower extremities become, that punctures became necessary, from which she derived some temporary relief. The dropsy, however, did not subside: the breathing again became distressed, from the oedematous state of the pulmonary parenchyma.

The urinary sediment at four days' interval, March 31st, April 4th, and April 7th, is represented in Pl. IX, figs. 2, 3, 4. The urine was highly albuminous, and the sediment thrown down when at rest had the same flocculent aspect and exhibited very similar microscopical appearances on these several occasions : great variety of epithelial structures; pus-cells, epithelium from the straight tubes, from the calyces and pelvis, as well as from the bladder and meatus. Several very granular casts were visible, a few transparent ones, the former containing a few free nuclei, several compound granule-cells, and here and there some colourless granular flakes. As the punctures brought but little relief to the tension of the lower extremities, two incisions through the areolar tissue down to the fascia were made with a lancet above each inner ankle, and with the effect of bringing

away a considerable quantity of water. Nevertheless the dropsical state of the upper part of the body was unrelieved. The œedematous state of the lungs was shown in the short and frequent respirations, occasional cough, but without any physical signs within the chest of bronchitis or pneumonia. The compound jalap powder produced but little effect in acting on the bowels, and notwithstanding the risk of bringing on premature labour, it was decided to give a small dose of elaterium. It was very evident, from the increase of the dropsical effusion in the chest and abdomen, that nothing but some hydrogogue cathartic could prevent the patient succumbing to the effusion of water into the parenchyma of the lungs.

She took a quarter of a grain, and it produced two watery dejections, with some relief to the breathing. The same day premature labour came on, and she was delivered of a sixmonths' fœtus. Any anxiety arising from the belief that the effects of the elaterium had its share in bringing on abortion, was removed by the certainty that the child had been dead for two or three days previously, and this was corroborated by the statement of the patient, that she had ceased to feel its movements for from three to four days.

Mr. Newcomb assured me that the foetus had a livid, drowned appearance; and the placenta was macerated, sodden, and very friable. Had the gravid uterus any share in producing the dropsy, we should have expected that many of the more urgent symptoms would have abated after the removal of the contents of the womb. But convinced from the microscopic character of the urinary sediment that one form of morbus Brightii was the cause of the dropsy, I was scarcely surprised that each succeeding hour added to the gravity of the symptoms; and although the incisions through the cuticle above each ankle had reduced the tension of the lower extremities in a very satisfactory manner, yet the dropsical accumulation in the chest and abdomen remained undiminished. The respirations became short and husky, a semi-comatose state followed, and she died in the morning of April 11th.

The body was removed by the relations immediately after

death. Being Irish, they exhibited their characteristic prejudices against a post-mortem examination. The character, however, of the urinary sediment left no doubt on my mind as to the nature of the renal disease which caused the dropsy. In the absence of post-mortem evidence, it would be idle to speculate on the form of kidney disease which gave rise to these symptoms. The character of the urinary sediment, when first examined, led me at once to pronounce the case as hopeless. I had no hesitation in saying that the dropsy would not disappear after the delivery, and I ventured to express my fears that abortion would in all probability take place, and a fatal termination speedily follow.

A microscopic examination of the urinary sediment in any similar case will enable the physician at once to determine whether the dropsy be dependent on pregnancy only, or the more formidable conditions of renal disorganization.

The sediment in this case was remarkable for the great variety of epithelial structures which it presented.

The well-known fact that the urine sometimes becomes albuminous during pregnancy, rapidly disappearing after parturition; also, that a woman may conceive who is suffering from the early stage of morbus Brightii, and consequently has albuminous urine throughout her pregnancy; also that these latter are peculiarly subject to puerperal convulsions of a grave and often fatal character, has raised the question how far the state of pregnancy may operate as a predisposing cause of morbus Brightii.

Some writers conceive that pregnancy is a fertile source of this disorder; others are sceptical on this point.

Dr. Roberts, in his excellent work on 'Urinary and Renal Diseases,' discusses this point, and brings forward (p. 289 and following) some statistics to support the view.

My own experience is certainly opposed to these conclusions. That a young woman of scrofulous taint may conceive, in whom on marriage there existed no apparent signs of renal disorder, but whom there needed but slight disturbance in the equilibrium of the renal circulation, and which was furnished by the pres

sure of the gravid uterus, to produce the congestion or preliminary engorgement of the renal vessels to be followed by the full development of the disease, is not improbable; but that an otherwise healthy woman should, out of the passive congestion of the renal organs consequent on pregnancy, and apart from the ordinary exciting causes, become peculiarly susceptible to so serious a disease, is certainly not consistent with my own personal experience, nor is it with that of some distinguished metropolitan obstetricians, nor even with some statistics which have been collected to illustrate this view of the question.*

Women are less frequently the subject of renal dropsy than men. This doubtless arises from their being less under the influence of the most fertile source of the disease-exposure to cold and wet and the abuse of ardent spirits and fermented drinks.

The question of the relation of pregnancy to morbus Brightii might be viewed from this latter position. Would a pregnant woman of intemperate habits and exposed to the influence of cold and wet be more likely to suffer from this form of renal disease, than a non-pregnant woman under the same predisposing circumstances? The answer must certainly be in the affirmative; but then the circumstances are altogether exceptional, and can have but little bearing on the fundamental point whether pregnancy per se can be considered as a predisposing cause to morbus Brightii. My own conviction is that it is not.

See a Lecture, by Dr. Harley, Medical Times and Gazette,' December 16th, 1865.

CHAPTTR XVII.

ALBUMINURIA WITHOUT TUBE-CASTS-NON-TUBULAR.

Ir occasionally happens that all the symptoms of renal dropsy may exist without the sediment of the urine containing any of the characteristic tube-casts; in the place of which, however, pus-cells, isolated or cohering in groups, and even arranged in a tubular form, and evidently derived from the uriniferous tubes, are among the characteristic objects in the sediment.

General anasarca-Flaky deposit of pus-cells coherent in masses with epithelium from the calyces, pelvis, and ureters of the kidneys-Membranous débris stained with hæmatin.

CASE XXVIII.-This case is worthy of notice, from the sediment of the urine presenting some exceptional conditions to what are usually found in albuminous urine associated with general dropsy. The urine for many weeks had been highly albuminous, of a comparatively high specific gravity-1026 to 1030; micturition had been frequent, and the amount of urine voided each time was small in quantity. There had been more or less lumbar pain, and the anasarca, though not very great, had involved the legs and backs of the hands; there had been puffiness of the eyelids and face for a few hours in the morning, subsiding as the day advanced.

These are all characteristic symptoms of renal dropsy. The urine had the usual albuminous character, except that, on one occasion only, have tube-casts been seen in the sediment.