How strongly are inherited tendencies observed by those of us who give time and study to observation! If the unborn were conceived under one or all of a mental, moral, or physical abnormality, an abnormal product is most surely to be the result. Evil-minded parents, such as murderers, criminals, and drunkards, bear monstrosities in which we observe disproportionate conditions and relations during parturition.. Neurotic and emotional parents have their procreative powers. so debilitated that an arrest in intra-uterine life of one organ. and an over-development of another is more often the rule than the exception. Syphilitic parents bear rachitic children, and tuberculous parents bear scrofulous children, etc. Visit our almshouses and children's institutions, such as reformatories, orphanages, and idiot asylums, obtain some history of inmates, trace them back if possible to the third, fourth, and fifth generations, see how woe has generated woe, crime begotten crime, and disease begotten disease. This will illustrate what we will be able to do for future generations. We will do nothing for the past, and but little for the present; the past will assist us, if we note the stones over which they have stumbled, to better direct the future. The physician should be the teacher of the parents, and the parents the teacher of their children.

There is no better teacher than the physician who stands guard at the gateway of life and watches with painful interest through the throes and pangs of motherhood the ushering in of the many deformed children who, thus burdened, are nervous wrecks, setting up in the business of life bankrupt, and laden with debts which they perforce must pay.

There is none better than the physician who can send out the warning cry of precaution and demand the attention of those to whom these fallacies are due, or who can better point out the possibilities within the reach of all parents of endowing their children richly or of robbing them of their birthright, the right to be well born.

Can anyone better than the physician repeat the fearful text, "The sins of the father shall be visited upon his children unto the third and fourth generations," and demonstrate by means of repeated object-lessons of specifically diseased chil

dren who have gotten from their parents a heritage of woe, which they in turn transmit to generations to come? It has been said, "To reform a man, begin with his grandfather," and here the physician can teach the diseases of heredity with a fullness of meaning. Learning the history of the patient, he can say, "You undoubtedly inherited this or that from your parents; take care, and you need not transmit it to your children; they have enough from generations behind.”

Childbirth must be preceded by dilatation of the parturient canal, and the rule established by old-time accoucheurs—let nature take its course to a prudent limit is a good one, and with this ancient expression I would associate the value of non-interference in connection with normal labors. Many lacerations result from normal labor in which the attendant knew not the value of this wonderful adjunct of parturition. I admit it is the exception that a mature child is born without more or less laceration occurring in the perineum or some of the soft parts of the vaginal walls, and these injuries are usually in direct proportion to the resistance which the soft parts afford to the passage of the fetus. They are fewer in number and less in extent in normal labor, and are as a rule greater in primiparæ than in multiparæ. They are also greater in deformities, malpositions, and in disproportions between fetal parts and parts of the mother.

For practical purposes perineal lacerations are divided into first, second, and third degree, according to their extent. When any portion to one-half of the perineum is ruptured it is of the first degree. When torn to the sphincter muscle it is of the second degree. When the entire tissue is torn, including the sphincter, into the rectum, it is a laceration of the third degree.

It is necessary to know what fetal cranial diameters must come in contact with and pass through their respective pelvic diameters in different positions and presentations in labor. In occip. ant. positions, the cervico-breg. diameter of the fetal cranium, which is 334 inches, is brought in apposition with. the ant. post. of the pelvis, which is 41⁄2 inches. The biparietal diameter of the head, which is 31⁄2 inches, is found in apposition with the transverse diameter of pelvis, which is nearly 5 inches in length. Consequently a difference of three

fourths of inch permits a normal, easy birth if other conditions are favorable.

In post. positions we find an inverse condition of lengths of diamenters. The occip. front. and the occip. ment., which diameters are 434 and 54 inches respectively, are found in apposition with the ant. post. diameter of the pelvis, which is, as before mentioned, 41⁄2 inches in diameter. This necessitates tedious labor, extreme exhaustion on the part of the mother, molding of the head of fetus, loss of child by asphyxiation, and ultimate instrumental delivery with laceration of second or third degree, and invalidism upon the suffering mother until the injury is successfully repaired, which should never be neglected.

Thanks to nature, many post. positions correct themselves, and also, thanks to progress in medical science and literature, they may all be corrected if the attendant arrives before engagement has occurred. In the majority of these cases obliquity of the uterus and incomplete flexion of the child's head are the cause of post. positions. Correct the former by means of pad, bandage, and position of the parturient mother. The latter by vaginal digitation and supra-pubic pressure, maintain the same until progress in labor makes a permanent anterior position. If you do not succeed in converting post. to ant. positions, perform version, thereby succeeding in changing the head diameters, compelling the shorter diameters of cranium to oppose the shorter diameters of the pelvis, and though the head be abnormally large, it passes through the parturient canal much more easily following than preceding the trunk of the child.

One word in regard to breech positions and presentations. Strictly adhere to the practice of non-interference; you will preserve the perineum and save the life of many a child which is otherwise sacrificed. If the pelvis is small and the lower extremities do not extend, introduce an aseptic hand, gently bring down the feet to outlet by means of little traction, and allow nature to complete the delivery. Nature preserves complete flexion of the head keeps the arms in contact with the sides of the child, avoiding increased diameters of parts passing through the pelvis. Traction on the part of the attendant pro

duces extension of the head, the same of the arms upon the head, with injury to the mother and death of the child by locking and hanging in the pelvis.

Protracted labor will make the perineum dry and oedematous, which frustrates the effort of the obstetrician to avoid a rupture. I would much prefer a rapid labor from beginning through the successive stages-flexion, descent, int. rotation— to extension and slow from the beginning of this stage until the child is practically born, giving time for the head and shoulders to pass through the soft parts, than to have labor passing through the 1, 2, 3 movements, slowly followed by a rapid process in extension and on to birth. In other words, if labor must be protracted, let us have a large portion of time spent in last stages; if it must be rapid, hasten the first movements and prolong the latter movements, thereby preserving the perineum; it being the foundation upon which the pelvic floor rests; if this support be removed sooner or later, if from no other cause, from gravity alone, we will see a displacement of all the organs in the pelvic cavity.

The attitude assumed by a mother in confinement must be regulated according to the stage of labor which she is undergoing. If the head does not readily engage, position varying from flexion of knees upon the abdomen to Walcher's position will no doubt be helpful; but this position must not be indulged at the close of the second stage of labor.

To satisfy ourselves by actual demonstration, let us observe the effects of thigh flexion and extension upon the perineum. When the thighs are sharply flexed upon the abdomen we note the skin over the area between the post. commissure and the anus becomes drawn tightly to both sides, putting it on the stretch, thus preventing normal bulging of the perineum in the outer direction of carus curve. We also note that full extension of the soft parts, which allows the oc. protuberance of child's head to pass just beneath the sub-pubic arch, before the eyebrows crown the perineum, gives the shortest diameter attainable for the passage of the head. Let us further observe the effect of complete ex. We see the skin relaxed and the greatest possible latitude for perineal extension attained. Now make another test by applying the forceps when the head is

above the lower plane of the pelvis, putting the limbs through the same movements; hold the forceps still and in the proper position for traction at a given plane, the posterior commissure will both be seen and felt to be put on the stretch, in flexion, with added danger to the perineum by the shafts of the forceps, and in extension the reverse is true. The attitude of extension or Sims' position gives great relief and lessens the risk of laceration in this stage of labor.

A few months ago a lady came to my office; age about thirty; the mother of two children, the older four and the younger one about a year and one-half. She said she had not been well since her second child was born. On inquiry in regard to this birth I thought at the time I was getting the history of a posterior position with a forceps delivery, from the amount of traction and the length of time required to deliver; also her train of after-symptoms seemed to confirm my diagnosis. Upon examination my index finger entered the rectum instead of the vagina. On inspection I found the posterior wall of the vagina torn completely through the sphincter ani; it had healed, leaving a contracted cicatricial tissue on either side, with the rectum gaping almost two inches, with fæces remaining after each stool in both vagina and rectum. Fortunately involution had been pretty thoroughly accomplished after her confinement, which had delayed and decreased her sufferings, that surely follow this loss of tissue normally supporting the pelvic organs. Her attending physician said nothing about her being torn, and of course did nothing in the way of repair. No one believes more in leniency to our colleagues than I, but had I the convicting power in such cases I should convict of criminal negligence or ignorance, as it might be, when such cases are allowed to pass into convalescence unnoticed.

Some authors tell us the use of fresh lard to the vagina prevents laceration of the soft parts; some tell us the use of vaseline, lanoine, or some of the oils will prevent laceration if applied daily to the perineum for several weeks before birth, with massage to the inner walls of the vagina and the outer walls of the perineum. Some advocate sitz baths, and some hotwater injections during labor to render the perineum elastic