amount of food ingested and the excreta thrown off, the body through the different channels of elimination, conditions of atmospheric temperature, and exercise should be taken into account, and physicians should see that the amount of food eaten is commensurate with the ability of the excretory functions to take care of the waste material. Sometimes it will be found necessary, in order to have the patient properly nourished, to keep the skin, kidneys and bowels stimulated to activity by the different agencies at our command. Within reasonable limits, the size of a babe at birth, as compared to that of its parents, bears no relation to longevity or mental and physical development in after life; and while we may admit that a bountiful menu generously partaken of three times a day or oftener, is an essential ingredient in the ability to nurture and bring forth a bouncing baby of immense avordupois, it is a fact of no special virtue other than tickling the vanity of a proud father, while piled up in the other side of the balance is discomfort and disease, lack of muscular tone, making labor tedious, injury to some of the bodily structures which the skillful hand of the surgeon can only approximate to their original integrity, anguish of soul and body and too frequently death, either before or after delivery.

The remaining perplexity with which one has to deal occasionally is reflex nausea which does not yield to dietetic or medicinal means and which has to be overcome by cervical dilation, a remedy ordinarily efficient and yet attended with grave danger to the life of the fetus. No definite rule can be laid down as to the amount of force to be applied or the extent of dilation to be made, the toleration of the tissues of the mother being variable. A safe proceeding is to begin with the smallest amount of dilation observable, using a steel dilator, increasing the amount of dilation at intervals determined by the length of time required for the disturbance occasioned thereby to subside, until the trouble disappears or until the pregnancy is terminated.

An opiate administered hypodermically is a useful adjunct, as long as any hope is entertained of preserving the life of the fetus intact.

The Management of and Preparation for the First Stage of Labor

By WILLIAM W. PENNELL, M. D., Fredericktown

The preparation for the first stage of labor antedates that event by several months when possible. Usually, in the country districts at least, the physician is not apprised of the fact that an heir is expected until some wild, stormy night an alarm is heard at the door, and a voice informs him that "The old woman is sick and we want you mighty quick!" and he has all his managing and preparing to be done in but few moments, or not at all. Fortunately, the importance of seeking salutary advice respecting the whole period of gestation is becoming more and more a matter of concern.

In all cases, and particularly where she is an old primipara in whom the parts are apt to be firm and unyielding, the exclusion from the patient's diet all articles containing much lime is insisted upon for the purpose of retarding osseous formation to the end, that the bones may offer the least possible resistance to birth. The fatty, sweet and very starchy compounds are limited so as to produce a child of moderate size-lean but healthy. Much fat and advanced bony development retard the onset of the first stage, and intensify the pains of labor, if not increasing its dangers. Large babies produce great suffering, and the size of a child determines whether it can be born dead or alive. If it is lean and healthy its world for expansion is greater after birth.

The abdomen and genital region should have a daily bath, followed by a free application of clean lard, vaseline or lanolin. This is done to keep the skin soft and pliable, the vaginal orifice easier to dilate and to prevent the unsightly checking or scarring from distension. Frequent bathing of the whole body is, of course, not to be neglected.

The patient should have regular exercise, eat abundantly of fruits and vegetables with some lean meats, preferably

well-cured ham and fish. It isn't best to try to satisfy the longings of a depraved appetite which is but an evidence of some ailment and of which the attendant should seek out and remove the cause. It is not enough that she does her household duties for exercise, but should seek refreshment and exhilaration out of doors at seasonable times, avoiding all sorts of violent exertion. Carriage drives, cheerful surroundings, not omitting reading and other mental occupations, and all such environments as produce health of body and peace of mind, should be hers. In a word, the home-life should be bent to the one object of assisting the expectant mother to bring forth, as easily and speedily as possible, a healthy infant, physically and mentally.

The bowels should be regular throughout the whole period of gestation. If constipation exists its remedy lies in a relaxing diet and adoption of regular habits, resorting to aperients only when demanded. The urine should be tested at frequent intervals for albumin and casts, if there should be headache, particularly if the headache and edema are associated.

Corsets should be avoided, especially in the latter months, the clothing being supported by straps from the shoulders, care being taken to keep the lower limbs warm and the whole body comfortable.

In the primipara the preparation of the nipples for nursing purposes should not be neglected. Pulling by the fingers or suction by the breast pump to lengthen them, and the application of an astringent wash or lotion to avoid excoriations and fissures later on are never to be omitted. Infection with mammary abscess may thereby be averted.

With the approach of labor a laxative, consisting of such an agent as is best borne and usually taken by the patient, is administered and its action assisted by enemas of warm water and common salt, so as to clear the lower bowel of any accumulation; and if for any reason the urinary bladder is not completely emptied, a catheter is employed.

The preparation of the bed is supervised, though the

patient is not placed thereon until just previous to the rupture of the sac unless her condition requires. Her body, her clothing and her bedding are scrupulously clean, but no vaginal antiseptic or other washes are employed except in cases where a specific disease is present, or a strong presumption of it.

She is allowed the freedom of a room which is as cheerfully located as may be and which has a temperature of 65° or 70°; here she rests where she will while dilating pains are preparing her for the next stage.

The bed is by choice a firm mattress, easy of access from either side. Rubber sheeting or oil-cloth is laid over the lower two-thirds of a thick quilt placed next the mattress, and over the rubber an ordinary sheet which should be made fast to the mattress by safety-pins. When possible, over these is laid another rubber covering and upon this another cotton sheet upon which is placed a thick pad, or several smaller pads, made from clean, folded materials, to be arranged under the patient's hips to receive discharges during labor, so that when the act is completed the upper sheets and pads may be removed, leaving the patient upon the dry first sheet. When not, the pads are used without the second rubber covering.

The patient is prepared for the bed by removing her day garments and putting on an under-vest and night-gown, and a light skirt to cover the lower part of the body and limbs. On getting into bed the night-gown is rolled up out of the way to prevent soiling, the skirt being removed with the other soiled articles at the completion of labor.

If dilation proceeds normally, it is left to the efforts of nature; but when the uterine mouth is firm, retarding dilation, a full dose of morphin is administered, and, when the effect of the drug is procured, dilation is assisted by the finger.

When dilation is far enough advanced the presentation and position of the child is ascertained, and such adjustments are made as are demanded and feasible.

Anesthetics in Labor

By FRANK D. BAIN, KENTON.

The subject assigned to me for this symposium, "Anesthetics in Labor," is certainly a very practical one. There is not a practician present who has not had frequent occasion to study this subject. It is a subject on which none of us have spent too much time, but with a majority of my hearers, nothing that I might say in the time allotted to me would have but little effect in changing their long-continued practice.

The few thoughts that I present to you will be preceded by a short historic sketch of the stormy introduction of anesthesia in labor, and to me the study of the history of "Anesthesia" as applied to this branch of medicine has been both an interesting and instructive one.

The exhibition of drugs for the relief of the pangs of child-birth has finally brought the science, or rather the art, into the best repute and is one in which we all have been intensely interested. It is surprising to learn how fascinated some of the early masters became over the introduction of anesthetics in obstetrics, and from being conservative they became bold and almost reckless in the use of anesthesia. We know the history of surgical anesthesia, and it was but a step to the artificial sleep of obstetric work. To Sir James Y. Simpson, of Edinburg, Scotland, belongs the credit of first administering an anesthetic in child-birth. The first successful case in which the mother and the child were both saved took place in Edinburg, February 3, 1847.

Who among us, would not have been thrilled with delight and thankfulness to have stood in the place of Simpson; to have seen for the first time the awful pains of labor brought under the magic spell of the anesthetic. In that day there were few who would have been as intrepid as was that great Scotchman who first took the immense risk,