recollect how many times she actually fell in this manner, and with such following phenomena, but the accident was repeated several times. In nearing the term, the swelling of the limbs from oedema was greatly augmented, so as to affect the thighs, and the buttocks, and labia; the pericardium became also the seat of a dropsical effusion, so that complete orthopnoea soon declared itself.

"My patient could not lie down day or night. If she sat up with pillows against her back and shoulders, the oppression became so dreadful, she was obliged to throw them away; but, requiring some support, she placed her back against one of the posts at the foot of the bed; leaning against the slender cylindrical bedpost, she could find the needful support or rest without the oppression brought on by pillows or cushions. Here she sat day and night for many days, with very bad thin blood, which was imperfectly oxygenated, and so, greatly increased the disorders of the innervation. Her condition was truly deplorable, and it was difficult to imagine that the heart could ever recover its form, consistency, and power, should she even escape death in the impending conflict of labor. In fine labor came on, and in due time I delivered her with the forceps in order to save her from the necessity of exerting any voluntary force."

This young woman is now in the enjoyment of perfect health, having since given birth to several children, without any accident or extraordinary trouble whatever. Nor does she at present labor under any disease of the heart. Was this state of things brought about solely by nephritis albuminosa?

CASE.-Many years ago, I had charge of the case of Mrs. F. B., who was at that time the mother of two children and had been in delicate health since the birth of the last one. She came under my care during the last sickness of a medical friend, who had treated her many months as laboring under disease of the heart. To rise from her bed, and take a seat upon the sofa, was sufficient, on may occasions, to develop signs of approaching asphyxia from the disordered circulation consequent upon even the most moderate muscular exertion. I frequently observed the respiration and the heart's action to be so violently disturbed by these moderate efforts as to excite my serious apprehension of her imminent death. The pulsations of her heart were as well discoverable far to the right of the sternum, as in the left side of her chest. She was deadly pale; her lips swollen and blue; and to lay the expanded palm upon her breast was to discover under it a quaking and a tremulous motion like that perceived upon pressing on a quagmire. After a long treatment, her health amended somewhat.

She conceived, and proceeded with doubt and difficulty to the term of her utero-gestation. I confidently expected she should perish in her approaching labor, during the greater part of which she was obliged to be raised against pillows on account of a distressing orthopnoea. As the labor drew very nigh its close, it was necessary for her to take a lower recumbent position for the greater convenience of her delivery. I expected consequently, during the progress of her labor, to find her convulsed, and in fact the crisis which was brought about by the last uterine contraction, and the final strong tenesmic effort of expulsion which brought her infant to the light, was instantly followed by a short but most frightful convulsion, which, as it retired, left her apparently moribund. Somehow,-I know not how,-yet by the spontaneous powers of the constitution, she revived from this condition, and had no further serious trouble during her lying-in. In fine, this lady recovered a state of robust health. Her vast dilated heart, which seemed to me as large as a quart measure, regained its normal generical magnitude and force, so that, a few years afterwards, when I visited her sick daughter, she ran before me as light as a girl up to the fourth story of the Washington Hotel, without drawing a long breath on reaching the top. Her heart, I feel perfectly assured, was sound and well again. Was it morbus Brightii? If it was so-in what stage of the disease? This was a case of anæmia gravidarum, and the labor was preternatural, for it was orthopnoeic, and it was fol lowed by a terrific convulsion.

With regard to the treatment of labors rendered preternatural, by aggravated degrees of anæmia, I have only this counsel to give to the Student: 1. That he should clearly disclose to the friends of the patient the whole extent of the perils by which she is surrounded, while he gives to herself the reasonable assurances of his hope to conduct her safely through the whole course of her labor. 2. That, in the Conduct of the case, he should take all possible precautions to avoid undue excitement of the nervous and vascular systems, forbidding the bystanders to exhort her to bear down, and frequently advising her to bear her pains patiently, waiting for their dilating effects, and so continuing until the presenting part, having come within reach of the hand or the forceps, may be gently drawn away almost without any spontaneous assistance of her own. If there can be found a case in which the power of the forceps can be deemed more beneficent than in another case, it is that in which a parturient woman, with an im mensely dilated heart, useless valves, with cellular infiltration, and serous effusions within the chest, has barely power to live, but not enough both to live and expel the child from the womb.

It is true that the woman may be greatly infiltrated in pregnancy without having a dilated heart, and that such infiltrations readily disappear after the birth of the child; but they mostly leave the patient pale and chlorotic-or, in other words, hydræmic. I shall think that the woman excessively affected with oedema gravidarum should always be held to be threatened with relaxation or flabbiness of the muscular fibres of the heart, and the thereupon dependent disorders of which I have spoken. In order to overcome the oedema, it might in some cases be necessary, and no doubt is often effectual, to draw blood from the arm, to regulate the diet carefully, to entertain a soluble state of the bowels, and more than all these, to command the patient for a week, or more than a fortnight even, to take an unintermitted horizontal rest upon her bed or couch. To rest for a long time, and in doing so to avoid the dorsal decubitus as much as possible, is to put a stop to the progress of the infiltrating secretion, which I believe in true cedema gravidarum always begins and ends in the most dependent parts-to wit, the feet and legs. The circulation in such a posture becomes more and more moderate, and the aqueous humor already effused, being now dispersed almost over the whole of the subcutaneous cellular tela, is imbibed by thousands of absorbing orifices, to whose action it could never be exposed while accumulated solely in the lower part of the trunk and in the inferior extremities. I confidently recommend this mode of treatment, and assure the Student that I saw a young lady, a primipara, in October, 1848, who was five months past gone with child, in whom the cedema gravidarum had distended not the legs only, but very much also the pudenda: in this case the whole of the dropsical effusion disappeared in some ten days of a horizontal recumbency which she observed in consequence of my recommendation. These dropsical effusions should not be regarded by the Student as signs of an hydropic diathesis, but rather, as I have elsewhere explained, as the results of mechanical pressure and obstruction upon veins and absorbent trunks. Where the oedema has become very great, and the anæmical condition aggravated, there arises a real hydropic tendency or diathesis which leads to effusions into the belly or into the chest. As to the advice to draw, on certain occasions, blood from the arm of the hydræmic patient, I do not find I am inconsistent with myself: it is to be remembered that the hydræmia is in this case produced by a pathological state of the hæmatosic tissues, and that to bleed is, in some cases, to cure that malady.

Common experience and observation show very clearly the propriety there is, in all those cases where the anæmia has become thoroughly established, to prescribe for the patient the use of ferruginous

tonics. It is scarcely necessary for me to repeat, in this place, that the article most suitable for the occasion is the metallic iron of M. Quevenne. It may be given in doses of two grains in the form of a pill, to be taken immediately after meals three times a day.

Exhaustion.-Labors are sometimes rendered preternatural by the occurrence of what is called Exhaustion. Any disproportion between the child to be born, and the straits or the excavation of the pelvis, might, by protracting the vain efforts of the woman, serve to exhaust her forces. The disproportion may be absolute or relative. The child may be preternaturally large, to that degree indeed as to make it impossible for it to pass, unreduced in magnitude, through the parts; or the child may be of the normal size, while the pelvis is of under size, though in other respects well fashioned. Again, both the child and the pelvis may be duly proportioned to each other; yet the child may so present itself to the passages, as to retard or render impossible its spontaneous exclusion. Thus, if the child should present its head in extension at the superior strait, and descend in face presentation, with its chin to the sacrum and its forehead to the front of the pelvis, it would prove a very extraordinary circumstance should the woman fail to fall into the state of Exhaustion, unless delivered by the hands of the accoucheur: or there might be a departure of the chin from the breast; or such an occipito-posterior position of the head as to cause the two extremities of the occipito-frontal diameter to become immovably fixed upon opposite surfaces of the pelvis, constituting what is called arrest, and ultimately impaction of the cranium. An unturned or unevolved shoulder presentation; a prolapsion of a hand or a foot along with the head; or the impaction of the parts of two children at the same time in the pelvis, might serve to exhaust the expulsive as well as the vital powers of the woman. In addition to the above causes of this kind of preternatural labor, we ought to mention rigidity of the vaginal cervix, whether simple rigidity, or whether rigidity arising from carcinoma, or the remains of uncured inflammation of the os uteri. I have found that the action of the womb may be contravened by the intrusion of a loop of intestine betwixt the front aspect of the womb and the contracting abdominal muscles, occasioning during the labor throe, such great pain in the prolapsed loop of intestine, by compressing it between the hardened globe of the uterus and the contracting abdominal muscles, as to overcome the proper conformableness of the innervations ad partum. It is scarcely necessary for me to enumerate all the possible causes of exhaustion in labor; it is better that I should say that the parturient

action of the uterus and accessory muscles is effected at a certain expense of power developed in the nervous mass of the patient, and that while a woman in ordinary labor, and even in severe and longprotracted labor, is generally found capable of evolving from her nervous mass and sending down to the uterus and adjuvant muscles, an amount of innervative force sufficient to enable them to overcome all obstacles, yet obstacles are in some instances so rebellious that the sources of the nerve streams become exhausted, and the cerebro-spinal axis refuses any longer to repeat vain attempts to deliver; the woman lying motionless, feeble, and in a state which, to be truly denominated, should be called exhaustion, or the commencement of the moribund state. Exhaustion does not mean fatigued, but it means constitutional irritation of the most dangerous sort.

The heart has lost its force and increased its frequency, for the sources of its innervation are greatly diminished, and its own physical structure has become changed in impressionability and power. The respiration is hurried and short, for the diaphragm, the respiratory piston, makes short strokes frequently repeated-its power being nearly done. These states of the respiration and circulation necessarily involve disordered and diminished evolution of life-force in the nervous mass, and the blood, the fluid body, becomes fatally changed. Let the Student take heed, therefore, of the beginnings of exhaustion, for she who has gone far into it is irrecoverably gone into it. It is exigent to deliver her, and that in the manner least likely to consume her feeble remains of life power. Exhaustion is preternatural in labor, and even if it were not so, the duty becomes incumbent on him to render the labor preternatural by delivering with the vectis, the forceps, or the embryotomy forceps. Let him bring the chin to the front of the pelvis; or let him use the vectis; or let him reduce its magnitude with the perforator, in order that the child may be born; or let him extract it with the forceps. Let him, where there is departure of the chin and consequent impaction, restore the chin to the breast, or convert it altogether into a face presentation; let him convert the occipito posterior into an occipito-anterior position; let him return the prolapsed arm above the head; let him put away the foot, and give space for the head to descend through the pelvis; let him turn and deliver by the feet, or promote the spontaneous evolution of the foetus; let him disengage the prolapsed loop of intestine from betwixt the womb and abdominal muscles; let him reduce the size of the hydrencephalic head of the foetus, in order that it may pass the straits; let him take away from the woman any further necessity to evolve biotic force for the expelling womb and abdomen; let him take