away from her agonized nervous mass all further occasion to perceive the irritation, the pressure, or the pain; and then, tenderly placing her upon her pillows, wait until perchance her blood may be redeemed from its perilous disorders, and her neurine again come to send down its streams of biotic power to all her organs and organisms, with a gently increasing, conformable, and normal power.

There is a great difference between exhaustion and the mere cessation or suspension of labor pains. The woman may fall into labor, and after proceeding many hours towards the accomplishment of her delivery, she may stop for many hours to commence again, and again to cease the work of expulsion. The act of labor being established, does not necessarily imply that the effort shall be continued until the completion of the process. A woman may be in labor during several hours daily for a whole month, dilating her os uteri to the size of a half dollar, and then closing it again so that it shall become as small as before the commencement of the process; so a woman, even in advanced labor, may cease to labor for hours, or for many days, and yet suffer no perceptible illness. Such a case is not sickness. It is not exhaustion. Hence, I warn the Student that he ought not to commit the serious mistake of concluding, merely from the cessation of the pains, that the woman is in a state of exhaustion, or even beginning to fall into that dangerous state. I know not why it happens, as it often does happen, that labors begin and stop without any apparent indisposition; but I know that the records of a man's practice should furnish him with many instances of the kind.

To know the state of real exhaustion, let him look upon the condition of the vital triad-the brain, heart, and lungs; or, in other words, the innervative, the circulatory, and the oxygenating functions. He will discover the condition of the brain by the psychical signs, such as illusions, hallucinations, delirium, altered temper; and by the physical signs, loss of co-ordinating power in the cerebellum, seeing power in the quadrigeminal tubercles, respiratory power in the indispensable respiratory bulb, and lessened intensity of the nervous force in general. The embarrassment of the circulation is discoverable by lessened power of systemic injection, and augmentation of the fre quency of it-the oxygenation shows its failure by change of temperature and of colorific power, all of which must be studied, and profoundly studied and understood, in the manifest action of the mind and the whole physical conduct and aspect of the patient. In a difficult labor, tending to exhaustion, there will first be discoverable a most marked violence in the effort of the arterial pulse, which becomes voluminous, hard, and frequent-beating about 110 pulses per minute.

Whenever, after some time of protracted and fatiguing efforts with such a state of the pulse, the contractions of the heart are found to be repeated 120 to 140 times a minute, the volume of the artery becoming reduced, the temperature being also lessened, with a dry mouth and parching thirst, loss of courage and resolution on the part of the poor woman, the presenting part in the mean time making no progress whatever, exhaustion has begun, and has already proceeded even too far.

Exhaustion is not likely to arise from the resistance of the soft tissues only. Even the most rigid cervix uteri gives way when the strength begins to go down. So also the most resisting perineum yields before the constitutional force is abolished or overthrown. But the impacted head, the unturned shoulder, or the impracticable pelvis, can never give way; and the efforts of the nervous, circulatory, and oxygenating forces must ever fail in presence of inexpugnable resistance: in such instances, the sources of the innervation must sooner or later become wholly exhausted, and the woman be lost if she be left to the powers of her own constitution.

In the beginning of exhaustion, to deliver is to save the mother. A too long procrastination of her deliverance is most apt to insure her death.

Exhaustion not being likely to ensue in consequence of soft resistance only, we have, even in the most obstinate cases of soft resistance, little to fear from contusion and a coincident irritation or shock; nor have we ground to look for dangerous sloughing at a later period. But when exhaustion arises from vain attempts to overcome the resistance of solid bone, we have, in addition to the direct effect of such efforts in vitiating the blood and modifying the crasis of the nervous mass, much mischievous impression upon the whole nervous system, radiating from parts engorged, contused, or ruptured. The violent excitement of the sanguiferous system, in painful protracted labors, serves in a sense to demolish the organization of the blood, which becomes broken down, its plastic portion being increased excessively, while it loses in a measure its sensibility to the action of oxygen; it loses, in other words, its healthy crasis and the innervative results of its oxygeniferous force; and its contaction with the nervous mass become unconformable to the wants of the organs, which fail and die under such want.

Cramp. I do not remember to have met with any published statement of cases of cramp in the legs as causes of Preternatural labor, and yet, having met with examples of it in my own practice which rendered the use of forceps absolutely indispensable, I have thought

fit to relate them in this book. There is no need for great surprise at the announcement of this cause of preternatural labor, since it is well known that the compression or tension of a nerve may give rise to pain so great as to disturb in the most violent manner the functions of life. The head of the foetus, in descending, may be impelled with so great a degree of force against certain of the internal sacral nerves as to render the patient almost or quite frantic from the agonizing sensations developed thereby. Under such intense suffering, the womb may cease to act, or act inefficiently, and the practitioner, seeing that the distress of his patient is greater than she should be permitted to bear, hastens to extend to her the only prompt and efficient means of relief.

Without further discussion of the reasons which, à priori, should include the violent cramps to which I refer among the causes of preternatural labor, I beg to refer the Student back to page 48 for accounts of the cases, which I have no occasion to repeat in this connection.

Prolapse of the Cord.-There are other circumstances that may suffice to convert a natural into a preternatural labor. Among these may be mentioned the prolapsion of the umbilical cord. The cord very rarely gets down below the presenting part of the child, and we have reason to be astonished at the rareness of the accident when we consider the great length of that part of the secundines, which is sometimes found to be six feet in length. The mere falling of the loop could not, under any circumstances, interfere with the ability of the woman to deliver herself, because it could not inconveniently occupy any space in the pelvis to the hinderance of the birth. The importance of the accident is relative only to the child, and not to the mother. The child is placed in imminent danger of dying by asphyxia from pressure on its umbilical vein and arteries when they fall below its head in labor. Hence, the necessity of expediting the delivery by manual or instrumental means, and the conversion of the natural into the preternatural kind of labor, either by turning or the forceps.

I do not wish to be understood as advising a resort to art as an invariable rule of practice in such cases; for it fortunately happens, in some instances, that the pelvis is large and roomy, the os uteri dilating rapidly, and the pains sufficiently strong to assure us that the child will be born so speedily by the unaided powers of nature, as to make it unnecessary for us to interfere. The child has so good a chance for escaping uninjured, in a rapid delivery, that it is more

advisable to confide in that chance, than to expose both the woman and the child to the hazards of a forced delivery. I repeat that it is a rare occurrence to meet with a cord prolapsing, after the labor is fairly begun. Indeed, the head so completely fills up the cone of the cervix uteri, as to prevent the navel string from falling down betwixt the head and the walls of that cone. If we find it fallen down, therefore, and the os impracticable, what madness would it be to attempt to turn before the cervix is dilated! Such an attempt would be likely to fail, or kill the patient. But if the os is dilated, and the head on the point of escaping into the vagina, we may expect, as soon as it has cleared the os, to be able with the forceps to rescue the infant, and that with almost no risk to the mother. We also have the advantage of being able, by touching the prolapsed cord, to ascertain the state of the foetus: if the pulsations continue vigorous, we shall suppose the child to be doing well, and if they become faint and feeble, we shall be led to resort to the forceps or to turning, as the case may be. When the prolapsed cord has no pulsation and is cold, the child is dead, and of course no steps need be taken on account of the prolapsion, which, in that case, becomes a matter of indifference. These prolapsions rarely take place after the mouth of the womb has become well dilated. The cord is probably down, in most cases, before the labor begins, for it is found protruding through an os uteri not larger than a half dollar. Such an os uteri is impassable to the hand; therefore the accoucheur can by no means return the fallen cord into a cavity to which he cannot have access: he makes vain attempts to succeed by pushing the loop back within the constricted circle of the mouth of the womb, from which it again immediately escapes. If he could carry the string quite above the head, it would stay there. It is evident, therefore, that, with the hand alone, little success can be expected, in even the most patient endeavors to get the prolapsed part in a place of safety. I have succeeded with my hand alone, but have much more often failed.

Many various methods of repositing the cord, or putting it back into the womb, above the foetal head, have been proposed; they have mostly been found ineffectual, from its being apt to fall down again, even after it has been put into the proper place. I have never yet had an opportunity to try a method which I beg leave to propose to my readers, and which is as follows: Take a piece of ribbon or tape, a quarter of an inch wide and four or five inches long. Half an inch from the end, fold the tape back, and sew the edges so as to make a small pocket. Then fold the other end in the opposite direction, and sew that also, to make a pocket of it. Now, if the cord be taken in the tape, and held as in a sling, a catheter may be pushed into one of the pockets, and

that one thrust into the other, so that we shall have the cord held as in a sling, which is itself supported on the end of the catheter or womb. sound. Let the catheter be now pushed up into the womb, beyond the foetal head; it will carry the secured portion of cord with it, and the catheter being withdrawn, the tape is left in the uterine cavity, where no harm can be occasioned by its presence. If required, several such tapes could be secured round the cord, and all of them fixed on the end of the same catheter, and pushed at the same moment far up within the cavity of the womb. By using this method, Dr. S. P. Browne, of Greensburg, in Westmoreland County, Pennsylvania, succeeded in separating the umbilical string, as did also his son, Dr. Robert Browne.

Fainting.-Fainting or syncope, when often repeated in labor, is sometimes of so alarming a nature as to induce the practitioner to be willing to expedite the birth of the child, in order to put an end to so threatening a symptom. No prudent person, however, would be led to perform so serious an operation as Turning, or the application of the forceps, without being first fully convinced of its necessity. Of the degree and imminency of the danger here, none but a medical person can be supposed a competent judge, and the case must be left in his hands, strengthened, as he should be, by the counsel of a professional brother. I shall feel satisfied, therefore, to have merely referred to this cause, and to leave it to the discretion of the attendant physician, without any additional remarks.

Hernia. A hernia, especially if of a kind liable to strangulation, might be a warrant for the accoucheur to hasten the moment of relief by the employment of the resources of art. We have also, in a few very rare instances, the dreadful accident of laceration of the womb or vagina to contend with. Of course, as soon as either of these accidents is known to exist, we should resolve to take the management of the delivery into our own hands, in order that we may, at least, save the infant, while we can also offer some faint chances of hope for the safety of the patient.

Engagement of a Loop of Intestine in front of the Womb.Though the gravid uterus, at full term, lies behind the abdominal integu ments, and quite in front of the mass of intestinal convolutions and transverse colon and its sigma, it sometimes happens that a portion of the mesentery or mesocolon, I know not which, becomes so relaxed or elongated in the direction of its radius, as to permit a considerable por