to the head, and painfully, slowly, and with much effort, extracted the child, which was dead.

The patient was sorely exhausted by such a dreadful labor. Her very bad pulse did not amend after the delivery; the injured parts were attacked with erysipelas, to which she fell a victim, in the course of a few days.

I have thus given an account of a case which I hope may set, in a clear point of view, the nature and dangers of these bloody infiltrations; and I wish the perusal of it may set you on guard against similar occurrences, of which you will perhaps become the interested spectators. I should think the foregoing remarks enough to show you that the mere filling up a labium is a matter of small consequence, in comparison with the inward mischief and demolition likely to accompany such accidents. I pray you, then, not to disregard the complaints of your patients in child-bed, as to the affections of the external genitals; but the rather, that you should pay very great regard to them, nor suffer the fastidiousness of a modest female, or your own sense of delicacy, to prevent a complete and early investigation.

Do you not think that if a patient under your care, in labor, should begin to have extravasation (thrombus) filling up the labium, it would be charitable, and dutiful, and prudential to lay open the mucous surface by an incision conducted in the longitude of the organ, and deep enough to give issue to the infiltrating blood? Would not such an aperture, by allowing the hemorrhage to exhaust itself upon cloths or napkins, prevent it from tearing to pieces, or obstructing the lax textures outside of the vagina and inside of the pelvis? Be you the judges to decide upon any case presented in the course of your practice. I think, that where a labium is already filled with blood, before the distending power of the head begins to be exerted upon it, if you allow the injecting force of the hemorrhage to go on unchecked or unrestrained, you will have reason to dread the extending of the thrombus to very deep-seated textures; and hence I should much prefer to allow the fluid to escape through an incision made on the mucous face of the labium.

I pray you to consult Dr. Dewees' article on this subject, in the Treatise on Females; it is a very good one, and you ought certainly to consult the writings of that celebrated man—the more especially as he was an American authority.

I have said nothing of the after treatment of the accident. Of course, you will not expect to discharge from the thrombus all the blood contained in it, by an incision. You will get out all the coagula, very great in quantity, and pass out much fluid blood. and serum of the coagulations. The discharge of the rest will take place, partly by outflowing under the textural contractility of the parts, and partly by the absorbents, which will carry it away. I am sure I have seen at least a pint of blood effused beneath a man's skin, from a blow, taken up and carried away by the absorbents in about a fortnight.

The most convenient treatment will consist in very emollient dressings, either of tepid water, mixed with a little red wine or vinegar, or of flaxseed tea, mucilage of slippery elm, applied as stupes or fomentations, or linseed or bread and milk poultices, or poultices composed of crumbs of bread mixed with the petals of chamomile. These dressings, when the tumefaction becomes sufficiently reduced, ought to be followed by cerate dressings; whether of simple cerate, basilicon, or Goulard's cerate. The selection will depend on your judgment as to the wants of the case.

When a woman has suffered from such an accident, it must be expected, if the injury be of a grave character, that she will have great pain and constitutional disturbance from it. I need not say, that you ought not to leave the nerve system to the unmitigated perception of such painful impressions; but that you ought to quell both its impressible and perceptive faculties, by keeping them within moderate bounds, by the use of anodyne medicines in some convenient form; such as the Dover's powders, which may be repeated in doses of four grains every two, four, or six hours, until the therapeutical end of its exhibition is attained.

Should much febrile heat, and sanguine exaltation attend the early stages, you might perhaps prefer a medicine like the following recipe.

Take of fresh lemon juice, 1 tablespoonful; carb. of potash, 18 grains; mix them and add, solution of sulphate of morphia, of a grain to make a draught, to be taken every two, four, or six hours.

It will be obvious also, that where a full or tense pulse is found to accompany the accident, or to follow it as a consequence, it

may be needful to reduce the force of the sanguine circulation, by venesection, to a proper extent.

During the treatment, the bladder of urine should not become over full, and the alvine dejection should be procured at least once in twenty-four hours. The most scrupulous cleanliness, as to the parts, ought to be insisted on-and all sour poultices, or remainders of dressings, carefully expunged. But all these precautions would be of little avail, without the most profound recumbent rest. She should not leave her couch until cured.

Watch such a patient vigilantly. She is always to be esteemed, until suppuration is established, in danger of erysipelas of the wounded parts. If attacked with erysipelas, she will scarcely escape death from peritoneal fever. I say then, watch such a patient well, through the dangerous five or six days ensuing the accouchement. If the disposition to erysipelas become manifest, you should apply the nitrate of silver pencil freely to all the inflaming skin, if not to the very margin or lips of the wound. The antiphlogistic power of the nitrate, is probably the most dependable of your resources for such circumstances, and may be handled so as not to give any pain. C. D. M.

LETTER VII.

BESIDES the affections I have now treated of in the two former letters, the labia externa are subject to rupture or laceration, not attended with the terrible conjunction of concealed hemorrhage, last spoken of. Indeed, it would, à priori, be evident to you, that a fracture of the tissue, laying it open to the air, would not consist with the formation of a thrombus within its walls.

It is always a subject of regret, when the labium is torn in labor; for I presume that no professional rank or station of the accoucheur, could preserve him from the maligning tongues that are so fond to wag against their betters. The more exalted your station, the more will you be liable to the assaults of the envious and the malignant; who will not fail to spread abroad the bruit

of the misfortune, accusing you of ignorance, inattention or rashness; and averring that you tore her dreadfully; when they do not know, that your knowledge of Professor Carus' curve and the agents in the extension of the head, with your own probe and faithful regard to duty, could not, all combined, prevent the innocent head of the child from breaking in pieces an obstruction which it could not otherwise overcome.

I doubt not, my friends, after the repeated illustrations made in your presence, that you perfectly understand why it is the head of the child, which in vertex presentations enters the pelvis obliquely and in flexion-descends and rotates still in flexion, until the occiput, engaging under the crown of the pubal arch, is pressed upwards, as it emerges, along the exterior face of the symphysis, being compelled to move so, coincidently with Carus' curve, by the strongly resisting perineum, against which the sagittal suture is driven by the labor throes.

You may remember that I urged you not only to aid the perineum to compel the extension, but to aid it in compelling the head to move out in coincidence with Carus' curve; and that because, should it quit Carus' curve at a tangent, the perineum must give way, or a labium be broken off, or perhaps both of them be detached somewhere in their longitude; a horrid accident, which I trust may never occur in the hands of any member of the class.

Only conceive of a rent commencing at the lower end of the labium, and running back through the whole thinned structure of the perineum, not thicker than this sheet of paper sometimes, so as to burst through into the rectum. Take care then, I pray you, of the women, who under faith of your diploma, or your acknowledged skill, commit such precious interests into your charge.

Let me warn you against the risk of cutting the perineum with the child's elbow. You will be very apt to allow the accident to happen whenever the child's hand, in a vertex presentation, descends, applied to its face or throat; for the ulna of the child lies in contact with the posterior wall of the vagina, and as it slides forth, and comes to press with its olecranon on the fourchette, that olecranon cuts the tissue like a sharp knife-whence, I beg you be careful to prevent the accident, which I have so often told you can only be prevented by supporting the perineum, knowing why, and how it is to be supported.

Such a laceration as I have now mentioned, is very difficult of

cure, and will not be cured, provided any sloughing process should attend the inevitably consequent inflammation. If uncured, the woman becomes converted into a monotrême, and is a pitiable object for the balance of her existence here. Take you, then, scrupulous heed to the tedious doctrines of the mechanism of the pelvis and head in labor, and never lose sight of them in conducting your cases, and especially your cases terminated with instruments. I have been for many years engaged in midwifery practice to a great extent of occupation, and I defy any one to point out the sample of a female who has suffered under any durable lesion or disability of the organs concerned in the transmission of the fœtus, under my administration over labors. I confess I take pleasure in claiming the merit of such a success, not as impertinently arrogating any superiority of skill over my brethren, but as evidence of the good results that must ever attend a watchful care over those who are committed to our hands.

When a labium gives way in labor, it is because of some too sudden and violent an exertion of the expulsive force of the womb and the abdominal muscles in the last agonies of the labor throes. The tenesmic sensations and propensities of a female, whose perineum is frightfully extended by the presenting part, are so irresistible, that she cannot be prevented in some cases I might say in many cases-from an involuntary and excessive effort to free herself from them; and I have made it a rule to give due warning beforehand of strict obedience to the directions I should give as to not bearing down the pains; and then, reflecting on the causes of the extension of the head, and the direction of the axis of the plane of the perineal strait, have safely guarded my patient against injury.

Do not, I pray you, accuse me of quitting my proper task here in order to talk to you again of a purely obstetric subject. I am well aware that my letter relates to the accidents that befall the labia and perineum; but I cannot forget the sound though homely adage that prevention is better than cure; and I deem my remarks germain to the subject in hand; and hope that they may serve, if not to eschew fractures of the labia in the whole, yet, at least, to render them less extensive and mischievous; nor do I doubt of your success in eschewing them, if you should suffer yourselves to be governed by these views.

When the accident has occurred, there is but little reason to